Gestational weight gain: Toward best practices in managing gestational weight gain in patients with obesity: Comparison of recommendations.

BACKGROUND AND AIMS: In 2009, the Institute of Medicine (IOM) issued recommendations for gestational weight gain (GWG) based on body mass index (BMI). Several studies have challenged those recommendations for women with obesity, considering them too liberal and advising more limited weight gain - or even weight loss - during pregnancy to improve maternal and neonatal outcomes. Our aim was to study how gestational weight gain in women with obesity impacted maternal and fetal complications in the Belgian population. We did this by comparing the results from two groups of patients with obesity: those who met the 2009 IOM standards and those who satisfied the stricter recommendations suggested by other authors. MATERIALS AND METHODS: This is a retrospective cohort study using data collected at the Centre d'Epidémiologie Périnatale (CEpiP) from obese (BMI ≥ 30 kg/m2) pregnant women with live singleton deliveries between 2010 and 2019 in Wallonia-Brussels Federation (n = 65,314). RESULTS: Compared to obese patients whose GWG satisfied the IOM standards, those with GWG meeting the stricter recommendations had lower rates of gestational hypertension (7.1 % vs. 10.1 %; p = 0.0059), cesarean section (22.1 % vs. 26.3 %; p = 0.0074), and macrosomia (12.0 % vs. 17.7 %; p < 0.0001). There was no significant difference in the rate of preterm delivery (6.9 % vs 5.8 %; p = 0.12) or small-for-gestational-age births (7.2 % vs. 6.2 %; p = 0.16). CONCLUSION: Gestational weight gain below that currently recommended by the IOM appears beneficial to the health of mothers with obesity and their children. These data, from our population, further challenge the standards proposed since 2009.

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus.

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

[Gliflozins and finerenone: what are the prospects for their combination?] / Gliflozines et finérénone : quelles perspectives pour leur association?

Chronic kidney disease is a common complication of diabetes. Progressive deterioration of renal function is responsible for an increased risk of cardiovascular diseases. The end-stage renal disease with the vital recourse to dialysis sessions remains a major burden for the patients as well as for the society given the major cost of this treatment. Recently, two classes of drugs have demonstrated significant benefits in terms of cardio-renal protection: SGLT2 inhibitors (gliflozins) and finerenone, a selective nonsteroidal mineralo-receptor antagonist. Given their different mechanisms of action, a combination of the two pharmacological classes seems logical and promising based on a number of exploratory current analyses and considerations.

La maladie rénale chronique (MRC) est une complication fréquente liée à diverses pathologies dont le diabète. La dégradation progressive de la fonction rénale est responsable d'un risque accru de présenter des maladies cardiovasculaires. Son évolution terminale avec le recours vital à la dialyse reste un fardeau majeur pour les personnes qui en souffrent ainsi que pour la société compte tenu du coût qui en résulte. Récemment, deux classes médicamenteuses ont démontré des avantages significatifs en termes de protection cardiorénale : les inhibiteurs du SGLT2 (gliflozines) et la finérénone, un antagoniste sélectif non stéroïdien des récepteurs de l'aldostérone. Compte tenu de mécanismes d'action différents, leur combinaison semble logique et prometteuse sur la base de plusieurs analyses exploratoires.

Discordance Between Glycated Hemoglobin A1c and the Glucose Management Indicator in People With Diabetes and Chronic Kidney Disease.

INTRODUCTION: Assessment of glucose exposure via glycated hemoglobin A1c (HbA1c) has limitations for interpretation in individuals with diabetes and chronic kidney disease (CKD). The glucose management indicator (GMI) derived from continuous glucose monitoring (CGM) data could be an alternative. However, the concordance between HbA1c measured in laboratory and GMI (HbA1c-GMI) is uncertain in individuals with CKD. The purpose of this study is to analyze this discrepancy. MATERIAL AND METHOD: We performed a multicentric, retrospective, observational study. A group of individuals with diabetes and CKD (n = 170) was compared with a group of individuals with diabetes without CKD (n = 185). All individuals used an intermittently scanned continuous glucose monitoring (isCGM). A comparison of 14-day and 90-day glucose data recorded by the isCGM was performed to calculate GMI and the discordance between lab HbA1c and GMI was analyzed by a Bland-Altman method and linear regression. RESULTS: HbA1c-GMI discordance was significantly higher in the CKD group versus without CKD group (0.78 ± 0.57 [0.66-0.90] vs 0.59 ± 0.44 [0.50-0.66]%, P < .005). An absolute difference >0.5% was found in 68.2% of individuals with CKD versus 42.2% of individuals without CKD. We suggest a new specific formula to estimate HbA1c from the linear regression between HbA1c and mean glucose CGM, namely CKD-GMI = 0.0261 × 90-day mean glucose (mg/L) + 3.5579 (r2 = 0.59). CONCLUSIONS: HbA1c-GMI discordance is frequent and usually in favor of an HbA1c level higher than the GMI value, which can lead to errors in changes in glucose-lowering therapy, especially for individuals with CKD. This latter population should benefit from the CGM to measure their glucose exposure more precisely.

[Renewed interest for the control of post-prandial hyperglycaemia]. / Regain d'intérêt pour le contrôle de l'hyperglycémie postprandiale.

Postprandial hyperglycaemia (PPH) may sometimes be relegated to the background in the treatment of diabetic patients, while its control seems important if not essential to reach an adequate overall glycaemic control. PPH is correlated with glycated haemoglobin and diabetic complications. It is also identified as a cardiovascular risk factor. PPH's monitoring and adequate control are not only a therapeutic goal for diabetes itself but also for reducing associated adverse outcomes other than diabetic complications. PPH is related to the quality of life of patients. Continuous glucose monitoring allows a better appraisal of PPH. The use of new insulin formulations as ultra-fast insulins seems to be the better way to manage post-prandial blood glucose peaks.

L'hyperglycémie postprandiale (HGPP) peut parfois passer au second plan lors de la prise en charge globale du patient diabétique. Néanmoins, sa maîtrise est indispensable pour obtenir un équilibre glycémique global optimal. L'HGPP est corrélée à l'hémoglobine glyquée ainsi qu'aux complications du diabète. Elle semble également jouer un rôle par rapport au risque cardiovasculaire. Outre son intérêt dans la prise en charge thérapeutique du diabète proprement dit, l'HGPP doit être maîtrisée en raison de son lien avec d'autres conséquences médicales et de son impact négatif sur la qualité de vie des patients. Le monitoring continu du glucose permet une meilleure appréciation de l'HGPP. Les nouvelles insulines ultra-rapides paraissent être les molécules les plus adéquates pour réduire, au mieux et au plus vite, l'HGPP.

Evolution of maternal and neonatal outcomes before and after the adoption of the IADPSG/WHO guidelines in Belgium: A descriptive study of 444,228 pregnancies.

Objectives: To appraise adverse pregnancy outcomes after the adoption of IADPSG/WHO guidelines in Belgium. Methods: A retrospective study of the Center for Perinatal Epidemiology registry was conducted. Demographic changes and adverse pregnancy outcomes were compared between a pre- and post-guideline period in women with and without hyperglycemia in pregnancy (HIP). Adjusted odds ratios with a 95% confidence interval (CI) were used to compare maternal and neonatal outcomes controlling for potential confounders (maternal age, body mass index (BMI), hypertension, parity, and multiple births). Results: The prevalence of HIP increased (6.0%-9.2%). In the overall population regardless of glycemic status, gestational weight gain (12.3 ± 5.7 vs 11.9 ± 5.8; p < 0.001), hypertension (0.92; 95% CI, 0.89-0.94; p < 0.001), and neonatal intensive care unit/special care nursery (0.89; 95% CI, 0.87-0.91; p < 0.001) decreased despite increasing maternal age and pre-pregnancy BMI. Emergency cesarean section rates (1.07; 95% CI, 1.05-1.09; p < 0.001) increased, but not in the HIP population (1.02; 95% CI, 0.95-1.10; ns). The overall incidence of preterm birth (1.09; 95% CI, 1.06-1.12; p < 0.001), stillbirth (1.10; 95% CI, 1.01-1.21; p < 0.05), and perinatal mortality (1.10; 95% CI, 1.01-1.19; p < 0.05) increased, except in the HIP population (1.03; 95% CI, 0.95-1.11; ns), (1.04; 95% CI, 0.74-1.47; ns) and (1.09; 95% CI, 0.80-1.49; ns), respectively. The overall incidence of small- for-gestational-age remained unchanged (0.99; 95%CI, 0.97-1.01; ns) regardless of glycemic status. In the HIP population, large-for-gestational age (0.90; 95% CI, 0.84-0.95; p < 0.001) and macrosomia (0.84; 95% CI, 0.78-0.92; p < 0.001) decreased. Conclusion: After the implementation of IADPSG/WHO guidelines, the prevalence of HIP increased by 53.7% and the incidence of major HIP-related pregnancy complications appears to be lower. However, we cannot conclude that the reduction of LGA-macrosomia is due to a better management of diabetes or due to greater recruitment of women with mild HIP associated with a lower risk of obstetrical complications.

[Gestational diabetes mellitus : what after delivery ?] / Diabète gestationnel : et après ?

Gestational diabetes mellitus (GDM) occurs in an increasing number of pregnancies. Due to its disappearance after delivery, GDM can be underestimated despite description of many risks for mothers and offsprings later in life. These women are at higher risk for metabolic abnormalities and cardiovascular disease. Overweight/obesity, metabolic disturbances, cardiovascular complications and lower cognitive abilities are more frequent in offsprings. These two populations need an early and adequate prevention of metabolic and cardiovascular disorder from a public health point of view. Lifestyle (healthy diet and exercise) is the best advice to promote in these families. For these women with previous DG, breast-feeding as long as possible and metformin may also be part of the management.

Le diabète gestationnel (DG) complique un nombre croissant de grossesses. Parfois banalisé en raison de sa fréquente disparition après l'accouchement, le DG expose pourtant les mères et leur progéniture à des risques non négligeables dans leur vie. Les mamans ayant présenté un DG sont à plus haut risque sur les plans métabolique et cardiovasculaire. Parallèlement, les enfants présentent des risques accrus sur les plans pondéral, métabolique et cardiovasculaire ainsi que d'éventuels troubles cognitifs. Identifier ces deux populations et leurs risques respectifs est une mesure importante en termes de santé publique. Une bonne hygiène de vie est le meilleur conseil à prodiguer à ces familles tout au long de leur vie. L'allaitement prolongé et la metformine peuvent également être suggérés comme éléments protecteurs sur le plan métabolique.

[Gestational diabetes mellitus†: management in 2020 and long-term risk]. / Diabète gestationnel†: prise en charge en 2020 et risque futur.

Gestational diabetes mellitus is a frequent complication of pregnancy. Its diagnosis and management tend now to a better uniformization than in the past years, even if some guidelines still remain debated. Nevertheless, useful actions in GDM's management, as well as the follow-up regarding the long-term metabolic risk for women who underwent this dysglycaemia in a limited time are now quite well described in the literature. In this review, we aim to discuss recent data related to this very particular metabolic disease.

Le diabète gestationnel est une complication fréquente de la grossesse. Son dépistage et sa prise en charge tendent, enfin, à s'uniformiser, même si différents éléments sont toujours débattus. Par contre, les grands principes de prise en charge et les données quant au risque de présenter des troubles métaboliques futurs sont bien décrits dans la littérature depuis plusieurs années. Nous évoquons ici les informations actualisées relatives à cette pathologie métabolique si particulière.

[Potential role of SGLT2 inhibitors in the management of type 1 diabetes]. / Intérêt potentiel des inhibiteursdes SGLT2 dans le traitementdu diabète de type 1.

Type 1 diabetes (T1D) management is still complex. Some drugs have been proposed as adjunctive treatment to insulin for type 1 diabetes but results are not encouraging. Sodium-glucose cotransporter 2 (SGLT2) inhibitors act independently of insulin and initial proof-of-concept studies related to their use in T1D led to larger phase 3 trials. Several trials have demonstrated some beneficial and consistent effects as HbA1c, body weight and insulin dose reductions, and lesser glycaemic excursions. Nevertheless, adverse events were also reported, especially a higher rate of diabetic ketoacidosis when using gliflozins in T1D. Balance between positive and negative effects must be carefully studied in the near future with data from real-life and large trials dedicated to this potential new help in T1D.

La gestion du diabète de type 1 (DT1) reste complexe en raison de la difficulté d'obtenir une équilibration glycémique optimale sans épisodes hypoglycémiques fréquents ou sévères. Les tentatives de traitements adjuvants à l'insuline sont des échecs. Le concept d'associer des inhibiteurs des SGLT2 est un succès en termes de réduction de l'HbA1c, du poids et des doses d'insuline. Ce traitement est, par ailleurs, associé à une moindre variabilité glycémique. De larges études contrôlées confirment ces bénéfices, mais attirent l'attention sur des effets indésirables tels que la survenue d'une acidocétose. Cette balance risque/bénéfice sera mieux appréciée dans un futur proche au fil des données rapportées dans la vie réelle ainsi que la poursuite de grandes études dédiées à l'intérêt potentiel de cette classe médicamenteuse dans le DT1.

Squatting test: a dynamic postural manoeuvre to study baroreflex sensitivity.

INTRODUCTION: Squatting is an active posture test that can be used to assess baroreflex sensitivity. Indeed, the shift from squatting to standing imposes a major orthostatic stress leading to rapid and large changes in arterial blood pressure (BP) and heart rate (HR) allowing precise baroreflex assessment. MATERIAL AND METHODS: BP and HR can be continuously and non-invasively monitored with a Finapres device. RESULTS: The standing to squatting transition is accompanied by rises in BP, pulse pressure and cardiac output, mainly due to increased venous return, and by a secondary reduction in HR. Conversely, the squatting to standing transition is associated with an immediate drop in BP and both reflex tachycardia and vasoconstriction. This mirror changes in BP and HR, mimicking those observed with the classical pharmacological approach using vasopressor/vasodilating agents, allows the calculation of the so-called baroreflex gain. DISCUSSION: The present review describes the haemodynamic changes occurring in normal subjects during the shifts from standing to squatting and from squatting to standing and discusses the underlying cardiovascular and autonomic mechanisms. CONCLUSION: This careful analysis in healthy individuals should help in the understanding of disturbances that may be observed in patients with autonomic dysfunction, such as in diabetic patients with cardiovascular autonomic neuropathy.

Squatting test: A posture to study and counteract cardiovascular abnormalities associated with autonomic dysfunction.

The squatting test is an active posture manoeuvre that imposes one of the most potent orthostatic stresses. In normal subjects, the changes in blood pressure and heart rate are transient because of appropriate baroreflex homeostasis and do not provoke symptoms. However, in various pathological conditions, both the increase in blood pressure during squatting and the decrease in blood pressure during standing may be more important and sustained, potentially leading to complaints and adverse events. Squatting has been used to evaluate patients with tetralogy of Fallot, heart transplant, dysautonomia, including diabetic cardiovascular autonomic neuropathy, and individuals prone to vasovagal syncope. Careful analysis of changes in blood pressure and heart rate during the transition from standing to squatting and from squatting to standing allows the early detection of altered vagal and/or sympathetic function. Of note squatting position has been proposed as a therapeutic means to counteract the fall in blood pressure in patients suffering from dizziness due to dysautonomia and orthostatic hypotension or presenting pre-syncope symptoms, such as soon after exercise. The aims of the present review are to analyse the haemodynamic pattern during a squatting test in various pathological situations and to describe what may be the negative and positive haemodynamic changes associated with this posture. We were especially interested in using the squatting test for the assessment of cardiovascular autonomic neuropathy associated with diabetes mellitus.

Pulsatile stress in middle-aged patients with type 1 or type 2 diabetes compared with nondiabetic control subjects.

OBJECTIVE: Arterial pulse pressure is considered to be an independent cardiovascular risk factor. We compared pulse pressure during an active orthostatic test in middle-aged patients with type 1 diabetes and with type 2 diabetes and corresponding nondiabetic control subjects. RESEARCH DESIGN AND METHODS: Forty patients with type 1 diabetes (mean age 50 years, diabetes duration 23 years, and BMI 23.0 kg/m2) were compared with 40 nonhypertensive patients with type 2 diabetes (respectively, 50 years, 8 years, and 29.7 kg/m2). Patients taking antihypertensive agents or with renal insufficiency were excluded. All patients were evaluated with a continuous noninvasive arterial blood pressure monitoring (Finapres) in standing (1 min), squatting (1 min), and again standing position (1 min). Patients with type 1 or type 2 diabetes were compared with two groups of 40 age-, sex- and BMI-matched healthy subjects. RESULTS: Patients with type 1 diabetes and patients with type 2 diabetes showed significantly higher pulse pressure, heart rate, and double product of pulse pressure and heart rate (PP×HR) (type 1: 5,263 vs. 4,121 mmHg/min, P=0.0004; type 2: 5,359 vs. 4,321 mmHg, P=0.0023) levels than corresponding control subjects. There were no significant differences between patients with type 1 diabetes and type 2 diabetes regarding pulse pressure (59 vs. 58 mmHg), heart rate (89 vs. 88/min), and PP×HR (5,263 vs. 5,359 mmHg/min). CONCLUSIONS: Patients with type 1 diabetes have increased levels of peripheral PP, an indirect marker of arterial stiffness, and PP×HR, an index of pulsatile stress, comparable to those of nonhypertensive patients with type 2 diabetes at similar mean age of 50 years.

Squatting amplifies pulse pressure increase with disease duration in patients with type 1 diabetes.

OBJECTIVE: To evaluate pulse pressure changes according to duration of type 1 diabetes and to assess the influence of posture. RESEARCH DESIGN AND METHODS: We performed continuous measurement of blood pressure with a Finapres device during a 3 x 1 min posture test (standing, squatting, standing) in 159 type 1 diabetic patients divided into four groups according to diabetes duration (30 years, groups 1-4, respectively) and compared the results with those of age-matched nondiabetic subjects. RESULTS: Pulse pressure progressively increased according to type 1 diabetes duration (P < 0.0001), especially in women, but not in age-matched nondiabetic subjects (NS). Pulse-pressure increase from group 1 to group 4 was amplified in the squatting position (from 50 +/- 17 to 69 +/- 14 mmHg) compared with standing (from 44 +/- 15 to 55 +/- 12 mmHg). CONCLUSIONS: Pulse pressure increases according to type 1 diabetes duration more in women than in men, and the squatting position sensitizes such pulse-pressure increase in both sexes.

Insulin detemir in the treatment of type 1 and type 2 diabetes.

Insulin detemir is a soluble long-acting human insulin analogue at neutral pH with a unique mechanism of action. Following subcutaneous injection, insulin detemir binds to albumin via fatty acid chain, thereby providing slow absorption and a prolonged metabolic effect. Insulin detemir has a less variable pharmacokinetic profile than insulin suspension isophane or insulin ultralente. The use of insulin detemir can reduce the risk of hypoglycemia (especially nocturnal hypoglycemia) in type 1 and type 2 diabetic patients. However, overall glycemic control, as assessed by glycated hemoglobin, is only marginally and not significantly improved compared with usual insulin therapy. The weight gain commonly associated with insulin therapy is rather limited when insulin detemir is used. In our experience, this new insulin analogue is preferably administrated at bedtime but can be proposed twice a day (in the morning and either before the dinner or at bedtime). Detemir is a promising option for basal insulin therapy in type 1 or type 2 diabetic patients.

Effect of peroxisome proliferator-activated receptor gamma agonist, rosiglitazone, on dedifferentiated thyroid cancers.

BACKGROUND AND METHOD: As genetic alterations in the gene for the peroxisome proliferator-activated receptor gamma (PPARgamma) have been described and PPAR agonists have been shown to redifferentiate thyroid cancers in animal models, we performed a pilot study in five patients with thyroglobulin-positive and I scan-negative thyroid cancers using the PPARgamma agonist rosiglitazone. RESULTS: Although thyroglobulin levels increased in four of the five patients after 3 months of treatment with rosiglitazone, the I scan remained negative in four patients and became only faintly positive in one patient for two lung metastases that could be correlated with metabolically active lung metastases shown by F-fluorodeoxyglucose positron emission tomography (F-FDG PET) and by computed tomography (CT). F-FDG PET, performed in four patients, revealed metastases of significant size in two patients, including the patient mentioned above and in a second patient confirmed by surgery. CONCLUSIONS: Treatment with rosiglitazone increased the production of thyroglobulin in some patients with thyroid cancers, but only rarely restored scintigraphically significant iodine trapping. It remains to be shown whether longer treatment periods might result in a more efficient redifferentiating effect.