Diabetes and Obesity Combo a Major Red Flag in Pregnancy

Type 2 diabetes and obesity in pregnancy is a daunting duo, according to new research published this month in The Journal of Maternal-Fetal and Neonatal Medicine. The study shows that both conditions independently contribute to higher risks, opening the door to a wide range of pregnancy, delivery and newborn complications.

Study authors say the findings are important because obesity and type 2 diabetes are skyrocketing in women of childbearing age. A study in The Journal of the American Medical Association reports that between 2007 and 2008 the prevalence of obesity among adult women in the United States was more than 35 percent. A report from the Centers for Disease Control and Prevention states that approximately 11 percent of women above the age of 20 had diabetes in 2010.

Loralei Thornburg, M.D., senior study author and a high-risk pregnancy expert at the University of Rochester Medical Center, emphasizes that the research is needed now more than ever. “We’ve never seen the degree of obesity and type 2 diabetes in women that we are seeing right now, because for a very long time diabetes was a disease of an older population, so we rarely dealt with it in prenatal care. We hope this new knowledge will help physicians better understand and care for this rapidly expanding group of high-risk women.”

While numerous studies have established that obesity, in the absence of diabetes, is associated with problems in pregnancy – preterm birth, birth trauma, blood loss and a prolonged hospital stay, to name a few – less is known about type 2 diabetes and what causes difficulties when the two conditions coexist. Researchers from Rochester wanted to determine if obesity alone accounts for the increased risks in this “dual-diagnosis” group, or if diabetes plays a role as well.

To determine the influence of obesity and type 2 diabetes when the conditions coexist in pregnancy, Thornburg and lead study author Kristin Knight, M.D., used clinical records and the hospital’s birth certificate database to identify 213 pairs of women who delivered babies at the Medical Center between 2000 and 2008. Each pair included a diabetic and a non-diabetic patient with approximately the same pre-pregnancy body mass index (BMI). The majority of women in the study were overweight, obese or morbidly obese.

“We matched the pairs pound for pound, because if obesity was the main problem, we’d see similar outcomes between women, whether they had diabetes or not. But if we saw different outcomes between pairs, we’d know the diabetes was impacting outcomes as well,” said Thornburg.

Using mathematical models and controlling for outside factors, such as age and tobacco use, researchers found that the patients with type 2 diabetes had overall worse pregnancy, delivery and newborn outcomes than their BMI-matched counterparts. Specifically, diabetic patients had higher rates of preeclampsia, cesarean delivery, shoulder dystocia, preterm delivery, large for gestational age infant, fetal anomaly and admission to the neonatal intensive care unit.

“Women and their physicians need to be aware that each condition on its own increases risk in pregnancy, so when they coexist the situation is even more worrisome,” said Knight, a maternal fetal medicine fellow at Rochester. “Pregnancy is a time of great change, and fortunately many women are very open to making modifications during this period in their life. Anything a woman can do to improve her condition, from controlling blood sugar and exercising, to eating nutritious foods and maintaining an optimal weight, will help her deliver a healthier baby.”

Knight originally focused her research on the effects of type 1 and type 2 diabetes on pregnancy. In a previous study, she found that women with type 2 diabetes, most of whom were also obese, had poorer outcomes. Consequently, her research turned to obese, type 2 diabetics and their experiences in pregnancy.

“If a woman enters pregnancy obese, but hasn’t developed type 2 diabetes, she is in a better place than if she had both,” concluded Thornburg.

In addition to Knight and Thornburg, Eva K. Pressman, M.D., and David N. Hackney, M.D., from the Medical Center, also participated in the research.

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Obesity in Early Adulthood Associated With Increased Risk of Psoriatic Arthritis

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Chicago — Among persons with psoriasis, those who reported being obese at age 18 had an increased risk of developing psoriatic arthritis, according to a report in the July 19 issue of Archives of Dermatology, one of the JAMA/Archives journals.

Psoriatic arthritis is a specific type of arthritis that develops in the joints of some patients who have psoriasis. According to background information in the article, “obesity has emerged as a significant risk factor for psoriasis,” and “psoriatic arthritis affects 6 percent to 42 percent of people with psoriasis.” Additionally, “psoriatic arthritis shares some clinical features with rheumatoid arthritis, both leading to joint destruction and significant morbidity.”

Razieh Soltani-Arabshahi, M.D., of the University of Utah School of Medicine, Salt Lake City, and colleagues studied a volunteer sample of patients with dermatologist-diagnosed psoriasis enrolled in the Utah Psoriasis Initiative from November 2002 to October 2008. Of the 943 participants, 50.2 percent were women and psoriatic arthritis was present in 26.5 percent of participants with psoriasis (250 persons).

The study found that body mass index (BMI) at age 18 was predictive of psoriatic arthritis. Other predictors included younger age at psoriasis onset, being female and having larger body surface areas affected with psoriasis. Additionally, the findings show “the obese group having an earlier onset of psoriatic arthritis, followed by the overweight group and finally the normal BMI group.” Twenty percent of the overweight or obese group developed psoriatic arthritis by age 35 years while 20 percent of those individuals in the normal BMI group developed psoriatic arthritis by age 48.

The authors conclude that their findings, “support a growing concept that patients more prone to psoriatic arthritis might benefit from more frequent and meticulous screening measures for early detection and treatment of psoriatic arthritis, i.e., before the development of irreversible joint destruction.”

Bariatric Surgery in Diabetic Adults Improves Insulin Sensitivity Better than Diet

San Diego, CA — Gastric bypass surgery improves Type 2 diabetes by other mechanisms in addition to weight loss and does so better than a low-calorie diet despite achieving equal weight loss, a new study finds. The results will be presented Monday at The Endocrine Society’s 92nd Annual Meeting in San Diego.

“Our study shows that in the short term, weight loss by diet alone does not achieve the same improvements in diabetes as gastric bypass surgery,” said the presenting author, Judith Korner, MD, PhD, assistant professor of medicine at Columbia University College of Physicians and Surgeons, New York.

Korner and her colleagues found that gastric bypass surgery better improved insulin sensitivity, the body’s ability to successfully clear glucose sugar from the bloodstream into the cells. Insulin sensitivity is impaired in people with Type 2 diabetes, and obesity adds to this problem. The result is a buildup of sugar in the blood.

The study compared the effects on diabetic adults of a low-calorie diet versus Roux-en-Y gastric bypass, the most common gastric bypass procedure. Roux-en-Y gastric bypass decreases the size of the stomach and reroutes the digestive tract to bypass most of the stomach and part of the small intestine. After gastric bypass, many diabetic patients achieve normal blood glucose control or vastly improved control, and some may no longer require diabetes medications.

In the study, seven obese patients with Type 2 diabetes received a daily 800-calorie liquid diet and no surgery, while seven other obese diabetic adults underwent gastric bypass surgery. The study ended when both groups lost the same amount of weight: an average of 8 percent of body weight. However, the surgery-treated patients lost the weight faster: in about 3.5 weeks compared with 8 weeks for the dieters.

Surgical patients were able to discontinue all of their diabetes medications by the study’s end, but the dieters reduced their medication use by 55 percent, Korner reported.

The researchers found significant improvements in the surgery group in measures of insulin sensitivity and function of beta cells, the insulin-producing cells in the pancreas. Improvements in insulin sensitivity in the low-calorie diet group were not statistically significant and beta cell function improved to a lesser extent.

Korner speculated that hormonal changes may be responsible for the improvements resulting from Roux-en-Y surgery in individuals with Type 2 diabetes.

“It will be important to understand how surgery works to produce these results so that we can develop medical therapies of equivalent efficacy,” she said.

The National Institute of Diabetes and Digestive and Kidney Diseases funded this study.

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Obese women who have bariatric surgery before getting pregnant are at significantly lower risk for developing dangerous hypertensive disorders during pregnancy than those who don’t, according to a study of medical insurance records by Johns Hopkins experts.

Hypertensive disorders in pregnancy — which include gestational hypertension, preeclampsia and eclampsia — complicate an estimated 7 percent of pregnancies in the United States. Researchers say they are much more common in obese women, who make up a third of women of childbearing age.

“We have long known that women who have these blood pressure disorders are not only at an increased risk for pregnancy complications in themselves and their babies, but also for chronic diseases in the future,” says Wendy L. Bennett, M.D., M.P.H., assistant professor of medicine at the Johns Hopkins University School of Medicine and a study leader. “Can we prevent the development of these disorders in pregnancy with bariatric surgery? These findings suggest the answer may be ‘yes.’”

Results of the research are published online in the British Medical Journal.

Before and after bariatric surgery

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New Study May Explain How Weight-loss Surgery Reverses Type 2 Diabetes

California – A team of researchers, led by a UC Davis veterinary endocrinologist, has shown for the first time that a surgical procedure in rats that is similar to bariatric surgery in humans can delay the onset of type 2 diabetes. The researchers also have identified biochemical changes caused by the surgeries that may be responsible for that delay.

Findings from the study, published online in the journal Gastroenterology, should help researchers identify strategies for preventing and treating type 2 diabetes, a chronic condition in which the body is unable to properly metabolize sugar and fat, leading to serious complications including heart disease, blindness and kidney failure.

Type 2 diabetes affects more than 21 million people in the United States, where it results in more than $150 billion in direct and indirect annual costs, according to the National Institutes of Health.

“Bariatric surgery currently is considered to be the most effective long-term treatment for human obesity and often leads to marked improvements in diabetes,” said the study’s lead author Peter Havel, a professor with joint appointments in the School of Veterinary Medicine and Department of Nutrition.

“It has been thought that reduction of blood sugar, which indicates a reversal of type 2 diabetes, in patients following bariatric surgery was due to post-surgery weight loss,” Havel said. “This study, however, supports the observations from a number of earlier clinical studies reporting that diabetes is often improved prior to substantial weight loss. It also suggests that endocrine changes in hormones produced by the gastrointestinal tract may contribute to the early effects of bariatric surgery, in addition to the later effects of weight loss.”

“This study confirms our clinical observations that metabolic regulation — specifically homeostasis of glucose — occurs quickly after gastric bypass surgery,” said Mohamed Ali, an associate professor of gastrointestinal surgery and a specialist in bariatric surgery at UC Davis Health System. “It’s clear from the outcome that something physiologic is at work with controlling diabetes that is not related to weight loss.

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Obese Teens Who Receive Gastric Banding Achieve Significant Weight Loss

Chicago — A higher percentage of severely obese adolescents who received laparoscopic adjustable gastric banding lost more than 50 percent of excess weight and experienced greater benefits to health and quality of life compared to those in an intensive lifestyle management program, according to a study in the February 10 issue of JAMA.

Adolescent obesity is a serious health challenge globally. In the U.S., more than 17.4 percent, or more than 5 million adolescents were obese in 2004, an increase from 14.8 percent in 2000. Obesity is associated with both immediate and late health effects and reduced life expectancy, according to background information in the article. Lifestyle programs that have included changes in diet, exercise, and behavior to promote weight loss often have poor results. “Bariatric surgery is now extensively used for adults and is being evaluated for adolescents,” the authors write. “Laparoscopic adjustable gastric banding (gastric banding) has the potential to provide a safe and effective treatment.”

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Obesity Now Poses As Great a Threat to Quality of Life As Smoking

San Diego, CA – As the US population becomes increasingly obese while smoking rates continue to decline, obesity has become an equal, if not greater, contributor to the burden of disease and shortening of healthy life in comparison to smoking. In an article published in the February 2010 issue of the American Journal of Preventive Medicine, researchers from Columbia University and The City College of New York calculate that the Quality-Adjusted Life Years (QALYs) lost due to obesity is now equal to, if not greater than, those lost due to smoking, both modifiable risk factors.

QALYs use preference-based measurements of Health-Related Quality of Life (HRQOL) which allow a person to state a relative preference for a given health outcome. Since one person may value a particular outcome differently than another person, these measures capture how each respondent views his or her own quality of life.

The 1993–2008 Behavioral Risk Factor Surveillance System (BRFSS), the largest ongoing state-based health survey of US adults, has conducted interviews of more than 3,500,000 individuals; annual interviews started with 102,263 in 1993 and culminated with 406,749 in 2008. This survey includes a set of questions that measures HRQOL, asking about recent poor health days and tracking overall physical and mental health of the population. The authors analyzed these data and converted the measures to QALYs lost due to smoking and obesity.

From 1993 to 2008, when the proportion of smokers among US adults declined 18.5%, smoking-related QALYs lost were relatively stable at 0.0438 QALYs lost per population. During the same period, the proportion of obese people increased 85% and this resulted in 0.0464 QALYs lost. Smoking had a bigger impact on deaths while obesity had a bigger impact on illness.

Investigators Haomiao Jia, PhD and Erica I. Lubetkin, MD, MPH, state, “Although life expectancy and QALE have increased over time, the increase in the contribution of mortality to QALYs lost from obesity may result in a decline in future life expectancy. Such data are essential in setting targets for reducing modifiable health risks and eliminating health disparities.”

The article is “Trends in Quality-Adjusted Life-Years Lost Contributed by Smoking and Obesity” by Haomiao Jia, PhD, and Erica I. Lubetkin, MD, MPH. The article appears in the American Journal of Preventive Medicine, Volume 38, Issue 2 (February 2010) published by Elsevier.

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Reproductive Health Findings for Bariatric Patients: Obesity at Young Age Increases Likelihood of Infertility and Polycystic Ovarian Syndrome; Chances of Pregnancy and Live Birth Are Good

In an observational study of the reproductive health of women undergoing bariatric surgery, researchers analyzed data from 1,538 patients treated at six US clinical sites participating in the Longitudinal Assessment of Bariatric Surgery (LABS) study, supported by the National Institutes of Health.

The participants were measured for height and weight and answered questions about their sexual history, pregnancy history, infertility history, history of polycystic ovarian syndrome (PCOS), history of contraceptive use, and plans for future pregnancy. The participants also completed a validated self-administered weight history, giving their weights at 18, 25 and 30 years.

The researchers found that women who became obese by age 18 were more likely to have a history of infertility and polycystic ovarian syndrome and less likely to become pregnant than women who became obese later in life. However, the overall percentages of LABS-2 participants who had at least one pregnancy (79%) and at least one live birth (74%) were comparable to the general US population.

While about half of the women surveyed between ages 18 and 44 and not reporting menopause, sterilization, partner sterilization, or other impediments to pregnancy said that they would never try to become pregnant after bariatric surgery, 30% of women in this category thought the possibility of future pregnancy was very important. Of those women, almost 33% planned to get pregnant within two years of having bariatric surgery.

“As the incidence of obesity increases in the United States, women’s health care practitioners are likely to care for a substantial number of patients who will undergo bariatric surgery. Studies like this one are extremely useful to help us determine how to advise these patients and best meet their needs,” remarked William Gibbons, MD, President-Elect of the American Society for Reproductive Medicine.

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