Perceived psychosocial stress and glucose intolerance among pregnant Hispanic women.

AIM: Prior literature suggests a positive association between psychosocial stress and the risk of diabetes in non-pregnant populations, but studies during pregnancy are sparse. We evaluated the relationship between stress and glucose intolerance among 1115 Hispanic (predominantly Puerto Rican) prenatal care patients in Proyecto Buena Salud, a prospective cohort study in Western Massachusetts (2006-2011). METHODS: Cohen's Perceived Stress Scale (PSS-14) was administered in early (mean = 12.3 weeks gestation; range 4.1-18 weeks) and mid- (mean = 21.3 weeks gestation; range 18.1-26 weeks) pregnancy. Participants were classified as having a pregnancy complicated by gestational diabetes mellitus, impaired glucose tolerance, and abnormal glucose tolerance, based on the degree of abnormality on glucose tolerance testing between 24 and 28 weeks of gestation. RESULTS: The prevalence of gestational diabetes mellitus, impaired glucose tolerance, and abnormal glucose tolerance was 4.1%, 7.2%, and 14.5%, respectively. Absolute levels of early or mid-pregnancy stress were not significantly associated with glucose intolerance. However, participants with an increase in stress from early to mid-pregnancy had a 2.6-fold increased odds of gestational diabetes mellitus (95% confidence intervals: 1.0-6.9) as compared to those with no change or a decrease in stress after adjusting for age and pre-pregnancy body mass index. In addition, every one-point increase in stress scores was associated with a 5.5mg/dL increase in screening glucose level (ß=5.5; standard deviation=2.8; P=0.05), after adjusting for the same variables. CONCLUSION: In this population of predominantly Puerto Rican women, stress patterns during pregnancy may influence the risk of glucose intolerance.

Physical activity before and during pregnancy and risk of abnormal glucose tolerance among Hispanic women.

AIM: Women diagnosed with abnormal glucose tolerance and gestational diabetes mellitus are at increased risk for subsequent type 2 diabetes, with higher risks in Hispanic women. Studies suggest that physical activity may be associated with a reduced risk of these disorders; however, studies in Hispanic women are sparse. METHODS: We prospectively evaluated this association among 1241 Hispanic participants in Proyecto Buena Salud. The Pregnancy Physical Activity Questionnaire was used to assess pre, early, and mid pregnancy physical activity. Medical records were abstracted for pregnancy outcomes. RESULTS: A total of 175 women (14.1%) were diagnosed with abnormal glucose tolerance and 57 women (4.6%) were diagnosed with gestational diabetes. Increasing age and body mass index were strongly and positively associated with risk of gestational diabetes. We did not observe statistically significant associations between total physical activity or meeting exercise guidelines and risk. However, after adjusting for age, BMI, gestational weight gain, and other important risk factors, women in the top quartile of moderate-intensity activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio=0.48, 95% Confidence Interval 0.27-0.88, Ptrend=0.03) as compared to those in the lowest quartile. Similarly, women with the highest levels of occupational activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio=0.48, 95% Confidence Interval 0.28-0.85, Ptrend=0.02) as compared to women who were unemployed. CONCLUSION: In this Hispanic population, total physical activity and meeting exercise guidelines were not associated with risk. However, high levels of moderate-intensity and occupational activity were associated with risk reduction.

Life-course weight characteristics and the risk of gestational diabetes.

AIMS/HYPOTHESIS: We prospectively determined the risk of gestational diabetes mellitus in association with life-course weight characteristics and adult abdominal adiposity. METHODS: We investigated the joint and independent impact of birthweight, childhood size by somatotypes, adolescent and adult BMI, and abdominal adiposity on gestational diabetes mellitus risk among the 21,647 women in the Nurses' Health Study II who reported a singleton pregnancy between 1989 and 2001. A total of 1,386 incident cases of gestational diabetes mellitus were reported. Relative risk was estimated by pooled logistic regression adjusting for age, prematurity, race, smoking status, parental history of diabetes, age of first birth, parity and physical activity. RESULTS: Birthweight was inversely associated with gestational diabetes mellitus risk (p = 0.02 for trend). Childhood somatotypes at ages 5 and 10 years were not associated with risk. U-shaped associations were found for BMI at age 18 years and somatotype at age 20 years. Weight gain between adolescence and adulthood, pre-gravid BMI and abdominal adiposity were positively associated with risk (p < 0.01 for all trends). Multivariate adjusted RRs for gestational diabetes from lowest to highest quintile of WHR were 1.00, 1.50, 1.51, 2.03, 2.12 (p = 0.0003 for trend). Lower birthweight (<7 lb) without adulthood overweight (BMI > 25 kg/m(2)) was associated with a 20% increased risk (95% CI 1.02-1.41). However, adulthood overweight alone was related to a 2.36 times greater risk (95% CI 2.12-3.77). CONCLUSIONS/INTERPRETATION: Although lower birthweight is an independent risk factor for gestational diabetes mellitus, weight gain since early adulthood, and overall and central obesity in adulthood were more strongly associated with elevated risk of the condition independently of other known risk factors.

A prospective study of dietary patterns, meat intake and the risk of gestational diabetes mellitus.

AIMS/HYPOTHESIS: The aim of this study was to prospectively examine whether dietary patterns are related to risk of gestational diabetes mellitus (GDM). METHODS: This prospective cohort study included 13,110 women who were free of cardiovascular disease, cancer, type 2 diabetes and history of GDM. Subjects completed a validated semi-quantitative food frequency questionnaire in 1991, and reported at least one singleton pregnancy between 1992 and 1998 in the Nurses' Health Study II. Two major dietary patterns (i.e. 'prudent' and 'Western') were identified through factor analysis. The prudent pattern was characterised by a high intake of fruit, green leafy vegetables, poultry and fish, whereas the Western pattern was characterised by high intake of red meat, processed meat, refined grain products, sweets, French fries and pizza. RESULTS: We documented 758 incident cases of GDM. After adjustment for age, parity, pre-pregnancy BMI and other covariates, the relative risk (RR) of GDM, comparing the highest with the lowest quintile of the Western pattern scores, was 1.63 (95% CI 1.20-2.21; p (trend)=0.001), whereas the RR comparing the lowest with the highest quintile of the prudent pattern scores was 1.39 (95% CI 1.08-1.80; p (trend)=0.018). The RR for each increment of one serving/day was 1.61 (95% CI 1.25-2.07) for red meat and 1.64 (95% CI 1.13-2.38) for processed meat. CONCLUSIONS/INTERPRETATION: These findings suggest that pre-pregnancy dietary patterns may affect women's risk of developing GDM. A diet high in red and processed meat was associated with a significantly elevated risk.

Hyperproinsulinaemia and risk of Type 2 diabetes mellitus in women.

AIMS: Our objective was to examine prospectively the associations between fasting plasma proinsulin and the proinsulin/insulin ratio and the incidence of Type 2 diabetes in women. SUBJECTS AND METHODS: We designed a nested case-control study within the Nurses' Health Study, a cohort of 121,700 US women aged 30-55 years at study inception in 1976. Fasting plasma proinsulin, specific insulin and C-peptide levels were determined in 183 women with a new diagnosis of diabetes made after blood sampling between 1989 and 1990, and 369 control subjects without diabetes. RESULTS: After adjustment for age, body mass index, family history of diabetes and other potential confounders, including HbA1c, the odds ratios for diabetes associated with increasing quartiles of proinsulin were 1.00, 0.85, 2.49 and 5.73 (P for trend: < 0.001). Proinsulin remained significantly associated with diabetes risk after adjusting for C-peptide and specific insulin (multivariate odds ratios for quartiles: 1.00, 0.78, 1.94, 3.69; P for trend = 0.001). In addition, the proinsulin/insulin ratio was significantly associated with diabetes risk, controlling in multivariate analysis for C-peptide (odds ratios for extreme quartiles: 2.48; 95% CI: 1.14-5.41; P for trend = 0.005). CONCLUSIONS: These data suggest that proinsulin and the proinsulin/insulin ratio are strong independent predictors of diabetes risk, after adjustment for obesity and other potential confounders.

Long or highly irregular menstrual cycles as a marker for risk of type 2 diabetes mellitus.

CONTEXT: Although oligomenorrhea has been associated cross-sectionally with insulin resistance and glucose intolerance, it is not known whether oligomenorrhea is a marker for increased future risk of type 2 diabetes mellitus (DM). OBJECTIVE: To prospectively assess risk of type 2 DM in women with a history of long or highly irregular menstrual cycles. DESIGN AND SETTING: The Nurses' Health Study II, a prospective observational cohort study. PARTICIPANTS: A total of 101 073 women who had no prior history of DM and who reported their usual menstrual cycle pattern at age 18 to 22 years on the baseline (1989) questionnaire. MAIN OUTCOME MEASURE: Incident reports of DM, with follow-up through 1997, compared among women categorized by menstrual cycle length (5 categories). RESULTS: During 564 333 person-years of follow-up, there were 507 cases of type 2 DM. Compared with women with a usual cycle length of 26 to 31 days (referent category) at age 18 to 22 years, the relative risk (RR) of type 2 DM among women with a menstrual cycle length that was 40 days or more or was too irregular to estimate was 2.08 (95% confidence interval [CI], 1.62-2.66), adjusting for body mass index at age 18 years and several other potential confounding variables. The RR of type 2 DM associated with long or highly irregular menstrual cycles was greater in obese women, but was also increased in nonobese women (at body mass indexes at age 18 years of <25, 25-29, and >/=30 kg/m, RRs were 1.67 [95% CI, 1.14-2.45], 1.74 [95% CI, 1.07-2.82], and 3.86 [95% CI, 2.33-6.38], respectively). CONCLUSION: Women with long or highly irregular menstrual cycles have a significantly increased risk for developing type 2 DM that is not completely explained by obesity.

Diet, lifestyle, and the risk of type 2 diabetes mellitus in women.

BACKGROUND: Previous studies have examined individual dietary and lifestyle factors in relation to type 2 diabetes, but the combined effects of these factors are largely unknown. METHODS: We followed 84,941 female nurses from 1980 to 1996; these women were free of diagnosed cardiovascular disease, diabetes, and cancer at base line. Information about their diet and lifestyle was updated periodically. A low-risk group was defined according to a combination of five variables: a bodymass index (the weight in kilograms divided by the square of the height in meters) of less than 25; a diet high in cereal fiber and polyunsaturated fat and low in trans fat and glycemic load (which reflects the effect of diet on the blood glucose level); engagement in moderate-to-vigorous physical activity for at least half an hour per day; no current smoking; and the consumption of an average of at least half a drink of an alcoholic beverage per day. RESULTS: During 16 years of follow-up, we documented 3300 new cases of type 2 diabetes. Overweight or obesity was the single most important predictor of diabetes. Lack of exercise, a poor diet, current smoking, and abstinence from alcohol use were all associated with a significantly increased risk of diabetes, even after adjustment for the body-mass index. As compared with the rest of the cohort, women in the low-risk group (3.4 percent of the women) had a relative risk of diabetes of 0.09 (95 percent confidence interval, 0.05 to 0.17). A total of 91 percent of the cases of diabetes in this cohort (95 percent confidence interval, 83 to 95) could be attributed to habits and forms of behavior that did not conform to the low-risk pattern. CONCLUSIONS: Our findings support the hypothesis that the vast majority of cases of type 2 diabetes could be prevented by the adoption of a healthier lifestyle.

The impact of diabetes mellitus on mortality from all causes and coronary heart disease in women: 20 years of follow-up.

BACKGROUND: Few data are available on the long-term impact of type 2 diabetes mellitus on total mortality and fatal coronary heart disease (CHD) in women. METHODS: We examined prospectively the impact of type 2 diabetes and history of prior CHD on mortality from all causes and CHD among 121 046 women aged 30 to 55 years with type 2 diabetes in the Nurses' Health Study who were followed up for 20 years from 1976 to 1996. RESULTS: During 20 years of follow-up, we documented 8464 deaths from all causes, including 1239 fatal CHD events. Compared with women with no diabetes or CHD at baseline, age-adjusted relative risks (RRs) of overall mortality were 3.39 (95% confidence interval [CI], 3.08-3.73) for women with a history of diabetes and no CHD at baseline, 3.00 (95% CI, 2.50-3.60) for women with a history of CHD and no diabetes at baseline, and 6.84 (95% CI, 4.71-9.95) for women with both conditions at baseline. The corresponding age-adjusted RRs of fatal CHD across these 4 groups were 1.0, 8.70, 10.6, and 25.8, respectively. Multivariate adjustment for body mass index and other coronary risk factors only modestly attenuated the RRs. Compared with nondiabetic persons, the multivariate RRs of fatal CHD across categories of diabetes duration (< or =5, 6-10, 11-15, 16-25, >25 years) were 2.75, 3.63, 5.51, 6.38, and 11.9 (P< .001 for trend), respectively. The combination of prior CHD and a long duration of clinical diabetes (ie, >15 years) was associated with a 30-fold (95% CI, 20.7-43.5) increased risk of fatal CHD. CONCLUSIONS: Our data indicate that among women, history of diabetes is associated with dramatically increased risks of death from all causes and fatal CHD. The combination of diabetes and prior CHD identifies particularly high-risk women.

Brief review: hypertension in pregnancy : a manifestation of the insulin resistance syndrome?

Pregnancy-induced hypertension (PIH), which includes both gestational hypertension and preeclampsia, is a common and morbid pregnancy complication for which the pathogenesis remains unclear. Emerging evidence suggests that insulin resistance, which has been linked to essential hypertension, may play a role in PIH. Conditions associated with increased insulin resistance, including gestational diabetes, polycystic ovary syndrome, and obesity, may predispose to hypertensive pregnancy. Furthermore, metabolic abnormalities linked to the insulin resistance syndrome are also observed in women with PIH to a greater degree than in normotensive pregnant women: These include glucose intolerance, hyperinsulinemia, hyperlipidemia, and high levels of plasminogen activator inhibitor-1, leptin, and tumor necrosis factor-alpha. These observations suggest the possibility that insulin resistance may be involved in the pathogenesis of PIH and that approaches that improve insulin sensitivity might have benefit in the prevention or treatment of this syndrome, although this requires further study.

Provider characteristics: impact on bone density utilization at a health maintenance organization.

OBJECTIVE: Information from bone mineral density (BMD) is relevant in guiding postmenopausal osteoporosis prevention and treatment, yet many providers do not typically order BMDs. This study was designed to identify physician characteristics associated with utilization of bone densitometry in a northeastern US health maintenance organization (HMO). DESIGN: Internal medicine primary providers in practice at a northeastern HMO between April 1997 and March 1998 were categorized by BMD utilization, based on the number of BMDs performed during that time per number of women older than 50 years in their patient panel. In one analysis, providers in the highest quintile for this parameter were considered "high utilizers" (n = 25), and those in the lowest quintile, "low utilizers." These groups were compared with respect to provider characteristics and practice composition. In a second analysis, multiple variable linear regression was used to predict the likelihood of utilization of BMD as a function of those parameters for all providers. RESULTS: The range of BMDs by provider was 0 to 190 per 1,000 women >50 years (median = 34) over this 1-year period. Providers who were high utilizers had a significantly greater number of female patients more than age 50 in their practice (p < 0.05) and were also more likely themselves to be female (62% vs. 48%; p < 0.05). There was no association between BMD utilization and age of provider or years in practice. Female provider gender (p < 0.01) and greater percentage of women more than age 50 in the practice (p < 0.05) were independent predictors of BMD utilization in a multivariate model. CONCLUSION: BMDs were infrequently utilized by the majority of providers over this 1-year period. Female provider gender was associated with a significantly greater likelihood of BMD utilization that was not simply explained by the greater number of women in these providers' practices. These findings may be relevant to identifying strategies to improve bone health care in this population.

Moderate alcohol consumption and risk of coronary heart disease among women with type 2 diabetes mellitus.

BACKGROUND: Moderate alcohol consumption is associated with reduced risk for coronary heart disease (CHD) in generally healthy populations. We assessed prospectively the association between moderate alcohol intake and CHD risk in women with type 2 diabetes mellitus, a group at high risk for cardiovascular disease. METHODS AND RESULTS: We studied women in the Nurses' Health Study who reported a diagnosis of diabetes mellitus at >/=30 years of age. During 39 092 person-years of follow-up from 1980 to 1994, there were 295 CHD events documented among this population, including 194 cases of nonfatal myocardial infarction and 101 cases of fatal CHD. Odds ratios derived from logistic regression were used to estimate relative risks (RRs) for CHD as a function of usual alcohol intake, with adjustment for potential confounders. Compared with diabetic women reporting no alcohol intake, the age-adjusted RR for nonfatal or fatal CHD among diabetic women reporting usual intake of 0.1 to 4.9 g (<0.5 drinks) of alcohol daily was 0.74 (95% CI 0.56 to 0.98), and among those reporting usual intake >/=5 g/d, it was 0.48 (95% CI 0.32 to 0.72) (P for trend <0.0001). Inverse associations between alcohol intake and CHD risk remained significant in multivariate analysis adjusting for several other coronary risk factors (0.1 to 4. 9 g/d: RR 0.72 [95% CI 0.54 to 0.96]; >/=5 g/d: RR 0.45 [0.29 to 0.68]). CONCLUSIONS: Although potential risks of alcohol consumption must be considered, these data suggest that moderate alcohol consumption is associated with reduced CHD risk in women with diabetes and should not be routinely discouraged.

High body mass index and hypercholesterolemia: risk of hypertensive disorders of pregnancy.

OBJECTIVE: To examine the relationship between pregravid body mass index (BMI), elevated cholesterol level, and the development of hypertensive disorders of pregnancy. METHODS: We studied 15,262 women who gave birth between 1991 and 1995. Pregravid exposures including BMI and self-reported history of elevated cholesterol were ascertained by biennial mailed questionnaires. Gestational hypertension or preeclampsia was confirmed by medical record review according to standard criteria. Proportional hazards analysis was used to adjust for potential confounding variables. RESULTS: We confirmed 216 cases of gestational hypertension and 86 cases of preeclampsia. The risk of gestational hypertension increased as pregravid BMI increased (P < .01). Compared with women with a pregravid BMI of 21-22.9 kg/m2, the relative risk (RR) of gestational hypertension was 1.6 (95% confidence interval [CI] 1.0, 2.3) for women with BMI of 23-24.9 kg/m2, 2.0 (95% CI 1.3, 3.0) for BMI 25-29.9 kg/m2, and 2.6 (95% CI 1.6, 4.4) for BMI over 30 kg/m2. Leaner women (BMI less than 21 kg/m2) had a reduced risk (RR 0.7, 95% CI 0.4, 1.0). For preeclampsia, the RR of women with pregravid BMI over 30 kg/m2 was 2.1 (95% CI 1.0, 4.6) (P for trend 0.09). A history of elevated cholesterol was not associated with the risk of gestational hypertension (RR 0.9, 95% CI, 0.6, 1.4). In contrast, the RR of preeclampsia in women with a history of elevated cholesterol was 2.0 (95% CI 1.2, 3.3). CONCLUSION: Pregravid BMI and hypercholesterolemia could identify women at higher risk for hypertensive disorders during pregnancy.

Walking compared with vigorous physical activity and risk of type 2 diabetes in women: a prospective study.

CONTEXT: Although many studies suggest that physical activity may reduce risk of type 2 diabetes, the role of moderate-intensity activity such as walking is not well understood. OBJECTIVES: To examine the relationship of total physical activity and incidence of type 2 diabetes in women and to compare the benefits of walking vs vigorous activity as predictors of subsequent risk of type 2 diabetes. DESIGN AND SETTING: The Nurses' Health Study, a prospective cohort study that included detailed data for physical activity from women surveyed in 11 US states in 1986, with updates in 1988 and 1992. PARTICIPANTS: A total of 70,102 female nurses aged 40 to 65 years who did not have diabetes, cardiovascular disease, or cancer at baseline (1986). MAIN OUTCOME MEASURE: Risk of type 2 diabetes by quintile of metabolic equivalent task (MET) score, based on time spent per week on each of 8 common physical activities, including walking. RESULTS: During 8 years of follow-up (534, 928 person-years), we documented 1419 incident cases of type 2 diabetes. After adjusting for age, smoking, alcohol use, history of hypertension, history of high cholesterol level, and other covariates, the relative risks (RRs) of developing type 2 diabetes across quintiles of physical activity (least to most) were 1.0, 0.77, 0.75, 0.62, and 0.54 (P for trend <.001); after adjusting for body mass index (BMI), RRs were 1.0, 0.84, 0.87, 0.77, and 0.74 (P for trend = .002). Among women who did not perform vigorous activity, multivariate RRs of type 2 diabetes across quintiles of MET score for walking were 1.0, 0.91,0.73, 0.69, and 0.58 (P for trend <.001). After adjusting for BMI, the trend remained statistically significant (RRs were 1.0, 0.95, 0.80, 0.81, 0.74; P for trend = .01). Faster usual walking pace was independently associated with decreased risk. Equivalent energy expenditures from walking and vigorous activity resulted in comparable magnitudes of risk reduction. CONCLUSIONS: Our data suggest that greater physical activity level is associated with substantial reduction in risk of type 2 diabetes, including physical activity of moderate intensity and duration.

The epidemiology of polycystic ovary syndrome. Prevalence and associated disease risks.

Polycystic ovary syndrome is a common problem affecting approximately 5% of women of reproductive age when defined by clinical features of anovulation and hyperandrogenism. Metabolic derangements associated with this condition may predispose to a range of diseases with attendant morbidity and mortality risks. In general, available data support significantly increased rates of type II diabetes mellitus, dyslipidemia, and endometrial cancer in PCOS that are not completely explained by obesity; data also suggest that rates of hypertension, gestational diabetes, and pregnancy-induced hypertension may likewise be increased, although the extent to which obesity mediates these risks is not clear. The increased prevalence of several cardiovascular risk factors in PCOS and limited cross-sectional data suggest that cardiovascular disease should be more likely in PCOS, but prospective data are lacking to confirm this supposition. Limited data have suggested an association between PCOS and ovarian cancer risk and require further study. The present data do not support an increased risk for breast cancer in this condition. Long-term prospective data are clearly needed to better delineate the nature and magnitude of disease risks associated with PCOS, with appropriate adjustment for associated obesity. Such information is a necessary background for understanding the role of established and emerging PCOS therapies, including oral contraceptives, intermittent progesterone, ovulation induction agents, and insulin sensitizers, in modifying such risks. In the meantime, close follow-up of women with PCOS and encouragement of lifestyle practices likely to reduce disease risks, such as regular exercise and weight control, should be standard practice.

Higher cholesterol and insulin levels in pregnancy are associated with increased risk for pregnancy-induced hypertension.

Hyperinsulinemia and dyslipidemia are known to be associated with essential hypertension but their role in pregnancy-induced hypertension remains unclear. We performed a case-control study comparing cholesterol, insulin, and glucose levels in the early third trimester of pregnancy among 31 women who developed pregnancy-induced hypertension (PIH) (either preeclampsia [n = 6] or nonproteinuric gestational hypertension [n = 25]), with 31 women remaining normotensive through pregnancy. As compared with women remaining normotensive, women subsequently developing PIH had higher fasting cholesterol levels (279 v 247 mg/dL; P = .02) and higher fasting insulin levels (13.3 v 7.9 microU/mL; P = .03), although fasting glucose levels and levels of glucose and insulin after glucose load did not differ significantly between groups. In comparing hypertensive subgroups, fasting insulin levels were significantly higher among women who subsequently developed preeclampsia, but not among those subsequently developing nonproteinuric gestational hypertension. Although women developing PIH had higher pregravid body mass index (25.1 v 22.6 kg/m2, P = .06), fasting cholesterol and insulin levels were associated with risk for PIH even after adjustment for body mass index and age (relative risks for one unit increase, respectively: 1.02 (P = .03) and 1.12 (P = .03). Higher fasting cholesterol and insulin levels in mid- to late pregnancy are associated with increased risk for PIH. These observations support a role for insulin resistance in the development of this complication of pregnancy.

Eclampsia: a 13-year experience at a United States tertiary care center.

Eclampsia, the occurrence of a grand mal seizure in the setting of hypertension in pregnancy, remains a major women's health issue and an important cause of maternal and fetal morbidity in the United States. We reviewed the incidence, management, and outcome of cases of eclampsia during a 13-year period at a major maternity hospital. We confirmed 33 cases of eclampsia seen during that period and have evaluated risk factors in this population. Medical records were reviewed to obtain demographic and clinical data. Characteristics of the eclamptic women were compared with those of the general obstetric population during the same time period. The overall incidence of eclampsia at this tertiary care center was 0.028%. The majority of eclamptic women (75%) had four or more prenatal visits. Young age (< or = 20 years) and first pregnancy remained important risk factors for eclampsia. Although many women with eclampsia had preceding hypertension or elevated urine protein levels or both, some experienced eclampsia as their first disease manifestation. Although the occurrence of eclampsia was low, eclampsia continues to complicate pregnancy in this large U.S. obstetric population.

Obesity and mortality: a review of the epidemiologic data.

At least one-third of Americans are obese, as defined by body mass indexes corresponding to body weight > or = 120% of ideal body weight, and this figure is rising steadily. Women and nonwhites have particularly high rates of obesity. Obesity greatly increases risks for many serious and morbid conditions, including diabetes mellitus, hypertension, dyslipidemia, coronary artery disease, and some cancers. Obesity is clearly associated with increased risk for mortality, but there has been controversy regarding optimal weight with respect to mortality risk. We review the literature concerning obesity and mortality, with reference to body fat distribution and weight gain, and consider potential effects of sex, age, and race on this relation. We conclude that when appropriate adjustments are made for effects of smoking and underlying disease, optimal weights are below average in both men and women; this appears to be true throughout the adult life span. Central obesity, most commonly approximated by the waist-to-hip ratio, may be particularly detrimental, although this requires further study. Weight gain in adulthood is also associated with increased mortality. These observations support public health measures to reduce obesity and weight gain, including recent recommendations to limit weight gain in the adult years to 4.5 kg (10 lb).

A prospective study of pregravid determinants of gestational diabetes mellitus.

CONTEXT: Gestational diabetes mellitus (GDM) affects 3% to 5% of pregnancies. Knowledge of risk factors for GDM is needed to identify possible preventive strategies. OBJECTIVE: To assess whether recognized determinants of noninsulin-dependent diabetes mellitus also may be markers for increased risk of GDM. DESIGN: Prospective cohort study. SETTING: The Nurses' Health Study II, which involves female US nurses aged 25 to 42 years at entry. PARTICIPANTS: The analyses included 14613 women without previous GDM or other known diabetes who reported a singleton pregnancy between 1990 and 1994. Of these women, 722 (4.9%) reported a new diagnosis of GDM. MAIN OUTCOME MEASURE: Self-report of GDM, validated by medical record review in a subset. RESULTS: In multivariate analyses including age, pregravid body mass index (BMI), and other GDM risk factors, the risk for GDM increased significantly with increasing maternal age (P for trend, <.01) and family history of diabetes mellitus (relative risk, 1.68; 95% confidence interval [CI], 1.39-2.04). Relative risks for GDM were 2.13 (95% CI, 1.65-2.74) for pregravid BMI of 25 to 29.9 kg/m2 and 2.90 (95% CI, 2.15-3.91) for BMI of 30 kg/m2 or more (vs BMI of <20 kg/m2). Risk for GDM increased with greater weight gain in early adulthood, and it also increased among nonwhite women. Pregravid current smokers had a relative risk for GDM of 1.43 (95% CI, 1.14-1.80), and pregravid vigorous exercise was associated with a nonsignificant reduction in GDM risk. CONCLUSIONS: Advanced maternal age, family history of diabetes mellitus, nonwhite ethnicity, higher BMI, weight gain in early adulthood, and cigarette smoking predict increased GDM risk. These observations may facilitate the identification of women at particular risk for GDM and suggest potential strategies for reducing this risk even before a woman becomes pregnant, such as avoiding substantial weight gain and smoking.

Body fat distribution and risk of non-insulin-dependent diabetes mellitus in women. The Nurses' Health Study.

Obesity is an established risk factor for non-insulin-dependent diabetes mellitus (NIDDM). Anthropometric measures of overall and central obesity as predictors of NIDDM risk have not been as well studied, especially in women. Among 43,581 women enrolled in the Nurses' Health Study who in 1986 provided waist, hip, and weight information and who were initially free from diabetes and other major chronic diseases, NIDDM incidence was followed from 1986 to 1994. After adjustment for age, family history of diabetes, smoking, exercise, and several dietary factors, the relative risk of NIDDM for the 90th percentile of body mass index (BMI) (weight (kg)/height (m)2) (BMI = 29.9) versus the 10th percentile (BMI = 20.1) was 11.2 (95% confidence interval (CI) 7.9-15.9). Controlling for BMI and other potentially confounding factors, the relative risk for the 90th percentile of waist: hip ratio (WHR) (WHR = 0.86) versus the 10th percentile (WHR = 0.70) was 3.1 (95% CI 2.3-4.1), and the relative risk for the 90th percentile of waist circumference (36.2 inches or 92 cm) versus the 10th percentile (26.2 inches or 67 cm) was 5.1 (95% CI 2.9-8.9). BMI, WHR, and waist circumference are powerful independent predictors of NIDDM in US women. Measurement of BMI and waist circumference (with or without hip circumference) are potentially useful tools for clinicians in counseling patients regarding NIDDM risk and risk reduction.