Gestational diabetes, insulin resistance and physical activity in pregnancy in a multi-ethnic population - a public health perspective

Aims: To summarize findings from the STORK-Groruddalen Study regarding ethnic differences in the prevalence of gestational diabetes (GDM) by the WHO and modified International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria (no one hour value), insulin resistance, β-cell function and physical activity (PA) level. Methods: Population-based cohort study of 823 healthy pregnant women (59% ethnic minorities). Data from questionnaires, fasting blood samples, anthropometrics and objectively recorded PA level (SenseWear Armband), were collected at <20 (Visit 1) and 28±2 (Visit 2) weeks of gestation. The 75-g OGTT was performed at Visit 2. Insulin resistance (HOMA-IR) and β-cell function (HOMA-β) were estimated from venous fasting plasma glucose and C-peptide. Results: The GDM prevalence was 13.0% with the WHO and 31.5% with the IADPSG criteria. The ethnic minority women, especially South Asians, had highest figures. South and East Asian women had highest HOMA-IR at Visit 1 after adjustment for BMI. HOMA-IR increased from Visit 1 to Visit 2 irrespective of ethnic origin. Compared with Western European women, the absolute and percentage increase in HOMA-β from Visit 1 to Visit 2 was poorest for the South and East Asian women. All ethnic groups walked less and spent less time in moderate-to-vigorous physical activity (MVPA) during weekend days compared with weekdays. South Asian women were least active, measured by steps and by time spent in MVPA. Conclusion: Alarmingly high rates of GDM were found, highest among South Asians. South Asian women were less physically active, more insulin resistant and showed poorer β-cell compensation compared with Western European

Adiposity and hyperglycaemia in pregnancy and related health outcomes in European ethnic minorities of Asian and African origin: a review.

Background: Ethnic minorities in Europe have high susceptibility to type 2 diabetes (T2DM) and, in some groups, also cardiovascular disease (CVD). Pregnancy can be considered a stress test that predicts future morbidity patterns in women and that affects future health of the child. Objective: To review ethnic differences in: 1) adiposity, hyperglycaemia, and pre-eclampsia during pregnancy; 2) future risk in the mother of obesity, T2DM and CVD; and 3) prenatal development and possible influences of maternal obesity, hyperglycaemia, and pre-eclampsia on offspring’s future disease risk, as relevant for ethnic minorities in Europe of Asian and African origin. Design: Literature review. Results: Maternal health among ethnic minorities is still sparsely documented. Higher pre-pregnant body mass index (BMI) is found in women of African and Middle Eastern descent, and lower BMI in women from East and South Asia compared with women from the majority population. Within study populations, risk of gestational diabetes mellitus (GDM) is considerably higher in many minority groups, particularly South Asians, than in the majority population. This increased risk is apparent at lower BMI and younger ages. Women of African origin have higher risk of pre-eclampsia. A GDM pregnancy implies approximately seven-fold higher risk of T2DM than normal pregnancies, and both GDM and pre-eclampsia increase later risk of CVD. Asian neonates have lower birth weights, and mostly also African neonates. This may translate into increased risks of later obesity, T2DM, and CVD. Foetal overgrowth can promote the same conditions. Breastfeeding represents a possible strategy to reduce risk of T2DM in both the mother and the child. Conclusions: Ethnic minority women in Europe with Asian and African origin and their offspring seem to be at increased risk of T2DM and CVD, both currently and in the future. Pregnancy is an important window of opportunity for short and long-term disease prevention

Ethnic differences in maternal dietary patterns are largely explained by socioeconomic score and integration score: a population-based study

Background: The impact of socio-economic position and integration level on the observed ethnic differences in dietary habits has received little attention. Objectives: To identify and describe dietary patterns in a multi-ethnic population of pregnant women, to explore ethnic differences in odds ratio (OR) for belonging to a dietary pattern, when adjusted for socioeconomic status and integration level and to examine whether the dietary patterns were reflected in levels of biomarkers related to obesity and hyperglycaemia. Design: This cross-sectional study was a part of the STORK Groruddalen study. In total, 757 pregnant women, of whom 59% were of a non-Western origin, completed a food frequency questionnaire in gestational week 28 ± 2. Dietary patterns were extracted through cluster analysis using Ward’s method. Results: Four robust clusters were identified where cluster 4 was considered the healthier dietary pattern and cluster 1 the least healthy. All non-European women as compared to Europeans had higher OR for belonging to the unhealthier dietary patterns 1-3 vs. cluster 4. Women from the Middle East and Africa had the highest OR, 21.5 (95% CI 10.6-43.7), of falling into cluster 1 vs. 4 as compared to Europeans. The ORs decreased substantially after adjusting for socio-economic score and integration score. A non-European ethnic origin, low socio-economic and integration scores, conduced higher OR for belonging to clusters 1, 2, and 3 as compared to cluster 4. Significant differences in fasting and 2-h glucose, fasting insulin, glycosylated haemoglobin (HbA1c), insulin resistance (HOMA-IR), and total cholesterol were observed across the dietary patterns. After adjusting for ethnicity, differences in fasting insulin (p=0.015) and HOMA-IR (p=0.040) across clusters remained significant, despite low power. Conclusion: The results indicate that socio-economic and integration level may explain a large proportion of the ethnic differences in dietary patterns.Norges forskningsråd SPH 19454

Metabolic Changes in Urine during and after Pregnancy in a Large, Multiethnic Population-Based Cohort Study of Gestational Diabetes

This study aims to identify novel markers for gestational diabetes (GDM) in the biochemical profile of maternal urine using NMR metabolomics. It also catalogs the general effects of pregnancy and delivery on the urine profile. Urine samples were collected at three time points (visit V1: gestational week 8–20; V2: week 28±2; V3:10–16 weeks post partum) from participants in the STORK Groruddalen program, a prospective, multiethnic cohort study of 823 healthy, pregnant women in Oslo, Norway, and analyzed using 1H-NMR spectroscopy. Metabolites were identified and quantified where possible. PCA, PLS-DA and univariate statistics were applied and found substantial differences between the time points, dominated by a steady increase of urinary lactose concentrations, and an increase during pregnancy and subsequent dramatic reduction of several unidentified NMR signals between 0.5 and 1.1 ppm. Multivariate methods could not reliably identify GDM cases based on the WHO or graded criteria based on IADPSG definitions, indicating that the pattern of urinary metabolites above micromolar concentrations is not influenced strongly and consistently enough by the disease. However, univariate analysis suggests elevated mean citrate concentrations with increasing hyperglycemia. Multivariate classification with respect to ethnic background produced weak but statistically significant models. These results suggest that although NMR-based metabolomics can monitor changes in the urinary excretion profile of pregnant women, it may not be a prudent choice for the study of GDM.The study was supported by grants from the University of Oslo and the Oslo Diabetes Research Centre. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Failure to increase insulin secretory capacity during pregnancy-induced insulin resistance is associated with ethnicity and gestational diabetes

Objective To assess changes in insulin resistance and β-cell function in a multiethnic cohort of women in Oslo, Norway, from early to 28 weeks' gestation and 3 months post partum and relate the findings to gestational diabetes mellitus (GDM). Method Population-based cohort study of 695 healthy pregnant women from Western Europe (41%), South Asia (25%), Middle East (15%), East Asia (6%) and elsewhere (13%). Blood samples and demographics were recorded at mean 15 (V1) and 28 (V2) weeks' gestation and 3 months post partum (V3). Universal screening was by 75 g oral glucose tolerance test at V2, GDM with modified IADPSG criteria (no 1-h measurement): fasting plasma glucose (PG) ≥5.1 or 2-h PG ≥8.5 mmol/l. Homeostatic model assessment (HOMA)-β (β-cell function) and HOMA-IR (insulin resistance) were calculated from fasting glucose and C-peptide. Result Characteristics were comparable across ethnic groups, except age (South Asians: younger, P<0.001) and prepregnant BMI (East Asians: lower, P=0.040). East and South Asians were more insulin resistant than Western Europeans at V1. From V1 to V2, the increase in insulin resistance was similar across the ethnic groups, but the increase in β-cell function was significantly lower for the East and South Asians compared with Western Europeans. GDM women compared with non-GDM women were more insulin resistant at V1; from V1 to V2, their β-cell function increased significantly less and the percentage increase in β-cell function did not match the change in insulin resistance. Conclusion Pregnant women from East Asia and South Asia were more insulin resistant and showed poorer HOMA-β-cell function than Western Europeans

A digital health registry with clinical decision support for improving quality of antenatal care in Palestine (eRegQual): a pragmatic, cluster-randomised, controlled, superiority trial

Background Health worker compliance with clinical guidelines is enhanced by digital clinical decision support at the point of care. The Palestinian public health system is implementing a digital maternal and child health eRegistry with clinical decision support. We aimed to compare the quality of antenatal care between clinics using the eRegistry and those using paper-based records. Methods The eRegQual cluster-randomised controlled trial was done in primary health-care clinics offering routine antenatal care in the West Bank, Palestine. The intervention was the eRegistry with clinical decision support for antenatal care, implemented in District Health Information Systems 2 (DHIS2) Tracker software. 133 clinics forming 120 clusters were included and randomised; clusters were randomly assigned (1:1) to either the control (paper-based documentation) or intervention (eRegistry with clinical decision support) groups. The primary process outcomes were appropriate screening and management of anaemia, hypertension, and diabetes during pregnancy and foetal growth monitoring. The primary health outcome at delivery was a composite of moderate or severe anaemia; severe hypertension; large-for-gestational-age baby; malpresentation and small-for-gestational-age baby undetected before delivery. Data were analysed with mixed-effects logistic regression, accounting for clustering within clinics and pregnancies as appropriate. This trial is registered with the ISRCTN registry (ISRCTN18008445). Findings Between Jan 15 and Sept 15, 2017, 3219 pregnant women received care in the intervention clinics (n=60 clusters) and 3148 pregnant women received care in the control primary health-care clinics (n=59 clusters). Compared with the control group, the intervention led to higher guideline adherence for screening and management of anaemia (1535 [28·9%] of 5320 vs 2297 [44·3%] of 5182; adjusted odds ratio [OR] 1·88 [95% CI 1·52–2·32]), hypertension (7555 [94·7%] of 7982 vs 7314 [96·6%] of 7569; adjusted OR 1·62 [95% CI 1·29–2·05]), and gestational diabetes (1726 (39·7%) of 4348 vs 2189 (50·7%) of 4321; adjusted OR 1·45 [95% CI 1·14–1·83]) at eligible antenatal contacts. Only 599 (9·4%) of 6367 women attended the full antenatal care schedule, and better care provision did not translate to fewer adverse health outcomes in the intervention clusters (700 cases; 21·7%) compared to the control clusters (688 cases; 21·9%; adjusted OR 0·99; 95% CI 0·87–1·12). Interpretation Clinical decision support for antenatal care in the eRegistry was superior for most process outcomes but had no effect on the adverse health outcomes. The improvements in process outcomes strengthen the evidence for the WHO guideline for digital client tracking with clinical decision support in lower-middle-income settings. Digital health interventions to address gaps in attendance might help achieve effective coverage of antenatal care.publishedVersio

Prevalence of multiple non-communicable diseases risk factors among adolescents in 140 countries:A population-based study

BACKGROUND: Modifiable non-communicable disease (NCD) risk factors are becoming increasingly common among adolescents, with clustering of these risk factors in individuals of particular concern. The aim of this study was to assess global status of clustering of common modifiable NCD risk factors among adolescents. METHODS: We used latest available data from nationally representative survey for 140 countries, namely the Global School-based Student Health Survey, the Health Behaviour in School-Aged Children and the longitudinal study of Australian Children. Weighted mean estimates of prevalence with corresponding 95% confidence intervals of nine NCD risk factors - physical inactivity, sedentary behaviour, insufficient fruits and vegetable consumption, carbonated soft drink consumption, fast food consumption, tobacco use, alcohol consumption and overweight/obesity - were calculated by country, region and sex. FINDINGS: Over 487,565 adolescents, aged 11–17 years, were included in this study. According to trend analysis, prevalence of four or more NCD risk factors increased gradually over time. Prevalence of four or more NCD risk factors was 14.8% in 2003–2007 and increased to 44% in 2013–2017, an approximately three-fold increase (44.0%). Similar trends were also observed for three and two risk factors. Large variation between countries in the prevalence of adolescents with four or more risk factors was found in all regions. The country level range was higher in the South-East Asia Region (minimum Sri Lanka = 8%, maximum Myanmar = 84%) than Western Pacific Region (minimum China = 3%, maximum Niue = 72%), European Region (minimum Sweden = 13.9%, maximum Ireland = 66.0%), African Region (minimum Senegal = 0.8%, maximum Uganda = 82.1%) and Eastern Mediterranean Region (minimum Libya = 0.2%, maximum Lebanon = 80.2%). Insufficient vegetable consumption, insufficient fruit consumption and physically inactivity were three of the four most prevalent risk factors in all regions. INTERPRETATION: Our results suggest a high prevalence of four or more NCD risk factors in adolescents globally, although variation was found between countries. Results from our study indicate that efforts to reduce adolescent NCD risk factors and the associated health burden need to be improved. These findings can assist policy makers to target the rollout of country- specific interventions. FUNDING: None

Impact of ethnicity on gestational diabetes identified with the WHO and the modified International Association of Diabetes and Pregnancy Study Groups criteria: a population-based cohort study

Objective The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recently proposed new criteria for diagnosing gestational diabetes mellitus (GDM). We compared prevalence rates, risk factors, and the effect of ethnicity using the World Health Organization (WHO) and modified IADPSG criteria. Methods This was a population-based cohort study of 823 (74% of eligible) healthy pregnant women, of whom 59% were from ethnic minorities. Universal screening was performed at 28±2 weeks of gestation with the 75 g oral glucose tolerance test (OGTT). Venous plasma glucose (PG) was measured on site. GDM was diagnosed as per the definition of WHO criteria as fasting PG (FPG) ≥7.0 or 2-h PG ≥7.8 mmol/l; and as per the modified IADPSG criteria as FPG ≥5.1 or 2-h PG ≥8.5 mmol/l. Results OGTT was performed in 759 women. Crude GDM prevalence was 13.0% with WHO (Western Europeans 11%, ethnic minorities 15%, P=0.14) and 31.5% with modified IADPSG criteria (Western Europeans 24%, ethnic minorities 37%, P< 0.001). Using the WHO criteria, ethnic minority origin was an independent predictor (South Asians, odds ratio (OR) 2.24 (95% confidence interval (CI) 1.26–3.97); Middle Easterners, OR 2.13 (1.12–4.08)) after adjustments for age, parity, and prepregnant body mass index (BMI). This increased OR was unapparent after further adjustments for body height (proxy for early life socioeconomic status), education and family history of diabetes. Using the modified IADPSG criteria, prepregnant BMI (1.09 (1.05–1.13)) and ethnic minority origin (South Asians, 2.54 (1.56–4.13)) were independent predictors, while education, body height and family history had little impact. Conclusion GDM prevalence was overall 2.4-times higher with the modified IADPSG criteria compared with the WHO criteria. The new criteria identified many subjects with a relatively mild increase in FPG, strongly associated with South Asian origin and prepregnant overweigh

“The prevalence of and risk factors for diabetic peripheral neuropathy among type 2 diabetic outpatients in Bangladesh”

ABSTRACT The prevalence of and risk factors for diabetic peripheral neuropathy among type 2 diabetic outpatients in Bangladesh Author: Kjersti Mørkrid Supervisors: Akhtar Hussain, Liaquat Ali Aims/hypothesis: The purpose of the study was to estimate the prevalence and risk factors for diabetic peripheral neuropathy (DPN), and additionally, evaluate the sensory and musculoskeletal lower-leg function, in type 2 diabetic outpatients, attending the BIRDEM hospital in Bangladesh. Materials and methods: Type 2 diabetic outpatients, diagnosed 5-11 years prior the investigation was randomly drawn. The Neuropathy Symptom Score (NSS) and the Neuropathy Disability Score (NDS) was employed to assess DPN. Data about socio-demographic characters, blood pressure, height, weight, waist and hip circumference, and random blood and urine samples were collected. For the lower-leg function evaluation, the plantar cutaneous sensation (Semmer-Weinstein 5.07 g monofilament), 1st MTP and ankle joint rang of motion (ROM) (goniometry) and muscle function (Kendall’s muscle test) in addition to balance (one and two leg static balance, tandem walk) was examined. Results: Two hundred and ninety four (139 men, 155 women) type 2 diabetic outpatients were studied. The overall DPN prevalence was 19.7 %, male (20.9%) and female (18.7 %). The prevalence rate increased with increasing age (from 11.1% in the 23-40 year-old group to 32.3% in the 60-80 year-old group) and duration of diabetes (from 14.1% in patients with 5 years to 29.2% in patients with 9-11 years duration). Age > 60 years (OR 4.2, 95% CI 1.4 – 12.3), low/normal WHR (OR 3.8, 95%CI 1.6-9.3), treatment with insulin (OR 2.0, 95% CI 1.0-4.0) and income < 800 TK (OR 3.1, 95% CI 1.1-9.3) were independent, statistically significant risk factors for the occurrence of DPN, longer duration of diabetes (OR 1.2, 95% CI 1.0-1.4) and higher HbA1c (OR 1.1, 95% CI 1.0-1.3) were independent, borderline statistically significant risk factors for DPN. The 1st MTP dorsal (p=0.03) and plantar flexion (p=0.003) joint ROM, the Tibialis anterior (p=0.03) and Flexor hallucis (p=0.02) strength, balance (<0.001) and protective sensation (p<0.001) was statistically significant diminished in the DPN group compared to the non-DPN-group. After controlling for age, protective sensation, balance, 1st MTP plantar and dorsal flexion ROM, and Tibialis anterior and Flexor hallucis strength in a multivariate logistic regression model, the DPN-group still had reduced balance (OR 1.4, 95% CI 1.1-1.6), diminished protective sensation (OR2.0, 95% CI 1.5-2.6) and Flexor hallucis weakness (OR 3.2, 95% CI 1.1-9.4). Conclusions/interpretations: We observed a DPN prevalence of 19.7%. Higher age, low socioeconomic status and treatment with insulin were statistically significant risk factors, while longer duration of diabetes and poor glycemic control were borderline statistically significant risk factors for DPN. The DPN subjects preformed worse on all the lower-leg function tests, especially for the protective sensation and balance test. They may therefore be at high risk for developing foot complications. In societies like Bangladesh, where the resources are scare, the awareness among patients and professionals should be raised. Necessary measures ought to be taken to prevent diabetes complication and secure the quality of care to reduce the burden and costs for both the individual family and the society at large. Key words: Type 2 diabetes, peripheral neuropathy, risk factors, balance, strength, physical therapy techniques, plantar cutaneous sensation Financed by: The Institute of General Practice and Community Medicine, University of Osl

The prevalence of and risk factors for diabetic peripheral neuropathy, additional to the lower leg function among type 2 diabetic outpatients in Bangladesh

Aims/hypothesis: The purpose of the study was to estimate the prevalence and risk factors for diabetic peripheral neuropathy (DPN), and additionally, evaluate the sensory and musculoskeletal lower-leg function, in type 2 diabetic outpatients, attending the BIRDEM hospital in Bangladesh. Materials and methods: Type 2 diabetic outpatients, diagnosed 5-11 years prior the investigation was randomly drawn. The Neuropathy Symptom Score (NSS) and the Neuropathy Disability Score (NDS) was employed to assess DPN. Data about socio-demographic characters, blood pressure, height, weight, waist and hip circumference, and random blood and urine samples were collected. For the lower-leg function evaluation, the plantar cutaneous sensation (Semmer-Weinstein 5.07 g monofilament), 1st MTP and ankle joint rang of motion (ROM) (goniometry) and muscle function (Kendall’s muscle test) in addition to balance (one and two leg static balance, tandem walk) was examined. Results: Two hundred and ninety four (139 men, 155 women) type 2 diabetic outpatients were studied. The overall DPN prevalence was 19.7 %, male (20.9%) and female (18.7 %). The prevalence rate increased with increasing age (from 11.1% in the 23-40 year-old group to 32.3% in the 60-80 year-old group) and duration of diabetes (from 14.1% in patients with 5 years to 29.2% in patients with 9-11 years duration). Age > 60 years (OR 4.2, 95% CI 1.4 – 12.3), low/normal WHR (OR 3.8, 95%CI 1.6-9.3), treatment with insulin (OR 2.0, 95% CI 1.0-4.0) and income < 800 TK (OR 3.1, 95% CI 1.1-9.3) were independent, statistically significant risk factors for the occurrence of DPN, longer duration of diabetes (OR 1.2, 95% CI 1.0-1.4) and higher HbA1c (OR 1.1, 95% CI 1.0-1.3) were independent, borderline statistically significant risk factors for DPN. The 1st MTP dorsal (p=0.03) and plantar flexion (p=0.003) joint ROM, the Tibialis anterior (p=0.03) and Flexor hallucis (p=0.02) strength, balance (<0.001) and protective sensation (p<0.001) was statistically significant diminished in the DPN group compared to the non-DPN-group. After controlling for age, protective sensation, balance, 1st MTP plantar and dorsal flexion ROM, and Tibialis anterior and Flexor hallucis strength in a multivariate logistic regression model, the DPN-group still had reduced balance (OR 1.4, 95% CI 1.1-1.6), diminished protective sensation (OR2.0, 95% CI 1.5-2.6) and Flexor hallucis weakness (OR 3.2, 95% CI 1.1-9.4). Conclusions/interpretations: We observed a DPN prevalence of 19.7%. Higher age, low socioeconomic status and treatment with insulin were statistically significant risk factors, while longer duration of diabetes and poor glycemic control were borderline statistically significant risk factors for DPN. The DPN subjects preformed worse on all the lower-leg function tests, especially for the protective sensation and balance test. They may therefore be at high risk for developing foot complications. In societies like Bangladesh, where the resources are scare, the awareness among patients and professionals should be raised. Necessary measures ought to be taken to prevent diabetes complication and secure the quality of care to reduce the burden and costs for both the individual family and the society at large