Dietary Intake and Oral Glucose Tolerance Test Results in Women with Gestational Diabetes.

Background/Objective: Diet is a risk factor for gestational diabetes mellitus (GDM). There are few studies on women's diet and glucose tolerance test (GTT) results during pregnancy. The objective of this study was to evaluate the relationship between one's previous diet and the number of abnormal values on the diagnostic GTT in women with GDM. We hypothesized that there would be an inverse relation between antioxidant micronutrient consumption and the number of abnormal GTT values. Methods: This cross-sectional study included 60 women diagnosed with GDM (2-h, 75 g-GTT), divided in two groups as follows: 1 abnormal glucose value and 2-3 abnormal values. Shortly after the diagnosis, participants answered a validated food frequency questionnaire to assess their food consumption in the last 6 months. The Mann-Whitney test was used to compare the dietary intake of the participants in the two groups. Results: The participant characteristics were similar. The median intake of total calories, carbohydrates, lipids, and proteins did not differ significantly between groups. Participants with 1 abnormal GTT value had significantly higher intakes of fiber (11.9 vs. 11.0 g/day p = 0.049), vitamin D (40.6 vs. 40.4 mcg/day p = 0.049), and vitamin C (180.0 vs. 151.0 mg/day p = 0.008) than those with 2-3 abnormal values. Conclusions: Our results suggest a possible association between the consumption of fiber and antioxidant micronutrients and the number of abnormal GTT values.

Prolactin does not seem to mediate the improvement on insulin resistance markers and blood glucose levels related to breastfeeding.

Introduction: The prevalence of type 2 diabetes mellitus (T2DM) is increasing worldwide. Strategies to decrease this risk should be strongly encouraged. Lactation has been associated, for the mother, with reduction in future T2DM risk in several studies. The mechanisms behind this phenomenon, however, are poorly understood. The aims of this study were, first, to compare blood glucose levels and markers of insulin resistance (MIR) in early postpartum women with overweight/obesity according to their breastfeeding status and, second, to evaluate whether prolactin (PRL) levels could mediate improvements in these parameters. Methods: The prospective study followed 95 women older than 18 years from early pregnancy for up to 60 to 180 days postpartum. All participants had a BMI > 25 kg/m2 and a singleton pregnancy. At each visit, questionnaires and clinical and biochemical evaluations were performed. Participants were divided into two groups according to the breastfeeding status as "yes" for exclusive or predominant breastfeeding, and "no" for not breastfeeding. Results: Breastfeeding women (n = 44) had significantly higher PRL levels [47.8 (29.6-88.2) vs. 20.0 (12.0-33.8), p< 0.001]. They also had significantly lower fasting blood glucose levels [89.0 (8.0) vs. 93.9 (12.6) mg/dl, p = 0.04], triglycerides (TG) [92.2 (37.9) vs. 122.4 (64.4) mg/dl, p = 0.01], TG/HDL ratio [1.8 (0.8) vs. 2.4 (1.6) mg/dl, p = 0.02], TyG index [8.24 (0.4) vs. 8.52 (0.53), p = 0.005], fasting serum insulin [8.9 (6.3-11.6) vs. 11.4 (7.7-17.0), p = 0.048], and HOMA-IR [2.0 (1.3-2.7) vs. 2.6 (1.6-3.9), p = 0.025] in the postpartum period compared to the non-breastfeeding group. Groups were homogeneous in relation to prevalence of GDM, pre-gestational BMI, as well as daily caloric intake, physical activity, and weight loss at postpartum. Linear regression analysis with adjustments for confounders showed a statistically significant association of breastfeeding with fasting blood glucose [-6.37 (-10.91 to -1.83), p = 0.006], HOMA-IR [-0.27 (-0.51 to -0.04), p = 0.024], TyG index [-0.04 (-0.06 to -0.02), p = 0.001], and TG/HDL ratio [-0.25 (-0.48 to -0.01), p = 0.038]. Mediation analysis showed that PRL did not mediate these effects. Sensitivity analyses considering different cutoffs for PRL levels also did not show modification effect in the mediation analyses. Conclusion: Breastfeeding was associated with improvement in glucose metabolism and MIR 60 to 180 days after birth in overweight and obese women, even when adjusted for confounders. PRL levels were not found to mediate the association between breastfeeding and improvement in MIR.

Maternal-fetal outcomes of pregnant women with type 1 diabetes treated with continuous subcutaneous insulin infusion or multiple daily injections during pregnancy - A Brazilian health care referral center cohort study.

Objective: Pregnant women with type 1 diabetes (T1D) have an increased risk of maternal-fetal complications. Regarding treatment, continuous subcutaneous insulin infusion (CSII) has advantages compared to multiple daily injections (MDI), but data about the best option during pregnancy are limited. This study's aim was to compare maternal-fetal outcomes among T1D patients treated with CSII or MDI during pregnancy. Subjects and methods: This study evaluated 174 pregnancies of T1D patients. Variables of interest were compared between the groups (CSII versus MDI), and logistic regression analysis was performed (p < 0.05). Results: Of the 174 included pregnancies, CSII was used in 21.3% (37) and MDI were used in 78.7% (137). HbA1c values improved throughout gestation in both groups, with no difference in the first and third trimesters. The frequency of cesarean section was significantly higher in the CSII group [94.1 vs. 75.4%, p = 0.017], but there was no significant difference in the frequency of other complications, such as miscarriage, premature delivery and preeclampsia. The mean birth weight and occurrence of neonatal complications were also similar, except for the proportion of congenital malformations, which was significantly lower in the CSII group [2.9 vs. 15.6%, p = 0.048]. In regression analysis, the association of CSII with cesarean section and malformations lost significance after adjusting for HbA1c and other covariates of interest. Conclusion: In this study, we observed a higher frequency of cesarean section and a lower occurrence of congenital malformations in the CSII group, but the adjusted results might indicate that these associations are influenced by glycemic control.

Prediction of lung maturity through quantitative ultrasound analysis of fetal lung texture in women with diabetes during pregnancy.

OBJECTIVES: The present study aimed to evaluate the performance of QuantusFLM® software, which performs quantitative ultrasound analysis of fetal lung texture, in predicting lung maturity in fetuses of diabetic mothers. METHODS: The patients included in this study were between 34 and 38 weeks and 6 days gestation and were divided into two groups: (1) patients with diabetes on medication and (2) control. The ultrasound images were performed up to 48 h prior to delivery and analyzed using QuantusFLM® software, which classified each fetus as high or low risk for neonatal respiratory morbidity based on lung maturity or immaturity. RESULTS: A total of 111 patients were included in the study, being 55 in diabetes and 56 in control group. The pregnant women with diabetes had significantly higher body mass index (27.8 kg/m2 vs. 25.9 kg/m2, respectively, p=0.02), increased birth weight (3,135 g vs. 2,887 g, respectively, p=0.002), and a higher rate of labor induction (63.6 vs. 30.4 %, respectively, p<0.001) compared to the control group. QuantusFLM® software was able to predict lung maturity in diabetes group with 96.4 % accuracy, 96.4 % sensitivity and 100 % positive predictive value. Considering the total number of patients, the software demonstrated accuracy, sensitivity, specificity, positive predictive value and negative predictive value of 95.5 , 97.2, 33.3, 98.1 and 25 %, respectively. CONCLUSIONS: QuantusFLM® was an accurate method for predicting lung maturity in normal and DM singleton pregnancies and has the potential to aid in deciding the timing of delivery for pregnant women with DM.

Inadequate pregnancy planning in diabetics, and its impact on glycemic control and complications.

INTRODUCTION: To assess the intention of actual pregnancy and its influence on glycated hemoglobin (HbA1c) profile before and during the pregnancy of women with previous diabetes mellitus (DM). METHODS: Prospective cohort study included pregnant women with previous DM assisted from October/2018 to October/2019. Data were collected with standardized questionnaire and from medical records. Comparisons of variables of interest (Student's t test, Mann-Whitney or chi-square test) were performed between the group of women who did or denied report having interest to become pregnant. And a logistic regression analysis were performed considering prematurity or fetal/neonatal complication as dependent variables. RESULTS: Sixty patients were included, with HbA1c mean of pre-pregnancy, first and third trimesters of 9.3, 8.1 and 6.8%, respectively. 7.7% women had HbA1c ≤ 6.5% in pre-pregnancy and 16.7% in first trimester. 83.3% reported having received guidance on the importance of glucose control and contraception before their current pregnancy. Although 28.3% reported the intention to become pregnant, only 28.3% reported regular use of any contraceptive method before it, none of which had HbA1c in the recommended goal for pregnancy. Glycemic control did not differ between groups intending or not to become pregnant. Women with adequate glycemic control in first trimester had a lower frequency of prematurity (p = 0.015) and fetal complications (p = 0.001), and better control at the end of pregnancy. DISCUSSION: Although most of these women reported having had information about the importance of a planned pregnancy, adequate glycemic control of women with diabetes before and during the pregnancy is still not a reality nowadays. It might be necessary to improve medical communication in pregnancy planning.

Maternal-fetal outcomes of pregnant women with type 1 diabetes treated with continuous subcutaneous insulin infusion or multiple daily injections during pregnancy - A Brazilian health care referral center cohort study

ABSTRACT Objective: Pregnant women with type 1 diabetes (T1D) have an increased risk of maternal-fetal complications. Regarding treatment, continuous subcutaneous insulin infusion (CSII) has advantages compared to multiple daily injections (MDI), but data about the best option during pregnancy are limited. This study's aim was to compare maternal-fetal outcomes among T1D patients treated with CSII or MDI during pregnancy. Subjects and methods: This study evaluated 174 pregnancies of T1D patients. Variables of interest were compared between the groups (CSII versus MDI), and logistic regression analysis was performed (p < 0.05). Results: Of the 174 included pregnancies, CSII was used in 21.3% (37) and MDI were used in 78.7% (137). HbA1c values improved throughout gestation in both groups, with no difference in the first and third trimesters. The frequency of cesarean section was significantly higher in the CSII group [94.1 vs. 75.4%, p = 0.017], but there was no significant difference in the frequency of other complications, such as miscarriage, premature delivery and preeclampsia. The mean birth weight and occurrence of neonatal complications were also similar, except for the proportion of congenital malformations, which was significantly lower in the CSII group [2.9 vs. 15.6%, p = 0.048]. In regression analysis, the association of CSII with cesarean section and malformations lost significance after adjusting for HbA1c and other covariates of interest. Conclusion: In this study, we observed a higher frequency of cesarean section and a lower occurrence of congenital malformations in the CSII group, but the adjusted results might indicate that these associations are influenced by glycemic control.

The gut microbiome of obese postpartum women with and without previous gestational diabetes mellitus and the gut microbiota of their babies.

BACKGROUND: The incidence of gestational diabetes mellitus (GDM) is increasing worldwide, and has been associated with some changes in the gut microbiota. Studies have shown that the maternal gut microbiota pattern with hyperglycemia can be transmitted to the offspring. The study aimed to evaluate the gut microbiota of obese postpartum women with and without previous GDM and their offspring. METHODS: We evaluated a total of 84 puerperal women who had (n = 40) or not GDM (n = 44), and their infants were also included. Stool samples were obtained 2-6 months after delivery. The molecular profile of the fecal microbiota was obtained by sequencing V4 region of 16S rRNA gene (Illumina® MiSeq). RESULTS: We found that the gut microbiota structures of the puerperal women and their infants were similar. Stratifying according to the type of delivery, the relative abundance of Victivallis genus was higher in women who had natural delivery. Exposure to exclusive breastfeeding was associated with a greater abundance of Bacteroides and Staphylococcus. The differential abundance test showed correlations to clinical and laboratory parameters. This work showed no difference in the microbiota of obese puerperal women with and without GDM and their offspring. However, breastfeeding contributed to the ecological succession of the intestinal microbiota of the offspring. CONCLUSION: This work can contribute to understanding the potential effects of GDM and early life events on the gut microbiome of mothers and their offspring and its possible role in metabolism later in life.

Neck circumference as a predictor of gestational diabetes and risk of adverse outcomes in pregnancy of Brazilian woman with overweight and obesity

ABSTRACT Objective: To evaluate the association of neck circumference (NC) with gestational diabetes (GDM) and adverse outcomes in women with overweight and obesity. Subjects and methods: This prospective study included 132 (BMI > 25 kg/m2) pregnant women without and with GDM. Standardized questionnaire and biochemical/physical evaluation were performed during the 1st to 3rd trimester. Fifth-five women were evaluated regarding hypertension in pregnancy, type of delivery and neonatal complications (death, intensive care unit admission and hypoglycemia). Results: Women with (n = 61) and without (n = 71) GDM had similar mean (SD) pre-gestational BMI [30.3 (4.0) vs. 29.4 (3.5) kg/m2, p = 0.16]. Women with GDM were older [32 (6) vs. 28 (6) yrs, p < 0.001] and had greater NC [36.0 (2.7) vs. 34.5 (1.8) cm, p < 0.001]. NC was similar in women with GDM diagnosed in first or third trimester [p = 0.4] and was correlated with FPG [r 0.29, p = 0.01] and systolic [r 0.28, p = 0.001] and diastolic [r 0.25, p = 0.004] blood pressure. NC was associated with GDM [OR 1.25, 95%CI 1.03-1.52] adjusted for age, physical activity, education and familiar history of diabetes. In ROC analysis, the area under the curve was 0.655 and the cut-off value of 34.5 cm had 0.70 of sensitivity and 0.51 of specificity for GDM. Women who had NC ≥ 34.5 vs. < 34.5 cm had higher frequencies of hypertension [32.3 vs. 4.2%, p = 0.01]. Conclusions: In a group of pregnant women with overweight or obesity, NC can be a useful tool for identifying risk of GDM and obstetric adverse outcomes.

Neck circumference as a predictor of gestational diabetes and risk of adverse outcomes in pregnancy of Brazilian woman with overweight and obesity.

Objective: To evaluate the association of neck circumference (NC) with gestational diabetes (GDM) and adverse outcomes in women with overweight and obesity. Subjects and methods: This prospective study included 132 (BMI > 25 kg/m2) pregnant women without and with GDM. Standardized questionnaire and biochemical/physical evaluation were performed during the 1st to 3rd trimester. Fifth-five women were evaluated regarding hypertension in pregnancy, type of delivery and neonatal complications (death, intensive care unit admission and hypoglycemia). Results: Women with (n = 61) and without (n = 71) GDM had similar mean (SD) pre-gestational BMI [30.3 (4.0) vs. 29.4 (3.5) kg/m2, p = 0.16]. Women with GDM were older [32 (6) vs. 28 (6) yrs, p < 0.001] and had greater NC [36.0 (2.7) vs. 34.5 (1.8) cm, p < 0.001]. NC was similar in women with GDM diagnosed in first or third trimester [p = 0.4] and was correlated with FPG [r 0.29, p = 0.01] and systolic [r 0.28, p = 0.001] and diastolic [r 0.25, p = 0.004] blood pressure. NC was associated with GDM [OR 1.25, 95%CI 1.03-1.52] adjusted for age, physical activity, education and familiar history of diabetes. In ROC analysis, the area under the curve was 0.655 and the cut-off value of 34.5 cm had 0.70 of sensitivity and 0.51 of specificity for GDM. Women who had NC ≥ 34.5 vs. < 34.5 cm had higher frequencies of hypertension [32.3 vs. 4.2%, p = 0.01]. Conclusion: In a group of pregnant women with overweight or obesity, NC can be a useful tool for identifying risk of GDM and obstetric adverse outcomes.

The first series of cases of ketosis-prone type 2 diabetes (flatbush diabetes) in Brazilian adults.

Ketosis-prone type 2 diabetes (KPD) is an emerging form of diabetes mellitus characterized by unprovoked ketoacidosis, absence of autoimmunity and beta-cell dysfunction. The KPD may improve after initial glycemic compensation and evolve to exogenous insulin independence, most cases were observed in populations with African or Hispanic backgrounds. We reviewed the literature on KPD and, to date, only one case of KPD has been described in Brazil's multi-ethnic population. A group of adult Brazilian KPD patients without autoimmunity and insulinopenia was identified for this study. We report a retrospective study of four KPD cases (3 males) evaluated in southeast Brazil, the patients were overweight or obese, age between the third and fifth decades of life, had a family history of type 2 diabetes, hyperglycemia (809.5 ± 344.2 mg/dL), acidosis (pH 7.21 ± 0.07; normal range (nr): 7.35-7.45 and bicarbonate 9.1 ± 6.2; nr: 22-26 mEq/mL), ketonuria (142.5 ± 114.4 mg/dL; nr: absence), absence of glutamic acid decarboxylase antibodies (GAD-65), and beta-cell function reserve (C-peptide 1.19 ± 0.53 ng/mL - nr: 1.1-4.4 ng/mL) on diagnosis. After glycemic compensation, there was increase of C-peptide (2.21 ± 0.41) indicating the recovery of beta-cell function and the time to insulin independence was 7.7 ± 3.5 months. They evolved after the period of glucotoxicity with insulin withdrawal and could be treated with oral antidiabetic therapy. This is the first case series of KPD described in Brazil being characterized by ketoacidosis at diagnosis, absence of autoimmunity, recovery of beta-cell function and insulin independence.

Maternal near miss and potentially life-threatening condition determinants in patients with type 1 diabetes mellitus at a university hospital in São Paulo, Brazil: a retrospective study.

BACKGROUND: To date, the rates of potentially life-threatening condition (PTLC), maternal near miss (MNM) and maternal deaths in pregnant patients with type 1 diabetes mellitus (T1DM) and variables associated to it have not been studied. METHODS: This study was as a cross-sectional retrospective study conducted at São Paulo Hospital of Universidade Federal de São Paulo, a tertiary hospital that provides public medical care through the Brazilian unified health system to high-risk pregnancies. Inclusion criteria were T1DM pregnant women who delivered from January 2005 to December 2015. Three groups were established by the World Heath Organization criteria and associations were assessed using the chi-square test in between MNM and no morbidity or PLTC and no morbidity. A P value < 0.05 was considered statistically significant. RESULTS: The final sample included 137 patients, 8 MNM cases (5.84%), 51 PLTC (37.23%), no cases of maternal deaths and 78 patients (56.93%) did not present any complication. Moreover, there were 122 live births, resulting in a near miss rate of 65.5 per 1.000 live births in patients with T1DM. Two of the MNM cases were for clinical criteria (uncontrollable fit in both) and laboratory criteria for the other six: one patient with severe acute azotemia (creatinine > 300 µmol/ml), one patient with severe hypoperfusion (lactate > 5 mmol/L) and four of them with loss of consciousness and the presence of glucose and ketoacids in urine. PLTC criteria were studied in MNM and PLTC cases. Prolonged hospital stay was the most prevalent PLTC criteria in both groups (100% of MNM cases and 96% of PLTC), followed by renal failure in 50% of MNM cases and severe preeclampsia in 22% of PLTC cases. This study could not find any association between prenatal factors or sociodemographic characteristics with maternal morbidity. CONCLUSIONS: MNM rate in T1DM was extremely high, and determined by complications of the primary disease or hypertensive disorders. No sociodemographic variables studied were related to maternal morbidity; therefore, we could not predict what increases MNM and PLTC in this specific population.

Rastreamento e diagnóstico de diabetes mellitus gestacional no Brasil / Screening and diagnosis of gestational diabetes mellitus in Brazil

Em primeiro de agosto de 2016, considerando-se a relevância do Diabetes Mellitus Gestacional (DMG), tanto por sua prevalência como pelas consequências para o binômio materno-fetal em curto e em longo prazo, foi realizado, em São Paulo, um fórum de discussão sobre o tema, com o objetivo de definir uma proposta para o diagnóstico de DMG para o Brasil. Nesse contexto, participaram da reunião médicos especializados na assistência a mulheres com DMG: obstetras da Federação Brasileira de Ginecologia e Obstetrícia (Febrasgo), endocrinologistas da Sociedade Brasileira de Diabetes (SBD) e consultores da Organização Panamericana de Saúde (Opas/OMS Brasil) e assessores técnicos do Ministério da Saúde. Apresentamos neste documento os principais pontos debatidos visando à análise cuidadosa das possibilidades para diagnóstico de DMG, considerando-se as diferenças de acesso aos serviços de saúde existentes no Brasil.(AU)

Obesidade / Obesity

A obesidade é atualmente um dos mais graves problemas de saúde pública. A prevalência da obesidade tem crescido acentuadamente nas últimas décadas, tanto nos países desenvolvidos como nos em desenvolvimento. Estes dados a levaram à condição de epidemia global(1).Os estudos epidemiológicos em populações latino-americanas têm revelado dados preocupantes nesse sentido. Entre as camadas mais pobres da população, à medida que se consegue erradicar a miséria, a obesidade desponta como um problema mais freqüente e mais grave que a desnutrição. É o fenômeno denominado de transição nutricional.Entre as complicações médicas associadas com a obesidade podemos citar as doenças cardiovasculares, hipertensão arterial, dislipidemias, diabetes mellitus, esteatose hepática, calculose de vesícula biliar, osteoartrite e diversos tipos de câncer. Estas doenças são responsáveis por uma demanda crescente no nosso sistema de saúde(2). É provável que 200.000 pessoas morram anualmente em decorrência destas complicações na América Latina.A abordagem atual da obesidade, entretanto, continua produzindo resultados insatisfatórios, em grande parte por estratégias equivocadas e pelo mau uso dos recursos terapêuticos disponíveis. Além da procura de planos terapêuticos mais eficazes, faz-se necessário, também, que sejam adotadas medidas de prevenção para conter a crescente demanda.A obesidade é definida como uma doença crônica que se caracteriza pelo acúmulo excessivo de gordura e comprometimento da saúde. Deve ser considerado que existe diferença na distribuição regional de gordura corpórea(3). O acúmulo de gordura abdominal (gordura visceral) é considerado um fator de risco maior para o desenvolvimento das doenças decorrentes da obesidade(4).Os compartimentos corpóreos sofrem variações fisiológicas em relação á idade e ao sexo. O compartimento aquoso tem uma relação inversa com a idade, já os compartimentos muscular e adiposo apresentam relação direta com a faixa etária. Durante a infância e a adolescência ocorrem as maiores flutuações entre estes compartimentos. É importante lembrar que as diferenças entre os gêneros se acentuam a partir da puberdade, sendo o compartimento adiposo maior na mulher do que no homem(5).