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January 2013, Diabetes Care Supplement

Contains all the current standards of care for diabetes, and several interesting articles. There is no charge to download the articles in the supplement.             

The American Diabetes Association (ADA) has been actively involved in the development and dissemination of diabetes care standards, guidelines, and related documents for many years. These statements are published in one or more of the Association's professional journals. This supplement contains the latest update of the ADA's major position statement, “Standards of Medical Care in Diabetes,” which contains all of the Association's key recommendations. In addition, contained herein are selected position statements on certain topics not adequately covered in the “Standards.” ADA hopes that this is a convenient and important resource for all health care professionals who care for people with diabetes.

Obese Women with Diabetes May Need Different Workouts Than Men

Small study found specific exercise program did less to improve their health

(HealthDay News) -- Certain exercises that benefit the hearts of obese men with type 2 diabetes may not help women with the same health issues, according to a small new study.  The findings could help researchers and health care professionals develop targeted exercise routines for these women, the study authors said.  The investigators examined the cardiovascular responses -- such as heart rate and blood pressure – of about 75 obese men and women with diabetes.   

The Hyperglycemia and Adverse Pregnancy Outcome Study: Associations of GDM and obesity with pregnancy outcomes

Patrick M. Catalano, MD; H. David McIntyre, MD; J. Kennedy Cruickshank, MD; David R, McCance, MD; Alan R. Dyer, PHD; Boyd E. Metzger, MD; Lynn P. Lowe, PHD; Elisabeth R. Trimble, MD; Donald R. Coustan, MD; David R. Hadden, MD; Bengt Persson, MD, PHD; Moshe Hod, MD; Jeremy J.N. Oats, MD; for the HAPO Study Cooperative  Research Group

OBJECTIVE - To determine associations of gestational diabetes mellitus (GDM) and obesity with adverse pregnancy outcomes in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study.

RESEARCH DESIGN AND METHODS - Participants underwent a 75-g oral glucose tolerance test (OGTT) between 24 and 32 weeks. GDM was diagnosed post hoc using International Association of Diabetes and Pregnancy Study Groups criteria. Neonatal anthropometrics and cord serum C-peptide were measured. Adverse pregnancy outcomes included birth weight, newborn percent body fat, and cord C-peptide > 90th percentiles, primary cesarean delivery, preeclampsia, and shoulder dystocia/birth injury. BMI was determined at the OGTT. Multiple logistic regression was used to examine associations of GDM and obesity with outcomes.

RESULTS - Mean maternal BMI was 27.7, 13.7% were obese (BMI 33.0 kg/m2), and GDM was diagnosed in 16.1%. Relative to non-GDM and non-obese women, odds ratio for birth weight > 90th percentile for GDM alone was 2.19 (1.93 2.47), for obesity alone 1.73(1.50 2.00), and for both GDM and obesity 3.62 (3.04 4.32).  Results for primary cesarean delivery and preeclampsia and for cord C-peptide and new born percent body fat > 90th percentiles were similar. Odds for birth weight > 90th percentile were progressively greater with both higher OGTT glucose and higher maternal BMI. There was a 339-g difference in birth weight for babies of obese GDM women, compared with babies of normal/underweight women (64.2% of all women) with normal glucose based on a composite OGTT

measure of fasting plasma glucose and 1- and 2-h plasma glucose values (61.8% of all women).

CONCLUSIONS - Both maternal GDM and obesity are independently associated with adverse pregnancy outcomes. Their combination has a greater impact than either one alone.


Gestational diabetes and pregnancy outcomes - a systematic review of the World Health Organization (WHO) and the International Association of Diabetes in Pregnancy Study Groups (IADPSG) diagnostic criteria.      

Eliana M Wendland, Maria R Torloni, Maicon Falavigna, Janet Trujillo, Maria A Dode, Maria A Campos, Bruce B Duncan, Maria I Schmidt. BMC Pregnancy and Childbirth 2012, 12:23.

Background - Two criteria based on a 2h75g OGTT are being used for the diagnosis Of gestational diabetes (GDM), those recommended over the years by The World Health Organization (WHO), and those recently  recommended by the International Association for Diabetes in Pregnancy  Study Group (IADPSG), the latter generated in the HAPO Study and based on pregnancy outcomes. Our aim is to systematically Review the evidence for the associations between GDM (according to These criteria) and adverse outcomes.

Methods - We searched relevant studies in MEDLINE, EMBASE, LILACS, the Cochrane Library, CINHAL, WHO -  Afro library, IMSEAR, EMCAT, IMEMR and WPRIM. We included cohort studies permitting the evaluation of GDM diagnosed by WHO and or IADPSG criteria against adverse maternal and perinatal outcomes in untreated women. Only studies with universal application of a 75 g OGTT were

included. Relative risks (RRs) and their 95% confidence intervals (CI) were obtained for each study.  We combined study results using a random – effects model. Inconsistency across studies was defined  by an inconsistency index (I 2 ) >50%.

Results-Data were extracted from eight studies, totaling 44,829 women. Greater risk of adverse outcomes was observed for both diagnostic criteria. When using the WHO criteria, consistent associations were seen for macrosomia (RR = 1.81; 95%CI 1.47 - 2.22; p < 0.001); large for gestational age (RR = 1.53; 95%CI 1.39 - 1.69; p < 0.001); perinatal mortality (RR = 1.55; 95% CI 0.88 - 2.73; p = 0.13); preeclampsia (RR = 1.69; 95%CI 1.31 - 2.18; p < 0.001); and cesarean delivery (RR  = 1.37;95%CI 1.24 - 1.51;  p < 0.001). Less data were available for the IADPSG criteria, and associations were inconsistent across studies (I2>73%). Magnitudes of RRs and their 95% CI’s were 1.73 (1.28 - 2.35; p = 0.001) for large for gestational age; 1.71 (1.38 - 2.13; p < 0.001) for preeclampsia; and 1.23 (1.01 -

1.51; p = 0.04) for cesarean delivery. Excluding either the HAPO or the EBDG studies minimally altered these associations, but the RRs seen for the IADPSG criteria were reduced after excluding HAPO. Conclusions-The WHO and the IADPSG criteria for GDM identified women at a small increased risk for adverse pregnancy outcomes. Associations were of similar magnitude for both criteria. However, high inconsistency was seen for those with the IADPSG criteria. Full evaluation of the latter in settings other than HAPO requires additional studies.


Weight Gain in Pregnancy: Is Less Truly More for Mother and Infant?   

Linda A. Barbour, MD, MSPH. Obstetric Medicine 2012; 5: 58-64.

Although more than 50% of women gain weight above the Institute of Medicine (IOM) guidelines for weight gain in pregnancy and excessive weight gain is an independent risk factor for significant maternal and neonatal morbidity and offspring obesity, there is little consensus over the ideal weight gain during pregnancy. Surprisingly, the 2009 IOM guidelines varied minimally from the 1990 IOM guidelines, and many critics advocate lower weight gain recommendations. This review explores the energy costs of pregnancy, the relationship between gestational weight gain and birth weight, and considers what gestational weight gain minimizes both large-for-gestational age as well as small-for-gestational age infants. An extensive examination of the current data leads this author to question whether the current weight gain recommendations are too liberal, especially for obese pregnant women.


Gestational Diabetes and Hypertensive Disorders of Pregnancy as Vascular Risk Signals: An Overview and Grading of the Evidence.
Nerenberg K, Daskalopoulou SS, Dasgupta K. Can J Cardiol. 2014 Jul;30(7):765-773.

The occurrence of common pregnancy-related medical disorders identifies women at high risk of developing future vascular disease. Systematic reviews of cohort studies demonstrate that gestational diabetes confers a 7-fold risk increase for type 2 diabetes, and preeclampsia confers a 1.8-fold risk increase for type 2 diabetes and 3.4-fold risk increase for hypertension. Gestational diabetes and hypertensive disorders of pregnancy (HDP) increase the risk of premature vascular disease, but the 2-fold risk increase associated with preeclampsia is only partially explained by the development of traditional vascular risk factors. Despite the compelling evidence for gestational diabetes and HDP as vascular risk indicators, there are no published Canadian vascular prevention guidelines that recognize these postpartum women. In contrast, the 2011 American Heart Association guidelines on cardiovascular disease in women include gestational diabetes and HDP in their vascular risk assessment. Studies indicate that the importance surveillance of vascular risk factors in these women after pregnancy is underappreciated by the women themselves and their physicians. Although a prudent diet and physically active lifestyle were demonstrated to reduce diabetes risk in women with a gestational diabetes history in the American Diabetes Prevention Program trial, adoption of these health behaviours is low; qualitative studies confirm a need for tailored strategies that address barriers and provide social support. Further research is also needed on approaches to reduce vascular risk in women with a history of gestational diabetes and HDP. Otherwise, an early window of opportunity for chronic disease prevention in young, high-risk women will be missed.

The Clinical Approach to Obesity in Pregnancy.
Overcash RT1, Lacoursiere DY. Clin Obstet Gynecol. 2014 Jul 11
Over one third of reproductive age women are obese, and this marked prevalence is impacting pregnancy. Obese women face many challenges from preconception to postpartum. They are at increased risk for both maternal and fetal complications including gestational diabetes, hypertension, preeclampsia, congenital anomalies, stillbirth, fetal macrosomia, cesarean delivery, venous thromboembolism, wound complications, breast-feeding difficulty, postpartum depression, postpartum weight retention, and neonatal death. This discussion is designed to help clinicians understand how obesity affects pregnancy, how to counsel patients regarding gestational weight gain, and how to implement management strategies during pregnancy to optimize health outcomes for these patients.

Living with gestational diabetes in a rural community.
Abraham K, Wilk N. Am J Matern Child Nurs. 2014 Jul-Aug;39(4):239-45.
PURPOSE: To explore the lived experiences of women with a recent history of gestational diabetes mellitus (GDM) who live in rural communities.
STUDY DESIGN AND METHODS: A phenomenological study exploring the lived experiences of 10 women aged 25 to 49 years with a history of GDM in the last 5 years. Data were collected through two semi structured short interviews that were conducted in person or by telephone.
RESULTS: Five themes emerged: Authentic emotion, Judgment, It's only a matter of time, I can't do this alone, and Missed opportunities. Strong emotions were experienced at the time of diagnosis. Some women felt judged by healthcare professionals and others based on having GDM. Some were concerned about future risk of developing Type 2 DM. There is a lack of understanding of GDM by women at the time of diagnosis and after they give birth. The majority of women in this study noted that healthcare professionals did not discuss future implications of Type 2 DM and the need for follow- up glucose testing. Many opportunities are missed to provide education and support to facilitate lifestyle interventions.
CLINICAL NURSING IMPLICATIONS: Self-management of GDM is more likely to be successful if women understand GDM and believe that they can manage it. Nurses should use every opportunity to provide women with GDM information and available resources. This may be important in rural communities where fewer resources are available for support. Nurses should recognize that negative emotions may affect motivation of women to understand and ask questions about GDM. Nurses can favorably influence the return rates for postpartum glucose testing by raising awareness of implications of GDM on future health.

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