Gestational diabetes mellitus (GDM)

1 Defining the condition
The widely accepted definition is that given by the American Diabetes Association (ADA) ‘…any degree of glucose intolerance with onset or first recognition during pregnancy’ [5]. The definition is applicable even if ‘the condition persists after pregnancy’. ‘It does not exclude the possibility that unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy.’ The widespread acceptance of this definition is in no small part due to the fact that it does not mention any specific diagnostic criteria. Any definition of GDM has to take into account three elements of risk – of perinatal morbidity and mortality in the current pregnancy, of the mother developing type 2 diabetes, and of intra-uterine programming of the developing fetus with subsequent expression of disorders in later life.

2 Diagnosis of GDM
There is a continuum of risk for maternal glucose levels and, at least, adverse pregnancy outcomes [6-11]. Currently there is a lack of international consensus regarding the diagnostic
criteria for GDM. In most parts of the world the diagnostic criteria are based on either the 100 gram 3-hour test as commonly used in the USA or the 75 gram 2-hour World Health Organization (WHO) test. Many national bodies have derived their own criteria based on local experience and their healthcare delivery systems. This lack of consensus may well be addressed by recommendations arising from the International Association of Diabetes in Pregnancy Study Groups (IADPSG), a working group analysing the results of the HAPO study. Any recommendations from this group will then need to be considered by relevant national
bodies and incorporated into the local health service arrangements. This process will take some time. Other than by chance, it is not clear if any diagnostic criteria of GDM
based exclusively on pregnancy outcomes will be applicable to the other two elements of risk.

3 Rationale for treating GDM
It is generally acknowledged that women with GDM are at increased risk of adverse pregnancy outcomes, particularly relating to perinatal mortality and morbidity. It
is also generally acknowledged that treatment of women with GDM, by whatever means, can reduce the risk of these problems. In the developed world an increased perinatal mortality rate is unlikely but can still be demonstrated in a sufficiently large series [12]. However, in
settings where obstetric care does not uniformly reach modern quality standards, perinatal mortality is still an important issue [13].
Perinatal morbidity is an ongoing concern. Macrosomic or large-for-gestational-age (LGA) infants are still common, and can be considered a surrogate marker for at least
some of the effects of intra-uterine programming.  An earlier prospective controlled trial demonstrated that ‘tight’ control, with a high rate of insulin use, improved perinatal
outcomes [14]. Later, a prospective non-randomized intervention study demonstrated for women with GDM that intensive control (versus conventional control) improved
perinatal outcomes to a level that was comparable to a group without GDM [15]. The hazards of a late diagnosis of GDM, and therefore effectively no treatment, have been
outlined [16]. The Australian Carbohydrate Intolerance Study in Pregnancy (ACHOIS), a blinded randomized trial including 1000 women, designed to examine whether the treatment
of women with GDM would reduce perinatal complications, found a significant reduction in serious perinatal complications in the treated group [17]. Recently the results of the
Maternal-Fetal Medicine Unit (MFMU) Network study have become available. Treating women with designated ‘mild’ GDM lowered the risk for many adverse pregnancy outcomes [18].
Limited observational studies in humans strongly suggest that any pregnancy complicated by hyperglycaemia confers a risk to the offspring of developing type 2 diabetes [19-24],
and that improving maternal glycaemic control may reduce this risk. However, the long follow-up necessary makes it unlikely that any randomized controlled trial (RCT) evidence will be forthcoming in the foreseeable future

The ABCs of Diabetes

The most motivated clients I work with are those who have already had a stroke or heart attack, or who have gotten one or more of the complications of diabetes. Because they now realize that  merely knowing their blood glucose numbers isn't enough to safeguard their health , these clients take great care to control their diabetes. I'm going to discuss some other important numbers you can use to track how well you are controlling your diabetes. 

Diabetes Acts Like Cardiovascular Disease

This disease can produce many of the same ills and impairments as heart disease does in the body. For example, the risk of heart disease or stroke in someone with diabetes is two to four times higher than for a person without diabetes. This is why, in order to get good control over your diabetes, you must know several other important numbers.

I often ask my clients if they know their A1C or cholesterol levels, and their answer is often, "No, but my doctor said it was OK." Please don't allow yourself to have such a vague notion about numbers as important as these. Diabetes is often a "silent disease" until its complications hit. Avoiding these serious risks of diabetes should be your incentive to take control and to know your numbers.

One way to remember your numbers is by the ABCs.

"A" is for your A1C Level

This number is an average of your blood glucose levels over the last two to three months. The American Diabetes Association (ADA) recommends that you aim for an A1C level of seven percent or less. Something called the estimated average glucose, or eAG, is another way to report A1C. This number converts your A1C into what the actual glucose reading on your meter would be. For example, an A1C of seven percent is equivalent to an eAG of 154 mg/dL.

If your A1C is above seven percent, lowering it by just one percentage point reduces your risk of developing kidney, eye, or nerve diseases by 40 percent. Your doctor should do an A1C test at least every 6 months--more often if you're not below the recommended seven percent target. Know your number.

"B" is for your Blood Pressure

People with diabetes need to keep their blood pressure a bit lower than does the general population--less than 130/80 mmHg. This is necessary because if your blood pressure is higher than this, your risks of stroke, heart attack, and kidney disease are also higher. Get your blood pressure checked every time you see a doctor--and know your number.

"C" is for your Cholesterol

Your cholesterol level is not just a single number. The medical term to describe a person's cholesterol status is a "lipid profile," and it consists of your total cholesterol, your LDL (or "bad") cholesterol, your HDL (or "good") cholesterol, and your triglycerides. Targets for your lipid panel are:

• Total cholesterol -- less than 200 mg/dL
• LDL, or "bad" cholesterol -- less than 100 mg/dL
• HDL, or "good" cholesterol -- greater than 40 mg/dL for men and greater than 50 mg/dL for women
• Triglycerides -- less than 150 mg/dL

Keeping your cholesterol levels in check can also prevent a stroke or heart attack. Know your numbers.

How to use these numbers 

If your numbers show that you are meeting your ABC goals, great work! If not, talk with your health care team about what steps you can take to get your numbers under better control.

Don't let a stroke or heart attack or a serious complication of diabetes suddenly motivate you to get control of your diabetes. Make the changes today that will allow you to know and control your ABCs.

Diabetes drugs tied to pancreatic cancer risk

SUMMARY: Women taking the diabetes drug metformin had fewer cases of pancreatic cancer. Other diabetes drugs were linked with a higher risk. Men on metformin did not have the same lowered risk as women.

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NEW YORK (Reuters Health) - A new study links the diabetes drug metformin to fewer cases of pancreatic cancer -- at least in women -- but finds other diabetes medications are associated with a higher risk of the disease.

The differences in medication history among people who did or didn't get pancreatic cancer were small, researchers said, and it's unclear why the drugs might affect cancer risks in men and women differently.

Still, the new finding is in line with previous research suggesting that metformin may decrease the risk of multiple cancers, said Dr. Peter Butler, a diabetes researcher at the University of California, Los Angeles David Geffen School of Medicine, who wasn't involved in the new study.

"One theme that seems to be coming through... is that the oldest drug we have for diabetes, metformin, is undoubtedly the best drug we have for diabetes," he told Reuters Health.

Pancreatic cancer is relatively rare as far as cancers go, but progresses quickly; most people don't survive more than a couple years after diagnosis. The National Cancer Institute estimates that about 44,000 people will be diagnosed with pancreatic cancer in the United States this year, and close to 38,000 will die from the disease.

Research has suggested that people with pancreatic cancer may have an increased risk of diabetes, but it's unclear how diabetes -- and the drugs used to treat it -- may affect pancreatic cancer risks in previously cancer-free people.

To help answer that question, Dr. Christoph Meier of the University Hospital Basel in Switzerland and his colleagues consulted a database of more than eight million people in the UK, including about 2,800 who were diagnosed with pancreatic cancer between 1995 and 2009.

For each of those people, they found another six of the same age and gender that didn't have pancreatic cancer to serve as a comparison group.

Using records from primary care doctors, the researchers determined how many people in the pancreatic cancer and cancer-free groups had previously been diagnosed with diabetes and were on an anti-diabetes drug, such as metformin or sulfonylureas, which include glimepiride and glyburide.

Those drugs cause the body to make or absorb less glucose (metformin) or to produce more insulin (sulfonylureas) to keep blood sugar levels in check.

One in nine people with pancreatic cancer had a prior diagnosis of diabetes, compared to about one in twelve in the cancer-free comparison group, according to findings published Tuesday in the American Journal of Gastroenterology.

According to their medical records, two percent of people with pancreatic cancer had been taking metformin long-term before they were diagnosed, compared to 1.6 percent of the group without cancer -- a difference that could have been due to chance.

But when the researchers separated the records by gender, they found that significantly fewer women with a new diagnosis of pancreatic cancer had been taking metformin for at least a few years, compared to cancer-free women.

That was after the researchers had already taken into account whether women were overweight or obese and if they smoked or drank alcohol.

The association in one gender but not the other was "somewhat unexpected," according to Meier's team, and there's no clear biology-based way to explain why metformin might help protect women against pancreatic cancer, but not men.

The findings were reversed for insulin and sulfonylureas in the study population. Significantly more people with pancreatic cancer had a history of long-term use of those drugs than cancer-free people.

Craig Currie, who has studied diabetes drugs and cancer at the Cardiff University School of Medicine in the UK, said it makes sense that insulin and sulfonylureas would increase the risk of pancreatic cancer. Insulin promotes cancer growth, he said, and also acts directly on the pancreas.

The study's investigators "raise doubts about these treatments," he told Reuters Health in an email.

"There is a possibility that exogenous insulin (insulin that's not made naturally by the body) is of questionable safety in people with type 2 diabetes," added Currie, who didn't participate in the new research.

Still, absolute differences in medication use were small even in people with cancer: less than one percent of those with or without pancreatic cancer had taken insulin long-term. Sulfonylurea users accounted for just over three percent of people with a new pancreatic cancer diagnosis and two percent without cancer.

Butler said it's hard to tease out what cancer risks may be due to the drugs, and what could be a result of poor diet and lack of exercise, for example, in people with diabetes. He said that more research will be needed to tease out those specific effects.

"Honestly for patients at this point, I think this is another piece of the jigsaw puzzle," Butler said.

"This paper in itself would not cause me to recommend a change in treatment for people."

That said, Butler concluded that evidence suggests most people with type 2 diabetes who don't have any medical reasons not to take metformin should be on the drug, either alone or in combination with other anti-diabetes medications.

SOURCE: http://bit.ly/kkA6Tc American Journal of Gastroenterology, online January 31, 2012.