Blood pressure measurement at two years in offspring of women randomized to a trial of metformin for GDM: follow up data from the MiG trial

Background: Offspring born following maternal gestational diabetes are at risk of excessive childhood weight gain and Type 2 diabetes in childhood, which in turn is associated with an increased rate of hypertension. We aimed to determine the systolic and diastolic blood pressure at two years of age in a cohort of children exposed to gestational diabetes mellitus using data from the MiG trial of metformin use in gestational diabetes. The secondary aim was to analyze these data by randomization of treatment to insulin or metformin. Methods: The offspring of women who had gestational diabetes and had been assigned to either open treatment with metformin (with supplemental insulin if required) or insulin in the MiG trial were followed up at 2 years of age. Oscillometric measurement of BP in the right arm was performed by a researcher using an appropriately sized cuff. Results: A total of 489 measurement blood pressure measurements were obtained in 170 of the 222 children who were seen at a median (range) age of 29 (22-38) months corrected gestational age. At the time of assessment the mean (SD) weight and height was 13.8(2) kg and 90 (4.2) cm respectively. For the whole group the mean (SD) systolic pressure was 90.9 (9.9) mmHg and mean (SD) diastolic pressure was 55.7 (8.1) mmHg. No difference was found between the metformin and insulin treatment arms. In a regression model, height and weight were only two factors associated with the levels of systolic blood pressure. For each additional kg the systolic blood pressure increased by 1.0 mmHg. For each additional cm of height the systolic blood pressure increased by 0.42 mmHg. Conclusions: Blood pressure data was obtained at approximately two years of age in a substantial cohort of children whose mothers received treatment for GDM. These novel data compare favorably with published norms. Clinical Trials Registry: This study was registered under the Australian New Zealand Clinical Trials Registry ( ACTRN12605000311651 ).Malcolm R Battin, Victor Obolonkin, Elaine Rush, William Hague, Suzette Coat and Janet Rowa

Metformin in gestational diabetes: The Offspring Follow-Up (MiG TOFU): body composition at 2 years of age

OBJECTIVE: In women with gestational diabetes mellitus, who were randomized to metformin or insulin treatment, pregnancy outcomes were similar (Metformin in Gestational diabetes [MiG] trial). Metformin crosses the placenta, so it is important to assess potential effects on growth of the children. RESEARCH DESIGN AND METHODS: In Auckland, New Zealand, and Adelaide, Australia, women who had participated in the MiG trial were reviewed when their children were 2 years old. Body composition was measured in 154 and 164 children whose mothers had been randomized to metformin and insulin, respectively. Children were assessed with anthropometry, bioimpedance, and dual energy X-ray absorptiometry (DEXA), using standard methods. RESULTS: The children were similar for baseline maternal characteristics and pregnancy outcomes. In the metformin group, compared with the insulin group, children had larger mid-upper arm circumferences (17.2 6 1.5 vs. 16.7 6 1.5 cm; P = 0.002) and subscapular (6.3 6 1.9 vs. 6.0 6 1.7 mm; P = 0.02) and biceps skinfolds (6.03 6 1.9 vs. 5.6 6 1.7 mm; P = 0.04). Total fat mass and percentage body fat assessed by bioimpedance (n = 221) and DEXA (n = 114) were not different. CONCLUSIONS: Children exposed to metformin had larger measures of subcutaneous fat, but overall body fat was the same as in children whose mothers were treated with insulin alone. Further follow-up is required to examine whether these findings persist into later life and whether children exposed to metformin will develop less visceral fat and be more insulin sensitive. If so, this would have significant implications for the current pandemic of diabetes.Janet A. Rowan, Elaine C. Rush, Victor Obolonkin, Malcolm Battin, Trecia Wouldes and William M. Hagu

Metformin in gestational diabetes: the offspring follow-up (MiG TOFU): body composition and metabolic outcomes at 7-9 years of age

Objective: To compare body composition and metabolic outcomes at 7–9 years in offspring of women with gestational diabetes (GDM) randomized to metformin (±insulin) or insulin treatment during pregnancy. Research design and methods: Children were assessed at 7 years in Adelaide (n=109/181) and 9 years in Auckland (n=99/396) by anthropometry, bioimpedance analysis (BIA), dual-energy X-ray absorptiometry (DXA), magnetic resonance imaging (MRI) (n=92/99) and fasting bloods (n=82/99). Results: In the Adelaide subgroup, mothers were similar at enrollment. Women randomized to metformin versus insulin had higher treatment glycemia (p=0.002) and more infants with birth weight >90th percentile (20.7% vs 5.9%; p=0.029). At 7 years, there were no differences in offspring measures. In Auckland, at enrollment, women randomized to metformin had a higher body mass index (BMI) (p=0.08) but gained less weight during treatment (p=0.07). Offspring birth measures were similar. At 9 years, metformin offspring were larger by measures of weight, arm and waist circumferences, waist:height (p<0.05); BMI, triceps skinfold (p=0.05); DXA fat mass and lean mass (p=0.07); MRI abdominal fat volume (p=0.051). Body fat percent was similar between treatment groups by DXA and BIA. Abdominal fat percentages (visceral adipose tissue, subcutaneous adipose tissue and liver) were similar by MRI. Fasting glucose, triglyceride, insulin, insulin resistance, glycosylated hemoglobin (HbA1c), cholesterol, liver transaminases, leptin and adiponectin were similar. Conclusions: Metformin or insulin for GDM was associated with similar offspring total and abdominal body fat percent and metabolic measures at 7–9 years. Metformin-exposed children were larger at 9 years. Metformin may interact with fetal environmental factors to influence offspring outcomes.Janet A Rowan, Elaine C Rush, Lindsay D Plank, Jun Lu, Victor Obolonkin, Suzette Coat, William M Hagu

Beyond the randomised controlled trial and BMI – evaluation of effectiveness of through-school nutrition and physical activity programmes

Invited Commentary – Evidence has been slow to accumulate that school physical activity and nutrition interventions are effective at slowing the rate of physical growth and reducing the prevalence of obesity in children. This is in part because of the need for randomised controlled trials (RCT) that meet strict quality criteria. In addition, the focus on BMI-for-age criteria to define obesity and overweight, and therefore the outcome of ‘effective’ interventions, is a pragmatic measure but may be flawed in that the child’s nutritional and functional status may have improved but BMI may not change. For a population, BMI is a measure of energy balance; it is not a measure of the many other factors that are required for optimal growth, development and function. In this commentary we describe a large-scale intervention utilizing an alternative measure of programme effectiveness. We believe the model and measure can be applied in different contexts to evaluate effectiveness of a programme to improve health in children in a school setting

Growth Centiles of Pacific Children Living in Auckland, New Zealand

Background: Since 2000, the longitudinal Pacific Island Families study has measured the weight, height and body mass index (BMI) of 582 girls and 643 boys at 2, 4, 6 and 9 year data collection phases. Aim: To extend and record the age-related distribution of weight, height and BMI measures in Pacific children aged 2-10 years and to compare the distribution to population and clinical growth charts. Methods: Gender-specific age-related centile curves were derived using the LMS method for weight, height and BMI. The 50th centiles from the World Health Organisation growth reference for 2-5 year olds and the Centres for Disease Control (CDC) for 5-10 year olds were compared. Overweight and obesity were defined by the CDC BMI 85th and 95th centiles. Results: The proportion of children whose weight and height were above the reference 50th centile increased with age. At age 10, using CDC criteria, more than 50% of the children were classified as obese and 70% were overweight. Conclusions: These charts support the need to prioritize interventions for Pacific families to address childhood obesity. These centile curves could help assess the relative growth of Pacific children and identify children for further assessment and treatment

In response to Letter to the Editor: Beyond the randomised control - Assessment tool

Response to a previous letter to the editor regarding assessment of school-based physical activity and nutrition intervention

Under 5 Energize: Tracking Progress of a Preschool Nutrition and Physical Activity Programme With Regional Measures of Body Size and Dental Health at Age of Four Years

To reduce weight gain and encourage healthy eating including reduced sugar intake, Under 5 Energize (U5E) was introduced to 121 early-childhood-centres in the Waikato region of New Zealand in July 2013. Using anonymized data collected from January 2013 to September 2016 through free physical assessments of all 4-year-olds provided by the NZ Ministry of Health, the prevalence of obesity and dental decay children measured in the Waikato region was examined. Data were divided into four periods representing pre-implementation and 3 years of gradual implementation. Obesity was defined according to International Obesity Task Force criteria. Of 18,774 Waikato children included in the analysis, 32% were indigenous Māori, and 32% attended an U5E centre. Pre-implementation prevalences of obesity (4%) and visible dental decay (11%) of children attending and not-attending U5E centres were not different. While obesity prevalence did not change significantly over time, prevalence of dental decay decreased among children at U5E (trend p = 0.003) but not non-U5E (trend p = 0.14) centres, such that prevalences were significantly different between children at U5E vs. non-U5E centres at Year 3 (p = 0.02). The U5E intervention is a small but arguably effective part of the wider system approach that is required to improve children’s future health

Multivariate outlier detection of dairy herd testing data

This paper describes the challenge presented by the Livestock Improvement Corporation regarding the need to detect multivariate outliers in very large datasets of dairy herd milk testing data. Various approaches and techniques were applied to a subset of one dataset in order to establish the potential of both manual and automatic detection of outliers in large datasets using multivariate statistical techniques. References P. Filzmoser, R. G. Garrett and C. Reimann. Multivariate outlier detection in exploratory geochemistry. Computers and Geosciences, 31:579&ndash;587, 2005. P. Filzmoser, R. Maronna and M. Werner. Outlier identification in high dimensions. Computational Statistics and Data Analysis, 52:1694&ndash;1711, 2008. E. Gilleland, M. Ribatet and A. G. Stephenson. A software review for extreme value analysis. Extremes, 16:103&ndash;119, 2013. P Rousseeuw. Multivariate estimation with high breakdown point. In W. Grossmann, G. Pflug, I. Vincze, W. Wertz, editor, Mathematical Statistics and Applications Volume B, pages 283&ndash;297, Budapest, 1985. Akademiai Kiado

Project energize: Whole-region primary school nutrition and physical activity programme; evaluation of body size and fitness 5 years after the randomised controlled trial

Project Energize, a region-wide whole-school nutrition and physical activity programme, commenced as a randomised controlled trial (RCT) in the period 2004-6 in 124 schools in Waikato, New Zealand. In 2007, sixty-two control schools were engaged in the programme, and by 2011, all but two of the 235 schools in the region were engaged. Energizers (trained nutrition and physical activity specialists) work with eight to twelve schools each to achieve the goals of the programme, which are based on healthier eating and enhanced physical activity. In 2011, indices of obesity and physical fitness of 2474 younger (7·58 (sd 0·57) years) and 2330 older (10·30 (sd 0·51) years) children attending 193 of the 235 primary schools were compared with historical measurements. After adjusting for age, sex, ethnicity, socio-economic status (SES) and school cluster effects, the combined prevalence of obesity and overweight among younger and older children in 2011 was lower by 31 and 15%, respectively, than that among 'unEnergized' children in the 2004 to 2006 RCT. Similarly, BMI was lower by 3·0% (95% CI-5·8,- 1·3) and 2·4% (95% CI-4·3,-0·5). Physical fitness (time taken to complete a 550m run) was significantly higher in the Energized children (13·7 and 11·3%, respectively) than in a group of similarly aged children from another region. These effects were observed for boys and girls, both indigenous Māori and non-Māori children, and across SES. The long-term regional commitment to the Energize programme in schools may potentially lead to a secular reduction in the prevalence of overweight and obesity and gains in physical fitness, which may reduce the risk of developing obesity and type 2 diabetes. Copyright © The Authors 2013

Metformin in gestational diabetes: the offspring follow-up (MiG TOFU): body composition and metabolic outcomes at 7-9 years of age

Editorial CommentThis study was a follow-up study to the prospective randomized controlled trial comparing metformin versus insulin. In particular, it compared the body composition and metabolic outcomes at 7 to 9 years of children born to women with gestational diabetes mellitus (GDM) randomized to metformin (±insulin) or insulin treatment during pregnancy.Janet A. Rowan, Elaine C. Rush, Lindsay D. Plank, Jun Lu, Victor Obolonkin, Suzette Coat, and William M. Hagu