Postprandial Glucose Values Research Articles

Unrecognized hypo- and hyperglycemia in well-controlled patients with type 2 diabetes mellitus: the results of continuous glucose monitoring.

The aim of this study was to determine the prevalence and extent of glycemic excursions (hypo- and hyperglycemic) in elderly patients with well-controlled type 2 diabetes using a Continuous Glucose Monitor System (CGMS) (Medtronic MiniMed). Elderly patients (>65 years old) with type 2 diabetes were recruited if their glycosylated hemoglobin (HbA1c) was <7.5% and if their oral hypoglycemic therapy included a sulfonylurea. Patients were asked to undergo two consecutive 72-h periods of continuous glucose monitoring at baseline and then again at 1 month (total 288 h). Patients were asked to record four self-monitored capillary blood glucose levels each day for calibration of the monitor and also to record meal times, exercise, and symptoms of hypoglycemia. The number of hyperglycemic (>144 mg/dL), hypoglycemic (<50 mg/dL), and borderline-hypoglycemic (50-65 mg/dL) events were determined (an event was defined as a glucose value that persisted for at least 15 min with or without symptoms). Twenty-five patients (21 men, four women) 73.9 +/- 4.4 years old with an HbA1c of 6.2 +/- 0.8% were each monitored for an average of 187.57 h. The mean glucose values were: fasting, 139 +/- 40 mg/dL; 2 h post-breakfast, 167 +/- 58 mg/dL; 2 h post-lunch, 157 +/- 53 mg/dL; and 2 h post-dinner, 149 +/- 49 mg/dL. Twenty patients (80%) experienced a total of 103 hypoglycemic events, and 14 of these patients experienced 54 events where the glucose levels were </=40 mg/dL. Twenty-four patients (96%) experienced borderline-hypoglycemia (n = 229 events). Patients experienced a mean of 0.62 +/- 0.72 episodes of hypoglycemia (interstitial glucose <50 mg/dL) per day (four to five episodes overall), 0.35 +/- 0.6 episodes per day where the interstitial glucose was </=40 mg/dL (two to three episodes overall), and 1.37 +/- 1.22 episodes of borderline-hypoglycemia (nine to 10 episodes overall). Each episode of hypoglycemia persisted for 78 +/- 73 min, and borderline-hypoglycemia for 45 +/- 11 min. Patients were hypoglycemic 3.3% of the time and borderline-hypoglycemic 3.7% of the time. No episode of hypoglycemia was recorded by any patient in his or her daily diary. High postprandial glucose values (>144 mg/dL 2 h postprandial) were recorded after 57% of all meals (breakfast 60%, lunch 57.5%, dinner 55.2%). The CGMS was generally well tolerated, but 52% of patients could not be studied for the full 12 days of monitoring. Thus hypoglycemia and excessive postprandial glycemic excursions are common in well-controlled patients with type 2 diabetes treated with a sulfonylurea with or without metformin. The CGMS is a useful research and clinical tool to assess glycemia in patients with type 2 diabetes but is not tolerated by all subjects.

Clinical significance of targeting postprandial and fasting hyperglycemia in managing type 2 diabetes mellitus

SUMMARYMeasurement of glycosylated hemoglobin (HbA1C) remains the gold standard for the assessment of glycemic control in patients with type 2 diabetes. Recent investigations have studied the correlations between HbA1C levels and other aspects of glucose metabolism, specifically, postprandial glucose (PPG) and fasting plasma glucose (FPG). The results suggest that PPG is also important to overall glycemic control and may be a better index of glucose regulation than FPG. Further, elevated PPG values have been associated with cardiovascular complications and cardiovascular mortality. Such evidence has led to recommendations that PPG levels be monitored as part of type 2 diabetes management, in addition to HbA1C and FPG. These glycemic parameters are differentially affected by the various classes of oral antidiabetic agents usedin the treatment of type 2 diabetes - sulfonylureas, meglitinides, insulin sensitizers and α-glucosidase inhibitors. The sulfonylureas, for example, lower HbA1C, PPG and FPG, while the meglitinides have virtually no effect on FPG. The insulin sensitizer metformin, on the other hand, does not affect PPG levels, whereas the α-glucosidase inhibitors, in the presence of a high-carbohydrate diet, can effectively lower PPG. Many patients receive combination therapy, thereby benefiting from multiple mechanisms of glucose control, although in most cases insulin must later be added to the regimen in order to effectively suppress FPG. Thus, all aspects of glucose metabolism appear to be clinically relevant and should be monitored for effective diabetes management. Further study will more precisely define the clinical significance of PPG.

The number of abnormal plasma glucose values in the oral glucose tolerance test and the feto-maternal outcome of pregnancy

Objective: With respect to the feto-maternal outcome of pregnancy both appropriate screening and treatment of gestational diabetes mellitus (GDM) remain a matter of debate. Furthermore, the importance of only one abnormal glucose value at the glucose tolerance test (GTT) is still discussed, including the term “gestational impaired glucose tolerance” with normal fasting but an increased 2 h postprandial glucose value. Study design: We have evaluated the feto-maternal outcome of pregnancy in 152 women with abnormal glucose values during the oral 100 g GTT. The data were analysed with respect to the number of abnormal GTT values and compared to age- and body mass index (BMI)-matched control groups including 304 women with normal GTT values. Results: A positive family history of diabetes was found in 24.4% of the GDM women and in 16.4% of the control group. In 45.9% of the women with abnormal GTT values glucose target levels could be obtained by dietary management, 54.1% required additional insulin therapy. Insulin therapy was administered in 32.8% of the women with one abnormal GTT value, in 65.0% of the women with two abnormal values and in 83.3% of the women with three abnormal values. Compared to the age- and BMI-matched control group the percentage of women with hypertension was increased in women with one, two and three abnormal GTT values. The percentage of LGA and macrosomic infants was significantly increased only in women with three abnormal GTT values. Women with one, two or three abnormal GTT values revealed an increased percentage of caesarean section compared to the control group. Conclusions: Our results show that women with three abnormal GTT values are at an overall increased risk with respect to the feto-maternal outcome of pregnancy. Compared to the control group also women with only one abnormal GTT value revealed an increased risk indicating a need for further control and therapy.

Acarbose in the treatment of elderly patients with type 2 diabetes

Aims: To study the effect of acarbose, an α-glucosidase inhibitor, on glycemic control in elderly patients with type 2 diabetes. Methods: Elderly patients with type 2 diabetes treated with diet alone were randomly treated in a double-blind fashion with placebo ( n=99) or acarbose ( n=93) for 12 months. Results: After 12 months of therapy, there was a statistically significant difference in the change in glycated haemoglobin (HbA 1c) (−0.6%) in the acarbose group versus placebo, as well as in the incremental post-prandial glucose values (−2.1 mmol h/l) and mean fasting plasma glucose (−0.7 mmol/l). Although there was no effect of acarbose on insulin release, there was a clear effect of acarbose to decrease relative insulin resistance (−0.8) (HOMA method). In addition, acarbose was generally well tolerated and safe in the elderly; most discontinuations were due to gastrointestinal side effects such as flatulence and diarrhea. There were no cases of hypoglycemia reported, and no clinically relevant changes in laboratory abnormalities or vital signs during the study. Conclusions: Acarbose improves the glycemic profile and insulin sensitivity in elderly patients with type 2 diabetes who are inadequately controlled on diet alone.

The glucose area under the profiles obtained with continuous glucose monitoring system relationships with HbA(lc) in pediatric type 1 diabetic patients.

The purpose of this study was to determine whether the continuous glucose monitoring system (CGMS) (MiniMed, Sylmar, CA) 1) is sufficiently representative of the overall metabolic control as assessed by HbA(1c), 2) could be used to identify a particular blood glucose threshold value affecting hemoglobin glycation; and 3) is able to show any relationship between particular glycemic profiles and HbA(1c) levels. Of 44 pediatric patients with type 1 diabetes who wore CGMS devices, 28 subjects were selected for the study. Criteria for inclusion were high levels of HbA(1c) (> or =8%) for more than 1 year or a history of frequent hypoglycemic episodes and a complete CGMS registration for 72 h. Age of the subjects ranged from 5.7 to 24.8 years, the mean duration of disease was 7.63 +/- 4.75 years, and the mean HbA(1c) value was 8.7 +/- 1.3%. CGMS data were downloaded and glucose profiles were analyzed. The area under each glucose profile was calculated by means of a professional digital planimeter. The glucose profiles showed a high frequency of prolonged hyperglycemic periods (80% of subjects) and a low frequency of postmeal glycemic peaks (29% of subjects). Postlunch values were significantly correlated with HbA(1c) levels, but the correlation disappeared when controlling for glucose area values. Glucose area values significantly correlated with HbA(1c) levels both when considered as a whole (40-400 mg/dl; r = 0.53, P = 0.002) and when considered fractioned (40-150, 40-200, 40-250, 40-300 mg/dl), apart from the 40-90 mg/dl partial area. HbA(1c) levels were significantly decreased 3 and 6 months after use of CGMS (P = 0.05 and 0.03, respectively, paired Student's t test). HbA(1c) levels may be decreased by using the information obtained with the CGMS. Three-day glucose profiles are representative of the overall glucose control, because glucose area values correlate with HbA(1c) levels. The only glucose threshold below which there seems to be no correlation with HbA(1c) is 90 mg/dl. Only glucose area, and not postprandial glucose values, are directly and independently correlated with HbA(1c). Therefore, to improve metabolic control, it is necessary to lower the whole mean 24-h glycemia and not just the postprandial glucose values.

Effect of betamethasone on maternal glucose

Objective: To determine the effect of single and multiple betamethasone courses on maternal fasting and postprandial glucose values. Study design: A prospective cohort study was performed in women receiving betamethasone at 24–34 weeks' gestation. Fasting and 1-h postprandial capillary glucose values were obtained daily following betamethasone therapy for hospitalized patients. A control group comprised outpatients who underwent weekly fasting and postprandial assessments for 3 weeks. Fasting and 1-h postprandial capillary glucose values were compared between control and betamethasone patients using an unpaired t test. Results: Thirty-five women received a single course of therapy, 19 received multiple courses and 28 served as controls. Mean fasting glucose values for control patients fell within a narrow range of 81.6 ± 10.3 to 82.2 ± 6.4 mg/dl for weeks 1–3. Of women receiving betamethasone, 59% of fasting glucose values were greater than 90 mg/dl as compared to 16% of control fasting values (p < 0.001, χ2 test). Mean 1-h postprandial values for control women ranged from 107.7 ± 15.1 to 112.3 ± 20.0 mg/dl for weeks 1-3. Mean 1-h postprandial glucose values were ≤ 140 mg/dl following one, two or three courses of betamethasone therapy. Conclusions: Betamethasone resulted in an acute increase in fasting glucose following a single course of betamethasone, whereas two or more courses of therapy resulted in a continuous elevation of fasting glucose values. One-hour postprandial values were not clinically abnormal.

Effective use of thiazolidinediones for the treatment of glucocorticoid-induced diabetes

We evaluated the efficacy of a thiazolidinedione in the treatment of diabetes induced by glucocorticoids. We examined the effectiveness of troglitazone in seven patients with long-standing steroid-induced diabetes. Five of the seven subjects were treated with insulin alone, one was treated with both insulin and oral therapy and one was treated with oral therapy alone. The mean insulin dose in six of the seven subjects was 0.66±0.09 units/kg per day. Diabetes status was assessed by measuring serum fructosamine, HgbA1c, oral glucose and meal tolerance tests (OGTT and MTT) at baseline and after treatment for 5–8 weeks with troglitazone 400 mg/day. Troglitazone caused a significant decrease in fructosamine (274±32 vs. 217±22 mmol/l; P<0.01) and HgbA1C (7.8±0.4 vs. 7.2±0.4%; P<0.01) as well as decrements in the areas under the OGTT 2,308±156 vs. 1,937±127 mmol/l; P<0.05) and MTT glucose curves (4694±449 vs. 4057±437 mmol/l; P<0.05). In addition, the area under the insulin curve for the oral glucose tolerance test showed a significant increase from 27,438±4,488 to 41,946±6,048 pmol/l ( P<0.05). Total and LDL cholesterol were also significantly decreased (6.4±0.9 vs. 5.0±0.6 mmol/l and 3.8±0.7 vs. 2.7±0.4 mmol/l, respectively, P<0.05). Fasting leptin values decreased by 23% despite an increase in body weight. Troglitazone is effective in the treatment of glucocorticoid-induced diabetes as manifested by lower measures of glycemia, HgbA1c, and post-prandial glucose values, while the doses of other diabetes medications remained unchanged or were reduced. The insulin-sensitizing drug also produced a marked increase in endogenous insulin secretion in response to glucose, lower total and LDL cholesterol, and decreased fasting leptin despite weight gain. Thiazolidinediones may improve diabetes-related parameters by antagonizing pathways of glucocorticoid-induced insulin resistance and by reversing adverse effects of glucocorticoids on beta cell function.

Beyond postprandial hyperglycaemia: metabolic factors associated with cardiovascular disease.

Type II (non-insulin-dependent) diabetes mellitus is associated with a considerably enhanced risk of cardiovascular disease morbidity and mortality. Several epidemiological studies have shown an association between the 2-h glucose value after a 75 gm glucose load (2hPG) and mortality from all causes and from cardiovascular disease. The key question is whether postprandial glucose is related causally to the adverse outcomes (risk factors) or just a marker of risk. Since insulin resistance is one of the determinants of the 2hPG, factors associated with the insulin resistance syndrome, in particular postprandial hypertriglyceridaemia, also need to be considered. Glycaemic excursions could contribute to oxidative stress, endothelial dysfunction, formation of advanced glycation end-products and prolongation of the QTc interval. However, high postprandial concentrations of triglyceride rich lipoproteins, which can be partly attributed to obesity and insulin resistance, have now been recognised to affect endothelial function, to promote atherogenesis, and to be associated with coronary artery disease. On the basis of present evidence Type II diabetic patients require good overall glycaemic control, as reflected by target values of HbA(1 c). However, postprandial hyperglycaemia should be considered as a marker of underlying metabolic abnormalities. Therefore, at present there is no evidence to support the recommendation to consider postprandial hyperglycaemia as a treatment target in itself and would thus require intervention studies showing added benefit of selectively targeting at meal-related glucose excursions in patients with an adequate HbA(1 c). Drugs aiming at improving only postprandial glucose values are not likely to lower the excess mortality associated with Type II diabetes.

Effect of betamethasone on maternal glucose

Objective: To determine the effect of single and multiple betamethasone courses on maternal fasting and postprandial glucose values.Study design: A prospective cohort study was performedin women receiving betamethasone at 24–34 weeks' gestation. Fasting and 1-h postprandial capillary glucose values were obtained daily following betamethasone therapy for hospitalized patients. A controlgroup comprised outpatients who underwent weekly fasting and postprandial assessments for 3 weeks. Fasting and 1-h postprandial capillary glucose values were compared between control and betamethasone patientsusing an unpaired t test.Results: Thirty-five women received a single course of therapy, 19 received multiple courses and 28 served as controls. Mean fasting glucose values for controlpatients fell within a narrow range of 81.6 ± 10.3 to 82.2 ± 6.4 mg/dl for weeks 1–3. Of women receiving betamethasone, 59% of fasting glucose values were greater than 90 mg/dl as comparedto 16% of control fasting values (p < 0.001, χ2 test). Mean 1-h postprandial values for control women ranged from 107.7 ± 15.1 to 112.3 ± 20.0 mg/dl for weeks 1-3.Mean 1-h postprandial glucose values were ≤ 140 mg/dl following one, two or three courses of betamethasone therapy.Conclusions: Betamethasone resulted in an acute increase in fasting glucosefollowing a single course of betamethasone, whereas two or more courses of therapy resulted in a continuous elevation of fasting glucose values. One-hour postprandial values were not clinically abnormal.

Relationship of neonatal body composition to maternal glucose control in women with gestational diabetes mellitus

Objective: To determine whether neonatal fat mass, which may be a better estimate of fetal overgrowth, is correlated with maternal fasting, preprandial and/or postprandial glucose values in womenwith gestational diabetes mellitus (GDM).Study Design: Women with GDM and no other medical or obstetric problems, and their infants, were the subjects of this study. Portable reflectance meterswere used by all participants for self-monitoring of blood glucose levels. Average fasting, preprandial, 2-h postprandial and bedtime glucose values were determined for each subject. Neonatal body compositionwas obtained by total body electric conductivity and/or anthropometric measurements within 48 h after delivery.Results: Eighteen women with their infants participated in this study. The age(mean ± SD) of the mothers was 28.0 ± 5.7 years. Nine were treated with diet and nine with diet and insulin. An average of 40 fasting (84 ± 13 mg/dl), 50 preprandial (87 ± 14mg/dl), 80 2-h postprandial (106 ± 19 mg/dl) and 17 bedtime (104 ± 19 mg/dl) glucose values were obtained from each subject. The average gestational age of the infants at birth was 38.3 ±1.3 weeks with a mean weight of 3356 ± 526 g. Three infants were > 4 kg and seven infants were > 90th centile for gestational age. The strongest correlation with neonatal fat mass was maternalfasting glucose level (r = 0.71, p < 0.01). Neonatal fat mass was not found to be significantly correlated with any other mean glucose value. Additionally, the infant's per cent body fat(r = 0.71, p < 0.01), sum of skinfold thicknesses (r = 0.70, p < 0.01), fat-free mass (r = 0.50, p < 0.05), and weight (r = 0.61, p < 0.01) were also found to becorrelated with maternal fasting glucose level. No other maternal glucose measurements were correlated with either birth weight or estimates of fat free mass.Conclusion: Maternal fasting glucoselevels correlated best with neonatal fat mass and other estimates of neonatal body composition.

A comparison of insulin lispro and buffered regular human insulin administered via continuous subcutaneous insulin infusion pump

This study compared glycemic control achieved with insulin lispro or buffered regular human insulin in patients with Type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) using an external insulin pump. In this 24-week multicenter, randomized, two-way crossover, open-label trial, 58 patients on CSII with adequate glycemic control received either insulin lispro or buffered regular human insulin for 12 weeks, followed by the alternate treatment for another 12 weeks. Efficacy and safety measures included hemoglobin A 1c (HbA 1c) at baseline and endpoint, home blood glucose monitoring, hypoglycemia, and frequency of pump catheter occlusion. Patients consumed a standard test meal on three occasions, with determinations of fasting, 1- and 2-h postprandial glucose values. Insulin lispro use was associated with a significantly lower HbA 1c than was buffered regular human insulin (7.41±0.97 vs. 7.65±0.85 mmol/l; P=.004). Fasting serum glucose values before the test meal were similar between the two therapies. The 1-h (11.16±4.29 vs. 13.20±4.68 mmol/l; P=.012) and 2-h (9.64±4.10 vs. 12.53±4.64 mmol/l; P=.001) postprandial glucose concentrations were significantly lower during treatment with insulin lispro. No differences between treatments were observed in basal or bolus insulin doses, weight gain, or the incidence and rate of hypoglycemia, hyperglycemia, or pump occlusions. When used in external pumps, insulin lispro provides better glycemic control than buffered regular human insulin with a similar adverse event profile.

Third-trimester maternal glucose levels from diurnal profiles in nondiabetic pregnancies: correlation with sonographic parameters of fetal growth.

To assess the 24-h glucose levels in a group of nondiabetic, nonobese pregnant women and to verify the presence of correlations between maternal glucose levels and sonographic parameters of fetal growth. A total of 66 Caucasian nonobese pregnant women with normal glucose challenge tests (GCT) enrolled in the study; from this population, we selected 51 women who delivered term (from 37 to 42 weeks completed) live-born infants without evidence of congenital malformations. The women were requested to have three main meals and to perform daily glucose profiles fortnightly from 28-38 weeks without modifying their lifestyle or following any dietary restriction. All subjects were taught how to monitor their blood glucose by using a reflectance meter. Fetal biometry was evaluated by ultrasound scan according to standard methodology at 22, 28, 32, and 36 weeks of pregnancy. The overall daily mean glucose level during the third trimester was 74.7 +/- 5.2 mg/dl. Daily mean glucose values increased between 28 (71.9 +/- 5.7 mg/dl) and 38 (78.3 +/- 5.4 mg/dl) weeks of pregnancy. We found a significant positive correlation at 28 weeks between 1-h postprandial glucose values and fetal abdominal circumference (AC). At 32 weeks, we documented positive correlations between fetal AC and maternal blood glucose levels 1 h after breakfast, 1 and 2 h after lunch, and 1 and 2 h after dinner. At 36 weeks, there was a positive correlation between fetal AC and 1- and 2-h postprandial blood glucose levels. In addition, there was a negative correlation between head-abdominal circumference ratio and 1-h postprandial blood glucose values. This longitudinal study first provides a contribution toward the definition of normoglycemia in nondiabetic, nonobese pregnant women; moreover, it reveals significant correlations of postprandial blood glucose levels with the growth of insulin-sensitive fetal tissues and, in particular, between 1-h postprandial blood glucose values and fetal AC.

Antenatal fetal testing in well-controlled GDMA2 patients – does it correlate with glycemic control? Is it necessary?

Background: Because GDMA2 pregnancies are believed to be at increased risk of perinatal morbidity and mortality, fetal surveillance is initiated in the third trimester. Objectives: To correlate the results of antepartum fetal surveillance with glycemic control and fetal outcomes. Materials and Methods: A retrospective chart study of 421 pregnant women with diabetes was performed over a 7-year period. Patients with GDMA1, preexisting hypertension, diabetes, severe preeclampsia, fetal growth restriction, noncompliance, and substance abuse were excluded. For study purposes good glycemic control was fasting (F) and 2-hour postprandial (PP) glucose values of <105 and <120 mg/dL, respectively; fair was F and 2-hour PP values of <150 mg/dL; and poor control was F and 2-hour PP values of >150 mg/dL. The mean of the F and 2-hour PP values was noted on the day of and the day preceding the nonstress test (NST). The number of NSTs and biophysical profile(s) (BPPs) each patient underwent, the frequency of abnormal test results dictating further testing/delivery, and the fetal outcomes were recorded and correlated with glycemic control. Results: One hundred fifty-two patients in the study underwent 1,555 NSTs. Of the NSTs, 7.4 % were nonreactive, and glycemic control was good in 4.2% and fair or poor in 3.0%. There was no statistically significant difference. Further data, including glycemic control in reactive NSTs and fetal outcomes, will be presented. Conclusions: The role of antepartum fetal surveillance in GDMA2 patients, especially well-controlled patients, remains to be determined.

Diabetes mellitus in renal transplantation

A total of 317 patients with live kidney transplantation were followed for over a period of 10 years from 1986 to 1996. Among them 53 were detected to develop DM. Mean age of the patients was 40 years (range 29 to 67 years; 41 males, 12 females). Of 53 cases, 13 were living-related transplantation (LRT) and 40 livingunrelated renal transplantation (LURT). DM developed in a mean period of 19 weeks (range 14 to 51 weeks) following transplantation. Posttransplant DM was defined as two consecutive fasting blood glucose values .6.8 mmol/L or 2-hour postprandial blood glucose values .10 mmol/L. A similar number of nondiabetic recipients matched for age, sex, and immunosuppressive therapy acted as controls. All patients received cyclosporine 8 mg/kg/d, azathioprine 1 mg/kg/d, and prednisolone 0.5 mg/kg/d. Cyclosporine however is withdrawn in 3 to 6 months time in LRT patients, but continued as maintenance therapy 2 to 3 mg/kg/d in LURT patients. Prednisolone at a dose of 10 mg/d was continued in both LRT and LURT patients. Acute rejection was treated with methyl prednisolone 1 g/d for 3 consecutive days in both groups. Statistical analysis included t test.

Effects of maternal gestational diabetes on offspring adiposity at 4-7 years of age.

The purpose of this study was to assess the long-term effects of maternal prenatal factors, including gestational diabetes mellitus (GDM), adiposity, and weight gain during pregnancy, on adiposity of offspring from 4 to 7 years of age. A second purpose was to investigate the relationships among childhood adiposity, blood pressure, and 2-h postprandial glucose level. Prospective observational study of four groups of children including large-for-gestational-age (LGA) offspring of mothers with gestational diabetes (OGDM); appropriate-for-gestational-age (AGA) OGDM; LGA control subjects; and AGA control subjects. Anthropometrics including skin-fold measurements, blood pressure measurements, and a 2-h postprandial glucose measurement were obtained at each visit. Repeated measures analysis of variance models were used to detect different patterns of longitudinal change among the groups. LGA OGDM were more likely to be heavier, have larger circumferences and skin-fold measurements, and have a higher BMI than AGA OGDM and control subjects, and these findings increased with increasing age. Blood pressures and postprandial glucose values were similar for OGDM and control subjects at 4-7 years. Multivariable analyses showed that infant BMI and maternal prepregnant BMI predicted 7-year BMI for OGDM, whereas for control subjects, maternal prepregnancy BMI and weight gain during pregnancy were positive predictors with a small negative contribution from birth BMI. We conclude that LGA OGDM have evidence of increasing body size and adiposity with increasing age and that maternal GDM and maternal prepregnant adiposity are significant predictors of their unique growth patterns.

Endothelial Cell Dysfunction and Arterial Wall Hypertrophy Are Associated With Disturbed Carbohydrate Metabolism in Patients at Risk for Cardiovascular Disease

To investigate the effects of fasting and postprandial glucose on endothelial cell function and intima-media thickness, we studied 60 men with cardiovascular risk factors. Postischemic, endothelium-dependent vasodilatation was measured after 3 minutes of ischemia at the radial artery with high-resolution echo tracking. Common carotid artery intima-media thickness was measured by B-mode ultrasound. Glucose tolerance was determined by a 75-g oral glucose load. Fasting glucose levels were inversely correlated with postischemic, endothelium-dependent vasodilatation (r=-0.24, P<0.05) and directly correlated with intima-media thickness (r=0.26, P<0.05). However, postischemic, endothelium-dependent vasodilatation and intima-media thickness were not correlated. All subjects with normal postischemic, endothelium-dependent vasodilatation also had a normal intima-media thickness, whereas some subjects with impaired postischemic, endothelium-dependent vasodilatation also had a normal intima-media thickness. Multiple regression analysis revealed a profound influence of age on intima-media thickness to the exclusion of all other variables. The same age-adjusted analysis for postischemic, endothelium-dependent vasodilatation accepted fasting glucose, followed by 2-hour postprandial glucose, as variables, but no others. Subjects with fasting glucose values >100 mg/dL showed reduced postischemic, endothelium-dependent vasodilatation (59 versus 120 microm, P<0.05) and a higher intima-media thickness (right: 0.76 versus 0.62 mm, P<0.05; left: 0.78 versus 0.63 mm, P<0. 05) compared with those with fasting glucose values <100 mg/dL. Subjects with 2-hour postprandial glucose values >125 mg/dL had no reduced postischemic, endothelium-dependent vasodilatation compared with subjects with a 2-hour postprandial glucose <125 mg/dL; however, their intima-media thickness (right: 0.66 versus 0.62 mm; left: 0. 68 versus 0.62 mm; P<0.05 for both) was greater. Thus, high fasting rather than postprandial glucose values are associated with both postischemic, endothelium-dependent vasodilatation and increased intima-media thickness. Postischemic endothelium-dependent vasodilatation may precede increased intima-media thickness.

The Effects of Carbohydrate Restriction in Patients With Diet-Controlled Gestational Diabetes

Objective: To determine the effect of carbohydrate restriction on perinatal outcome in patients with diet-controlled gestational diabetes mellitus (GDM).Methods: Women with diet-controlled GDM were divided non-randomly into two groups based on their dietary carbohydrate content: those with low dietary carbohydrate content (below 42%) and those with high dietary carbohydrate content (exceeding 45%). Subjects kept dietary accounts and were followed with daily fasting and postprandial glucose assessments. Subjects also were tested daily for urinary ketones. Glycosylated hemoglobin, mean fasting and postprandial glucose values, incidence of macrosomia and large for gestational age (LGA) infants, cesarean deliveries for cephalopelvic disproportion and macrosomia, and need for insulin therapy were compared between the groups.Results: The two groups were identical in terms of demographic characteristics. Significant reductions in the postprandial glucose values were seen among subjects in the low-carbohydrate group (P < .04). Fewer subjects in the low-carbohydrate group required the addition of insulin for glucose control (P < .047; relative risk [RR] 0.14; 95% confidence interval [CI] 0.02, 1.00). The incidence of LGA infants was significantly lower in the low-carbohydrate group (P < .035; RR 0.22; 95% CI 0.05, 0.91). Subjects in the low carbohydrate group also had a lower rate of cesarean deliveries for cephalopelvic disproportion and macrosomia (P < .037; RR 0.15; 95% CI 0.04, 0.94).Conclusion: Carbohydrate restriction in patients with diet-controlled GDM results in improved glycemic control, less need for insulin therapy, a decrease in the incidence LGA infants, and a decrease in cesarean deliveries for cephalopelvic disproportion and macrosomia.

The Effects of Carbohydrate Restriction in Patients With Diet-Controlled Gestational Diabetes

In Brief Objective To determine the effect of carbohydrate restriction on perinatal outcome in patients with diet-controlled gestational diabetes mellitus (GDM). Methods Women with diet-controlled GDM were divided non-randomly into two groups based on their dietary carbohydrate content: those with low dietary carbohydrate content (below 43%) and those with high dietary carbohydrate content (exceeding 45%). Subjects kept dietary accounts and were followed with daily fasting and postprandial glucose assessments. Subjects also were tested daily for urinary ketones. Glycosylated hemoglobin, mean fasting and postprandial glucose values, incidence of macrosomia and large for gestational age (LGA) infants, cesarean deliveries for cephalopelvic disproportion and macrosomia, and need for insulin therapy were compared between the groups. Results The two groups were identical in terms of demographic characteristics. Significant reductions in the postprandial glucose values were seen among subjects in the low-carbohydrate group (P < .04). Fewer subjects in the low-carbohydrate group required the addition of insulin for glucose control (P < .047; relative risk [RR] 0.14; 95% confidence interval [CI] 0.02, 1.00). The incidence of LGA infants was significantly lower in the low-carbohydrate group (P < 0.35; RR 0.22; 95% CI 0.05. 0.91). Subjects in the low carbohydrate group also had a lower rate of cesarean deliveries for cephalopelvic disproportion and macrosomia (P < .037; RR 0.15; 95% CI 0.04, 0.94). Conclusion Carbohydrate restriction in patients with diet-controlled GDM results in improved glycemic control, less need for insulin therapy, a decrease in the incidence LGA infants, and a decrease in cesarean deliveries for cephalopelvic disproporftion and macrosomia. Carbohydrate restriction in patients with diet-controlled gestational diabetes improves glycemic control and perinatal outcome.

New Orally Administered Antihyperglycemic Agents for the Management of Patients with Type II Diabetes and the Syndrome of Insulin Resistance

To describe several newly developed orally administered antidiabetic drugs, which are effective for type II diabetes. Detailed clinical information about three types of antihyperglycemic agents--carbohydrase inhibitors, biguanides, and thiazolidinediones--is presented. Miglitol and acarbose, two a-glucosidase inhibitors, effectively reduce postprandial blood glucose values and do not cause hypoglycemia. The biguanide metformin has been shown to suppress hepatic glucose production, augment glucose uptake, and enhance insulin action in peripheral tissues. Metformin is effective alone or in combination with other orally administered antidiabetic agents or insulin. A new class of antidiabetic agents called the thiazolidinediones (not yet available for clinical use) apparently works by mainly reducing insulin resistance in skeletal muscle. The most extensively studied drug in this category is troglitazone. Carbohydrase inhibitors as well as biguanides may be useful in patients with the insulin resistance syndrome, especially those with obesity, hypertension, and hyperinsulinemia. Because of the development of new antihyperglycemic agents for oral administration, the need for insulin injections in patients with type II diabetes will be minimized, and the clinical management of such patients will be improved.

Daytime Glibenclamide and Bedtime NPH Insulin Compared to Intensive Insulin Treatment in Secondary Sulphonylurea Failure: a 1-Year Follow‐up

The aim of this study was to compare the metabolic effects of a combination of daytime glibenclamide and evening NPH insulin with intensive insulin treatment (rapid acting insulin before meals and NPH insulin at bedtime) in patients exhibiting secondary failure to sulphonylurea treatment. Thirty-nine mildly obese NIDDM patients (BMI 25.6 ± 0.5) were randomized after 6 weeks of intensive insulin treatment to either a combination treatment (CT, n = 20) or continued intensive insulin treatment (IT, n = 19). There were no differences between the two groups in age, diabetes duration, BMI, HbA1c, or basal and glucagon stimulated C-peptide. The patients were followed for 1 year and the findings were analysed on an intent to treat basis. Two patients in the CT group were excluded after 2 and 6 months, respectively, due to unacceptably high postprandial glucose values. There was a significant difference in HbA1c between the CT and IT groups at 6 months (8.2 ± 0.2, n = 19, vs 6.8 ± 0.4%, n = 19, p < 0.001)), but not at 12 months (7.8 ± 0.3, n = 18, vs 7.5 ± 0.4%, n = 19). After the initial intensive insulin treatment, BMI was constant in the CT group but increased significantly at 6 and 12 months in the IT group. We conclude that both treatments are associated with a marked and long-term improvement of glycaemic control. The intensive insulin treatment leads to a more pronounced weight increase which in the long run might have negative effect on overall metabolic control. Therefore, the combination treatment together with intensified education and dietary advice should be regarded as the initial treatment of choice for oral agent failure in moderately obese NIDDM patients.