Gestational diabetes and ethics

Winter, G. | Gestational Diabetes and Ethics| British Journal of Midwifery | Vol. 28, No. 4 | Published Online 2nd April 2020

With cases of gestational diabetes on the rise due to the increase in obesity rates, the author reveals the importance of screening and diagnosis. According to the National Institute for Health and Care Excellence around 700 000 women give birth in England and Wales annually; up to 5% of these women have either pre-existing diabetes or gestational diabetes mellitus; and the incidence of GDM is rising because of higher obesity rates in the general population and more pregnancies in older women.

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Are preoperative metformin prescriptions associated with a lower risk of postoperative mortality and readmission among patients with type 2 diabetes who underwent a major surgical intervention?

Reitz, K.M. et al. (2020). Association Between Preoperative Metformin Exposure and Postoperative Outcomes in Adults With Type 2 Diabetes. JAMA Surg. Published online April 08, 2020. doi:10.1001/jamasurg.2020.0416
Are preoperative metformin prescriptions associated with a lower risk of postoperative mortality and readmission among patients with type 2 diabetes who underwent a major surgical intervention? This is the question used to inform research into US patients with diabetes who were had a preoperative prescription and those without preoperative prescription, the research team looked at data from over 5000 patients who had undergone surgery. The researchers identified an association between metformin prescriptions before major surgery and reduced risk-adjusted mortality and readmission following the procedure (Source: Reitz, 2020 et al).

Key Points


Question
  Are preoperative metformin prescriptions associated with a lower risk of postoperative mortality and readmission among patients with type 2 diabetes who underwent a major surgical intervention?

Findings  In this cohort study of 5460 patients with diabetes who had a major surgical procedure, preoperative prescriptions of metformin were associated with a statistically significant decrease in the risk of 90-day mortality as well as 30- and 90-day readmission compared with no such prescriptions.

Meaning  Findings from this study suggest that preoperative metformin prescriptions may be associated with decreased postoperative mortality and readmission compared with no preoperative exposure to this medication, but further research is needed to ascertain if this relationship is causal.

Abstract

Importance  Adults with comorbidity have less physiological reserve and an increased rate of postoperative mortality and readmission after the stress of a major surgical intervention.

Objective  To assess postoperative mortality and readmission among individuals with diabetes with or without preoperative prescriptions for metformin.

Design, Setting, and Participants  This cohort study obtained data from the electronic health record of a multicenter, single health care system in Pennsylvania. Included were adults with diabetes who underwent a major operation with hospital admission from January 1, 2010, to January 1, 2016, at 15 community and academic hospitals within the system. Individuals without a clinical indication for metformin therapy were excluded. Follow-up continued until December 18, 2018.

Exposures  Preoperative metformin exposure was defined as 1 or more prescriptions for metformin in the 180 days before the surgical procedure.

Main Outcomes and Measures  All-cause postoperative mortality, hospital readmission within 90 days of discharge, and preoperative inflammation measured by the neutrophil to leukocyte ratio were compared between those with and without preoperative prescriptions for metformin. The corresponding absolute risk reduction (ARR) and adjusted hazard ratio (HR) with 95% CI were calculated in a propensity score–matched cohort.

Results  Among the 10 088 individuals with diabetes who underwent a major surgical intervention, 5962 (59%) had preoperative metformin prescriptions. A total of 5460 patients were propensity score–matched, among whom the mean (SD) age was 67.7 (12.2) years, and 2866 (53%) were women. In the propensity score–matched cohort, preoperative metformin prescriptions were associated with a reduced hazard for 90-day mortality; ARR, 1.28%  and hazard of readmission, with mortality as a competing risk at both 30 days and 90 days. Preoperative inflammation was reduced in those with metformin prescriptions compared with those without. E-value analysis suggested robustness to unmeasured confounding.

Conclusions and Relevance  This study found an association between metformin prescriptions provided to individuals with type 2 diabetes before a major surgical procedure and reduced risk-adjusted mortality and readmission after the operation. This association warrants further investigation.

 

Related: Diabetes UK Metformin associated with reduced mortality rates after major surgery

JAMA Surgery

Obesity, unfavourable lifestyle and genetic risk of type 2 diabetes: a case-cohort study

Schnurr, T.M.. et al. (2020). Obesity, unfavourable lifestyle and genetic risk of type 2 diabetes: a case-cohort study. Diabetologia. https://doi.org/10.1007/s00125-020-05140-5

A study reports that obesity is the greatest risk factor for developing type 2 diabetes. The case-cohort studied over 400 Danes who developed type 2 during follow up as part of a different study, their data was compared to a sample of more than 5000 individuals, who were randomly selected. The findings,published in Diabetologica, show a risk factor eight times greater for those with obesity

Abstract

Aims/hypothesis

We aimed to investigate whether the impact of obesity and unfavourable lifestyle on type 2 diabetes risk is accentuated by genetic predisposition.

Methods

We examined the joint association of genetic predisposition, obesity and unfavourable lifestyle with incident type 2 diabetes using a case-cohort study nested within the Diet, Cancer and Health cohort in Denmark. The study sample included 4729 individuals who developed type 2 diabetes during a median 14.7 years of follow-up, and a randomly selected cohort sample of 5402 individuals. Genetic predisposition was quantified using a genetic risk score (GRS) comprising 193 known type 2 diabetes-associated loci (excluding known BMI loci) and stratified into low (quintile 1), intermediate and high (quintile 5) genetic risk groups. Lifestyle was assessed by a lifestyle score composed of smoking, alcohol consumption, physical activity and diet. We used Prentice-weighted Cox proportional-hazards models to test the associations of the GRS, obesity and lifestyle score with incident type 2 diabetes, as well as the interactions of the GRS with obesity and unfavourable lifestyle in relation to incident type 2 diabetes.

Results

Obesity (BMI more than or equal to 30 kg/m2) and unfavourable lifestyle were associated with higher risk for incident type 2 diabetes regardless of genetic predisposition. The effect of obesity on type 2 diabetes risk was high, whereas the effects of high genetic risk and unfavourable lifestyle were relatively modest. Even among individuals with low GRS and favourable lifestyle, obesity was associated with a more than 8-fold risk of type 2 diabetes compared with normal-weight individuals in the same GRS and lifestyle stratum.

Conclusions/interpretation

Having normal body weight is crucial in the prevention of type 2 diabetes, regardless of genetic predisposition.

Abstract from Diabetologica

Related:

Diabetes UK Obesity is greatest risk factor for type 2 diabetes irrespective of genetics

 

Association of Childhood Family Connection With Flourishing in Young Adulthood Among Those With Type 1 Diabetes

Whitaker, R.C. et al. (2020) Association of Childhood Family Connection With Flourishing in Young Adulthood Among Those With Type 1 Diabetes. JAMA Netw Open|3| (3):e200427. doi:10.1001/jamanetworkopen.2020.0427

Research published in the journal JAMA Network Open explored the research question: Is family connection during childhood associated with greater levels of flourishing in young adulthood among those with type 1 diabetes.

Abstract

Importance  Higher levels of childhood family connection have been associated with measures of adult flourishing or eudaimonic well-being, such as purpose, self-acceptance, positive relationships, and growth. However, this association has not been examined among those with childhood-onset chronic disease.

Objectives  To investigate whether higher levels of childhood family connection were associated with greater flourishing in young adulthood among those with type 1 diabetes and, secondarily, whether this association was present across levels of adverse childhood experiences and childhood social position.

Design, Setting, and Participants  In 2017, the cross-sectional Type 1 Flourish survey was administered to all 743 young adults, aged 18 to 29 years, with type 1 diabetes who had received outpatient care in 2016 at a diabetes specialty clinic in New York, New York. Eligible participants completed the survey online or during clinic visits. Data analyses were conducted in September and October 2019.

Exposures  The main exposure was childhood family connection (sample-defined tertiles), based on scores from a 7-item scale assessing parental attention, affection, and communication during childhood. Adverse childhood experiences, childhood social position, and other sociodemographic characteristics were also reported. Recent hemoglobin A1c levels were abstracted from medical records.

Main Outcomes and Measures  Flourishing score calculated from the 42-item Psychological Well-being Scale developed by Ryff.

Results  The survey was completed by 423 of 743 patients (56.9%), and the analysis included 415 participants (98.1%) with complete data on family connection and flourishing. The mean (SD) age of the sample was 25.0 (3.2) years, with 246 (59.3%) female respondents and 288 (69.6%) non-Hispanic white respondents. The mean (SD) flourishing score was 221.8 (37.7). After adjusting for age, sex, race/ethnicity, education, income, age at type 1 diabetes diagnosis, and hemoglobin A1c level, mean flourishing scores increased from the lowest to medium to highest tertiles of family connection; compared with those in the lowest tertile of family connection, the flourishing scores were 1.04 SD units higher among those in the highest tertile and 0.64  SD units higher among those in the middle tertile. This association was also present across levels of childhood adversity. In the subgroup of respondents with 2 or more adverse childhood experiences, those in the highest tertile of family connection had adjusted flourishing scores 0.76 SD units higher than those in the lowest tertile. In the subgroup with low childhood social position, those in the highest tertile of family connection had flourishing scores 1.08 SD units higher than those in the lowest tertile.

Conclusions and Relevance  In this cross-sectional study of young adults with type 1 diabetes, higher levels of childhood family connection were associated with greater flourishing in young adulthood across levels of childhood adversity. Beyond disease management, clinician support of family connection may help children with type 1 diabetes flourish in adulthood.

 

Full article available from JAMA Open Network

Early puberty and risk for type 2 diabetes in men

Ohlsson, C., Bygdell, M., Nethander, M. et al. 2020. Early puberty and risk for type 2 diabetes in men. Diabetologia.  https://doi.org/10.1007/s00125-020-05121-8

Data from more than 30000 Swedish males such as their BMI was used to evaluate the association between pubertal timing and risk of adult type 2 diabetes. 

Abstract

Aims/hypothesis

The association between pubertal timing and type 2 diabetes, independent of prepubertal BMI, is not fully understood. The aim of the present study was to evaluate the association between pubertal timing and risk of adult type 2 diabetes, independent of prepubertal BMI, in Swedish men.

Methods

We included 30,697 men who had data for BMI at age 8 and 20 years and age at Peak Height Velocity (PHV), an objective assessment of pubertal timing, available from the BMI Epidemiology Study Gothenburg (BEST Gothenburg), Sweden. Information on type 2 diabetes (n = 1851) was retrieved from the Swedish National Patient Register. HRs and 95% CIs were estimated by Cox regression analysis. We observed violations of the assumption of proportional hazards for the association between age at PHV and the risk of type 2 diabetes and therefore split the follow-up period at the median age of type 2 diabetes diagnosis (57.2 years of age) to define early (≤57.2 years) and late (>57.2 years) type 2 diabetes diagnosis.

Results

Age at PHV was inversely associated with both early (HR 1.28 per year decrease in age at PHV, 95% CI 1.21, 1.36) and late (HR 1.13, 95% CI 1.06, 1.19) type 2 diabetes. After adjustment for childhood BMI, the associations between age at PHV and both early (HR 1.24, 95% CI 1.17, 1.31) and late (HR 1.11, 95% CI 1.05, 1.17) type 2 diabetes were similar. Moreover, early age at PHV predicted insulin treatment of type 2 diabetes (OR 1.25 per year decrease in age at PHV, 95% CI 1.17, 1.33). Assuming a higher risk among those with an age at PHV below the median, the population attributable factor indicates that 15% fewer of the diagnosed individuals would have developed type 2 diabetes had they not reached puberty early.

Conclusions/interpretation

These findings indicate that early puberty may be a novel independent risk factor for type 2 diabetes.

Impact of obesity on the increasing incidence of type 1 diabetes

Buzzetti, R. Zampetti, S., & Pozzilli, P. 2020 Impact of obesity on the increasing incidence of type 1 diabetes. Diabetes, obesity and metabolism.  https://doi.org/10.1111/dom.14022

Abstract

Published estimates of the incidence of type 1 diabetes (T1D) in children in the last decade varies between 2% and 4% per annum. If this trend continued, the disease incidence would double in the next 20 years. The risk of developing T1D is determined by a complex interaction between multiple genes (mainly human leukocyte antigens) and environmental factors. Notwithstanding that genetic susceptibility represents a relevant element in T1D risk, genetics alone cannot explain the increase in incidence. Various environmental factors have been suggested as potential triggers for T1D, including several viruses and the hygiene hypothesis; however, none of these seems to explain the large increase in T1D incidence observed over the last decades. Several studies have demonstrated that the prevalence of childhood/adolescence overweight and obesity has risen during the past 30 years in T1D. Currently, at diagnosis, the majority of patients with T1D have normal or elevated body weight and ~50% of patients with longstanding T1D are either overweight or obese. The growing prevalence of obesity in childhood and adolescence offers a plausible explanation for the increase in T1D incidence observed in recent decades. Possible mechanisms of the enhancement of β‐cell autoimmunity by obesity include: a) insulin resistance‐induced β‐cell secretory demand triggering autoimmunity through cytokine release, neo‐epitope antigen formation and increase in β‐cell apoptosis, and b) obesity‐induced low‐grade inflammation with pro‐inflammatory cytokines secreted by locally infiltrating macrophages, which contribute to the presentation by islet cells of autoantigens generally not accessible to T cells. Further studies are needed to clarify whether the control of body weight can prevent or delay the current and continuing rise in T1D incidence.

 

The full article is available from Diabetes, obesity and metabolism