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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 70-74

Reducing the risk of gestational diabetes mellitus in pregnant women with metabolic syndrome by dietary intervention during early pregnancy


Zengcheng Hospital of Guangzhou Women and Children's Medical Center, Guangzhou, China

Date of Submission02-Dec-2021
Date of Decision12-Feb-2022
Date of Acceptance20-Feb-2022
Date of Web Publication25-Aug-2022

Correspondence Address:
Dr. Xiao-Hua Wang
Zengcheng Hospital of Guangzhou Women and Children's Medical Center, Guangzhou 511300
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mtsm.mtsm_19_21

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  Abstract 


Objective: The study objective was to explore the clinical observation of reducing the risk of gestational diabetes mellitus (GDM) in pregnant women with metabolic syndrome (MS) by dietary intervention during early pregnancy. Methods: Singleton pregnant women who set early pregnancy filings and had regular prenatal care and delivery at Zengcheng Hospital of Guangzhou Women and Children's Medical Center of Guangdong Province from January 2020 to June 2021 were screened out according to the diagnostic criteria for MS promulgated by the International Diabetes Federation in 2005. Pregnant women meeting the diagnostic criteria for MS were randomly divided into the intervention group (n = 80) and the control group (n = 80). The changes in the indicators of MS (fasting plasma glucose 70, total cholesterol [TC], triglyceride [TG], high-density lipoprotein [HDL], low-density lipoprotein [LDL], systolic blood pressure [SBP], and diastolic blood pressure [DBP]) in early and late pregnancy were observed, and the incidence of GDM was analyzed. Results: There was no significant difference (P > 0.05) in TC, TG, FPG, LDL, HDL, SBP, or DBP of women in early pregnancy between the two groups. There was no significant difference (P > 0.05) in TC and TG of women in late pregnancy between the two groups. The FPG, LDL, SBP, and DBP of the intervention group were lower than those of the control group, and the HDL of the intervention group was higher than that of the control group, which showed a significant difference in the two groups (P < 0.05). The incidence of GDM in the intervention group was lower than those of the control group (P < 0.05). Conclusion: Pregnant women with MS before their pregnancy were at a high risk of GDM. Diet and exercise interventions in early pregnancy could improve the indicators of their blood metabolism and lipid metabolism, which could effectively reduce the incidence of GDM and thus improve the adverse pregnancy outcome and ensure the safety of the mothers and the infants.

Keywords: Dietary intervention, gestational diabetes mellitus, metabolic syndrome


How to cite this article:
Wang XH, Liu CL, Hu HP, Chen XT. Reducing the risk of gestational diabetes mellitus in pregnant women with metabolic syndrome by dietary intervention during early pregnancy. Matrix Sci Med 2022;6:70-4

How to cite this URL:
Wang XH, Liu CL, Hu HP, Chen XT. Reducing the risk of gestational diabetes mellitus in pregnant women with metabolic syndrome by dietary intervention during early pregnancy. Matrix Sci Med [serial online] 2022 [cited 2022 Oct 4];6:70-4. Available from: https://www.matrixscimed.org/text.asp?2022/6/3/70/354527




  Introduction Top


Gestational diabetes mellitus (GDM) is one of the most common complications in obstetrics. The guidelines on GDM of many countries show how GDM increases pregnancy and postpartum maternal complications. Thus, that how to reduce the occurrence of GDM so as to improve the maternal and fetal outcome is of important clinical value. The incidence of metabolic syndrome (MS) has increased dramatically in some countries for nearly 30 years. According to the data released by the International Diabetes Federation (IDF), 1/4th of the people in the world were diagnosed with MS.[1] At present, the incidence of MS in adults over 20 years old in Chinese cities reaches 15%.[2] The pathogenesis of MS, a high risk factor of GDM, is insulin resistance (IR), which is similar to GDM. It is internationally recognized that diet and exercise interventions can improve and delay the progression of MS. This paper screens out pregnant women at a high risk of GDM, namely, pregnant women with MS, and concludes that early diet intervention can reduce the incidence of GDM and improve the biochemical indicators of MS, which provides a research reference for the high-risk management of GDM.


  Data and Methods Top


Clinical data

Object

Singleton pregnant women who set early pregnancy filings and had regular prenatal care and delivery at Zengcheng Hospital of Guangzhou Women and Children's Medical Center of Guangdong Province from January 2020 to June 2021 were screened out according to the diagnostic criteria for MS promulgated by the IDF in 2005. Diagnostic criteria: overweight or obesity: body mass index (BMI) ≥25; two of the following four factors were added: increasing triglyceride (TG) level: 1.7 mmol/L, or having received special treatment for the lipid abnormality; reducing high-density lipoprotein (HDL)-C level: <1.29 mmol/L, or having received special treatment for the lipid abnormality; elevating blood pressure: systolic blood pressure (SBP) >130 mmHg or diastolic blood pressure (DBP) >85 mmHg or having been diagnosed with hypertension; Elevating fasting plasma glucose (FPG): FPG >5.6 mmol/L, or having been diagnosed with type 2 diabetes. Pregnant women meeting the diagnostic criteria for MS were randomly divided into the intervention group (n = 80) and the control group (n = 80). The clinical data comparison of pregnant women between the two groups showed that before pregnancy, there was no significant difference in BMI, age, the number of times of pregnancy and height (P > 0.05), as shown in [Table 1].
Table 1: Clinical data comparison of pregnant women between the two groups

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Inclusion criteria

(a) Meeting the global unified diagnostic criteria for MS promulgated by the IDF in 2005: focusing on central obesity, the standard for obesity was changed to BMI >25 because pregnant women were a special population. Pregnant women diagnosed with MS by clinical manifestation and laboratory examination in early pregnancy or before pregnancy were voluntarily surveyed. (b) Singleton pregnant. (c) Informed consent of pregnant women themselves and their families. (d) Approved by the Ethics Committee of the hospital.

Exclusion criteria

Spontaneous abortion, artificial abortion, stillbirth, twins pregnancy and assisted reproductive pregnancy during pregnancy, being diagnosed with diabetes before pregnancy, and having a history of GDM.


  Methods Top


Clinical data collection

Research tools

The electronic medical record system and prenatal care system of Guangzhou Women and Children's Medical Center of Guangdong Province were used for collection and statistics of data for pregnant women (including the collection of prenatal care data, such as level of education, economic level, age, number of times of pregnancies, BMI during and before pregnancy (height/weight^2), height, blood pressure, past medical history, delivery history, records of other high-risk factors). According to the principle of convenient sampling, pregnant women who set their electronic files at their first prenatal care <14 weeks ago and had regular prenatal care and follow-up visits were screened out to ensure the consistency of the pregnancy treatment plan for all the study subjects and a sufficient source of the sample size. SBP and DBP were measured at the first filing by an electronic sphygmomanometer. Blood pressure of the same arm was measured three times after 10 min' rest and was recorded and averaged. Biochemical indicators including FPG, total cholesterol (TC), TG, HDL, low-density lipoprotein (LDL) were measured. Regular prenatal care and follow-up visit were carried out according to the high-risk registration management of the prenatal care system. The mobile Lanniu tracking system (an electronic medical record system of the Guangzhou Women and Children's Medical Center) was used for follow-up of health guidance. Personalized diet guidance was offered via WeChat groups.

Research methods

Pregnant women with MS were randomly divided into the diet intervention group and control group. Specific implementation plan: (1) nutrition assessment: daily calorie card was calculated according to different energy coefficients reflected by BMI to set the target for personal weight gain management during pregnancy. (2) Health education: pregnant women were advised to go to schools for pregnant women and study the relationship between nutrition and diseases, and the mobile Lanniu tracking system was used for health guidance follow-up; high-risk prenatal care system was used for regular telephone tracking and following up the regular prenatal care for pregnant women; WeChat group was established for online regular education and follow-up; pregnant women were advised to adjust their diet structures during pregnancy, record their diet recipes, have more protein but less high glycemic index food, and eat according to the proportion, as well as make phased summary. (3) Prenatal care: including regular prenatal examination, blood pressure monitoring, weight monitoring, informing the impact of diabetes on mothers and infants, as well as blood glucose monitoring and routine urine tests if necessary. (4) Exercise guidance: exercise such as yoga for pregnancy, exercise for pregnant woman, and walking on the condition that there was no high-risk factor or abortion. (5) Psychological guidance: appropriate support and encouragement were provided to enhance pregnant women's confidence in delivery because most pregnant women with MS may have difficulty in delivery and may be anxious for pregnancy.

Indicators for observation

Change in metabolic indicators in early and late pregnancy: FPG, TC, TG, HDL, LDL, SBP, DBP; OGTT test at the 24th–28th week of pregnancy between the two groups was compared and the incidence of GDM was calculated.

Statistical analysis

Statistical software SPSS 23.0 (International Business Machines Corporation Armonk, New York, USA) was used for data processing, measurement data were shown by frequency or rate, and counting data were used for statistical analysis by Chi-square test, with P < 0.05 being a statistically significant difference.


  Results Top


Comparison of blood biochemical indicators between the two groups

There was no significant difference (P > 0.05) in TC, TG, FPG, LDL, HDL, SBP, and DBP between the two groups, as shown in [Table 2].
Table 2: Comparison of metabolic indicators in early pregnancy between the two groups (X¯±S mmol/L)

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There was no significant difference (P > 0.05) in TC and TG between the two groups [Table 3]. FPG, LDL, SBP, and DBP of the intervention group were all lower than those of the control group, and the HDL of the intervention group was higher than that of the control group, which indicted a significant difference (P < 0.05) between the two groups.
Table 3: Comparison of metabolic indicators in late pregnancy between the two groups (X¯±S mmol/L)

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Incidence of gestational diabetes mellitus of the two groups

There were significant differences (P<0.05) between the intervention group and the control group [Table 4].
Table 4: Incidence of gestational diabetes mellitus of the two groups (number of case, %)

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  Discussion Top


With the growth of China's economic level and the change of people's living habits, the appearance of the takeout diet mode of “high sugar, high fat, and high protein” and insufficient exercise, and the full implementation of two-child policy, the proportion of elderly pregnant women has been increasing and the incidence of GDM has gone up year by year. The International Association of Diabetes and Pregnancy Study Groups showed the total incidence of GDM reached 17.8%, (9.3%~25.5%).[3] According to the statistics of the Third Affiliated Hospital of Guangzhou Medical University, the incidence of GDM in Guangzhou is 18%–20%. This is not the only case. The incidence of MS that has the same pathogenesis as GDM is also increasing year by year around the world, which has become a common problem that affects the global public health. Scholars at home and abroad have been exploring the high-risk factors and screening process of GDM, as well as the way to reduce GDM incidence, but no unified conclusion has been reached yet. MS is a high-risk factor of GDM, and it is recognized that pregnant women with MS face a higher risk of GDM. Establishment of a combined lifestyle especially diet structure adjustment and weight control is the most important method to prevent and treat MS. Therefore, it is of important clinical value to study whether the incidence of GDM can be reduced through the treatment of MS.

Harm of gestational diabetes mellitus

GDM has both short-term and long-term impacts on mothers and infants, leading to increased hypertension during pregnancy, fetal macrosomia, fetal growth restriction, stillbirth, as well as a higher rate of cesarean section and postpartum hemorrhage.[4] It was reported that the relationship between the history of GDM and the incidence of Type 2 diabetes suggested a higher probability of postpartum Type 2 diabetes for pregnant women, and the probability of postpartum Type 2 diabetes was even higher for pregnant women who used insulin during pregnancy or was diagnosed with complications of preeclampsia or premature delivery before 20 weeks of their pregnancy.[5] The 9th edition of the Obstetrics and Gynecology textbook also clearly states that most pregnant women with GDM can return to normal glucose metabolism after the delivery, but they face a higher chance of developing Type 2 diabetes in the future, and 17%–63% of these women will develop into gestational Type 2 diabetes. Meanwhile, these women have a higher incidence of long-term cardiovascular diseases (CVDs).[6] A cohort study conducted by Shah et al. for 11 years showed an increased incidence of Type 2 diabetes mellitus in pregnant women with GDM, and heart rate = 1.71 (95% confidence interval: 1.08–2.69) for CVD events.[7] The Guidelines for Prevention of Female Cardiac Disease released by the American Heart Society in 2011 clearly list the history of GDM as one of the risk factors for CVDs in women.[8]

Pathogenesis of gestational diabetes mellitus

In order to ensure the growth and development of the fetus during the whole pregnancy, there are physiological changes in the endocrine system of pregnant women, of which IR is the most direct manifestation. IR means the reduction of insulin-mediated glucose intake and utilization leads to compensatory increase in insulin secretion so as to maintain a stable internal environment and normal blood sugar, which results in hyperinsulinemia. Both hPGH and hPL of the hormones secreted in the placenta during pregnancy resist insulin, reduce insulin-mediated glucose uptake and glycogen synthesis, and destroy the insulin function of inhibiting hepatic gluconeogenesis. Progesterone also plays a small part in resisting insulin.[1] Moreover, 50%–60% decrease in insulin sensitivity during pregnancy causes severe compensatory resistance to islet β cells, resulting in insulin deficiency and consequent GDM. Thus, IR is the key reason for GDM development, including physiological IR and pathological IR.

Relationship between metabolic syndrome and gestational diabetes mellitus

MS is a comprehensive manifestation of a variety of metabolic abnormalities in the body, and its key factor is the visceral fat accumulation caused by obesity. Excess energy leads to the release of TG and metabolites into blood, resulting in the increase of blood fat. Long-term high-calorie diet increases insulin secretion, and the activity and sensitivity of insulin receptors decrease, which leads to IR, thus inducing abnormal glucose metabolism, dyslipidemia, and damage of extensive vascular endothelial cells as well as mild inflammatory response resulting from oxidative stress. Therefore, MS is also known as insulin resistance syndrome.[9] The pathophysiological basis of MS is similar to that of GDM from the perspective of pathogenesis. For pregnant women who have MS before their pregnancy or during their early pregnancy, they face excessive BMI, increased body calories, excessive insulin secreted from insulin cells through excessive stimulation, reduced insulin receptors, and decreased insulin sensitivity. Accordingly, there is IR before their pregnancy or during their early pregnancy. In addition, lipid and glucose metabolism disorders lead to a significant increase in the incidence of GDM.[10] Weight loss before pregnancy can significantly reduce the incidence of GDM.[11] The Guidelines for Diagnosis and Treatment of Diabetes of the American Diabetes Association include obesity (BMI >25), MS, Asian nationality, hypertensive polycystic ovary syndrome, family history of diabetes, and advanced age as high-risk factors in the risk assessment of GDM.[12] This shows pregnant women with MS are at a high risk of GDM. However, China screens out GDM in all pregnant women at a high risk at 24th–28th week of their pregnancy when glucose and lipid metabolism disorders have already existed for a long time, which increases the risk during pregnancy. Therefore, early interventions are urgently needed for pregnant women with high-risk factors.

In this study, pregnant women with MS were screened out for diet and exercise interventions, the incidence of GDM in the intervention and control groups was calculated, and a contrast analysis of MS indicators was conducted. This study showed that intervention by individualized diet and daily exercise of moderate intensity for 30 min for pregnant women with MS during their early pregnancy lower the incidence of GDM in the intervention group, which was statistically significant. During pregnancy, the ability of the body to absorb fat was enhanced due to the fetal development and postpartum lactation, leading to a physiological increase in blood lipid. Excess fatty acids in plenty of the fat cells accumulated in the body of obese pregnant women with MS was released into blood and caused inflammatory changes, which aggravated IR. Pregnant women with MS suffered from long-term lipid metabolism disorder and physiologic lipid elevation, so their blood lipid could not be reduced by short-term diet control. There was no significant difference (P > 0.05) in TG and TC between the two groups, which was not statistically significant and was consistent with clinical conclusions. IR is a central link in a range of pathophysiological changes caused by obesity, an inducing factor of MS. According to the Chinese Diabetes Society, changing dietary habits plays an important part in improving MS. Therefore, early exercise and diet interventions can improve the IR in early pregnancy, and thus reduce the occurrence of GDM and ultimately improve the indicators of MS. In this study, there were significant differences (P < 0.05) between the two groups, with the FPG, LDL, SBP, and DBP of the intervention group being lower than those of the control group, whereas the HDL of the intervention group being higher, which was statistically significant.


  Conclusion Top


To sum up, GDM is a common obstetrical complication, and MS is the high-risk factor of GDM. Our research shows that, for pregnant women with MS, appropriate dietary guidance and clinical intervention given from the early pregnancy can reduce the incidence of gestational diabetes, so as to improve the outcome of maternal and fetal pregnancy, which has practical clinical value.

Financial support and sponsorship

This project was financially supported by Science and Technology Project of Science and Technology Bureau of Zengcheng District, Guangzhou City, Guangdong Province, China (No. ZCKJ2019-015).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Catalano PM, McIntyre HD, Cruickshank JK, McCance DR, Dyer AR, Metzger BE, et al. The hyperglycemia and adverse pregnancy outcome study: Associations of GDM and obesity with pregnancy outcomes. Diabetes Care 2012;35:780-6.  Back to cited text no. 3
    
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Rayanagoudar G, Hashi AA, Zamora J, Khan KS, Hitman GA, Thangaratinam S. Quantification of the type 2 diabetes risk in women with gestational diabetes: A systematic review and meta-analysis of 95,750 women. Diabetologia 2016;59:1403-11.  Back to cited text no. 5
    
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Shah BR, Retnakaran R, Booth GL. Increased risk of cardiovascular disease in young women following gestational diabetes mellitus. Diabetes Care 2008;31:1668-9.  Back to cited text no. 7
    
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Smith SC Jr., Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: A guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. J Am Coll Cardiol 2011;58:2432-46.  Back to cited text no. 8
    
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Xu Y, Shen S, Sun L, Yang H, Jin B, Cao X. Metabolic syndrome risk after gestational diabetes: A systematic review and meta-analysis. PLoS One 2014;9:e87863.  Back to cited text no. 9
    
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Catalano PM. Trying to understand gestational diabetes. Diabet Med 2014;31:273-81.  Back to cited text no. 10
    
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Leng J, Li W, Zhang S, Liu H, Wang L, Liu G, et al. GDM women's pre-pregnancy overweight/obesity and gestational weight gain on offspring overweight status. PLoS One 2015;10:e0129536.  Back to cited text no. 11
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Introduction
Data and Methods
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