Preconception care of women with diabetes: a review of current guideline recommendations

<p>Abstract</p> <p>Background</p> <p>The prevalence of type 2 diabetes mellitus (T2DM) continues to rise worldwide. More women from developing countries who are in the reproductive age group have diabetes resulting in more pregnancies complicated by T2DM, and placing both mother and foetus at higher risk. Management of these risks is best achieved through comprehensive preconception care and glycaemic control, both prior to, and during pregnancy. The aim of this review was to compare the quality and content of current guidelines concerned with the preconception care of women with diabetes and to develop a summary of recommendations to assist in the management of diabetic women contemplating pregnancy.</p> <p>Methods</p> <p>Relevant clinical guidelines were identified through a search of several databases (MEDLINE, SCOPUS and The Cochrane Library) and relevant websites. Five guidelines were identified. Each guideline was assessed for quality using the AGREE instrument. Guideline recommendations were extracted, compared and contrasted.</p> <p>Results</p> <p>All guidelines were assessed as being of high quality and strongly recommended for use in practice. All were consistent in counselling about the risk of congenital malformation related to uncontrolled blood sugar preconceptionally, ensuring adequate contraception until glycaemic control is achieved, use of HBA1C to monitor metabolic control, when to commence insulin and switching from ACE inhibitors to other antihypertensives. Major differences were in the targets recommended for optimal metabolic control and opinion regarding the usage of metformin as an adjunct or alternative treatment before or during pregnancy.</p> <p>Conclusions</p> <p>International guidelines for the care of women with diabetes who are contemplating pregnancy are consistent in their recommendations; however some are more comprehensive than others. Having established current standards for the preconception care of diabetic women, there is now a need to focus on guideline implementation through an examination of the barriers and enablers to successful implementation, and the applicability of the recommendations in the local setting.</p

Trends in obesity and diabetes across Africa from 1980 to 2014: an analysis of pooled population-based studies

Background: The 2016 Dar Es Salaam Call to Action on Diabetes and Other non-communicable diseases (NCDs) advocates national multi-sectoral NCD strategies and action plans based on available data and information from countries of sub-Saharan Africa and beyond. We estimated trends from 1980 to 2014 in age-standardized mean body mass index (BMI) and diabetes prevalence in these countries, in order to assess the co-progression and assist policy formulation. Methods: We pooled data from African and worldwide population-based studies which measured height, weight and biomarkers to assess diabetes status in adults aged ≥ 18 years. A Bayesian hierarchical model was used to estimate trends by sex for 200 countries and territories including 53 countries across five African regions (central, eastern, northern, southern and western), in mean BMI and diabetes prevalence (defined as either fasting plasma glucose of ≥ 7.0 mmol/l, history of diabetes diagnosis, or use of insulin or oral glucose control agents). Results: African data came from 245 population-based surveys (1.2 million participants) for BMI and 76 surveys (182 000 participants) for diabetes prevalence estimates. Countries with the highest number of data sources for BMI were South Africa (n = 17), Nigeria (n = 15) and Egypt (n = 13); and for diabetes estimates, Tanzania (n = 8), Tunisia (n = 7), and Cameroon, Egypt and South Africa (all n = 6). The age-standardized mean BMI increased from 21.0 kg/m2 (95% credible interval: 20.3–21.7) to 23.0 kg/m2 (22.7–23.3) in men, and from 21.9 kg/m2 (21.3–22.5) to 24.9 kg/m2 (24.6–25.1) in women. The age-standardized prevalence of diabetes increased from 3.4% (1.5–6.3) to 8.5% (6.5–10.8) in men, and from 4.1% (2.0–7.5) to 8.9% (6.9–11.2) in women. Estimates in northern and southern regions were mostly higher than the global average; those in central, eastern and western regions were lower than global averages. A positive association (correlation coefficient ≃ 0.9) was observed between mean BMI and diabetes prevalence in both sexes in 1980 and 2014. Conclusions: These estimates, based on limited data sources, confirm the rapidly increasing burden of diabetes in Africa. This rise is being driven, at least in part, by increasing adiposity, with regional variations in observed trends. African countries’ efforts to prevent and control diabetes and obesity should integrate the setting up of reliable monitoring systems, consistent with the World Health Organization’s Global Monitoring System Framework

Diabetes mellitus type 2 in urban Ghana: characteristics and associated factors

BACKGROUND: Sub-Saharan Africa faces a rapid spread of diabetes mellitus type 2 (DM2) but its potentially specific characteristics are inadequately defined. In this hospital-based study in Kumasi, Ghana, we aimed at characterizing clinical, anthropometric, socio-economic, nutritional and behavioural parameters of DM2 patients and at identifying associated factors. METHODS: Between August 2007 and June 2008, 1466 individuals were recruited from diabetes and hypertension clinics, outpatients, community, and hospital staff. Fasting plasma glucose (FPG), serum lipids and urinary albumin were measured. Physical examination, anthropometry, and interviews on medical history, socio-economic status (SES), physical activity and nutritional behaviour were performed. RESULTS: The majority of the 675 DM2 patients (mean FPG, 8.31 mmol/L) was female (75%) and aged 40-60 years (mean, 55 years). DM2 was known in 97% of patients, almost all were on medication. Many had hypertension (63%) and microalbuminuria (43%); diabetic complications occurred in 20%. Overweight (body mass index > 25 kg/m2), increased body fat (> 20% (male), > 33% (female)), and central adiposity (waist-to-hip ratio > 0.90 (male), > 0.85 (female)) were frequent occurring in 53%, 56%, and 75%, respectively. Triglycerides were increased (≥ 1.695 mmol/L) in 31% and cholesterol (≥ 5.17 mmol/L) in 65%. Illiteracy (46%) was high and SES indicators generally low. Factors independently associated with DM2 included a diabetes family history (adjusted odds ratio (aOR), 3.8; 95% confidence interval (95%CI), 2.6-5.5), abdominal adiposity (aOR, 2.6; 95%CI, 1.8-3.9), increased triglycerides (aOR, 1.8; 95%CI, 1.1-3.0), and also several indicators of low SES. CONCLUSIONS: In this study from urban Ghana, DM2 affects predominantly obese patients of rather low socio-economic status and frequently is accompanied by hypertension and hyperlipidaemia. Prevention and management need to account for a specific risk profile in this population

Costs and outcomes of increasing access to bariatric surgery for obesity: cohort study and cost-effectiveness analysis using electronic health records

Background: Bariatric surgery is known to be an effective treatment for extreme obesity but access to these procedures is currently limited. Objective: This study aimed to evaluate the costs and outcomes of increasing access to bariatric surgery for severe and morbid obesity. Design and methods: Primary care electronic health records from the UK Clinical Practice Research: Datalink were analysed for 3045 participants who received bariatric surgery and 247,537 general population controls. The cost-effectiveness of bariatric surgery was evaluated in severe and morbid obesity through a probabilistic Markov model populated with empirical data from electronic health records. Results: In participants who did not undergo bariatric surgery, the probability of participants with morbid obesity attaining normal body weight was 1 in 1290 annually for men and 1 in 677 for women. Costs of health-care utilisation increased with body mass index category but obesity-related physical and psychological comorbidities were the main drivers of health-care costs. In a cohort of 3045 adult obese patients with first bariatric surgery procedures between 2002 and 2014, bariatric surgery procedure rates were greatest among those aged 35–54 years, with a peak of 37 procedures per 100,000 population per year in women and 10 per 100,000 per year in men. During 7 years of follow-up, the incidence of diabetes diagnosis was 28.2 [95% confidence interval (CI) 24.4 to 32.7] per 1000 person-years in controls and 5.7 (95% CI 4.2 to 7.8) per 1000 person-years in bariatric surgery patients (adjusted hazard ratio was 0.20, 95% CI 0.13 to 0.30; p<0.0001). In 826 obese participants with type 2 diabetes mellitus who received bariatric surgery, the relative rate of diabetes remission, compared with controls, was 5.97 (95% CI 4.86 to 7.33; p<0.001). There was a slight reduction in depression in the first 3 years following bariatric surgery that was not maintained. Incremental lifetime costs associated with bariatric surgery were £15,258 (95% CI £15,184 to £15,330), including costs associated with bariatric surgical procedures of £9164 per participant. Incremental quality-adjusted life-years (QALYs) were 2.142 (95% CI 2.031 to 2.256) per participant. The estimated cost per QALY gained was £7129 (95% CI £6775 to £7506). Estimates were similar across gender, age and deprivation subgroups. Limitations: Intervention effects were derived from a randomised trial with generally short follow-up and non-randomised studies of longer duration. Conclusions: Bariatric surgery is associated with increased immediate and long-term health-care costs but these are exceeded by expected health benefits to obese individuals with reduced onset of new diabetes, remission of existing diabetes and lower mortality. Diverse obese individuals have clear capacity to benefit from bariatric surgery at acceptable cost. Future work: Future research should evaluate longer-term outcomes of currently used procedures, and ways of delivering these more efficiently and safely

A cross-sectional investigation of regional patterns of diet and cardio-metabolic risk in India

<p>Abstract</p> <p>Background</p> <p>The role of diet in India's rapidly progressing chronic disease epidemic is unclear; moreover, diet may vary considerably across North-South regions.</p> <p>Methods</p> <p>The India Health Study was a multicenter study of men and women aged 35-69, who provided diet, lifestyle, and medical histories, as well as blood pressure, fasting blood, urine, and anthropometric measurements. In each region (Delhi, n = 824; Mumbai, n = 743; Trivandrum, n = 2,247), we identified two dietary patterns with factor analysis. In multiple logistic regression models adjusted for age, gender, education, income, marital status, religion, physical activity, tobacco, alcohol, and total energy intake, we investigated associations between regional dietary patterns and abdominal adiposity, hypertension, diabetes, and dyslipidemia.</p> <p>Results</p> <p>Across the regions, more than 80% of the participants met the criteria for abdominal adiposity and 10 to 28% of participants were considered diabetic. In Delhi, the "fruit and dairy" dietary pattern was positively associated with abdominal adiposity [highest versus lowest tertile, multivariate-adjusted OR and 95% CI: 2.32 (1.03-5.23); P_trend= 0.008] and hypertension [2.20 (1.47-3.31); P_trend< 0.0001]. In Trivandrum, the "pulses and rice" pattern was inversely related to diabetes [0.70 (0.51-0.95); P_trend= 0.03] and the "snacks and sweets" pattern was positively associated with abdominal adiposity [2.05 (1.34-3.14); P_trend= 0.03]. In Mumbai, the "fruit and vegetable" pattern was inversely associated with hypertension [0.63 (0.40-0.99); P_trend= 0.05] and the "snack and meat" pattern appeared to be positively associated with abdominal adiposity.</p> <p>Conclusions</p> <p>Cardio-metabolic risk factors were highly prevalent in this population. Across all regions, we found little evidence of a Westernized diet; however, dietary patterns characterized by animal products, fried snacks, or sweets appeared to be positively associated with abdominal adiposity. Conversely, more traditional diets in the Southern regions were inversely related to diabetes and hypertension. Continued investigation of diet, as well as other environmental and biological factors, will be needed to better understand the risk profile in this population and potential means of prevention.</p

Does metformin reduce excess birthweight in offspring of obese pregnant women? A randomised controlled trial of efficacy, exploration of mechanisms and evaluation of other pregnancy complications

BackgroundMaternal obesity is associated with high birthweight, obesity and premature mortality in adult offspring, probably as a result of maternal hyperglycaemia and insulin resistance. We present the results of a trial designed to test the hypothesis that metformin will improve insulin sensitivity in obese pregnant women, thereby reducing the incidence of high-birthweight babies.ObjectiveTo determine the efficacy of metformin (up to 2500 mg daily) given to obese pregnant women in reducing the gestational age-, parity- and sex-adjusted birthweight centile of the baby.DesignDouble-blind, placebo-controlled, randomised controlled trial with embedded substudies.SettingFifteen NHS hospitals in the UK.ParticipantsPregnant women aged ≥ 16 years with a singleton fetus and a body mass index of ≥ 30 kg/m2.InterventionMetformin tablets (or placebo) administered between 12 and 16 weeks’ gestation until delivery of the baby.Main outcome measuresThe primary outcome measure was z-score corresponding to the gestational age-, parity- and sex-adjusted birthweight centile of live-born babies delivered at ≥ 24 weeks’ gestation. The main secondary outcome was maternal insulin resistance at 36 weeks’ gestation. Embedded substudies were included to assess the effect of metformin on insulin sensitivity using the hyperinsulinaemic–euglycaemic clamp; endothelial function; maternal and fetal fat distribution using magnetic resonance imaging; placental expression of 11β-hydroxysteroid dehydrogenase types 1 and 2 and glucocorticoid receptor; and myometrial contractility and glycogen storage.ResultsWe randomised 449 women to either placebo (n = 223) or metformin (n = 226), of whom 434 were included in the final intention-to-treat analysis. Mean birthweight at delivery was 3463 g [standard deviation (SD) 660 g] in the placebo group and 3462 g (SD 548 g) in the metformin group. The estimated effect size of metformin on the primary outcome was non-significant [adjusted mean difference in z-score –0.029, 95% confidence interval (CI) –0.217 to 0.158; p = 0.7597]. There was no evidence of a reduction in the main secondary outcome of homeostatic model assessment – insulin resistance (HOMA-IR) at 36 weeks’ gestation (mean HOMA-IR 5.98 and 6.30 molar units in the placebo and metformin groups, respectively; adjusted mean ratio 0.974, 95% CI 0.865 to 1.097). Metformin had no effect on the combined adverse outcome of miscarriage, termination of pregnancy, stillbirth or neonatal death. Subjects taking metformin demonstrated increased insulin sensitivity [glucose disposal per unit plasma insulin difference between means during high-dose insulin 0.02 mg/kg, 95% CI 0.001 to 0.03 mg/kg (fat-free mass)/minute/µIU/l; p = 0.04] compared with those taking placebo and enhanced endogenous glucose production [difference between means 0.54 mg/kg, 95% CI 0.08 to 1.00 mg/kg (fat-free mass)/minute; p = 0.02]. There were no differences in endothelial function, maternal or fetal body fat distribution, placental expression of 11β-hydroxysteroid dehydrogenase types 1 and 2 and glucocorticoid receptor, or myometrial contractility and glycogen storage.ConclusionsMetformin has no clinically significant effect on birthweight centile in obese pregnant women. Follow-up studies of the children born to participants in the trial are required to determine whether or not there are any longer-term benefits or harms of maternal metformin for offspring weight, fat mass or metabolism.Trial registrationCurrent Controlled Trials ISRCTN51279843.FundingThis project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership

Nivel de conocimientos de estudiantes de medicina sobre diagnóstico y manejo del infarto agudo del miocardio

Introduction: acute myocardial infarction is a disease with high morbidity and mortality.Objective: to determine the knowledge level of medical students about the diagnosis and management of acute myocardial infarction.Method: an observational, descriptive and cross-sectional study was carried out between January and February 2022 in medical students from the University of Medical Sciences of Pinar del Río who participated in the provincial update workshop on acute myocardial infarction. Through intentional sampling, a sample of 92 students was selected. To collect the information, a survey was used using Google Forms.Results: the female sex (65,21%), the age group from 21 to 22 years (65,21%) and the fourth-year students (50%) prevailed. Hypertension was the most identified risk factor (97,98%). 97,82% of the students identified precordial pain as the main clinical manifestation. 100% identified the presentation with complications, where sudden death was the most identified (81,52%). 100% point to the electrocardiogram as the main complementary, where ST alterations were the most identified (84,78%). 95,65% of the students indicated constant monitoring of vital parameters and cardiovascular function as the management measure.Conclusions: Medicine students belonging to the clinical area at the University of Medical Sciences of Pinar del Río have an adequate level of knowledge about the diagnosis and management of acute myocardial infarction.Introducción: el infarto agudo del miocardio constituye una enfermedad con elevada morbilidad y mortalidad.Objetivo: determinar el nivel de conocimientos de estudiantes de medicina sobre el diagnóstico y manejo del infarto agudo del miocardioMétodo: se realizó un estudio observacional, descriptivo y transversal entre enero y febrero de 2022 en estudiantes de Medicina de la Universidad de Ciencias Médicas de Pinar del Río del ciclo clínico que participaron en el Taller provincial de actualización sobre infarto agudo de miocardio. Mediante un muestreo intencional se seleccionó una muestra de 92 estudiantes. Para la recolección de la información se empleó una encuesta mediante Google Forms.Resultados: predominó el sexo femenino (65,21 %), el grupo etario de 21 a 22 años (65,21 %) y los estudiantes de cuarto año (50 %). La hipertensión fue el factor de riesgo más identificado (97,98 %). El 97,82 % de los estudiantes identificó el dolor precordial como principal manifestación clínica. El 100 % identificó la presentación con complicaciones, donde la muerte súbita fue la más identificada (81,52 %). El 100 % señala al electrocardiograma como principal complementario, donde las alteraciones del ST fueron las más identificada (84,78 %). El 95,65 % de los estudiantes indicaron la monitorización constante de los parámetros vitales y función cardiovascular como la medida de manejo.Conclusiones: los estudiantes de Medicina pertenecientes al área clínica en la Universidad de Ciencias Médicas de Pinar del Río poseen un adecuado nivel de conocimientos sobre el diagnóstico y manejo del infarto agudo del miocardio.