Associations of gestational weight gain with the long-term postpartum weight gain, body mass index, waist circumference and abdominal obesity: A 27-year prospective cohort study.

BACKGROUND: This prospective cohort study aimed to investigate the associations between gestational weight gain (GWG) and long-term postpartum maternal weight gain, body mass index (BMI), waist circumference (WC), and the risk of general and abdominal obesity, beyond motherhood (some 27 y after childbirth). METHODS: Participants were 1953 women enrolled in the Mater-University of Queensland Study of Pregnancy cohort study that started in the early 1980 s, with the most recent follow-up at 27 y postpartum. We examined the prospective associations of GWG in pregnancy with weight, BMI, and WC and the risk of adiposity 27 y after the index pregnancy. We used linear and multinomial logistic regressions to examine the independent effect of GWG on each outcome, adjusting for potential confounders and mediators. RESULTS: The average GWG during pregnancy was 14.88 kg (SD 5.24). One in four women (25.50%) gained below the Institute of Medicine (IOM) recommendations and one in three (34.00%) gained excess weight during pregnancy. Every 100 g/week increment of GWG was associated with 2.0 (95% CI: 1.5, 2.6) kg, 0.7 (0.5, 0.9) kg/m2, 1.3 (0.8, 1.8) cm greater body weight, BMI, and WC, respectively 27 y postpartum. Women who gained inadequate weight in pregnancy had significantly lower odds of general obesity (OR; 0.70, 95% CI:0.53,0.94) or abdominal obesity (0.73; 0.56,0.96), whereas those who gained excess gestational weight had much higher odds of general obesity (4.49; 3.36,6.00) and abdominal obesity (3.09; 2.29,4.16). These associations were independent of potential confounders. CONCLUSION: Maternal GWG in pregnancy independently and strongly predicted beyond motherhood weight gain trajectory. GWG within IOM recommendation may prevent long-term development of both general and central obesity.

Gestational diabetes mellitus care re-imagined - A cost-minimisation analysis: Cost savings from a tertiary hospital, using a novel, digital-based gestational diabetes management model.

BACKGROUND: Diagnosis of gestational diabetes mellitus (GDM) in a pregnancy has a significant impact on health service resources and represents a substantial financial and time impost on women. AIM: To describe a cost-minimisation analysis conducted following the demonstration of clinically equivalent care of women using a novel, digital model for GDM management, compared with conventional care. MATERIALS AND METHODS: A pre-implementation model of care was compared with the post-implementation model of care which included systematic development and delivery of education videos, use of the Commonwealth Scientific and Industrial Research Organisation 'M♡THer' smart phone app/portal and a dramatically reduced schedule of visits. The Mater Mothers' Hospital Brisbane cares for approximately 1200 women with GDM per annum, on which the cost estimates were based. Service costs were estimated using the resource method, where resource volumes and costs were gathered from experts within the health service. Patient costs were estimated using results from a short survey completed by a cohort of the study population. RESULTS: Health service costs showed a modest saving of AU$17 441.78 (US$12 158.92) in the intervention group over a 12-month period. Cost savings for the woman were estimated at $566.56 (US$394.96) per patient after accounting for lost wages, childcare expenses, and travel expenses avoided. This reduction led to an overall saving of $679 872 (US$473 948.82) for the cohort of 1200 women, primarily due to the reduction in face-to-face visits. CONCLUSION: Re-imagining GDM patient care by introducing a novel, digital-based GDM model of care has substantial positive cost implications for patients.

GDM care re-imagined: Maternal and neonatal outcomes following a major model of care change for gestational diabetes mellitus at a large metropolitan hospital.

BACKGROUND: The rapidly rising prevalence of gestational diabetes mellitus (GDM) poses major challenges to the efficient, timely and sustainable provision of diabetes care. AIM: To assess whether the implementation of a novel, digital model of care would provide improved efficiency without compromising clinical outcomes in a cohort of women with GDM. METHODS: A digital model of care was developed, implemented and evaluated using a prospective pre-post study design in 2020-21 at a quaternary centre. We introduced six culturally and linguistically tailored educational videos, home delivery of equipment and prescriptions, and a smartphone app-to-clinician portal for glycaemic review and management. Outcomes were prospectively recorded by an electronic medical record. Associations between model of care and maternal and neonatal characteristics and birth outcomes were examined for all women and separately by treatment received (diet, metformin, insulin). RESULTS: Comparing pre-implementation (n = 598) and post-implementation (n = 337) groups, maternal (onset, mode of birth) and neonatal (birthweight, large for gestational age (LGA), nursery admission) clinical outcomes confirmed that the novel model of care was similar to standard, traditional care. Minor birthweight variation was noted when separated by treatment type (diet, metformin, insulin). CONCLUSION: This pragmatic service redesign demonstrates reassuring clinical outcomes in a culturally diverse GDM cohort. Despite the lack of randomisation, this intervention has potential generalisability for GDM care and important key learnings for service redesign in the digital era.

Postpartum uptake of diabetes screening tests in women with gestational diabetes: The PANDORA study.

AIMS: To determine rates and predictors of postpartum diabetes screening among Aboriginal and/or Torres Strait Islander and non-Indigenous women with gestational diabetes mellitus (GDM). METHODS: PANDORA is a prospective longitudinal cohort of women recruited in pregnancy. Postpartum diabetes screening rates at 12 weeks (75-g oral glucose tolerance test (OGTT)) and 6, 12 and 18 months (OGTT, glycated haemoglobin [HbA1C ] or fasting plasma glucose) were assessed for women with GDM (n = 712). Associations between antenatal factors and screening with any test (OGTT, HbA1C , fasting plasma glucose) by 6 months postpartum were examined using Cox proportional hazards regression. RESULTS: Postpartum screening rates with an OGTT by 12 weeks and 6 months postpartum were lower among Aboriginal and/or Torres Strait Islander women than non-Indigenous women (18% vs. 30% at 12 weeks, and 23% vs. 37% at 6 months, p < 0.001). Aboriginal and/or Torres Strait Islander women were more likely to have completed a 6-month HbA1C compared to non-Indigenous women (16% vs. 2%, p < 0.001). Screening by 6 months postpartum with any test was 41% for Aboriginal and/or Torres Strait Islander women and 45% for non-Indigenous women (p = 0.304). Characteristics associated with higher screening rates with any test by 6 months postpartum included, insulin use in pregnancy, first pregnancy, not smoking and lower BMI. CONCLUSIONS: Given very high rates of type 2 diabetes among Aboriginal and Torres Strait Islander women, early postpartum screening with the most feasible test should be prioritised to detect prediabetes and diabetes for intervention.

Breastfeeding and infant growth in offspring of mothers with hyperglycaemia in pregnancy: The pregnancy and neonatal diabetes outcomes in remote Australia study.

BACKGROUND: Benefits of breastfeeding on infant growth in children born to mothers with gestational diabetes mellitus (GDM) are uncertain. OBJECTIVES: To describe growth trajectories between birth and 14 months according to breastfeeding and maternal hyperglycaemia in pregnancy, and assess associations between breastfeeding and 14 month growth outcomes among children born to mothers with GDM. SUBJECTS/METHODS: Data on 258 Aboriginal and Torres Strait Islander infants from the PANDORA study born to mothers with normoglycaemia (n = 73), GDM (n = 122), or with pre-existing type 2 diabetes (n = 63) in pregnancy were assessed. Infant weight and BMI growth trajectories according to predominant breastfeeding at 6 months and hyperglycaemia in pregnancy were developed using mixed-effect models and cubic splines. Associations between breastfeeding and 14-month growth outcomes (z-scores: weight-for-age, weight-for-length and BMI) were evaluated using linear regression in a subgroup of infants born to mothers with GDM. RESULTS: Predominantly breastfed infants had lower BMI trajectories compared to those not predominantly breastfed, irrespective of maternal hyperglycaemia in pregnancy status (p < 0.01 for all groups), and lower weight trajectories among those born to mothers with GDM (p = 0.006). Among offspring of women with GDM, predominant breastfeeding was only associated with lower weight-for-age at 14 months, however adjusting for maternal obesity, smoking, and parity attenuated observed associations. Maternal obesity remained significantly associated with greater infant growth. CONCLUSIONS: Predominant breastfeeding was associated with reduced growth among children born to women with and without hyperglycaemia in pregnancy. However, among children exposed to GDM in utero, maternal obesity largely explained this association.

Type 2 diabetes after a pregnancy with gestational diabetes among first nations women in Australia: The PANDORA study.

AIMS: To determine among First Nations and Europid pregnant women the cumulative incidence and predictors of postpartum type 2 diabetes and prediabetes and describe postpartum cardiovascular disease (CVD) risk profiles. METHODS: PANDORA is a prospective longitudinal cohort of women recruited in pregnancy. Ethnic-specific rates of postpartum type 2 diabetes and prediabetes were reported for women with diabetes in pregnancy (DIP), gestational diabetes (GDM) or normoglycaemia in pregnancy over a short follow-up of 2.5 years (n = 325). Pregnancy characteristics and CVD risk profiles according to glycaemic status, and factors associated with postpartum diabetes/prediabetes were examined in First Nations women. RESULTS: The cumulative incidence of postpartum type 2 diabetes among women with DIP or GDM were higher for First Nations women (48%, 13/27, women with DIP, 13%, 11/82, GDM), compared to Europid women (nil DIP or GDM p < 0.001). Characteristics associated with type 2 diabetes/prediabetes among First Nations women with GDM/DIP included, older age, multiparity, family history of diabetes, higher glucose values, insulin use and body mass index (BMI). CONCLUSIONS: First Nations women experience a high incidence of postpartum type 2 diabetes after GDM/DIP, highlighting the need for culturally responsive policies at an individual and systems level, to prevent diabetes and its complications.

Incorporating Aboriginal women's voices in improving care and reducing risk for women with diabetes in pregnancy - A phenomenological study.

BACKGROUND: There is a high burden of gestational diabetes (GDM) and type 2 diabetes in pregnancy for Aboriginal and Torres Strait Islander women. Postpartum diabetes programs have the potential to prevent recurrent GDM and improve management of type 2 diabetes. However, data on such programs are limited, particularly in the Indigenous context. We aimed to explore Aboriginal Australian women's and health providers' preferences for a program to prevent and improve diabetes after pregnancy. METHODS: A phenomenological methodology underpinned semi-structured in-depth interviews with eleven Aboriginal women and seven health professionals across the Northern Territory from October 2019- February 2020. Interviews were analysed using an inductive analysis framework to address the barriers and enablers of proposed diabetes prevention programs identified by participants. RESULTS: Identified structural barriers to lifestyle change included: food insecurity, persuasive marketing of unhealthy food options, lack of facilities and cultural inappropriateness of previous programs. Enablers to lifestyle change included: a strong link between a healthy lifestyle and connection with Country, family and community. Suggested strategies to improve lifestyle included: co-designed cooking classes or a community kitchen, team sports and structural change (targeting the social determinants of health). Lifestyle change was preferred over metformin to prevent and manage diabetes after pregnancy by participants and health care providers. CONCLUSIONS: We recommend individual level programs be designed alongside policies that address systemic inequalities. A postpartum lifestyle program should be co-designed with community members and grounded in Aboriginal conceptions of health to adequality address the health disparities experienced by Aboriginal people in remote communities.

Gestational diabetes is associated with postpartum hemorrhage in Indigenous Australian women in the PANDORA study: A prospective cohort.

OBJECTIVE: To assess associations of hyperglycemia in pregnancy with the risk of postpartum hemorrhage (PPH) in a prospective cohort of Indigenous and non-Indigenous women, compared with normoglycemia. METHODS: Data were from 1102 (48% Indigenous) women of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) Study. Age-adjusted associations of gestational diabetes mellitus (GDM) or pre-existing type 2 diabetes mellitus (T2DM), obstetric and demographic covariables with PPH (blood loss ≥500 ml) were assessed using logistic regression. Multivariable-adjusted models included Indigenous ethnicity, diabetes type and their interaction. RESULTS: A higher proportion of Indigenous women developed PPH than non-Indigenous women (32% versus 22%; P < 0.001). Compared with non-Indigenous women with normoglycemia, risks of PPH for Indigenous women with GDM or T2DM were higher (odds ratio [OR] 1.83, 95% confidence intervals [CI] 1.11-3.02, and OR 1.72, 95% CI 0.99-3.00 after age adjustment, OR 1.84, 95% CI 1.06-3.19, and OR 1.33, 95% CI 0.70-2.54 after adjustment for school education and delivery mode, and OR 1.62, 95% CI 0.95-2.77, and OR 0.99, 95% CI 0.53-1.86 after adjustment for birth weight). Importantly, Indigenous women without hyperglycemia in pregnancy were not at increased risk of PPH. CONCLUSION: The significantly higher rates of PPH experienced by Indigenous women compared with non-Indigenous women may be explained by a greater effect of GDM among Indigenous women that was only partly accounted for by birth weight.

Associations of gestational diabetes and type 2 diabetes during pregnancy with breastfeeding at hospital discharge and up to 6 months: the PANDORA study.

AIMS/HYPOTHESIS: Women with gestational diabetes mellitus (GDM) and obesity experience lower rates of breastfeeding. Little is known about breastfeeding among mothers with type 2 diabetes. Australian Indigenous women have a high prevalence of type 2 diabetes in pregnancy. We aimed to evaluate the association of hyperglycaemia, including type 2 diabetes, with breastfeeding outcomes. METHODS: Indigenous (n = 495) and non-Indigenous (n = 555) participants of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) cohort included women without hyperglycaemia in pregnancy (n = 222), with GDM (n = 684) and with type 2 diabetes (n = 144). The associations of hyperglycaemia in pregnancy and breastfeeding at hospital discharge, 6 weeks and 6 months post-partum were evaluated with logistic regression, after adjustment for maternal obesity, ethnicity, maternal and neonatal characteristics. RESULTS: Indigenous women were more likely to predominantly breastfeed at 6 weeks across all levels of hyperglycaemia. Compared with women with no hyperglycaemia in pregnancy, women with type 2 diabetes had lower odds for exclusive breastfeeding at discharge (adjusted OR for exclusive breastfeeding 0.4 [95% CI 0.2, 0.8] p = 0.006). At 6 weeks and 6 months, the relationship between type 2 diabetes and predominant breastfeeding was not statistically significant (6 weeks 0.7 [0.3, 1.6] p = 0.40, 6 months 0.8 [0.4, 1.6] p = 0.60). Women with gestational diabetes were as likely to achieve predominant breastfeeding at 6 weeks and 6 months as women without hyperglycaemia in pregnancy. CONCLUSIONS/INTERPRETATION: Indigenous women had high rates of breastfeeding. Women with type 2 diabetes had difficulty establishing exclusive breastfeeding at hospital discharge. Further research is needed to assess the impact on long-term breastfeeding outcomes. Graphical abstract.

Real-world experience of metformin use in pregnancy: Observational data from the Northern Territory Diabetes in Pregnancy Clinical Register.

BACKGROUND: In Australia's Northern Territory, Indigenous mothers account for 33% of births and have high rates of hyperglycemia in pregnancy. The prevalence of type 2 diabetes (T2D) in pregnancy is up to 10-fold higher in Indigenous than non-Indigenous Australian mothers, and the use of metformin is common. We assessed birth outcomes in relation to metformin use during pregnancy from a clinical register. METHODS: The study included women with gestational diabetes (GDM), newly diagnosed diabetes in pregnancy (DIP), or pre-existing T2D from 2012 to 2016. Data were analyzed for metformin use in the third trimester. Regression models were adjusted for maternal age, body mass index, parity, and insulin use. RESULTS: Of 1649 pregnancies, 814 (49.4%) were to Indigenous women, of whom 234 (28.7%) had T2D (vs 4.6% non-Indigenous women; P < 0.001). Metformin use was high in Indigenous women (84%-90% T2D, 42%-48% GDM/DIP) and increased over time in non-Indigenous women (43%-100% T2D, 14%-35% GDM/DIP). Among Indigenous women with GDM/DIP, there were no significant differences between groups with and without metformin in cesarean section (51% vs 39%; adjusted odds ratio [aOR] 1.25, 95% confidence interval [CI] 0.87-1.81), large for gestational age (24% vs 13%; aOR 1.5, 95% CI 0.9-2.5), or serious neonatal adverse events (9.4% vs 5.9%; aOR 1.32, 95% CI 0.68-2.57). Metformin use was independently associated with earlier gestational age (37.7 vs 38.5 weeks), but the risk did not remain independently higher after exclusion of women managed with medical nutrition therapy alone, and the increase in births <37 weeks was not significant on multivariate analysis. CONCLUSIONS: We found no clear evidence of any adverse outcomes related to the use of metformin for the treatment of hyperglycemia in pregnancy.

Maternal alcohol consumption during pregnancy and its association with offspring renal function at 30 years: Observation from a birth cohort study.

AIM: Prenatal exposure to alcohol has adverse ramifications on foetal development resulting in developmental abnormalities and major congenital anomalies. Experimental studies have documented effects on kidney structure and function among offspring exposed to alcohol during foetal life; however, human evidence is scarce. Thus, the present study aimed to determine the development of CKD among a cohort of 30-year-old Australian offspring whose mothers reported consumption of alcohol during pregnancy. METHODS: The study sample comprised 1626 offspring of the Australia cohort study (MUSP) whose serum creatinine was assessed at 30 years of age and CKD was categorized from stage 1 to stage 5 based on their level of eGFR following the CKD-EPI definition. RESULTS: Seven percent (n = 111) of offspring had mild (stage 2) CKD at 30 years. The overall adjusted odds of CKD were 2.10 (95% CI 1.02 to 4.33) for offspring of moderate to heavy drinking mothers in late pregnancy, 1.59 (0.69 to 3.66) for early pregnancy and 1.23 (0.75 to 2.04) for pre-pregnancy. The association was higher for female offspring-2.84 (1.07 to 7.54) for late pregnancy and 2.94 (1.10 to 7.88) for early pregnancy. Higher but insignificant odds were found for male offspring at late pregnancy 1.51 (0.49 to 4.73) only. CONCLUSION: Maternal alcohol exposure during early and late pregnancy is associated with development of mild CKD in their offspring at 30 years. This association is stronger for female than male offspring.

Pregnancy And Neonatal Diabetes Outcomes in Remote Australia: the PANDORA study-an observational birth cohort.

BACKGROUND: In Australia's Northern Territory, 33% of babies are born to Indigenous mothers, who experience high rates of hyperglycemia in pregnancy. We aimed to determine the extent to which pregnancy outcomes for Indigenous Australian women are explained by relative frequencies of diabetes type [type 2 diabetes (T2DM) and gestational diabetes (GDM)]. METHODS: This prospective birth cohort study examined participants recruited from a hyperglycemia in pregnancy register. Baseline data collected were antenatal and perinatal clinical information, cord blood and neonatal anthropometry. Of 1135 women (48% Indigenous), 900 had diabetes: 175 T2DM, 86 newly diagnosed diabetes in pregnancy (DIP) and 639 had GDM. A group of 235 women without hyperglycemia in pregnancy was also recruited. RESULTS: Diabetes type differed for Indigenous and non-Indigenous women (T2DM, 36 vs 5%; DIP, 15 vs 7%; GDM, 49 vs 88%, p < 0.001). Within each diabetes type, Indigenous women were younger and had higher smoking rates. Among women with GDM/DIP, Indigenous women demonstrated poorer birth outcomes than non-Indigenous women: large for gestational age, 19 vs 11%, p = 0·002; neonatal fat 11.3 vs 10.2%, p < 0.001. In the full cohort, on multivariate regression, T2DM and DIP were independently associated (and Indigenous ethnicity was not) with pregnancy outcomes. CONCLUSIONS: Higher rates of T2DM among Indigenous women predominantly contribute to absolute poorer pregnancy outcomes among Indigenous women with hyperglycemia. As with Indigenous and minority populations globally, prevention or delay of type 2 diabetes in younger women is vital to improve pregnancy outcomes and possibly to improve the long-term health of their offspring.

Lifestyle Intervention in Danish Obese Pregnant Women With Early Gestational Diabetes Mellitus According to WHO 2013 Criteria Does Not Change Pregnancy Outcomes: Results From the LiP (Lifestyle in Pregnancy) Study.

OBJECTIVE: To study effects of lifestyle intervention on metabolic and clinical outcomes in obese women fulfilling the World Health Organization (WHO) 2013 diagnostic criteria for gestational diabetes mellitus (GDM) in early gestation. RESEARCH DESIGN AND METHODS: Secondary analysis of data from the Lifestyle in Pregnancy (LiP) study, a lifestyle randomized controlled trial in 304 pregnant women with BMI ≥30 kg/m2. Early GDM (week 12-15) was diagnosed according to modified WHO 2013 GDM criteria: fasting venous plasma glucose ≥5.1 mmol/L and/or 2-h capillary blood glucose (CBG) ≥8.5 mmol/L (75-g oral glucose tolerance test [OGTT]). Women with treated GDM fulfilling local Danish GDM criteria (2-h CBG ≥9.0 mmol/L) (n = 16) and women with normal OGTT (n = 198) were excluded. RESULTS: Of 90 women with early GDM, 36 received lifestyle intervention and 54 standard care. All were Caucasian, and median age was 29 years (interquartile range 27-33) and BMI 34.5 kg/m2 (32.3-38.1). All baseline characteristics were similar in the lifestyle intervention and standard care groups. At gestational week 28-30, the women in the lifestyle intervention group had significantly higher fasting total cholesterol and fasting LDL. All other metabolic parameters including measurements of glucose, insulin, and HOMA of insulin resistance were similar. There were more planned cesarean sections in the lifestyle intervention group (22.2 vs. 5.6%), but all other obstetric outcomes were similar. CONCLUSIONS: Lifestyle intervention in obese women fulfilling WHO 2013 GDM criteria in early pregnancy was not effective in improving obstetric or metabolic outcomes. Future studies should focus on interventions starting prepregnancy.

Implementation of a diabetes in pregnancy clinical register in a complex setting: Findings from a process evaluation.

BACKGROUND: Rates of diabetes in pregnancy are disproportionately higher among Aboriginal than non-Aboriginal women in Australia. Additional challenges are posed by the context of Aboriginal health including remoteness and disadvantage. A clinical register was established in 2011 to improve care coordination, and as an epidemiological and quality assurance tool. This paper presents results from a process evaluation identifying what worked well, persisting challenges and opportunities for improvement. METHODS: Clinical register data were compared to the Northern Territory Midwives Data Collection. A cross-sectional survey of 113 health professionals across the region was also conducted in 2016 to assess use and value of the register; and five focus groups (49 healthcare professionals) documented improvements to models of care. RESULTS: From January 2012 to December 2015, 1,410 women were referred to the register, 48% of whom were Aboriginal. In 2014, women on the register represented 75% of those on the Midwives Data Collection for Aboriginal women with gestational diabetes and 100% for Aboriginal women with pre-existing diabetes. Since commencement of the register, an 80% increase in reported prevalence of gestational diabetes among Aboriginal women in the Midwives Data Collection occurred (2011-2013), prior to adoption of new diagnostic criteria (2014). As most women met both diagnostic criteria (81% in 2012 and 74% in 2015) it is unlikely that the changes in criteria contributed to this increase. Over half (57%) of survey respondents reported improvement in knowledge of the epidemiology of diabetes in pregnancy since establishment of the register. However, only 32% of survey respondents thought that the register improved care-coordination. The need for improved integration and awareness to increase use was also highlighted. CONCLUSION: Although the register has not been reported to improve care coordination, it has contributed to increased reported prevalence of gestational diabetes among high risk Aboriginal women, in a routinely collected jurisdiction-wide pregnancy dataset. It has therefore contributed to an improved understanding of epidemiology and disease burden and may in future contribute to improved management and outcomes. Regions with similar challenges in context and high risk populations for diabetes in pregnancy may benefit from this experience of implementing a register.

An early life course association of pulse pressure with adulthood estimated glomerular filtration rate: evidence from a large community-based birth cohort study.

BACKGROUND: Little is known about pulse pressure (PP) during early life and its association with renal function at young adulthood. This study describes an early life course association of PP with adult renal function at 30 years from a large community-based birth cohort study in Australia. METHOD: Sample comprises 1169 young adults aged 30 years from the Mater-University of Queensland Study of Pregnancy, whose blood pressure was recorded in at least three follow-ups (5, 14, 21, and 30 years) and renal function was assessed at 30 years. Estimated glomerular filtration rate was estimated to determine the stages of chronic kidney disease (CKD). A group-based trajectory modelling was developed to identify patterns of PP from childhood to adulthood. Multiple logistic regression was used to determine whether PP trajectories predict adult CKD. RESULTS: In total, 7% of participants (91) had mild CKD. Three PP trajectories were identified: 16% were in the high PP trajectory group characterized by substantial increase in PP over time; 58% were in the middle group who had lower PP at 5 years, which increased at 14 years and then gradually declined at 21 and 30 years, and the remaining 26% were in a lower group which remained static. In the adjusted model, significantly higher odds were found for the high [odds ratio: 2.42 (95% confidence interval: 1.02-5.74)] and middle [2.23 (1.19-4.19)] PP trajectory groups for development of mild CKD at 30 years compared with the low (static) group. CONCLUSION: Early life high and middle PP trajectories predict the risk of subclinical renal insufficiency by age 30 years.

Quantitative assessment of dietary intake in adults with Type 1 diabetes following flexible insulin therapy education with an active promotion of dietary freedom.

UNLABELLED: Clinical practice guidelines for diabetes include dietary guidelines to address the increased risk of cardiovascular disease. AIMS: To identify impact of flexible insulin education with an active promotion of dietary freedom on energy and macronutrient intake and achievement of nutrient recommendations in adults with Type 1 diabetes. METHODS: Dietary assessment was performed prior to and 12months following flexible insulin education. Nutrient intake and the proportion achieving the European Association for the Study of Diabetes (EASD) nutrient guidelines were compared at baseline and post course. RESULTS: Dietary data were available for 46 participants. Post course reductions were seen in median [IQR] energy kcal/d (1799 [1521-1931] to 1592 [1378-1940], p=0.002), fibre g/1000kcal (14 [12-16] to 13 [11-15], p=0.047), protein g/day (89 ([78-108] to 82 [74-93], p=0.001) and carbohydrate g/day (198 [172-330] to 162 [143-204], p=<0.001). The proportion experiencing at least 1 severe hypoglycaemia event over 12months was significantly reduced (χ(2)=7.7, p=0.006) from baseline (n=13, 26%) to post course (n=3, 6%). Achievement of EASD guidelines was poor and did not change post course. CONCLUSIONS: Flexible insulin education with an active promotion of dietary freedom does not appear to 'worsen' the achievement of EASD nutrition guidelines in adults with Type 1 diabetes. On the contrary, the dietary changes observed were reductions in energy, carbohydrate and protein intake. Flexible insulin education may offer benefits in enabling reduced energy intake without increasing hypoglycaemia.

Structured type 1 diabetes education delivered in routine care in Australia reduces diabetes-related emergencies and severe diabetes-related distress: The OzDAFNE program.

AIMS: To evaluate structured type 1 diabetes education delivered in routine practice throughout Australia. METHODS: Participants attended a five-day training program in insulin dose adjustment and carbohydrate counting between April 2007 and February 2012. Using an uncontrolled before-and-after study design, we investigated: HbA1c (% and mmol/mol); severe hypoglycaemia; diabetes ketoacidosis (DKA) requiring hospitalisation, and diabetes-related distress (Problem Areas in Diabetes scale; PAID), weight (kg); body mass index. Data were collected pre-training and 6-18 months post-training. Change in outcome scores were examined overall as well as between groups stratified by baseline HbA1c quartiles. Data are mean ± SD or % (n). RESULTS: 506 participants had data eligible for analysis. From baseline to follow-up, significant reductions were observed in the proportion of participants reporting at least one severe hypoglycaemic event (24.7% (n=123) vs 12.1% (n=59), p<0.001); and severe diabetes-related distress (29.3% (n=145) vs 12.6% (n=60), p<0.001). DKA requiring hospitalisation in the past year reduced from 4.1% (n=20) to 1.2% (n=6). For those with above target baseline HbA1c there was a small, statistically significant improvement (n=418, 8.4 ± 1.1% (69 ± 12 mmol/mol) to 8.2 ± 1.1% (66 ± 12 mmol/mol). HbA1c improvement was clinically significant among those in the highest baseline quartile (n=122, 9.7 ± 1.1% (82 ± 11 mmol/mol) to 9.0 ± 1.2% (75 ± 13 mmol/mol), p<0.001). CONCLUSIONS: The proportion of participants reporting severe hypoglycaemia, DKA and severe diabetes-related distress was at least halved, and HbA1c reduced by 0.7% (7 mmol/mol) among those with highest baseline levels. Structured type 1 diabetes education delivered in routine practice offers clinically important benefits for those with greatest clinical need.

Breastfeeding is protective to diabetes risk in young adults: a longitudinal study.

AIM: It is unclear whether any breastfeeding or a certain duration of breastfeeding is protective against the development of diabetes in adult offspring. METHODS: We followed a sub-sample of 3,595 offspring born in the Mater Hospital in Brisbane, Australia between 1981 and 1983 and for whom we had doctor diagnosed self-reported diabetes at age 21 years and maternal reported duration of breastfeeding at 6-month post-natal follow-up. Multiple logistic regression was used to examine the independent associations of duration of breastfeeding (never breastfeed, breastfed <4 months and breastfed ≥4 months) with offspring diabetes by age 21 years. RESULTS: Of 3,595 young adults, 45 (1.25 %) developed diabetes by age 21 years. The odds ratio of experiencing diabetes was 0.58 (95 % CI 0.29, 1.16) for offspring who were breastfed <4 months, and it was 0.29 (95 % CI 0.13, 0.63), for offspring who were breastfed at least 4 months compared to the never breastfed offspring. Adjusting for potential confounding and mediating factors including maternal age, education, pre-pregnancy body mass index (BMI), smoking, offspring sports, TV and their BMI at 21 years did not substantially alter this association. CONCLUSIONS: Findings of this study suggest that infants who are breastfed for longer than 4 months have a substantial protective effect against the development of diabetes in young adulthood, which is independent of current BMI. Promoting breastfeeding for a minimum of 4 months may be a useful strategy for the prevention of diabetes among young adults.