Quality of diabetes care: problem of patient or doctor adherence?

Current guidelines for treatment of type 2 diabetes mellitus include disease prevention and the control of blood pressure and lipids in addition to blood glucose management. However, physician compliance with treatment guidelines is relatively poor. In any given year, HbA1c and blood lipids are measured only in about half of patients and are below target in even less, while blood pressure is frequently measured but controlled in less than 50%. Some reasons for this unsatisfactory situation are providers' beliefs, frustration and lack of knowledge, patient barriers and the fact that the guidelines are not easy to access and implement. Patient non-adherence can be changed by improving education, perception, motivation and self-management. Strategies for improving disease management are discussed

How patients with insulin-treated type 1 and type 2 diabetes view their own and their physician's treatment goals.

To investigate the subjective treatment goals of insulin-treated diabetic patients. 297 type 1 and 205 type 2 diabetic patients, representative of the North-western Swiss population, filled out a self report questionnaire focusing on their own treatment goals using standardized measures wherever available. Factor analysis of the 16 items reflecting their treatment goals revealed four subscales (Crohnbach's alpha): High actual quality of life (0.73), weight reduction/maintenance and daily hassles (0.68), good medical care and knowledge (0.64) and good long term glucose control (0.71). Good long term glucose control was the single most important main treatment goal for most patients (type 1: 60.2%, type 2: 49.7%, p = 0.025). However, both type 1 and type 2 diabetic patients believed that this goal - especially the value of HbA1c - was overestimated (both p <0.0001), while high actual quality of life was underestimated (p = 0.003 and p = 0.05, respectively) by their physicians compared to their own assessment. Good long term glucose control (OR 1.63, p = 0.003) and high actual quality of life (OR 2.17, p <0.0001) were more important and weight reduction/maintenance and coping with daily hassles (OR 0.75, p = 0.07) were slightly less important treatment goals for type 1 than for type 2 diabetic patients. These differences in goals were best associated with the mode of insulin therapy, self-monitoring, and with the extent of diabetes education. Patients believe that physicians overestimate the importance of long term glucose control and underestimate the importance of actual quality of life. Diabetes education and self management have the largest impact on patients' own treatment goals

Diabète gestationnel--quelles sont les approches non médicales [Gestational diabetes--what are the non-medical approaches?].

Gestational diabetes is a multifactorial disease that increases the risk for complications for the mother and her child in the short and long term. The perinatal period represents an opportunity not only to assist the mother in improving her own health but also that of the future generation. This article focuses on lifestyle and psychological aspects that form the base for non-medical treatment approaches. Considering different risk factors separately is not sufficient for the improvement of the metabolic and mental health of women with gestational diabetes. With a multimodal interdisciplinary approach that includes physical activity, dietary advice and psychological support, an improvement of the health and well-being of both the mother and her child is expected. Future studies are necessary to confirm this proposed care approach

Prospective Associations Between Maternal Depression and Infant Sleep in Women With Gestational Diabetes Mellitus.

Women with gestational diabetes mellitus have higher rates of perinatal depressive symptoms, compared to healthy pregnant women. In the general population, maternal depressive symptoms have been associated with infant sleep difficulties during the first year postpartum. However, there is lack of data on infants of mothers with gestational diabetes mellitus. This study assessed the prospective associations between maternal perinatal depressive symptoms and infant sleep outcomes. The study population consisted of 95 Swiss women with gestational diabetes mellitus and their infants, enrolled in the control group of the MySweetheart trial (NCT02890693). Perinatal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale at the first gestational diabetes mellitus visit during pregnancy, at 6-8 weeks postpartum, and 1 year postpartum. The Brief Infant Sleep Questionnaire was used to assess infant sleep (i.e., nocturnal sleep duration, number of night waking, and maternal perception of infant sleep) at 1 year postpartum. Relevant maternal and infant measurements (e.g., infant sex or maternal age or social support) were collected or extracted from medical records as covariates. Antenatal maternal depressive symptoms at the first gestational diabetes mellitus visit were inversely associated with infant nocturnal sleep duration at 1 year postpartum (β = -5.9, p = 0.046). This association became marginally significant when covariates were added (β = -5.3, p = 0.057). Maternal depressive symptoms at 6-8 weeks postpartum were negatively and prospectively associated with infant nocturnal sleep duration (β = -9.35, p = 0.016), even when controlling for covariates (β = -7.32, p = 0.042). The association between maternal depressive symptoms and maternal perception of infant sleep as not a problem at all was significant at 1 year postpartum (β = -0.05, p = 0.006), although it became non-significant when controlling for appropriate covariates. No other significant associations were found. This study solely included measures derived from self-report validated questionnaires. Our findings suggest it is of utmost importance to support women with gestational diabetes mellitus as a means to reduce the detrimental impact of maternal perinatal depressive symptoms on infant sleep, given its predictive role on infant metabolic health

Mental health and its associations with weight in women with gestational diabetes mellitus. A prospective clinical cohort study.

Despite the prevalence of depression in women with gestational diabetes mellitus (GDM) and the relationship between mental health (depression and well-being) and metabolic health, little is known about mental health or its metabolic impact in GDM pregnancy. This prospective clinical cohort study aimed to investigate associations between 1) well-being and depression, and 2) mental health and weight/weight gain in women with GDM. We included 334 pregnant women with GDM treated at a Swiss University Hospital between January 2016 and December 2018. They completed two self-report questionnaires: The World Health Organization well-being index (WHO-5) at the first (29 weeks of gestation) and last (36 weeks of gestation) GDM visits during pregnancy and the Edinburgh Postnatal Depression Scale (EPDS) at the first GDM visit. A cut-off of ≥11 was selected for this questionnaire to indicate the presence of elevated depression scores. There was an inverse association between the well-being and depression total scores at the first GDM visit during pregnancy (r = -0.55; p < 0.0001). Elevated depression scores at the first GDM visit were associated with subsequent weight gain in GDM pregnancy (β = 1.249; p = 0.019). In women with GDM, elevated depression scores during pregnancy are prospectively associated with weight gain. Depression symptoms should therefore be screened for and treated in women with GDM to reduce the risks associated with excessive weight gain during pregnancy

Mental health and its associations with glucose-lowering medication in women with gestational diabetes mellitus. A prospective clinical cohort study.

Mental health symptoms are frequent in women with gestational diabetes mellitus (GDM) and may influence glycemic control. We therefore investigated if mental health symptoms (high depression and low well-being scores) predicted a need for glucose-lowering medication and if this use of medication influenced the trajectory of mental health during pregnancy and in the postpartum period. We included 341 pregnant women from a cohort of GDM women in a Swiss University Hospital. The World Health Organization Well-being Index-Five was collected at the first and last GDM and at the postpartum clinical visits and the Edinburgh Postnatal Depression Scale at the first GDM and the postpartum clinical visits. Medication intake was extracted from participants' medical records. We conducted linear and logistic regressions with depression as an interaction factor. Mental health symptoms did not predict a need for medication (all p ≥ 0.29). Mental health improved over time (both p ≤ 0.001) and use of medication did not predict this change (all p ≥ 0.40). In women with symptoms of depression, medication was associated with less improvement in well-being at the postpartum clinical visit (p for interaction=0.013). Mental health and glucose-lowering medication did not influence each other in an unfavourable way in this cohort of women with GDM

Intuitive eating is associated with weight and glucose control during pregnancy and in the early postpartum period in women with gestational diabetes mellitus (GDM): A clinical cohort study.

High pre-pregnancy weight and body mass index (BMI) increase the risk of gestational diabetes mellitus (GDM) and diabetes after pregnancy. To tackle weight and metabolic health problems, there is a need to investigate novel lifestyle approaches. Outside of pregnancy, higher adherence to intuitive eating (IE) is associated with lower BMI and improved glycemic control. This study investigated the association between IE and metabolic health during pregnancy and in the early postpartum period among women with GDM. Two-hundred and fourteen consecutive women aged ≥18, diagnosed with GDM between 2015 and 2017 and completed the "Eating for Physical rather than Emotional Reasons (EPR)" and "Reliance on Hunger and Satiety cues (RHSC) subscales" of the French Intuitive Eating Scale-2 (IES-2) questionnaire at the first GDM clinic visit were included in this study. Participants' mean age was 33.32 ± 5.20 years. Their weight and BMI before pregnancy were 68.18 ± 14.83 kg and 25.30 ± 5.19 kg/m <sup>2</sup> respectively. After adjusting for confounding variables, the cross-sectional analyses showed that the two subscales of IES-2 at the first GDM visit were associated with lower weight and BMI before pregnancy, and lower weight at the first GDM visit (β = -0.181 to -0.215, all p ≤ 0.008). In addition, the EPR subscale was associated with HbA1c and fasting plasma glucose at the first GDM visit (β = -0.170 and to -0.196; all p ≤ 0.016). In the longitudinal analyses, both subscales of IES-2 at first GDM visit were associated with lower weight at the end of pregnancy, BMI and fasting plasma glucose at 6-8 weeks postpartum (β = -0.143 to -0.218, all p ≤ 0.040) after adjusting for confounders. Increase adherence to IE could represent a novel approach to weight and glucose control during and after pregnancy in women with GDM

Copeptin Levels Remain Unchanged during the Menstrual Cycle.

BACKGROUND: Copeptin, a surrogate marker for arginin vasopressin production, is evaluated as an osmo-dependent stress and inflammatory biomarker in different diseases. We investigated copeptin during the menstrual cycle and its relationship to sex hormones, markers of subclinical inflammation and estimates of body fluid. METHODS: In 15 healthy women with regular menstrual cycles, blood was drawn on fifteen defined days of their menstrual cycle and was assayed for copeptin, progesterone, estradiol, luteinizing hormone, high-sensitive C-reactive protein, tumor necrosis factor-alpha and procalcitonin. Symptoms of fluid retention were assessed on each visit, and bio impedance analysis was measured thrice to estimate body fluid changes. Mixed linear model analysis was performed to assess the changes of copeptin across the menstrual cycle and the relationship of sex hormones, markers of subclinical inflammation and estimates of body fluid with copeptin. RESULTS: Copeptin levels did not significantly change during the menstrual cycle (p = 0.16). Throughout the menstrual cycle, changes in estradiol (p = 0.002) and in the physical premenstrual symptom score (p = 0.01) were positively related to copeptin, but changes in other sex hormones, in markers of subclinical inflammation or in bio impedance analysis-estimated body fluid were not (all p = ns). CONCLUSION: Although changes in estradiol and the physical premenstrual symptom score appear to be related to copeptin changes, copeptin does not significantly change during the menstrual cycle

Potentially modifiable predictors of adverse neonatal and maternal outcomes in pregnancies with gestational diabetes mellitus: can they help for future risk stratification and risk-adapted patient care?

Gestational diabetes mellitus (GDM) exposes mothers and their offspring to short and long-term complications. The objective of this study was to identify the importance of potentially modifiable predictors of adverse outcomes in pregnancies with GDM. We also aimed to assess the relationship between maternal predictors and pregnancy outcomes depending on HbA1c values and to provide a risk stratification for adverse pregnancy outcomes according to the prepregnancy BMI (Body mass index) and HbA1c at the 1st booking. This prospective study included 576 patients with GDM. Predictors were prepregnancy BMI, gestational weight gain (GWG), excessive weight gain, fasting, 1 and 2-h glucose values after the 75 g oral glucose challenge test (oGTT), HbA1c at the 1st GDM booking and at the end of pregnancy and maternal treatment requirement. Maternal and neonatal outcomes such as cesarean section, macrosomia, large and small for gestational age (LGA, SGA), neonatal hypoglycemia, prematurity, hospitalization in the neonatal unit and Apgar score at 5 min < 7 were evaluated. Univariate and multivariate regression analyses and probability analyses were performed. One-hour glucose after oGTT and prepregnancy BMI were correlated with cesarean section. GWG and HbA1c at the end pregnancy were associated with macrosomia and LGA, while prepregnancy BMI was inversely associated with SGA. The requirement for maternal treatment was correlated with neonatal hypoglycemia, and HbA1c at the end of pregnancy with prematurity (all p < 0.05). The correlations between predictors and pregnancy complications were exclusively observed when HbA1c was ≥5.5% (37 mmol/mol). In women with prepregnancy BMI ≥ 25 kg/m <sup>2</sup> and HbA1c ≥ 5.5% (37 mmol/mol) at the 1st booking, the risk for cesarean section and LGA was nearly doubled compared to women with BMI with < 25 kg/m <sup>2</sup> and HbA1c < 5.5% (37 mmol/mol). Prepregnancy BMI, GWG, maternal treatment requirement and HbA1c at the end of pregnancy can predict adverse pregnancy outcomes in women with GDM, particularly when HbA1c is ≥5.5% (37 mmol/mol). Stratification based on prepregnancy BMI and HbA1c at the 1st booking may allow for future risk-adapted care in these patients