[Type 2 diabetes and pregnancy: management from preconception to the postpartum]. / Diabète de type 2 et grossesse : prise en charge de la préconception au postpartum.

With the increasing prevalence of diabetes, we are more frequently confronted to treat pregnant women with pre-existing type 2 diabetes. Thereby, we need to take several factors into account such as glycemic control before and during pregnancy, comorbidities such as overweight/obesity and hypertension, as well as existing complications and the need for changes in diabetes treatment. Pregnancy leads to increased insulin requirements, particularly from the second trimester onwards. In this context, a healthy lifestyle and control of weight gain are also necessary. This article provides an overview of the interdisciplinary management of type 2 diabetes before and during pregnancy and in the postpartum period.

En raison de l'augmentation de la prévalence du diabète, nous sommes de plus en plus confrontés à des femmes enceintes avec un diabète de type 2 préexistant. Les défis sont le contrôle glycémique avant et durant la grossesse, les comorbidités telles que le surpoids/l'obésité et l'hypertension artérielle ainsi que les complications existantes et le besoin de changement de traitement du diabète. La grossesse entraîne une forte augmentation des besoins en insuline, en particulier à partir du deuxième trimestre. Dans ce contexte, une bonne hygiène de vie et le contrôle de la prise de poids sont également nécessaires. Cet article offre une vue d'ensemble de la prise en charge interdisciplinaire du diabète de type 2 pendant la grossesse, y compris les soins prénataux et la phase péripartum.

[The impact of gestational diabetes on the mother and her child: what strategies can we propose?] / Impact du diabète gestationnel sur la mère et l'enfant : quelles stratégies proposer ?

Gestational diabetes is often considered as a diagnosis that affects maternal and offspring health exclusively during pregnancy. However, we now know that there are also medium- and long-term risks beyond pregnancy for the mother and the child. Lifestyle changes have been proven to be effective, but they are still a major challenge for young women with no previous health problems and a busy schedule. However, it is also a time that can be seen as an opportunity to take care of one's health in a more global perspective including also transgenerational aspects. This article describes the medium- and long-term issues at stake, but above all the different ways to approach them.

Le diabète gestationnel (DG) reste souvent considéré comme un diagnostic qui n'impacte que le moment de la grossesse. Or, nous savons aujourd'hui qu'il représente aussi des risques au-delà de la grossesse, et ce pour la mère comme pour l'enfant, à moyen et long termes. Si les modifications du style de vie ont fait leurs preuves, elles restent néanmoins un enjeu de taille chez des jeunes femmes a priori sans antécédents de problèmes de santé et avec un emploi du temps bien chargé. Néanmoins, cette situation peut aussi être vue comme une opportunité de prendre soin de sa santé dans sa globalité et dans une perspective transgénérationnelle. Cet article s'attache à décrire les enjeux à moyen et long termes d'un DG mais surtout les moyens pour y faire face.

[The metabolic impact of fiber in gestational diabetes]. / Impact métabolique des fibres en cas de diabète gestationnel.

An adequate fiber intake is recommended for pregnant women, with or without gestational diabetes, similarly to the general population. Due to the lack of precise data on the composition of fiber in foods, dietary advices are not specific. Their objective is to increase the overall fiber consumption, ideally up to a daily consumption of 28g. Fiber intake has diverse effects and it is predominantly the intake of the viscous soluble fibers that improves the glycemic profile. In the case of gestational diabetes, supplementation with fiber products can be of interest in addition to the dietary recommendations to improve the postprandial glycemic profiles. More precise information on the impact of foods according to their fiber composition is needed to optimize the dietary advice.

Une consommation suffisante de fibres fait partie des recommandations pour les femmes enceintes, avec ou sans diabète gestationnel, tout comme pour la population générale. Par manque de données précises sur la composition des fibres des aliments, les conseils alimentaires se trouvent être peu spécifiques, avec pour objectif d'augmenter la consommation de manière générale à 28 g par jour. Les fibres ont des effets divers, et ce sont surtout les fibres solubles visqueuses qui améliorent le profil glycémique. En cas de diabète gestationnel, une supplémentation est intéressante pour limiter les élévations glycémiques, en plus des conseils pour majorer les fibres de manière générale dans l'alimentation. Plus de détails sur l'impact des aliments en fonction de leur composition en fibres sont nécessaires pour optimiser les conseils alimentaires.

[What is the place of a low carbohydrate or low glycemic index diet in gestational diabetes treatment?] / Quelle place pour une alimentation low-carb ou à index glycémique bas dans le diabète gestationnel ?

There is no real consensus on the ideal nutritional approach to recommend for gestational diabetes (GDM) treatment. A carbohydrates reduction (low-carb) is frequently suggested, although many studies have not found any consistent beneficial effects. On the other hand, according to recent meta-analyses, a low glycemic index (GI) diet would have favorable effects for the mother and the child. Although the clinical and practical value of GI is still being studied, a low GI diet seems to be the most appropriate approach in GDM. In addition, soluble fibers may have a beneficial metabolic impact in the short time of pregnancy. More evidence on the impact of these nutritional approaches in the short and long term for mother and child is needed.

Il n'y a pas de réel consensus concernant l'approche nutritionnelle idéale à recommander en cas de diabète gestationnel (DG). Une réduction des quantités de glucides (low-carb) est fréquemment mise en avant, alors que de nombreuses études n'y retrouvent pas d'effets bénéfiques notables. Toutefois, selon des méta-analyses récentes, une alimentation à index glycémique (IG) bas a des effets bénéfiques pour la mère et l'enfant. Même si la valeur clinique et pratique de l'IG fait encore l'objet d'études, cela semble être l'approche la plus appropriée en cas de DG. En complément, les fibres dites « solubles ¼ pourraient avoir un impact métabolique favorable dans le court délai imparti par la grossesse. Plus d'évidences sur l'impact de ces approches nutritionnelles à court et à long termes pour la mère et l'enfant sont indispensables.

Weight Categories, Trajectories, Eating Behavior, and Metabolic Consequences during Pregnancy and Postpartum in Women with GDM.

Pre-pregnancy overweight and obesity are associated with increased risk for adverse outcomes, such as gestational diabetes mellitus (GDM). This study investigated weight trajectories, eating behaviors, and metabolic consequences in women with GDM during pregnancy and postpartum according to pre-pregnancy BMI. We prospectively included 464 women with GDM. Intuitive eating (Intuitive Eating Scale-2 questionnaire), gestational weight gain (GWG), postpartum weight retention (PPWR) at 6-8 weeks and 1-year postpartum, and glucose intolerance (prediabetes and diabetes) at 1-year were assessed. Women with obesity (WOB) had lower GWG but gained more weight in the postpartum (p < 0.0001). PPWR at 1-year did not differ across BMI categories (p = 0.63), whereas postpartum weight loss was most pronounced in women with normal weight (p < 0.0001), and within this category, in their lowest tertile (p < 0.05). Intuitive eating was not linked to perinatal weight changes but differed among BMI categories. PPWR predicted a 2.5-fold increased risk of glucose intolerance at 1-year independent of pre-pregnancy BMI (p < 0.001), and the adverse metabolic impact of PPWR was most pronounced in WOB with odds of increased risk of glucose intolerance 8.9 times higher (95% CI 2.956;26.968). These findings suggest an adaptive capacity to relatively rapid weight changes in the perinatal period that is less present with higher BMI.

Postpartum glucose intolerance after gestational diabetes mellitus: tailored prediction according to data-driven clusters and BMI-categories.

Objectives: To account for the heterogeneity of gestational diabetes (GDM), this study investigated tailored predictors during pregnancy and at 6-8 weeks postpartum of glucose intolerance (GI) at 1-year postpartum. We identified predictors according to data-driven clusters, analogous to the newly proposed diabetes classification, and for clinical ease also based on BMI-categories. Methods: This is a secondary analysis of the MySweetheart trial. It included 179 women with GDM who underwent a 75g oral glucose tolerance test and HbA1c measurement at 1-year postpartum. Predictors were determined according to: a) cluster analysis based on age, BMI, HOMA-IR and HOMA-B; and b) BMI-categories (normal weight [NW], and overweight/obesity [OW/OB]). Results: We identified two clusters during pregnancy and at 6-8 weeks postpartum (for both time points an "insulin-resistant", and an "insulin-deficient" cluster). The "insulin-resistant" cluster was associated with a 2.9-fold (CI: 1.46-5.87; pregnancy) and 3.5-fold (CI: 1.63-7.52; at 6-8 weeks postpartum) increased risk of GI at 1-year postpartum. During pregnancy, the most relevant predictors of GI were history of previous GDM and fasting glucose for the "insulin-deficient" and NW category and HOMA-IR for the "insulin-resistant" and OW/OB category (all p ≤0.035). In the postpartum, predictors were more heterogenous and included the insulin-sensitivity-adjusted-secretion index and 1-h glucose in the "insulin-deficient" and NW women. Main conclusions: In women with GDM, we identified "insulin-resistant" and "insulin-deficient" clusters with distinct risks of future GI. Predictors varied according to clusters or BMI-categories emphasizing the need for tailored risk assessments.

Prospective associations between breast feeding, metabolic health, inflammation and bone density in women with prior gestational diabetes mellitus.

INTRODUCTION: The aim of the study is to investigate prospective associations between breastfeeding and metabolic outcomes, inflammation, and bone density in women with prior gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: We prospectively included 171 women with GDM from the MySweetheart trial. Women were followed during pregnancy (from 24 up to 32 weeks' gestational age) up to 1 year postpartum. Outcomes included weight, weight retention, body composition, insulin resistance and secretion indices, C reactive protein (CRP), and bone density. We compared differences in the associations between breastfeeding and health outcomes between women who breast fed <6 months vs ≥6 months. Analyses were adjusted for potential medical and sociodemographic confounders. RESULTS: Breastfeeding initiation was 94.2% (n=161) and mean breastfeeding duration was 6.6 months. Breastfeeding duration was independently associated with lower weight, weight retention, body fat, visceral adipose tissue, lean mass, CRP, insulin resistance (Homeostatic Model Assessment for Insulin Resistance), and insulin secretion (Homeostatic Model Assessment of ß-cell index) at 1 year postpartum (all p≤0.04) after adjusting for confounders. Breastfeeding was associated with higher insulin resistance-adjusted insulin secretion (Insulin Secretion-Sensitivity Index-2) in the unadjusted analyses only. There was no association between breastfeeding duration and bone density. Compared with <6 months, breastfeeding duration ≥6 months was associated with lower weight, weight retention, body fat, fat-free mass as well as lower CRP at 1 year postpartum (all p<0.05) after adjusting for confounders. CONCLUSIONS: Longer breastfeeding duration among women with prior GDM was associated with lower insulin resistance, weight, weight retention, body fat and inflammation, but not lower bone density at 1 year postpartum. Breastfeeding for ≥6 months after GDM can help to improve cardiometabolic health outcomes 1 year after delivery.

Association between maternal and fetal inflammatory biomarkers and offspring weight and BMI during the first year of life in pregnancies with GDM: MySweetheart study.

Background: Gestational Diabetes Mellitus (GDM) is frequently associated with chronic, low-grade inflammation. Whether this environment affects offspring anthropometry during early childhood remains to be elucidated. The aim of this study was to investigate the associations between maternal and fetal (cord blood-umbilical artery) inflammatory biomarkers and offspring weight and BMI up to 1 year in pregnancies with GDM. Methods: In this prospective secondary analysis of the MySweetheart study, we included 193 women with GDM and their offspring. Maternal and fetal (N=39) predictors included serum levels of inflammatory biomarkers including CRP, IL-6, and TNF-α at 24-32 weeks of gestational age (GA) and in the cord blood. Offspring outcomes were small and large for gestational age (SGA, LGA), sex- and age-adjusted weight, and BMI at birth and at 1 year. Univariate and multivariate regression models were performed. Associations were adjusted for maternal pre-pregnancy BMI, age, and ethnicity. Results: Mean maternal age was 33.6 ± 4.8 years, and pre-pregnancy BMI 25.9 ± 5.6 kg/m2. Their mean gestational age at the 1st GDM visit was 29 ± 2.4 weeks. Gestational age at delivery was 39.7 ± 1.1 weeks, with a mean birthweight of 3.4 ± 0.46 kg; 11.8% of offspring were LGA and 10.8% were SGA. At 1 year of age, mean offspring weight was 9.8 ± 1.2 kg and BMI z-score 0.23 ± 1.1 kg/m2. In the models including only maternal predictors, TNF-α at 24-32 weeks of GA was positively associated with SGA and inversely with offspring weight and BMI at birth and at 1 year (p ≤0.034). In the models including only fetal predictors and the combined model, CRP was inversely associated with BMI at 1 year (p ≤0.020). Conclusions: In women with GDM, maternal and fetal inflammatory biomarkers distinctively influenced offspring anthropometry during the first year of life, independent of maternal age, prepregnancy BMI and ethnicity. These results suggest that low-grade inflammation during pregnancy may affect the developing offspring by leading to a decrease in weight and BMI and may have implications for future personalized follow-up of women with GDM and their offspring.

Effect of the MySweetheart randomized controlled trial on birth, anthropometric and psychobehavioral outcomes in offspring of women with GDM.

Introduction: Gestational diabetes mellitus (GDM) may negatively affect offspring outcomes. A lifestyle intervention may therefore not only improve maternal, but also offspring outcomes. The effects of lifestyle interventions on birth, anthropometric, and psychobehavioral outcomes in offspring of women with GDM need further evidence. Design: The MySweetheart trial is a monocentric single-blind randomized controlled trial in 211 women with GDM. It tested the effect of a pre- and postpartum multidimensional interdisciplinary lifestyle and psychosocial intervention focusing on both the mothers and their infants and its effects on maternal (primary outcomes) and offspring (secondary outcomes) metabolic and psychobehavioral outcomes compared with guidelines-based usual-care. This paper focuses on offspring's birth, anthropometric, and maternal report of psychobehavioral outcomes at singular timepoints. Methods: Women with GDM aged ≥18 years, between 24-32 weeks of gestation, speaking French or English were included and randomly allocated to either the intervention or to an active guidelines-based usual-care group using a 1:1 allocation ratio. The intervention lasted from pregnancy until 1 year postpartum and focused on improving diet, physical activity, and mental health in the mother. For the offspring it focused on supporting breastfeeding, delaying the timing of introduction of solid foods, reducing the consumption of sweetened beverages, increasing physical activity of the family, and improving parental responsiveness to infant distress, hunger, satiety and sleeping cues, and difficult behavior. Results: Adverse birth and neonatal outcomes rarely occurred overall. There were no differences between groups in offspring birth, neonatal, anthropometric, or psychobehavioral outcomes up to one year. After adjustments for maternal age and the offspring's sex and age, there was a borderline significant between-group difference in birth length (ß:-0.64, CI:-1.27; -0.01, p: 0.05), i.e., offspring of mothers in the intervention group were born 0.64 cm shorter compared to those in the usual-care group. Conclusion: This is the first pre- and postpartum multidimensional interdisciplinary lifestyle and psychosocial intervention in GDM focusing on both the mother and the offspring. It did not lead to a significant improvement in most birth, anthropometric, and psychobehavioral outcomes in offspring of women with GDM. ClinicalTrials.gov Identifier: NCT02890693.

Maternal and fetal predictors of anthropometry in the first year of life in offspring of women with GDM.

Introduction: Gestational Diabetes Mellitus (GDM) carries an increased risk for adverse perinatal and longer-term cardiometabolic consequences in offspring. This study evaluated the utility of maternal anthropometric, metabolic and fetal (cord blood) parameters to predict offspring anthropometry up to 1 year in pregnancies with GDM. Materials and methods: In this prospective analysis of the MySweetheart study, we included 193/211 women with GDM that were followed up to 1 year postpartum. Maternal predictors included anthropometric (pre-pregnancy BMI, gestational weight gain (GWG), weight and fat mass at the 1st GDM visit), and metabolic parameters (fasting insulin and glucose, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), Quantitative insulin-sensitivity check index (QUICKI), HbA1c, triglycerides, and high-density lipoprotein (HDL) at the 1st visit and HbA1c at the end of pregnancy). Fetal predictors (N=46) comprised cord blood glucose and insulin, C-Peptide, HOMA-IR, triglycerides and HDL. Offspring outcomes were anthropometry at birth (weight/weight z-score, BMI, small and large for gestational age (SGA,LGA)), 6-8 weeks and 1 year (weight z-score, BMI/BMI z-score, and the sum of 4 skinfolds). Results: In multivariate analyses, birth anthropometry (weight, weight z-score, BMI and/or LGA), was positively associated with cord blood HDL and HbA1c at the 1st GDM visit, and negatively with maternal QUICKI and HDL at the 1st GDM visit (all p ≤ 0.045). At 6-8 weeks, offspring BMI was positively associated with GWG and cord blood insulin, whereas the sum of skinfolds was negatively associated with HDL at the 1st GDM visit (all p ≤0.023). At 1 year, weight z-score, BMI, BMI z-score, and/or the sum of skinfolds were positively associated with pre-pregnancy BMI, maternal weight, and fat mass at the 1st GDM visit and 3rd trimester HbA1c (all p ≤ 0.043). BMI z-score and/or the sum of skinfolds were negatively associated with cord blood C-peptide, insulin and HOMA-IR (all p ≤0.041). Discussion: Maternal anthropometric, metabolic, and fetal metabolic parameters independently affected offspring anthropometry during the 1st year of life in an age-dependent manner. These results show the complexity of pathophysiological mechanism for the developing offspring and could represent a base for future personalized follow-up of women with GDM and their offspring.

Brain responses to food viewing in women during pregnancy and post partum and their relationship with metabolic health: study protocol for the FOODY Brain Study, a prospective observational study.

INTRODUCTION: Food cravings are common in pregnancy and along with emotional eating and eating in the absence of hunger, they are associated with excessive weight gain and adverse effects on metabolic health including gestational diabetes mellitus (GDM). Women with GDM also show poorer mental health, which further can contribute to dysregulated eating behaviour. Food cravings can lead to greater activity in brain centres known to be involved in food 'wanting' and reward valuation as well as emotional eating. They are also related to gestational weight gain. Thus, there is a great need to link implicit brain responses to food with explicit measures of food intake behaviour, especially in the perinatal period. The aim of this study is to investigate the spatiotemporal brain dynamics to visual presentations of food in women during pregnancy and in the post partum, and link these brain responses to the eating behaviour and metabolic health outcomes in women with and without GDM. METHODS AND ANALYSIS: This prospective observational study will include 20 women with and 20 without GDM, that have valid data for the primary outcomes. Data will be assessed at 24-36 weeks gestational age and at 6 months post partum. The primary outcomes are brain responses to food pictures of varying carbohydrate and fat content during pregnancy and in the post partum using electroencephalography. Secondary outcomes including depressive symptoms, current mood and eating behaviours will be assessed with questionnaires, objective eating behaviours will be measured using Auracle and stress will be measured with heart rate and heart rate variability (Actiheart). Other secondary outcome measures include body composition and glycaemic control parameters. ETHICS AND DISSEMINATION: The Human Research Ethics Committee of the Canton de Vaud approved the study protocol (2021-01976). Study results will be presented at public and scientific conferences and in peer-reviewed journals.

Intuitive Eating Behavior, Diet Quality and Metabolic Health in the Postpartum in Women with Gestational Diabetes.

Little is known regarding intuitive eating (IE), diet quality and adherence. We investigated the associations between IE, diet quality and metabolic health after gestational diabetes (GDM), who have an increased diabetes risk. Data from 179 women with GDM from MySweetheart trial (NCT02872974) were analyzed. IE was assessed using the eating for physical rather than emotional reasons (EPR) and reliance on hunger and satiety cues (RHSC) subscales of the French Intuitive Eating Scale-2. Metabolic outcomes included weight, central body fat and insulin resistance. Diet quality was calculated using the Alternative Health Eating Index (AHEI) and compliance with national recommendations was evaluated. Both IE subscales were associated with lower BMI and fat mass (BIA) at 1-year postpartum (all p ≤ 0.034). The EPR subscale inversely correlated with fat mass (DXA) and visceral adipose tissue (both p ≤ 0.028), whereas RHSC with higher insulin sensitivity (Matsuda, p = 0.034). RHSC during pregnancy predicted increased AHEI (p = 0.043) at 1-year postpartum, whilst EPR predicted lower fat mass and insulin resistance (HOMA-IR) (all p ≤ 0.04). In longitudinal analyses, both subscales were associated with increased adherence to dairy and fiber intake recommendations (both p ≤ 0.023). These data suggest IE may be an interesting approach to improve diet quality and metabolic outcomes in women with GDM.