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Purpose: To assess predictors of gestational weight gain (GWG), according to the Institute of Medicine (IOM) 2009, in women with type 1 and type 2 diabetes. Methods: This was a retrospective cohort study conducted at a tertiary center. GWG based on the IOM was assessed both uncorrected and corrected for gestational age. General and diabetes-related clinical characteristics were analyzed as predictors. Results: We evaluated 633 pregnant women with type 1 and type 2 diabetes. GWG uncorrected for gestational age was inadequate (iGWG) in 20.4%, adequate in 37.1%, and excessive (eGWG) in 42.5% of the women. Predictors included general (height, prepregnancy body mass index category, and multiple pregnancy) and diabetes-related clinical characteristics. Neuropathy and follow-up length were associated with iGWG (odds ratio (OR) 3.00, 95% CI 1.22–7.37; OR 0.92, 95% CI 0.86–0.97, respectively), while pump use and third-trimester insulin dose were associated with eGWG (OR 1.68, 95% CI 1.07–2.66; OR 3.64, 95% CI 1.88–7.06, respectively). Independent predictors for corrected GWG and sensitivity analyses also included general and diabetes-related clinical characteristics. Conclusion: In this cohort of women with type 1 and type 2 diabetes, non-adequate GWG was common, mainly due to eGWG, and associated clinical characteristics were both general and diabetes-related. Current clinical care of these women during pregnancy may favor weight gain.

Purpose: Mobile applications (apps) have proven to be highly effective tools to empower patients with type 1 diabetes mellitus (T1DM) and enable them to achieve better self-care, quality of life (QOL), and glycemic control. The aim of the study is to examine whether mySugr®, an app for diabetes management, together with teleconsultations, can have a positive impact on these factors and, thereby, replace current clinical care. Methods: This study concerns an exploratory randomized clinical trial of 12 months’ duration. People with T1DM using multiple daily injections were randomized to usual care (bolus calculator, five face-to-face visits) or intervention (mySugr®app, three face-to-face visits, and two teleconsultations). The main outcome was increase in empowerment assessed with the Diabetes Empowerment Scale Short Form questionnaire (DES-SF-S). Secondary outcomes were change in additional glucose-related (blood glucose monitoring, mean blood glucose, standard deviation, coefficient of variation (CV), and high and low blood glucose index) and patient-reported outcome measures (PROMs) (self-management, QOL, and distress). Results: A total of 25 out of 28 participants completed the study (52% men, age 44.52 years, diabetes duration 21.28 years). At 12 months, no significant differences were identified in the change of DES-SF-S and additional PROMs between arms. Similarly, no differences were observed in glucose-related outcomes except for the change in CV at 9 (control − 1.87 ± 4.98 vs. intervention 5.89 ± 11.33, p= 0.008) and 12 months (control − 2.33 ± 3.54 vs. intervention 5.12 ± 11.32, p= 0.018). Adherence to and satisfaction with the app were high. Conclusion: Patients with diabetes using the mySugr®app and teleconsultation achieved similar results to those following usual care in empowerment, other PROMs, and most glucose-related outcomes, thus supporting its use in combination with face-to-face visits. The RCT was registered with ClinicalTrials.gov (NCT03819335, first registration 28/01/2019).

Precision medicine is part of the logical evolution of contemporary evidence-based medicine that seeks to reduce errors and optimize outcomes when making medical decisions and health recommendations. Diabetes affects hundreds of millions of people worldwide, many of whom will develop life-threatening complications and die prematurely. Precision medicine can potentially address this enormous problem by accounting for heterogeneity in the etiology, clinical presentation and pathogenesis of common forms of diabetes and risks of complications. This second international consensus report on precision diabetes medicine summarizes the findings from a systematic evidence review across the key pillars of precision medicine (prevention, diagnosis, treatment, prognosis) in four recognized forms of diabetes (monogenic, gestational, type 1, type 2). These reviews address key questions about the translation of precision medicine research into practice. Although not complete, owing to the vast literature on this topic, they revealed opportunities for the immediate or near-term clinical implementation of precision diabetes medicine; furthermore, we expose important gaps in knowledge, focusing on the need to obtain new clinically relevant evidence. Gaps include the need for common standards for clinical readiness, including consideration of cost-effectiveness, health equity, predictive accuracy, liability and accessibility. Key milestones are outlined for the broad clinical implementation of precision diabetes medicine.

Fear of hypoglycemia and hyperglycemia can lead to inappropriate diabetes self-management and untoward health outcomes. We report two patients, representative of these opposite conditions, who benefited from hybrid closed-loop technology. In the patient with fear of hypoglycemia, time in range improved from 26 to 56% and the patient did not present with severe hypoglycemia. Meanwhile, the patient with hyperglycemia aversiveness had a drastic reduction in time below range, from 19 to 4%. We conclude that hybrid closed-loop technology was an effective tool for improvement of glucose values in two patients with fear of hypoglycemia and hyperglycemia aversiveness, respectively.

Insulin degludec (degludec) is a second-generation basal insulin with an improved pharmacokinetic–pharmacodynamic profile compared with first-generation basal insulins, but there are few data regarding its use during pregnancy. In this non-inferiority trial, we aimed to compare the efficacy and safety of degludec with insulin detemir (detemir), both in combination with insulin aspart (aspart), in pregnant women with type 1 diabetes.

The relevance of type 1 diabetes during pregnancy stems from its impact on the health of mother and offspring and its increasing prevalence. Glycemic control during pregnancy is one of the main risk factors for adverse events. Besides, treatment becomes a major challenge not only due to the modifications in insulin requirements due to changes in hormones and cytokines but also to the stricter control targets. Given the recent appearance of new ultra-rapid and basal insulin analogues and the constant evolution of technology to treat people with diabetes, we review these aspects in relation to the treatment of women with type 1 diabetes during pregnancy.

Background/objectives: Obese pregnant women are at high risk of developing gestational diabetes mellitus (GDM), which might be reduced by sufficient physical activity (PA) and reduced sedentary time (ST). We assessed whether PA and ST are longitudinally associated with the glucose-insulin axis in obese pregnant women. Subjects/methods: In this secondary analysis of the DALI (vitamin D And Lifestyle Intervention for gestational diabetes mellitus prevention) study, pregnant women, <20 weeks gestation, with a pre-pregnancy body mass index (BMI)?=?29?kg/m2, without GDM on entry were included. Time spent in moderate-to-vigorous PA (MVPA) and ST were measured objectively with accelerometers at <20 weeks, 24–28 weeks and 35–37 weeks of gestation. Fasting glucose (mmol/l) and insulin (mU/l), insulin resistance (HOMA-IR) and first-phase and second-phase insulin release (Stumvoll first and second phase) were assessed at the same time. Linear mixed regression models were used to calculate between-participant differences and within-participant changes over time. Analyses were adjusted for gestational age, randomisation, pre-pregnancy BMI, education and age. MVPA, Insulin, HOMA-IR and Stumvoll first and second phase were log-transformed for analyses due to skewness. Results: 232 women were included in the analysis. Concerning differences between participants, more ST was associated with higher fasting glucose (Estimate: 0.008; 95% CI: 0.002, 0.014), fasting insulin (0.011; 0.002, 0.019), HOMA-IR (0.012; 0.004, 0.021) and Stumvoll first and second phase (0.008; 0.001, 0.014 and 0.007; 0.001, 0.014). Participants with more MVPA had lower Stumvoll first and second phase (-0.137; -0.210, -0.064 and -0.133; -0.202, -0.063). Concerning changes over time, an increase in ST during gestation was associated with elevated Stumvoll first and second phase (0.006; 0.000, 0.011). Conclusions: As the glucose-insulin axis is more strongly associated with ST than MVPA in our obese population, pregnant women could be advised to reduce ST in addition to increasing MVPA. Moreover, our findings suggest that behaviour change interventions aiming at GDM risk reduction should start in early or pre-pregnancy.

Pregnant women with type 1 diabetes are a high-risk population who are recommended to strive for optimal glucose control, but neonatal outcomes attributed to maternal hyperglycaemia remain suboptimal. Our aim was to examine the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control and obstetric and neonatal health outcomes.

To assess agreement between fasting plasma glucose (FPG) and hemoglobin A1c(HbA1c) levels for diagnosis of dysglycemia (diabetes and risk of diabetes), overall and depending on clinical characteristics.

To assess agreement between fasting plasma glucose (FPG) and hemoglobin A1c(HbA1c) levels for diagnosis of dysglycemia (diabetes and risk of diabetes), overall and depending on clinical characteristics.

Lifestyle approaches for preventing gestational diabetes mellitus (GDM) have produced mixed results.

Pregnancy in Cushing’s syndrome (CS) is extremely rare due to the influence of hypercortisolism on the reproductive axis. Purpose of this study is to investigate whether the etiology of CS in pregnancy determines a different impact on the fetal/newborn and maternal outcomes. We performed a systematic review of cases published in the literature from January 1952 to April 2015 including the words “Cushing AND pregnancy”. We included 168 manuscripts containing 220 patients and 263 pregnancies with active CS during pregnancy and with a history of CS but treated and cured hypercortisolism at the time of gestation. Adrenal adenoma was the main cause of active CS during pregnancy (44.1 %). Women with active CS had more gestational diabetes mellitus (36.9 vs. 2.3 %, p= 0.003), gestational hypertension (40.5 vs. 2.3 %, p< 0.001) and preeclampsia (26.3 vs. 2.3 %, p= 0.001) than those with cured disease. The proportion of fetal loss in active CS was higher than in cured CS (23.6 vs. 8.5 %, p= 0.021), as well as global fetal morbidity (33.3 vs. 4.9 %, p< 0.001). The predictors of fetal loss in active CS were etiology of hypercortisolism [Odds Ratio –OR—for pregnancy-induced CS 4.7 (95 % Confidence Interval–CI 1.16–18.96), p= 0.03], publication period [OR for “1975–1994” 0.10 (95 % CI 0.03–0.40), p= 0.001] and treatment during gestation (p= 0.037, [OR medical treatment 0.25 (95 % CI 0.06–1.02), p= 0.052], [OR surgical treatment 0.34 (95 % CI 0.11–1.06), p= 0.063]). The period of diagnosis of CS (before, during or after pregnancy) was the only predictor of overall fetal morbimortality [OR for diagnosis during pregnancy 4.66 (95 % CI 1.37–15.83), p= 0.014]. Patients with active CS, especially in pregnancy-induced CS, experienced more problems in pregnancy and had the worst fetal prognosis in comparison to other causes. Diagnosis of CS during pregnancy was also associated with worse overall fetal morbimortality. Both medical treatment and surgery during pregnancy appeared to be protective in avoiding fetal loss.

High post-challenge glucose plasma concentrations that are observed during pregnancy screening can help to identify women who are at an increased likelihood of later health issues, predominantly cardiovascular diseases. This finding offers a unique opportunity to improve the health of women, but further work is required to translate into clinical benefits.

(Abstracted from Lancet2017;390:2347–2359)It is established that optimal maternal glycemic control throughout pregnancy is associated with a decrease in adverse fetal outcomes. A proper glycemic index can be difficult to control in women with type 1 diabetes during pregnancy because of the complexity of insulin dose adjustment, gestational changes in insulin sensitivity, and day-to-day changes to insulin absorption in late pregnancy. Nationwide UK data show the rates of severe hypoglycemia, particularly in early pregnancy, are 5 times higher among pregnant women than nonpregnant and that only 40% of women with type 1 diabetes achieve target glycated hemoglobin (HbA1c) after 24 weeks of gestation. Continuous glucose monitoring (CGM) provides real-time quantitative information on the direction and rate of change of glucose levels.

La diabetes es una de las complicaciones metabólicas más frecuentes de la gestación y se asocia a un incremento del riesgo de morbimortalidad maternal y fetal, que pueden evitarse y/o reducirse con un adecuado control. En la diabetes pregestacional, la preparación específica previa a la gestación es indispensable para intentar conseguir un control glucémico lo más próximo a la normalidad, evaluar complicaciones y revisar las pautas de tratamientos farmacológicos. En el caso de la diabetes gestacional, el tratamiento de esta entidad ha demostrado disminuir la tasa de complicaciones maternas y perinatales, por lo que su diagnóstico está justificado. En relación con la estrategia diagnóstica, ante la falta de consenso y la controversia desatada tras la aparición de los nuevos criterios IADPSG, el grupo ha decidido mantener la misma estrategia diagnóstica en 2 pasos y con los mismos puntos de corte hasta disponer de datos sólidos que avalen la introducción de nuevos criterios.

Always granting that de novomutations are possible, family history and biological characteristics are nonetheless crucial for the diagnosis of monogenic diabetes. We report here the case of two patients with monogenic diabetes in which the initial family history misled the diagnostic work-up and did not support the diagnosis. Family history details changed substantially after the molecular diagnosis was established.

It is well established that folate requirements increase during pregnancy and that supplementing 0.4 mg folic acid/day to the general pregnant population is beneficial in terms of reducing the risk of neural tube defects. It is also well established that offspring of women with pregestational diabetes mellitus have an increased risk of congenital anomalies. In animal models, both in vivo and in vitro, folic acid supplementation reduces glucose-induced congenital anomalies. In recent years, several academic societies have included diabetic women in the high-risk category for neural tube defects, so that the supplementation applying for them would be 4-5 mg/day, the dose recommended for secondary prevention in women with a former fetus affected with a neural tube defect. The protection afforded by folic acid supplementation in diabetic pregnant women is not clear: multivitamin supplementation has been reported to reduce the risk of congenital anomalies but the composition of the supplements was unknown and the benefit probably included that of overall prepregnancy care. In addition, in real life, most diabetic women even when planning pregnancy do not take folic acid supplements. To complicate things further, folic acid supplementation has potential deleterious effects, with promotion of neoplasia being among them. Folic acid tolerable upper intake level is set at 1 mg/day, so that the aforementioned recommendations should be considered in the pharmacological range. After reviewing these issues, we conclude that big efforts should be made to ensure that diabetic women receive periconceptionally a folic acid supplementation of 0.4 mg/day, as one of the interventions of comprehensive prepregnancy care. Until a favourable risk-benefit ratio is documented, we propose that higher doses are restricted to women not achieving adequate blood glucose regulation, and that long periods of supplementation are avoided. In recent years there are multiple patents including methods of detection of abnormalities in folate metabolism and trying to improve the supplementation of this micronutrient. Only one of them would be specific for diabetes.

Gestational diabetes is a common complication in pregnancy that is typically treated with insulin. However, this complication is on the rise, and oral medications, such as glibenclamide (glyburide) and metformin, are being considered as an alternative to insulin. In recent years, oral agents have been more frequently used in pregnant women with gestational diabetes mellitus (GDM), but there have been no randomized controlled trials (RCTs) that comprehensively evaluate the effect of oral drug treatments on maternal and fetal outcomes. The goal of this study was to compare short-term outcomes of glibenclamide or metformin to insulin and glibenclamide versus metformin in a systematic review of RCTs.

La relevancia de la diabetes tipo 1 durante a la gestación deriva de su impacto en la salud de madre e hijo y de una prevalencia en aumento. El mayor riesgo se debe en gran medida al grado de control glucémico durante el embarazo. Por su parte, el tratamiento supone un reto ya que a los objetivos de control más estrictos se le suman las modificaciones en los requerimientos de insulina debido a los cambios hormonales y de citocinas. Ante la reciente aparición de nuevos análogos de insulina ultrarrápida y basal y la constante evolución de la tecnología para el tratamiento de las personas con diabetes, revisamos estos aspectos en relación al tratamiento de las mujeres con diabetes tipo 1 bajo la perspectiva de embarazo.

TO THE EDITOR. —Werner's syndrome is a rare, recessively inherited process, characterized by hypogonadism, juvenile cataracts bilaterally, premature aging, graying of the hair, osteoporosis, atrophy of subcutaneous fat and skin of the extremities resembling scleroderma, soft-tissue and vascular calcifications, and nonketotic insulin-resistant diabetes.1-3 We report a case of this syndrome in a 34-year-old man in whom a high resolution computed tomographic (CT) scan of the skull disclosed an empty sella. To our knowledge, this is the first time the association between Werner's syndrome and an empty sella is reported. REPORT OF A CASE. —The patient's parents were first cousins, and he has a twin sister who is a normal, fertile female. Cataracts that developed during his childhood were operated on during the patient's adolescence and, at age 18 years, his hair was completely gray and sparse. Physical exHigh-resolution computed tomographic scan revealing empty sella with eroded sellar floor.