Carbohydrate metabolism and cardiovascular risk factors 4 years after a pregnancy complicated by gestational diabetes

doi:10.1016/j.diabres.2009.05.001

Diabetes Research and Clinical Practice

Volume 85, Issue 2, August 2009, Pages 197-202

https://doi.org/10.1016/j.diabres.2009.05.001 Get rights and content

Abstract

Aims

The aim of the present study was to determine the prevalence of abnormal glucose tolerance and the metabolic syndrome in a cohort of previously gestational diabetic (GDM) women 4 years after delivery.

Methods

Sixty-eight prior GDM and a control group of 39 women with normal glucose tolerance during pregnancy were invited to participate in a follow-up study.

Results

The prevalence of diabetes, impaired glucose tolerance and impaired fasting glucose (IFG) was 21%, 16%, and 6% among prior GDM women and 0%, 15%, and 0% among controls respectively (P = 0.0039). Independently of the metabolic syndrome criteria used this status was found more frequently among women with prior GDM (all P < 0.05). The prevalence of the metabolic syndrome showed a dose–response relationship with the level of weight categories (P < 0.005) as well as with the level of glucose intolerance (P = 0.024).

Conclusion

According to our results a disturbed carbohydrate metabolism and a clustering of cardiovascular risk factors might be observed in previous GDM women 4 years after delivery.

Section snippets

Patients and methods

Data of 200 previous GDM women cared for at our institution during pregnancy between 1996 and 1998 were evaluated. GDM was diagnosed according to the WHO criteria at that time (WHO 1985): GDM if repeated fasting blood glucose value ≥7 mmol/l and/or 2 h postload glucose value during a 75 g oGTT ≥ 11.1 mmol/l, gestational IGT if the latter is between 7.8 and 11.1 mmol/l. Gestational IGT was considered and treated as GDM in agreement with the WHO recommendation [9].

In 2000 all 200 women were invited to

Results

Participants compared to non-responders and responders: Altogether 200 women cared for GDM (96 [48%] insulin treated during pregnancy) at our institution were invited to fill in the mailed questionnaire and to take part in a follow-up investigation. The response rate was 52.5% (105 questionnaire were sent back), and 68 women participated in the clinical examination. There was no significant difference (all P > 0.05) between the gestational parameters of responders and non-responders (age,

Discussion

Our hospital-based study confirms that the disturbances in glucose metabolism persist in women with prior GDM. Forty-three percent of the investigated prior GDM women have glucose intolerance, while 21% have diabetes mellitus 4 years after the index pregnancy. Previous GDM women had a worse cardiovascular risk profile compared to healthy controls. They had more pronounced obesity and insulin resistance, higher triglyceride, and diastolic blood pressure levels. Using any criteria of the

Conclusions

Our results highlight the public health importance of the regular screening (started early after delivery) and care of prior GDM women who have an increased risk for both diabetes mellitus and for cardiovascular disease.

Conflict of interest statement

All of the authors declare that research was conducted in the absence of any commercial or financial relationship that could be constructed as a potential conflict of interest.

Acknowledgments

We thank Dr. János Szalay and Prof. Dr. Isván Rákóczi for motivation of control subjects.

Funding: The research was supported by the Hungarian Scientific Medical Council (ETT 254/2000) and by the Hungarian Scientific Research Fund (OTKA 68575/2007).

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We compared pregnancy outcomes of untreated ‘mild’ GDM (GDM by WHO 2013 but not by WHO-1999) to normal glucose tolerant women (NGT).
In a universal screening program 4333 pregnant women had a 3-point 75 g OGTT in Hungary in 2009–2013. By WHO-2013 untreated NGT was diagnosed in n = 3303, ‘mild’ GDM in n = 336 cases.
‘Mild’ GDM women were older (mean difference, SE: 1.4, 0.3 yrs), had higher fasting (1.0, 0.02), 60-minute (1.0, 0.09), and 120-minute (0.4, 0.06 mmol/l) blood glucose, and blood pressure (2.6, 0.5/2.0, 0.5 mmHg). Weight gain was similar in both groups (−0.3, 0.3 kg). GDM newborns were heavier (142, 50 g) and were more frequently macrosomic (>4000 g, OR 1.85, 95 %CI 1.35–2.54). Hypertension during pregnancy was more prevalent in the GDM group (OR 1.55, 95 %CI 1.05–2.28), as well as induced (OR 1.38, 95 %CI 1.10–1.74) and instrumental delivery (OR 1.34, 95 %CI 1.07–1.68), and acute caesarean section (OR 1.32, 95 %CI 1.04–1.64). Most of these differences substantially attenuated or became non-significant after adjustment for pre-pregnancy BMI.
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The Relationship between 25-hydroxyvitamin D Levels, Insulin Sensitivity and Insulin Secretion in Women 3 Years after Delivery
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Citation Excerpt :
Increased prevalence of glucose intolerance and other abnormal glycemic measures and blood pressure levels have been well described following pregnancies involving GDM. Our current results strengthen our previous findings and correspond with other observations in the literature (18,42). Maternal vitamin D deficiency has been linked to elevated risks for GDM, both cross-sectionally and longitudinally (19–21).
There is a direct correlation between 25-hydroxyvitamin D (25[OH]D) levels and insulin sensitivity. Furthermore, women with gestational diabetes (GDM) may have lower levels of 25(OH)D compared to controls. The present study intended to investigate 25(OH)D levels and their association with insulin sensitivity and insulin secretion in women with prior GDM and in controls 3.2 years after delivery.
A total of 87 patients with prior GDM and 45 randomly selected controls (age range, 22 to 44 years) with normal glucose tolerance during pregnancy nested within a cohort of all deliveries at Saint Margit Hospital, Budapest, between January 1 2005, and December 31 2006, were examined. Their 25(OH) D levels were measured by radioimmunoassay. Insulin sensitivity and fasting insulin secretion were estimated using the homeostasis model asssessment (HOMA) calculator and early insulin secretion by the insulinogenic index based on a 75 g oral glucose tolerance test.
There was no significant difference in 25(OH)D levels between cases and controls (27.2±13.1 [±SD] vs. 26.9±9.8 ng/L). There was a positive association between HOMA insulin sensitivity and 25(OH)D levels (beta = 0.017; 95% CI 0.001 to 0.034/1 ng/mL) that was robust to adjustment for age and body mass index. There was a nonsignificant association between HOMA insulin secretion and 25(OH)D (p=0.099), while no association was found with the insulinogenic index.
Prior GDM status was not associated with 25(OH)D levels; however, 25(OH) D levels were associated with HOMA insulin sensitivity. It is hypothesized that the association between HOMA insulin secretion and 25(OH)D levels is related to the autoregulation of fasting glucose levels because no association between 25(OH)D and insulinogenic index was found.
Une corrélation directe a été établie entre les concentrations de 25-hydroxyvitamine D (25[OH]D) et la sensibilité à l'insuline. De plus, les femmes atteintes de diabète gestationnel peuvent présenter des concentrations inférieures de 25(OH)D comparativement à celles du groupe témoin. La présente étude visait à mesurer les concentrations de 25(OH)D et leur lien avec la sensibilité à l'insuline et la sécrétion d'insuline chez des femmes ayant des antécédents de diabète gestationnel et des femmes d'un groupe témoin 3,2 années après l'accouchement.
L'examen a porté sur 87 patientes ayant des antécédents de diabète gestationnel et 45 femmes qui ont présenté une tolérance normale au glucose durant leur grossesse, choisies au hasard pour constituer le groupe témoin parmi une cohorte de toutes les femmes ayant accouché à l'hôpital Saint Margit de Budapest au cours de la période allant du 1^er janvier 2005 au 12 décembre 2006. L'âge de la population à l'étude variait de 22 à 44 ans. Les concentrations de 25(OH) D ont été mesurées par radio-immunodosage. La sensibilité à l'insuline et la sécrétion d'insuline à jeun ont été estimées au moyen du modèle HOMA (évaluation du modèle d'homéostasie) et la sécrétion précoce d'insuline, par l'indice insulinogénique établi par l'épreuve de tolérance orale à 75 mg de glucose.
On n'a observé aucune différence significative entre les concentrations de 25(OH)D des femmes ayant des antécédents de diabète gestationnel et celles du groupe témoin (27,2±13,1 [±É.-T.] comparativement à 26,9±9,8 ng/L). Une association positive a été établie entre la sensibilité à l'insuline selon l'indice HOMA et les concentrations de 25(OH)D (bêta=0,017; IC à 95 %, de 0,001 à 0,034/1 ng/mL) et s'est maintenue après correction en fonction de l'âge et de l'indice de masse corporelle. On a constaté un lien non significatif entre la sécrétion d'insuline selon l'indice HOMA et les concentrations de 25(OH)D (p=0,099), mais aucune association avec l'indice insulinogénique.
On n'a établi aucune association entre les antécédents de diabète gestationnel et les concentrations de 25(OH)D; cependant, il existe un lien entre les concentrations de 25(OH)D et la sensibilité à l'insuline selon l'indice HOMA. On a émis l'hypothèse que l'association entre la sécrétion d'insuline selon l'indice HOMA et les concentrations de 25(OH)D s'explique par l'autorégulation de la glycémie à jeun en l'absence d'association entre les concentrations de 25(OH)D et l'indice insulinogénique.
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Estudio observacional de cohortes. Se seleccionó al total de pacientes con el diagnóstico de diabetes gestacional durante de los años 2000-2009 (n = 470) en el Complexo Hospitalario Universitario de Ourense. Se procedió a la revisión de la historia clínica electrónica, valorando la existencia y el año de realización de la última glucemia basal. El tiempo medio de seguimiento fue de 12,9 años. Se consideró cribado adecuado la constancia en la historia clínica de una glucemia basal en los últimos 3 años. Se analizaron las siguientes variables: adecuación del cribado de diabetes mellitus de tipo 2, edad, índice de masa corporal, diabetes gestacional en más de una gestación, medio rural/urbano. Se realizó el análisis descriptivo de los datos. Para la determinación de las diferencias entre subgrupos se utilizó la prueba Chi² y la prueba t de Student. Se consideró significación estadística p < 0,05.
El control a largo plazo de estas pacientes fue muy irregular. Solo el 67,0% del grupo a estudio realizó cribado de diabetes mellitus de tipo 2. Ni la edad, ni el índice de masa corporal, ni el lugar de residencia, ni el año del diagnóstico modificaron el grado de seguimiento. Las pacientes con más de un episodio de diabetes gestacional presentaron un control glucémico posterior que alcanzó el 94,1%.
La adecuación del cribado en nuestra área es muy irregular y altamente mejorable.
To assess long-term suitability of screening for type 2 diabetes mellitus in women with a previous diagnosis of gestational diabetes in Primary Care. The secondary objectives were to determine if there were clinical factors that modified the usefulness of the screening.
An observational cohort type study was performed, which included all patients with the diagnosis of gestational diabetes during the years 2000 to 2009 (n = 470) in the University Hospital Complex of Ourense. The electronic medical records were reviewed to assess the existence of gestational diabetes and the year of the last fasting blood glucose. The mean follow-up time was 12.9 years. The screening for evidence of a fasting blood glucose in the last 3 years was considered adequate. The following variables were analysed: adequacy of screening for type 2 diabetes mellitus, age, body mass index, gestational diabetes in more than one gestation, and rural/urban environment. A descriptive analysis of the data was performed, using Chi2 and Student's t-test to determine differences between subgroups. Statistical significance was considered as P<.05
The long-term monitoring of these patients was very irregular. Only 67.08% of the study group underwent diabetes mellitus type 2 screening. The level of follow-up was not associated with age, BMI, the place of residence, or the year of diagnosis. In patients with more than one episode of gestational diabetes, subsequent blood glucose control was achieved in 94.1%.
The adequacy of the screening in our area is very irregular and highly improvable.
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Citation Excerpt :
Feig et al. show the rate of developing diabetes after a GDM pregnancy is ∼20% by 9 years [19] though others estimate double this – 51% – by 8 years postpartum, with increased risk in both women with two or more live births and obese women [36]. Madarasz and colleagues show that the spectrum of glucose intolerance (T2DM, IFG and IGT) later in life is more prevalent within pGDM women compared with controls [45]. Collectively these abnormalities occur ∼3 times more frequently in women with pGDM.
Globally, cardiovascular disease (CVD) accounts for 1/3 of all deaths to women. While much research identifies the increased risk in CVD associated with pre-diabetes measurements, there is growing interest in the role of gestational diabetes mellitus (GDM)–a condition of glucose intolerance diagnosed during pregnancy–as a potential CVD risk factor. This article reviews existing evidence supporting this association, particularly regarding GDM and type 2 diabetes, hypertension, atherogenic dyslipedmia, and CVD events. Finally, it discusses the research and clinical ramifications of identifying GDM as a CVD risk factor, highlighting the need for more rigorous research on this topic.
Outcomes in women with a history of gestational diabetes. Screening and prevention of type 2 diabetes. Literature review
2010, Diabetes and Metabolism
Maternal and Dietary Factors Are Associated with Metabolic Syndrome in Women with a Previous History of Gestational Diabetes Mellitus
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Carbohydrate metabolism and cardiovascular risk factors 4 years after a pregnancy complicated by gestational diabetes

Abstract

Aims

Methods

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

Conclusions

Conflict of interest statement

Acknowledgments

Baillieres. Clin. Obstet. Gynaecol.

Eur. J. Intern. Med.

Am. J. Obstet. Gynecol.

Diabetes Res. Clin. Pract.

Gestational diabetes: current aspects on pathogenesis and treatment

Exp. Clin. Endocrinol. Diabetes

Universal screening for gestational diabetes mellitus: 3 year results

Diabet. Med.

Gestational diabetes and the incidence of type 2 diabetes

Diabetes Care

Gestational diabetes mellitus: early manifestation or predictor of the metabolic syndrome

Diabetol. Hung.

Predicting future diabetes in Latino women with gestational diabetes: utility of early postpartum glucose tolerance testing

Diabetes

Role of insulin resistance in human disease

Diabetes

A new IDF worldwide definition of the metabolic syndrome: the rationale and the results

Diabetes Voice

The metabolic syndrome: time for a critical appraisal

Diabetologia

Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man

Diabetologia

Use and abuse of HOMA modeling

Diabetes Care

Beta cell function and its relation to insulin action in humans: a critical appraisal

Diabetologia

Evaluation of simple indices of insulin sensitivity and insulin secretion for use in epidemiologic studies

Am. J. Epidemiol.