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Objectives: Gestational diabetes mellitus (GDM) affects about 15% of pregnancies in Australia, with approximately 30% of those diagnosed with GDM requiring insulin therapy. There are several established risk factors for developing GDM, however limited studies show how these can be used to predict need for insulin treatment. The aim of this study is to identify predictors of insulin therapy in women diagnosed with GDM once an oral glucose tolerance test (OGTT) is performed during pregnancy.Study Design: This is a retrospective cohort study of women with singleton pregnancies complicated by GDM between 2016 and 2017 at a single, large health network in Melbourne, Australia. Data were obtained from hospital record and pathology result systems. Univariable and multivariable logistic regression models were fit to the data to obtain crude and adjusted odds ratios.Results: Of 2,048 women diagnosed with GDM, 647 (31.6%) required insulin therapy. Positive predictors included in the final multivariable model after backwards, stepwise elimination were an elevated fasting result on an OGTT (adjusted odds ratio (AOR) 2.93 [95% CI 2.34-3.66]), previous birth weight greater than 90th% (AOR 2.04 [95% CI 1.412.94]), previous diagnosis of GDM (AOR 1.68 [95% CI 1.28-2.21]), being born in the South Asian region (AOR 1.58 [95% CI 1.27-1.98]), the 2hr OGTT result (AOR 1.14 [95% CI 1.05-1.24]), body mass index (BMI; AOR 1.13 [95% CI 1.04-1.23]) and age (AOR 1.03 [95% CI 1.00-1.05]) The final predictive model had an area under the receiver-operating characteristics (ROC) curve of 0.744 (95% CI 0.720-0.767).Conclusions: This study highlights the possible predictors of insulin use, informing counselling for women who are newly diagnosed with gestational diabetes. [ABSTRACT FROM AUTHOR]

Background: The adoption of the International Association of Diabetes Study Groups (IADPSG) criteria for gestational diabetes mellitus (GDM) in Australia has been controversial. Obesity in pregnancy is also a growing concern. Aims: To assess the impact of IADPSG criteria on the incidence of GDM and pregnancy outcomes, and to compare this to the effect of obesity, particularly among women who would not have GDM by the Australasian Diabetes in Pregnancy Society 1998 criteria (ADIPS1998). Material and Methods: A retrospective observational cohort study linking results of 75 g glucose tolerance tests with demographic and pregnancy data was conducted. Results: In our cohort of 6175 pregnancies, GDM was present in 926 (15%) women by the ADIPS1998 criteria; it increased to 1098 (17.8%) women by the IADPSG criteria. Among the 5248 pregnancies which did not meet the ADIPS1998 criteria and were not treated for GDM, women with IADPSG GDM had increased risk of gestational hypertension, pre‐eclampsia, induction of labour (IOL), primary caesarean section (PCS) and large for gestational age (LGA) compared to women without GDM (all P < 0.05), whereas obese women had increased risk of gestational hypertension, pre‐eclampsia, IOL, PCS, small for gestational age (SGA) and shoulder dystocia compared to women of normal weight (all P < 0.05). On multivariate analysis, IADPSG GDM was an independent risk factor only for IOL (P = 0.04) and LGA (<0.001). Obesity was an independent risk factor for gestational hypertension, pre‐eclampsia, IOL, PCS, shoulder dystocia and SGA (all P < 0.001). Conclusions: Within our population, of women who are not currently treated for GDM, obesity is associated with greater pregnancy risk than GDM diagnosed by IADPSG criteria. [ABSTRACT FROM AUTHOR]

Objective: To determine if testosterone treatment effect on glycaemia is mediated through changes in total fat mass, abdominal fat mass, skeletal muscle mass, non-dominant hand-grip, oestradiol (E2), and sex hormone-binding globulin (SHBG)., Design: Mediation analysis of a randomised placebo-controlled trial of testosterone., Methods: Six Australian tertiary care centres recruited 1007 males, aged 50-74 years, with waist circumference ≥95 cm, serum total testosterone ≤14 nmol/L (immunoassay), and either impaired glucose tolerance or newly diagnosed type 2 diabetes on an oral glucose tolerance test (OGTT). Participants were enrolled in a lifestyle programme and randomised 1:1 to 3 monthly injections of 1000 mg testosterone undecanoate or placebo for 2 years. Complete data were available for 709 participants (70%). Mediation analyses for the primary outcomes of type 2 diabetes at 2 years (OGTT ≥ 11.1 mmol/L and change in 2-h glucose from baseline), incorporating potential mediators: changes in fat mass, % abdominal fat, skeletal muscle mass, non-dominant hand-grip strength, E2, and SHBG, were performed., Results: For type 2 diabetes at 2 years, the unadjusted OR for treatment was 0.53 (95% CI:.35-.79), which became 0.48 (95% CI:.30-.76) after adjustment for covariates. Including potential mediators attenuated the treatment effect (OR 0.77; 95% CI:.44-1.35; direct effect) with 65% mediated. Only fat mass remained prognostic in the full model (OR: 1.23; 95% CI: 1.09-1.39; P < .001)., Conclusion: At least part of the testosterone treatment effect was found to be mediated by changes in fat mass, abdominal fat, skeletal muscle mass, grip strength, SHBG, and E2, but predominantly by changes in fat mass., (© The Author(s) 2023. Published by Oxford University Press on behalf of European Society of Endocrinology.)

Aims: In this study, we assessed changes in prevalence of gestational diabetes mellitus (GDM) in a region with diverse cultural backgrounds in Australia under the new World Health Organization (WHO) diagnostic criteria, with reference to the woman's ethnicity, age and pre-pregnant body mass index (BMI).Methods: We recorded results of all 75-gram oral glucose tolerance tests (OGTTs) performed on pregnant women between February and December 2015 together with their demographic details, and determined the prevalence of GDM based on the old Australian Diabetes in Pregnancy Society (ADIPS) and the new WHO criteria respectively.Results: Over that period, 2140 OGTTs were performed in 1725 pregnant women. The prevalence of GDM was 14.8% (255/1725 women) under old ADIPS criteria, but went up to 29.6% (510/1725) when using WHO criteria. An increase in prevalence was observed in all ethnic groups. Women from East/South-East Asia had the lowest increment (from 19.2 to 22.3%) while those from South Asia had the highest (from 22.0 to 44.4%). Prevalence of GDM was 45.9% amongst women with BMI>30kg/m2. For women from South Asia with BMI>30kg/m2, 70.0% would have GDM. Birth outcomes were similar between women who would have GDM under WHO but not the old ADIPS criteria (untreated), and those who were treated for GDM under old criteria.Conclusion: In parts of Australia, adoption of WHO diagnostic criteria could result in doubling of the prevalence of GDM, depending on the women's demographic characteristics. Women from South Asia or those with obesity should be targeted for pre-pregnant lifestyle intervention. [ABSTRACT FROM AUTHOR]

To improve birth outcomes, all pregnant women without known diabetes are recommended for an oral glucose tolerance test (OGTT) to screen for hyperglycaemia in pregnancy (diabetes in pregnancy or gestational diabetes mellitus (GDM)). This narrative review presents contemporary approaches to minimise preanalytical glycolysis in OGTT samples with a focus on GDM diagnosis using criteria derived from the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study. The challenges of implementing each approach across a diverse Australian healthcare setting were explored. Many Australian sites currently collect and transport OGTT samples at ambient temperature in sodium fluoride (NaF) tubes which is likely to lead to missed diagnosis of GDM in a significant proportion of cases. Alternative preanalytical solutions should be pragmatic and tailored to individual settings and as close as possible to the preanalytical conditions of the HAPO study for correct interpretation of OGTT results. Rapid centrifugation of barrier tubes to separate plasma could be suitable in urban settings provided time to centrifugation is strictly controlled. Tubes containing NaF and citrate could be useful for remote or resource poor settings with long delays to analysis but the impact on the interpretation of OGTT results should be carefully considered. Testing venous blood glucose at the point-of-care bypasses the need for glycolytic inhibition but requires careful selection of devices with robust analytical performance. Studies to evaluate the potential error of each solution compared to the HAPO protocol are required to assess the magnitude of misdiagnosis and inform clinicians regarding the potential impact on patient safety and healthcare costs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Gestational diabetes mellitus (GDM) has a rapidly increasing prevalence, which poses challenges to obstetric care and service provision, with known serious long-term impacts on the metabolic health of the mother and the affected offspring. The aim of this study was to evaluate the association between glucose levels on the 75 g oral glucose tolerance test and GDM treatment and outcomes. We performed a retrospective cohort study of women with GDM attending a tertiary Australian hospital obstetric clinic between 2013 and 2017, investigating the relationship between the 75 g oral glucose tolerance test (OGTT) glucose values, and obstetric (timing of delivery, caesarean section, preterm birth, preeclampsia), and neonatal (hypoglycaemia, jaundice, respiratory distress and NICU admission) outcomes. This time frame encompassed a change in diagnostic criteria for gestational diabetes, due to changes in international consensus guidelines. Our results showed that, based on the diagnostic 75 g OGTT, fasting hyperglycaemia, either alone or in combination with elevated 1 or 2 h glucose levels, was associated with the need for pharmacotherapy with either metformin and/or insulin ( p < 0.0001; HR 4.02, 95% CI 2.88-5.61), as compared to women with isolated hyperglycaemia at the 1 or 2 h post-glucose load timepoints. Fasting hyperglycaemia on the OGTT was more likely in women with higher BMI ( p < 0.0001). There was an increased risk of early term birth in women with mixed fasting and post-glucose hyperglycaemia (adjusted HR 1.72, 95% CI 1.09-2.71). There were no significant differences in rates of neonatal complications such as macrosomia or NICU admission. Fasting hyperglycaemia, either alone or in combination with post-glucose elevations on the OGTT, is a strong indicator of the need for pharmacotherapy in pregnant women with GDM, with significant ramifications for obstetric interventions and their timing.

Background Gestational diabetes mellitus ( GDM) affects 5-8% of pregnant women in Australia and is linked to adverse maternal and neonatal outcomes. Earlier diagnosis and treatment has been suggested to improve these outcomes. Aim To describe the experience of a change in GDM screening policy at a large tertiary hospital. Materials and Methods A 6-month audit was performed following a policy change involving introduction of screening for all women early in pregnancy (by either random blood glucose level ( BGL) or oral glucose tolerance testing ( OGTT), depending on their perceived risk of developing GDM), followed by universal OGTT at 26-28 weeks' gestation. The prevalence of GDM (including changes expected from new Australasian Diabetes in Pregnancy Society ( ADIPS) criteria), maternal and neonatal outcomes and adherence to new screening policy are reported. Results The prevalence of GDM was 7.9% (1.6% early, 6.3% later diagnoses). More women with early diagnoses required insulin. Early testing with random BGL for low-risk women only identified 1.7% of those with GDM. Early OGTT for high-risk women identified 24.9% of GDM diagnoses. Adherence to the new screening protocol was generally poor, with 26% adherence at booking, 64% at 26 weeks' gestation and 27% with unknown GDM status. Conclusions While early testing with OGTT for high-risk women may be helpful, the value of early testing with random BGL for low-risk women is questionable. The new ADIPS criteria are likely to increase the number of women diagnosed with GDM (with an emphasis on earlier diagnosis), but the absolute increase remains small. [ABSTRACT FROM AUTHOR]

Background: Treatment of gestational diabetes improves maternal and infant health, although diagnostic criteria remain unclear., Methods: We randomly assigned women at 24 to 32 weeks' gestation in a 1:1 ratio to be evaluated for gestational diabetes with the use of lower or higher glycemic criteria for diagnosis. The lower glycemic criterion was a fasting plasma glucose level of at least 92 mg per deciliter (≥5.1 mmol per liter), a 1-hour level of at least 180 mg per deciliter (≥10.0 mmol per liter), or a 2-hour level of at least 153 mg per deciliter (≥8.5 mmol per liter). The higher glycemic criterion was a fasting plasma glucose level of at least 99 mg per deciliter (≥5.5 mmol per liter) or a 2-hour level of at least 162 mg per deciliter (≥9.0 mmol per liter). The primary outcome was the birth of an infant who was large for gestational age (defined as a birth weight above the 90th percentile according to Fenton-World Health Organization standards). Secondary outcomes were maternal and infant health., Results: A total of 4061 women underwent randomization. Gestational diabetes was diagnosed in 310 of 2022 women (15.3%) in the lower-glycemic-criteria group and in 124 of 2039 women (6.1%) in the higher-glycemic-criteria group. Among 2019 infants born to women in the lower-glycemic-criteria group, 178 (8.8%) were large for gestational age, and among 2031 infants born to women in the higher-glycemic-criteria group, 181 (8.9%) were large for gestational age (adjusted relative risk, 0.98; 95% confidence interval, 0.80 to 1.19; P = 0.82). Induction of labor, use of health services, use of pharmacologic agents, and neonatal hypoglycemia were more common in the lower-glycemic-criteria group than in the higher-glycemic-criteria group. The results for the other secondary outcomes were similar in the two trial groups, and there were no substantial between-group differences in adverse events. Among the women in both groups who had glucose test results that fell between the lower and higher glycemic criteria, those who were treated for gestational diabetes (195 women), as compared with those who were not (178 women), had maternal and infant health benefits, including fewer large-for-gestational-age infants., Conclusions: The use of lower glycemic criteria for the diagnosis of gestational diabetes did not result in a lower risk of a large-for-gestational-age infant than the use of higher glycemic criteria. (Funded by the Health Research Council of New Zealand and others; GEMS Australian New Zealand Clinical Trials Registry number, ACTRN12615000290594.)., (Copyright © 2022 Massachusetts Medical Society.)

Aims: To improve perinatal outcomes, screening for hyperglycaemia using 75 g oral glucose tolerance test (OGTT) is recommended for all pregnant women at 24-28 weeks gestation (routine), and earlier if high-risk. Screening coverage for remote and Aboriginal Australian women is less than ideal. This study examined OGTT completion (early and routine) by women from rural and remote Western Australia compared with early glycated haemoglobin (HbA 1c )., Methods: In 2015-2018, 27 primary health care sites recruited 600 (233 Aboriginal) women aged ≥16-years, without pre-existing diabetes, who delivered >30-weeks gestation. All women presenting <20-weeks gestation (541) were offered an early study HbA 1c . Early OGTTs were requested at the discretion of the local clinician, with routine OGTT offered at 24-28 weeks., Results: HbA 1c uptake was high (85.7% Aboriginal, 86.4% non-Aboriginal); OGTT completion in Aboriginal women was low (early OGTT: 38.6% v 69.6% non-Aboriginal, P < 0.001; routine OGTT: 44.5% v 84.7% non-Aboriginal, P < 0.001). Aboriginal women with both early tests had HbA 1c completed 3-weeks prior to OGTT (9.6 ± 3.5 v 12.5 ± 3.5 weeks gestation, P < 0.001)., Conclusions: Universal early pregnancy HbA 1c appears feasible as an early screening test for women at risk of hyperglycaemia in pregnancy and would expedite and increase screening in Aboriginal women compared to an early OGTT., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

There is a paucity of data on whether Australian university students are meeting specific nutrient guidelines, and the relationship between diet and physical activity patterns with body composition and metabolic health. In this study, biomedical students from The University of Queensland were recruited (150 males and 211 females, 19-25 years), and nutritional intake (ASA24-Australia) and physical activity levels (Active Australia Survey) quantified. Body composition (height, waist circumference, body mass, BMI, and percentage body fat; BOD POD) and metabolic health (oral glucose tolerance test) were also measured. Median daily energy intake was 6760 kJ in females and 10,338 kJ in males, with more than 30% of total energy coming from energy-dense, nutrient-poor foods. Only 1 in 10 students met fruit or vegetable recommendations, with less than one third meeting recommendations for fibre, calcium, and potassium. Intakes of calcium and iron were particularly low among female students, with only 16% and 6% of students meeting the recommended dietary intake (RDI), respectively. The majority of males and almost half of all females exceeded the suggested dietary target (SDT) for sodium. Sufficient physical activity (≥150 min over ≥5 sessions per week) was met by more than 80% of students. Body composition and blood glucose concentrations were largely normal but an early sign of insulin resistance (HOMA-IR > 2.0), measured in a subset of students, was present in 21% of males and 17% of females. Modest reductions in blood glucose levels and percentage body fat were associated with increasing vigorous activity. Low intakes of fibre, calcium, and potassium could be corrected by increasing fruit, vegetable, and dairy intake, and, among females, health promotion messages focusing on iron-rich foods should be prioritised. While these nutrient deficiencies did not translate into immediate metabolic heath concerns, dietary behaviours can track into adulthood and have lasting effects on overall health.

Background and Objectives: The increasing incidence of type 2 diabetes (T2D) is a major Australian and worldwide health concern. The aim of this study was to examine trends in T2D pathology testing by Australian doctors, with a focus on screening and early identification., Method: A secondary analysis was conducted of publicly available data for eight pathology tests, accessed from the nationally funded Medicare Benefits Schedule (MBS). Descriptive statistics were used to analyse the annual trends, according to age and sex, for the calendar years 2010-19., Results: Over the 10 years, screening rates for T2D had doubled while glycated haemoglobin (HbA1c) tests for management remained constant. At the end of 2014, the MBS introduced HbA1c screening tests. By 2019, the HbA1c screening rates were three times higher than glucose tolerance tests, which had halved., Discussion: A strong adoption of the national screening guidelines introduced in 2015-16 was identified. Limitations in MBS data categorisation, such as no item number specific to fasting glucose or insulin, prevented detailed analysis of other potentially relevant tests that might be used to screen for prediabetes and diabetes.

Background: Post-partum follow up testing of women with gestational diabetes mellitus (GDM) is important. All women, and their family doctors, receive written reminders. There are no recent major Australian reviews of the efficacy and compliance with this advice conducted in an ethnically representative population and using the current diagnostic criteria., Aim: The aim was to examine a cohort of women with recently diagnosed GDM and a completed pregnancy to determine what proportion had been tested and what were the difficulties in having testing carried out., Methods: Women who were diagnosed with gestational diabetes and attended the Diabetes Service in 2017 were followed up in 2019. Attempted contact was made using an unidentified land line, an identifiable mobile phone and a postal survey. Compliance with testing advice was the major parameter considered., Results: There were 714 women with GDM, 75 were excluded: 64 after pass one and 11 after pass two. In total, only 339/639 (53.1%) could be contacted. Of these women, 334 agreed to be surveyed; 207 (62.0%) had a post-partum test. Of the 127 women who had not had a test, 113 agreed to have an HbA1c. Only 13/113 (11.5%) had this done within a month., Conclusion: Contacting women, even within a short time after the pregnancy, is difficult. The number of post-partum tests carried out is suboptimal. Written advice to all women and their doctors does not appear to be working. A review of the cost effectiveness of this approach and development of new methods may be worthwhile., (© 2021 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Aims: To assess whether early pregnancy HbA 1c can predict gestational diabetes mellitus (GDM) and adverse birth outcomes in Australian women., Methods: Prospective study of 466 women without diabetes, aged ≥16-years at first antenatal presentation. Recruitment was from 27 primary healthcare sites in rural and remote Australia from 9-January 2015 to 31-May 2018. HbA 1c was measured with first antenatal investigations (<20-weeks gestation). Primary outcome measure was predictive value of HbA 1c for GDM, by routine 75 g oral glucose tolerance test (OGTT; ≥24-weeks gestation), and for large-for-gestational-age (LGA) newborn., Results: Of 396 (129 Aboriginal) women with routine OGTT, 28.8% had GDM (24.0% Aboriginal). HbA 1c  ≥5.6% (≥38 mmol/mol) was highly predictive (71.4%, 95% CI; 47.8-88.7%) for GDM in Aboriginal women, and in the total cohort increased risk for LGA newborn (RR 2.04, 95% CI; 1.03-4.01, P = 0.040). There were clear differences between Aboriginal and non-Aboriginal women: 16.3% v 5.2% (P < 0.001) had elevated HbA 1c whereas 12.4% v 29.6% (P < 0.001) developed hyperglycemia during pregnancy., Conclusions: Early pregnancy HbA 1c  ≥5.6% (≥38 mmol/mol) identifies Aboriginal women with apparent prediabetes and elevated risk of having an LGA newborn. Universal HbA 1c at first antenatal presentation could facilitate earlier management of hyperglycemia and improved perinatal outcome in this high-risk population., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Aims: Metabolic associated fatty liver disease (MAFLD) is a leading cause of chronic liver disease and has been increasingly associated with gestational diabetes (GDM). This study aimed to assess the prevalence of MAFLD in women with GDM in the antenatal period., Methods: 108 pregnant women with GDM diagnosed on a 75-gram oral glucose tolerance test were enrolled from a multiethnic cohort attending a large obstetrics clinic in Sydney, Australia and had a single FibroScan® assessment after 24 weeks gestation to assess for hepatic steatosis and fibrosis. A control attenuated parameter (CAP) cut-off score of ≥ 233.5 dB/m was chosen to signify presence of hepatic steatosis which indicates MAFLD. Obstetric, anthropometric and metabolic measures were analysed., Results: 29 (26.9%) women had evidence of FibroScan®-detected MAFLD, whilst none had evidence of hepatic fibrosis. Increased maternal BMI (aOR 1.12, 95% CI: 1.04-1.20) was associated with the finding of MAFLD in this cohort., Conclusions: We found a significant antenatal prevalence of FibroScan®-detected MAFLD in this cohort of multiethnic women with GDM. FibroScan® is a safe and rapid assessment tool which may have a role in screening for MAFLD in pregnancy in appropriate at-risk women., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background and Aims: Gestational diabetes (GDM) is one of the most common medical complications of pregnancy and associated with significant perinatal and long-term morbidity. Temporary changes to the diagnostic testing for GDM have been recommended for the COVID-19 pandemic. This study aims to identify what proportion of women with GDM would be missed by the COVID-19 GDM screening criteria. Secondly an analysis of the relationship between HbA1c, fasting blood glucose (FBG) and pregnancy outcomes will be completed., Methods: This was a retrospective analysis of all GDM patients at an Australian secondary hospital between January 2019 and February 2020. The proportion of women with GDM who would have been missed using the COVID-19 guidelines was assessed. Patients were divided into groups according to how their GDM was managed during the pregnancy: Diet, Metformin (MF), Insulin and MF + Insulin groups. Differences between the groups were compared using one-way ANOVA and post-hoc analysis was completed using the Bonferroni test. Logistic regression was employed to further compare the differences between the groups., Results: The study group comprised 237 patients. Sixty patients (25.3%) would not have had GDM detected in their pregnancy using the COVID-19 guidelines. FBG was the most significant predictor for intervention with medication for GDM (p = 0.001)., Conclusion: HbA1c and FBG are poor screening tests for GDM. During the COVID-19 pandemic, the OGTT should be given clinical priority in high risk patients. Elevated FBG is a significant predictor for needing medical management and could be used in the future to better enable individualised treatment., Competing Interests: Declaration of competing interest There is no conflict of interest between authors and any institution., (Copyright © 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Background: Multiple professional bodies have temporarily revised recommendations for gestational diabetes mellitus (GDM) testing during the COVID-19 pandemic to reduce person-to-person contact. The current Australian temporary criteria advise that if the fasting glucose is ≤4.6 mmol/L, then no glucose tolerance test (GTT) is required., Aims: The aim of this study is to examine the extent of underdiagnosis of GDM using a fasting glucose ≤4.6 mmol/L as a cut-off to determine that a GTT is not necessary., Materials and Methods: De-identified data from pregnant women having a GTT test in the Illawarra area during a six-year period was used to determine the number of women with GDM and the proportion of positive cases that would be missed for different fasting glucose values., Results: There were 16 522 results identified and GDM was diagnosed in 12.2%. The majority of women were more than 30 years of age (85.2%) and diagnosed at ≥20 weeks gestation (81.1%). Of those diagnosed with GDM, 29% had a fasting glucose of ≤4.6 mmol/L and would have been missed., Conclusions: Our results show that using a fasting glucose of 4.6 mmol/L or less would miss nearly a third of women who would otherwise be diagnosed with GDM., (© 2020 Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Maternal obesity is a key risk factor for morbidity in pregnancy. Accurate data on trends in obesity are required in high-risk populations such as in western Sydney to implement effective policy., Aims: This study examines multi-site public hospital data on maternal ethnicity, body mass index (BMI), gestational diabetes mellitus (GDM) and hypertension across 20 years in Western Sydney Local Health District (WSLHD)., Materials and Methods: This is a retrospective cohort study of all women who delivered a live birth beyond 20 weeks at Westmead, Blacktown and Auburn Hospitals (WSLHD) between 1 January 1997 and 31 December 2016., Results: There were 112 308 pregnant women included. Between 1997 and 2006, mean booking-in BMI climbed from 24.9 (median 23.9) to peak at 26.2 (24.9). It then fell to 25.3 (24.1) in 2012 before rising to 25.6 (24.4) in 2016. Rates of hypertensive disorders changed little over the period, with a small fall in pre-eclampsia. In contrast, there was a progressive upward trend in the prevalence of GDM, accelerating considerably after 2010. These trends were associated with a shifting ethnic profile with proportions of Australia/New Zealand-born women falling from 56.9% to 36.8%, while those from South Asia increased from 4.5% to 26.3%., Conclusions: Western Sydney booking-in BMI fluctuated between 1997 and 2016, reaching its peak in 2006. Despite this, rates of GDM progressively rose, with one in six mothers in western Sydney now diagnosed with some form of the condition. Both patterns are associated with a notable shift in the ethnic profile of patients booking-in to antenatal care in the region., (© 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: Gestational diabetes mellitus (GDM) is a metabolic disorder of pregnancy that is increasingly prevalent among Chinese women. Few studies have examined whether the migration status of Chinese women contributes to the risks of developing GDM during pregnancy., Research Design and Methods: In this observational, cross-sectional and hospital-based study, we examined the prevalence of GDM and glycemic levels at oral glucose tolerance test (OGTT) among 491 Australian Chinese migrants (n=491) and native Chinese (n=1000). We defined GDM using the International Association of Diabetes and Pregnancy Study Groups guidelines. We collected data on maternal age, body mass index (BMI) and gestational age (GA) at booking and GA at delivery from medical records. We used multiple logistic and linear regression models to calculate the OR of having GDM and mean differences in glycemic levels in Australian Chinese migrants, relative to native Chinese., Results: Age-at-booking and BMI-at-booking adjusted GDM prevalence was significantly higher in Australian Chinese migrants than native Chinese (19.7% vs 14.6%; p=0.01). After adjusting for age, BMI at booking and GA at booking, fasting glucose levels were significantly lower (β -0.08 mmol/L; 95% CI -0.14 to 0.02), while 2-hour glucose levels were significantly higher (0.22 mmol/L; 0.02 to 0.43) in Australian Chinese immigrants than native Chinese., Conclusions: Migration status may be a marker for abnormal glucose metabolism during pregnancy among Australian Chinese migrants, possibly due to socio-economic disadvantages and lifestyle changes associated with migration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Women with gestational diabetes mellitus (GDM) have an increased risk of adverse pregnancy outcomes. This study examined predictors for GDM recurrence at their next pregnancy in a multi-ethnic population. Clinical outcomes of women with GDM at the index as well as the subsequent pregnancies were also compared., Materials and Methods: A retrospective review of women with GDM (between 2008 and 2016) who had a subsequent pregnancy at a tertiary institution was conducted. The clinical characteristics of both pregnancies were documented., Results: Among 3587 singleton pregnancies complicated by GDM, 501 fell pregnant again and 367 (73.1%) developed GDM in their subsequent pregnancies. Subsequent pregnancies had higher birthweight (3426 ± 563 vs 3290 ± 506 g, P < 0.001) but the rate of pre-eclampsia was lower (1.0% vs 4.2%, P = 0.003). Univariate analysis showed that older age, prior history of GDM, pre-pregnant body mass index (BMI), two-hour glucose level on glucose tolerance test (GTT), insulin requirement at the index pregnancy, and inter-pregnancy weight gain were associated with recurrent GDM. Using stepwise logistic regression analysis, pre-pregnant BMI, glucose levels on GTT at index pregnancy and inter-pregnancy weight gain were independent predictors for recurrent GDM. The odds ratios for recurrent GDM among those who gained more than 8 kg were 20.5 (5.0-84.5), compared with those who lost over 5 kg between the two pregnancies. GDM recurrence rate was independent of ethnic backgrounds., Conclusion: Women with GDM have high risk of GDM recurrence at their next pregnancy. Inter-pregnancy weight gain is a strong predictor of recurrent GDM, and strategies to help women lose weight post-partum may be invaluable., (© 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Gestational diabetes mellitus (GDM) is the most common antenatal complication in Australia. All pregnant women are recommended for screening by 75 g oral glucose tolerance test (OGTT). As part of a study to improve screening, 694 women from 27 regional, rural and remote clinics were recruited from 2015-2018 into the Optimisation of Rural Clinical and Haematological Indicators for Diabetes in pregnancy (ORCHID) study. Most routine OGTT samples were analysed more than four hours post fasting collection (median 5.0 h, range 2.3 to 124 h), potentially reducing glucose levels due to glycolysis. In 2019, to assess pre-analytical plasma glucose (PG) instability over time, we evaluated alternative sample handling protocols in a sample of participants. Four extra samples were collected alongside routine room temperature (RT) fluoride-oxalate samples (FLOX RT ): study FLOX RT ; ice slurry (FLOX ICE ); RT fluoride-citrate-EDTA (FC Mix), and RT lithium-heparin plasma separation tubes (PST). Time course glucose measurements were then used to estimate glycolysis from ORCHID participants who completed routine OGTT after 24 weeks gestation ( n = 501). Adjusting for glycolysis using FLOX ICE measurements estimated 62% under-diagnosis of GDM (FLOX RT 10.8% v FLOX ICE 28.5% (95% CI, 20.8-29.5%), p < 0.001). FC Mix tubes provided excellent glucose stability but gave slightly higher results (Fasting PG: +0.20 ± 0.05 mmol/L). While providing a realistic alternative to the impractical FLOX ICE protocol, direct substitution of FC Mix tubes in clinical practice may require revision of GDM diagnostic thresholds.

Background: The oral glucose-tolerance test (OGTT) is currently the standard method for diagnosis of gestational diabetes (GDM). We conducted a post hoc analysis using the Australian Hyperglycemia and Adverse Pregnancy Outcome (HAPO) data to determine seasonal variations in OGTT results, the consequent prevalence of GDM, and association with select perinatal parameters., Method: Women enrolled in the Australian HAPO study sites (Brisbane and Newcastle) from 2001 to 2006 were included if OGTT results between 24 to 32 weeks gestation were available (n = 2120). Fasting plasma glucose, 1-h plasma glucose, 2-h plasma glucose, HbA1c, HOMA-IR, and umbilical cord C-peptide and glucose values were categorized by season and correlated to monthly temperature records from the Australian Bureau of Meteorology for Brisbane and Newcastle. GDM was defined post hoc using the IADPSG/WHO criteria., Results: Small but significant (p <  0.01 on ANOVA) elevations in fasting glucose (+ 0.12 mM), HbA1c (+ 0.09%), and HOMA-IR (+ 0.88 units) were observed during the winter months. Conversely, higher 1-h (+ 0.19 mM) and 2-h (+ 0.33 mM) post-load glucose values (both p <  0.01) were observed during the summer months. The correlations between fasting glucose, 1-h glucose, 2-h glucose, and HbA1c with average monthly temperatures confirmed this trend, with positive Pearson's correlations between 1-h and 2-h glucose with increasing average monthly temperatures, and negative correlations with fasting glucose and HbA1c. Further, umbilical cord C-peptide and glucose displayed negative Pearson's correlation with average monthly temperature, aligned with trends seen in the fasting plasma glucose. Overall prevalence of GDM did not display significant seasonal variations due to the opposing trends seen in the fasting versus 1-h and 2-h post-load values., Conclusion: A significant winter increase was observed for fasting plasma glucose, HbA1c, and HOMA-IR, which contrasted with changes in 1-h and 2-h post-load venous plasma glucose values. Interestingly, umbilical cord C-peptide and glucose displayed similar trends to that of the fasting plasma glucose. While overall prevalence of GDM did not vary significantly by seasons, this study illustrates that seasonality is indeed an additional factor when interpreting OGTT results for the diagnosis of GDM and provides new direction for future research into the seasonal adjustment of OGTT results.

Objective: Given the role of gut microbiota in regulating metabolism, probiotics administered during pregnancy might prevent gestational diabetes mellitus (GDM). This question has not previously been studied in high-risk overweight and obese pregnant women. We aimed to determine whether probiotics ( Lactobacillus rhamnosus and Bifidobacterium animalis subspecies lactis ) administered from the second trimester in overweight and obese women prevent GDM as assessed by an oral glucose tolerance test (OGTT) at 28 weeks' gestation. Secondary outcomes included maternal and neonatal complications, maternal blood pressure and BMI, and infant body composition., Research Design and Methods: This was a double-blind randomized controlled trial of probiotic versus placebo in overweight and obese pregnant women in Brisbane, Australia., Results: The study was completed in 411 women. GDM occurred in 12.3% (25 of 204) in the placebo arm and 18.4% (38 of 207) in the probiotics arm ( P = 0.10). At OGTT, mean fasting glucose was higher in women randomized to probiotics (79.3 mg/dL) compared with placebo (77.5 mg/dL) ( P = 0.049). One- and two-hour glucose measures were similar. Preeclampsia occurred in 9.2% of women randomized to probiotics compared with 4.9% in the placebo arm ( P = 0.09). Excessive weight gain occurred in 32.5% of women in the probiotics arm (55 of 169) compared with 46% in the placebo arm (81 of 176) ( P = 0.01). Rates of small for gestational age (<10th percentile) were 2.4% in the probiotics arm (5 of 205) and 6.5% in the placebo arm (13 of 199) ( P = 0.042). There were no differences in other secondary outcomes., Conclusions: The probiotics used in this study did not prevent GDM in overweight and obese pregnant women., (© 2019 by the American Diabetes Association.)

Background: Gestational diabetes mellitus (GDM) causes adverse pregnancy outcomes that can be averted by treatment from 24-28 weeks' gestation. Assessing and treating women for overt diabetes in pregnancy (ODIP) at the first antenatal clinic booking is now recommended in international guidelines. As a consequence, women with milder hyperglycaemia are being diagnosed and treated for early GDM, but randomised controlled trial (RCTs) assessing the benefits and harms of such treatment have not been undertaken. The Treatment Of Booking Gestational diabetes Mellitus (TOBOGM) study is a multi-centre RCT examining whether diagnosing and treating GDM diagnosed at booking improves pregnancy outcomes. Methods and analysis: 4000 adult pregnant women (< 20 weeks' gestation) at risk of ODIP will be recruited from 12 hospital antenatal booking clinics and referred for an oral glucose tolerance test (OGTT). 800 women with hyperglycaemia (ie, booking GDM) according to the 2014 Australasian Diabetes-in-Pregnancy Society criteria for pregnant women at 24-28 weeks' gestation will be randomised to immediate treatment for GDM (intervention) or to no treatment (control), pending the results of a second OGTT at 24-28 weeks' gestation. Antenatal and GDM care will otherwise follow local guidelines. Randomisation will be stratified by site and OGTT glycaemic risk strata. The primary pregnancy outcome is a composite of respiratory distress, phototherapy, birth trauma, birth before 37 weeks' gestation, stillbirth or death, shoulder dystocia, and birthweight ≥ 4.5 kg. The primary neonatal outcome is neonatal lean body mass. The primary maternal outcome is pre-eclampsia. Ethics approval: South Western Sydney Local Health District Research and Ethics Office (reference, 15/LPOOL/551). Dissemination of results: Peer-reviewed publications, scientific meetings, collaboration with research groups undertaking comparable studies, discussions with guideline groups and policy makers., Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN12616000924459.

Background: Repeat dose(s) of antenatal betamethasone are recommended for women at <32 weeks with ongoing risk of preterm birth. However, there is concern that use of repeat dose(s) in fetal growth restriction (FGR) may increase the risk of later cardiometabolic disease., Methods: We undertook secondary analysis of data from the Australasian Collaborative Trial of Repeat Doses of Corticosteroids Midchildhood Outcome Study to determine if FGR influences the effect of repeat betamethasone on growth and cardiometabolic function. At 6 to 8 years, children underwent anthropometry, dual energy x-ray absorptiometry, intravenous glucose tolerance testing, ambulatory blood pressure monitoring, and spirometry. FGR was defined as severe FGR at entry, cesarean delivery for FGR, or customized birth weight below the third centile., Results: Of 266 children assessed, FGR occurred in 43 of 127 (34%) exposed to repeat betamethasone and 44 of 139 (32%) exposed to placebo. There was an interaction between FGR and repeat betamethasone treatment for the effect on height ( z score mean difference [95% confidence interval]; FGR: 0.59 [0.01 to 1.17]; non-FGR: -0.29 [-0.69 to 0.10]; P = .01). However, FGR did not influence the effect of repeat betamethasone on cardiometabolic function, which was similar in treatment groups, both in FGR and non-FGR subgroups., Conclusions: Repeat antenatal betamethasone treatment had no adverse effects on cardiometabolic function, even in the presence of FGR. It may have a positive effect on height in FGR. Clinicians should use repeat doses of antenatal corticosteroids when indicated before preterm birth, regardless of FGR, in view of the associated neonatal benefits., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objectives: The oral glucose tolerance test (OGTT) is a cumbersome test that is time consuming, labour intensive and often poorly tolerated by pregnant women. To date, glycosylated haemoglobin (HbA1c) is the most accepted measure of chronic glycaemia outside of pregnancy. HbA1c is an uncomplicated test, less time consuming, does not require any specific patient preparation and is considered straightforward compared with the OGTT. Therefore, we prospectively tested the utility of the HbA1c when used as a screening tool in pregnancy for gestational diabetes mellitus (GDM)., Settings: Primary health care. Single tertiary referral centre, Tasmania, Australia., Participants: A direct comparison between HbA1c levels and the OGTT results in pregnant women, tested concurrently at the 24-28 gestational week, was undertaken. A full profile of 480 pregnant women during the period from September 2012 to July 2014 was completed. Median and mean age of participants was 29 years (range 18-47 years)., Interventions: A simultaneous prospective assessment of HbA1c versus standard OGTT in a cohort of consecutive pregnant women presenting to our institute was performed., Results: The number of women who had GDM according to OGTT criteria was 57, representing 11.9% of the evaluated 480 pregnant women. Using a cut-off value for HbA1c at 5.1% (32 mmol/mol) for detecting GDM showed sensitivity of 61% and specificity of 68% with negative predictive value (NPV) of 93%, versus sensitivity of 27% and specificity of 95% with NPV of 91% when using HbA1c cut-off value of 5.4% (36 mmol/mol)., Conclusions: Our results suggest that pregnant women with an HbA1c of≥5.4% (36 mmol/mol) should proceed with an OGTT. This may result in a significant reduction in the burden of testing on both patients and testing facility staff and resources. Further investigations are required to integrate and optimise the HbA1c as a single, non-fasting, screening tool for GDM., Trial Registration Number: ACTRN12611000739910., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: This study assessed the effect of a 12-week sports-based exercise intervention on glucose regulation, anthropometry and inflammatory markers associated with the prevalence of type 2 diabetes mellitus (T2DM) in Indigenous Australian men., Design: Twenty-six inactive Indigenous Australian men (48.6±6.6 years) were randomized into exercise (n=16) or control (n=10)conditions., Methods: Training included ∼2-3 days/week for 12 weeks of sports and gym exercises in a group environment, whilst control participants maintained normal activity and dietary patterns. Pre- and post-intervention testing included: anthropometry, peak aerobic capacity, fasting blood chemistry of inflammatory cytokines, adiponectin, leptin, cholesterol, glucose, insulin and C-peptide. An oral glucose tolerance test measured glucose, insulin and C-peptide 30, 60, 90 and 120min post 75g glucose ingestion., Results: The exercise condition decreased insulin area under the curve (25±22%), increased estimated insulin sensitivity (35±62%) and decreased insulin resistance (9±35%; p<0.05), compared with control (p>0.05). The exercise condition decreased in body mass index, waist circumference and waist to hip ratio (p<0.05), compared to control (p>0.05). Leptin decreased in the exercise group, with no changes for adiponectin (p>0.05) or inflammatory markers (p>0.05) in either condition. Aerobic fitness variables showed significant increases in peak oxygen consumption for the exercise condition compared to no change in control (p>0.05)., Conclusions: Findings indicate positive clinical outcomes in metabolic, anthropometric and aerobic fitness variables. This study provides evidence for sport and group-based activities leading to improved clinical risk factors associated with T2DM development in clinically obese Indigenous Australian men., (Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Women with gestational diabetes have a high risk of type 2 diabetes postpartum, with Indigenous women particularly affected. This study reports postpartum diabetes screening rates among Indigenous and non-Indigenous women with gestational diabetes, in Far North Queensland, Australia. Retrospective study including 1,012 women with gestational diabetes giving birth at a regional hospital from 1/1/2004 to 31/12/2010. Data were linked between hospital records, midwives perinatal data, and laboratory results, then analysed using survival analysis and logistic regression. Indigenous women had significantly longer times to first oral glucose tolerance test (OGTT) [hazards ratio (HR) 0.62, 95 % confidence interval (CI) 0.48-0.79, p < 0.0001) and 'any' postpartum glucose test (HR 0.81, 95 % CI 0.67-0.98, p = 0.03], compared to non-Indigenous women. Postpartum screening rates among all women were low. However, early OGTT screening rates (<6 months) were significantly lower among Indigenous women (13.6 vs. 28.3 %, p < 0.0001), leading to a persistent gap in cumulative postpartum screening rates. By 3 years postpartum, cumulative rates of receiving an OGTT, were 24.6 % (95 % CI 19.9-30.2 %) and 34.1 % (95 % CI 30.6-38.0 %) among Indigenous and non-Indigenous women, respectively. Excluding OGTTs in previous periods, few women received OGTTs at 6-24 months (7.8 vs. 6.7 %) or 2-4 years (5.2 vs. 6.5 %), among Indigenous and non-Indigenous women, respectively. Low rates of postpartum diabetes screening demonstrate that essential 'ongoing management' and 'equity' criteria for population-based screening for gestational diabetes are not being met; particularly among Indigenous women, for whom recent guideline changes have specific implications. Strategies to improve postpartum screening after gestational diabetes are urgently needed.

Objectives: To explore factors associated with postpartum glucose screening among women with Gestational Diabetes Mellitus (GDM)., Methods: A retrospective study using linked records from women with GDM who gave birth at Cairns Hospital in Far North Queensland, Australia, from 1 January 2004 to 31 December 2010., Results: The rates of postpartum Oral Glucose Tolerance Test (OGTT) screening, while having increased significantly among both Indigenous* and non-Indigenous women from 2004 to 2010 (HR 1.15 per year, 95%CI 1.08-1.22, p<0.0001), remain low, particularly among Indigenous women (10% versus 27%, respectively at six months postpartum). Indigenous women in Cairns had a longer time to postpartum OGTT than Indigenous women in remote areas (HR 0.58, 0.38-0.71, p=0.01). Non-Indigenous women had a longer time to postpartum OGTT if they: were born in Australia (HR 0.76, 0.59-1.00, 0.05); were aged <25 years (HR 0.45, 0.23-0.89, p=0.02); had parity >5 (HR 0.33, 0.12-0.90, p=0.03); smoked (HR 0.48, 0.31-0.76, p=0.001); and did not breastfeed (HR 0.09, 0.01-0.64, p=0.02)., Conclusions: Postpartum diabetes screening rates following GDM in Far North Queensland are low, particularly among Indigenous women, with lower rates seen in the regional centre; and among non-Indigenous women with indicators of low socioeconomic status., Implications: Strategies are urgently needed to improve postpartum diabetes screening after GDM that reach women most at risk., (© 2014 Public Health Association of Australia.)

The International Association of Diabetes and Pregnancy Study Groups has recommended new blood glucose levels (BGLs) for the diagnosis of gestational diabetes mellitus (GDM). These BGLs supposedly identify women with at least a 75% increased risk of developing certain adverse neonatal outcomes. The new criteria result in a significant increase in the number of women diagnosed with GDM. Most of the women diagnosed with GDM according to the new criteria have only one elevated BGL. Due to the unrecognised effect of the other BGLs being normal, up to 50% of these women are inappropriately diagnosed with GDM as they do not meet the agreed risk threshold. In absolute terms, for every 100 women diagnosed with GDM who have only one elevated BGL, nearly 50 do not meet the agreed risk threshold for diagnosis, and there are only up to seven extra cases of large-for-gestational-age infants. A more statistically valid basis for diagnosing GDM consistent with the recommended risk threshold is suggested.

Despite its increasing incidence and high conferred risk to women and their children, gestational diabetes mellitus (GDM) is managed inconsistently during and after pregnancy due to an absence of a systemic approach to managing these women. New guidelines for GDM testing and diagnosis are based on stronger evidence, but raise concerns about increased workloads and confusion in a landscape of multiple, conflicting guidelines. Postnatal care and long-term preventive measures are particularly fragmented, with no professional group taking responsibility for this crucial role. Clearer guidelines and assistance from existing frameworks, such as the National Gestational Diabetes Register, could enable general practitioners to take ownership of the management of women at risk of type 2 diabetes following GDM, applying the principles of chronic disease management long term.

Background: Recommendations to change the diagnostic criteria for gestational diabetes mellitus (GDM) are controversial. Two sets of criteria are currently in use in Australia, which has led to considerable confusion., Objective: This article discusses the rationale behind the proposed changes to the diagnostic criteria, and aims to clarify the current approach to the testing for and diagnosis of GDM in Australia., Discussion: Gestational diabetes mellitus has adverse effects on pregnancy outcomes and implications for the long term wellbeing of mother and infant. New information about the relationship between hyperglycaemia in pregnancy and fetal outcomes has led to the formulation of revised recommendations for testing and diagnosis of GDM. The changes to the diagnostic threshold will increase the numbers of women diagnosed with GDM by up to 50%. Evidence that management of GDM improves neonatal outcomes mandates a proactive approach to diagnosis and management. General practitioners will have an increasing role in managing GDM.

Background: The evidence supporting a relationship between stress and diabetes has been inconsistent., Purpose: This study examined the effects of stress on abnormal glucose metabolism, using a population-based sample of 3,759, with normoglycemia at baseline, from the Australian Diabetes, Obesity and Lifestyle study., Methods: Perceived stress and stressful life events were measured at baseline, with health behavior and anthropometric information also collected. Oral glucose tolerance tests were undertaken at baseline and 5-year follow-up. The primary outcome was the development of abnormal glucose metabolism (impaired fasting glucose, impaired glucose tolerance, and type 2 diabetes), according to WHO 1999 criteria., Results: Perceived stress predicted incident abnormal glucose metabolism in women but not men, after multivariate adjustment. Life events showed an inconsistent relationship with abnormal glucose metabolism., Conclusions: Perceived stress predicted abnormal glucose metabolism in women. Healthcare professionals should consider psychosocial adversity when assessing risk factor profiles for the development of diabetes.

Background: Gestational Diabetes Mellitus (GDM) has well recognised adverse health implications for the mother and her newborn that are both short and long term. Obesity is a significant risk factor for developing GDM and the prevalence of obesity is increasing globally. It is a matter of public health importance that clinicians have evidence based strategies to inform practice and currently there is insufficient evidence regarding the impact of dietary and lifestyle interventions on improving maternal and newborn outcomes. The primary aim of this study is to measure the impact of a telephone based intervention that promotes positive lifestyle modifications on the incidence of GDM. Secondary aims include: the impact on gestational weight gain; large for gestational age babies; differences in blood glucose levels taken at the Oral Glucose Tolerance Test (OGTT) and selected factors relating to self-efficacy and psychological wellbeing., Method/design: A randomised controlled trial (RCT) will be conducted involving pregnant women who are overweight (BMI >25 to 29.9 k/gm2) or obese (BMI >30 kgm/2), less than 14 weeks gestation and recruited from the Barwon South West region of Victoria, Australia. From recruitment until birth, women in the intervention group will receive a program informed by the Theory of Self-efficacy and employing Motivational Interviewing. Brief ( less than 5 minute) phone contact will alternate with a text message/email and will involve goal setting, behaviour change reinforcement with weekly weighing and charting, and the provision of health information. Those in the control group will receive usual care. Data for primary and secondary outcomes will be collected from medical record review and a questionnaire at 36 weeks gestation., Discussion: Evidence based strategies that reduce the incidence of GDM are a priority for contemporary maternity care. Changing health behaviours is a complex undertaking and trialling a composite intervention that can be adopted in various primary health settings is required so women can be accessed as early in pregnancy as possible. Using a sound theoretical base to inform such an intervention will add depth to our understanding of this approach and to the interpretation of results, contributing to the evidence base for practice and policy., Trial Registration: This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000125729.

Aim: The aim of this study is to assess the efficacy and safety of vildagliptin 50 mg bid as add-on therapy to insulin in type 2 diabetes mellitus (T2DM)., Methods: This is a multicentre, double-blind, placebo-controlled, parallel group, clinical trial in T2DM patients inadequately controlled by stable insulin therapy, with or without metformin. Patients received treatment with vildagliptin 50 mg bid or placebo for 24 weeks., Results: In all, 449 patients were randomized to vildagliptin (n = 228) or placebo (n = 221). After 24 weeks, the difference in adjusted mean change in haemoglobin A1c (HbA1c) between vildagliptin and placebo was -0.7 ± 0.1% (p < 0.001) in the overall study population, -0.6 ± 0.1% (p < 0.001) in the subgroup also receiving metformin and -0.8 ± 0.2% (p < 0.001) in the subgroup without metformin. Vildagliptin therapy was well tolerated and had a similarly low incidence of hypoglycaemia compared with placebo (8.4 vs. 7.2%, p = 0.66) in spite of improved glycaemic control, and was not associated with weight gain. (+0.1 vs. -0.4 kg)., Conclusions: Vildagliptin 50 mg bid added to insulin significantly reduced HbA1c in patients with T2DM inadequately controlled by insulin, with or without metformin. Vildagliptin was well tolerated, with a safety profile similar to placebo. These results were achieved without weight gain or an increase in hypoglycaemia incidence or severity in spite of improved glycaemic control., (© 2012 Blackwell Publishing Ltd.)

Objective: To examine the role of area-level socioeconomic status (SES) on the development of abnormal glucose metabolism (AGM) using national, population-based data., Research Design and Methods: The Australian Diabetes, Obesity and Lifestyle (AusDiab) study is a national, population-based, longitudinal study of adults aged ≥25 years. A sample of 4,572 people provided complete baseline (1999 to 2000) and 5-year follow-up (2004 to 2005) data relevant for these analyses. Incident AGM was assessed using fasting plasma glucose and 2-h plasma glucose from oral glucose tolerance tests, and demographic, socioeconomic, and behavioral data were collected by interview and questionnaire. Area SES was defined using the Index of Relative Socioeconomic Disadvantage. Generalized linear mixed models were used to examine the relationship between area SES and incident AGM, with adjustment for covariates and correction for cluster design effects., Results: Area SES predicted the development of AGM, after adjustment for age, sex, and individual SES. People living in areas with the most disadvantage were significantly more likely to develop AGM, compared with those living in the least deprived areas (odds ratio 1.53; 95% CI 1.07-2.18). Health behaviors (in particular, physical activity) and central adiposity appeared to partially mediate this relationship., Conclusions: Our findings suggest that characteristics of the physical, social, and economic aspects of local areas influence diabetes risk. Future research should focus on identifying the aspects of local environment that are associated with diabetes risk and how they might be modified.

Socio-economic gradients in cardiovascular disease (CVD) and diabetes have been found throughout the developed world and there is some evidence to suggest that these gradients may be steeper for women. Research on social gradients in biological risk factors for CVD and diabetes has received less attention and we do not know the extent to which gradients in biomarkers vary for men and women. We examined the associations between two indicators of socio-economic position (education and household income) and biomarkers of diabetes and cardiovascular disease (CVD) for men and women in a national, population-based study of 11,247 Australian adults. Multi-level linear regression was used to assess associations between education and income and glucose tolerance, dyslipidaemia, blood pressure (BP) and waist circumference before and after adjustment for behaviours (diet, smoking, physical activity, TV viewing time, and alcohol use). Measures of glucose tolerance included fasting plasma glucose and insulin and the results of a glucose tolerance test (2 h glucose) with higher levels of each indicating poorer glucose tolerance. Triglycerides and High Density Lipoprotein (HDL) Cholesterol were used as measures of dyslipidaemia with higher levels of the former and lower levels of the later being associated with CVD risk. Lower education and low income were associated with higher levels of fasting insulin, triglycerides and waist circumference in women. Women with low education had higher systolic and diastolic BP and low income women had higher 2 h glucose and lower HDL cholesterol. With only one exception (low income and systolic BP), all of these estimates were reduced by more than 20% when behavioural risk factors were included. Men with lower education had higher fasting plasma glucose, 2 h glucose, waist circumference and systolic BP and, with the exception of waist circumference, all of these estimates were reduced when health behaviours were included in the models. While low income was associated with higher levels of 2-h glucose and triglycerides it was also associated with better biomarker profiles including lower insulin, waist circumference and diastolic BP. We conclude that low socio-economic position is more consistently associated with a worse profile of biomarkers for CVD and diabetes for women., (Copyright 2010. Published by Elsevier Ltd.)

Background: Postnatal blood glucose testing is recommended for reclassification of glucose tolerance following a pregnancy affected by gestational diabetes mellitus (GDM); however, there are limited data on the postnatal follow-up sought by Australian women., Aims: To describe postnatal diabetes testing patterns in Australian women following a pregnancy affected by GDM and identify factors associated with return for follow-up testing in accordance with the Australasian Diabetes in Pregnancy Society (ADIPS) guidelines., Methods: A cross-sectional self-administered survey of 1372 women diagnosed with GDM between 2003 and 2005, sampled from the National Diabetes Services Scheme database., Results: Postnatal diabetes testing was reported by 73.2% of survey respondents with 27.4% returning for an oral glucose test tolerance at six to eight weeks post-GDM pregnancy. Using logistic regression analysis, factors associated with appropriate postnatal testing were receiving individualised risk reduction advice (odds ratio (OR) 1.41 (1.08,1.84)) or written information (OR 1.35 (1.03,1.76)) and in two-way interactions, being under the care of an endocrinologist and not tertiary educated (OR 2.09 (1.49,2.93)) as well as seeing an obstetrician and diabetes educator during pregnancy (OR 1.72 (1.19,2.48)). Every five years increase in age reduced the likelihood of a woman returning for testing by 17%., Conclusions: Specialist diabetes care in non-tertiary educated women, or a team approach to management with diabetes education and obstetric care may act to reinforce the need for postnatal diabetes testing in accordance with the ADIPS guidelines. Individualised follow up from a health professional and provision of written information following a GDM pregnancy may also encourage return for postnatal testing in this high-risk group.

Background: The impact of borderline gestational diabetes mellitus (BGDM), defined as a positive oral glucose challenge test (OGCT) and normal oral glucose tolerance test (OGTT), on maternal and infant health is unclear. We assessed maternal and infant health outcomes in women with BGDM and compared these to women who had a normal OGCT screen for gestational diabetes., Methods: We compared demographic, obstetric and neonatal outcomes between women participating in the Australian Collaborative Trial of Supplements with antioxidants Vitamin C and Vitamin E to pregnant women for the prevention of pre-eclampsia (ACTS) who had BGDM and who screened negative on OGCT., Results: Women who had BGDM were older (mean difference 1.3 years, [95% confidence interval (CI) 0.3, 2.2], p = 0.01) and more likely to be obese (27.1% vs 14.1%, relative risk (RR) 1.92, [95% CI 1.41, 2.62], p < 0.0001) than women who screened negative on OGCT. The risk of adverse maternal outcome overall was higher (12.9% vs 8.1%, RR 1.59, [95% CI 1.00, 2.52], p = 0.05) in women with BGDM compared with women with a normal OGCT. Women with BGDM were more likely to develop pregnancy induced hypertension (17.9% vs 11.8%, RR 1.51, [95% CI 1.03, 2.20], p = 0.03), have a caesarean for fetal distress (17.1% vs 10.5%, RR 1.63, [95% CI 1.10, 2.41], p = 0.01), and require a longer postnatal hospital stay (mean difference 0.4 day, [95% CI 0.1, 0.7], p = 0.01) than those with a normal glucose tolerance.Infants born to BGDM mothers were more likely to be born preterm (10.7% vs 6.4%, RR 1.68, [95% CI 1.00, 2.80], p = 0.05), have macrosomia (birthweight > or =4.5 kg) (4.3% vs 1.7%, RR 2.53, [95% CI 1.06, 6.03], p = 0.04), be admitted to the neonatal intensive care unit (NICU) (6.5% vs 3.0%, RR 2.18, [95% CI 1.09, 4.36], p = 0.03) or the neonatal nursery (40.3% vs 28.4%, RR 1.42, [95% CI 1.14, 1.76], p = 0.002), and have a longer hospital stay (p = 0.001). More infants in the BGDM group had Sarnat stage 2 or 3 neonatal encephalopathy (12.9% vs 7.8%, RR 1.65, [95% CI 1.04, 2.63], p = 0.03)., Conclusion: Women with BGDM and their infants had an increased risk of adverse health outcomes compared with women with a negative OGCT. Intervention strategies to reduce the risks for these women and their infants need evaluation., Trial Registration: Current Controlled Trials ISRCTN00416244.

Objective: We determined the longitudinal association of glucose metabolism with retinopathy in a sample of the Australian population., Research Design and Methods: The Australian Diabetes Obesity and Lifestyle (AusDiab) study is a national, longitudinal study of adults aged > or =25 years from 42 randomly selected areas of Australia. Retinopathy was assessed at baseline in 1999-2000 and 5 years later in 2004-2005 in participants identified as having diabetes (based on self-report and oral glucose tolerance test) and impaired glucose metabolism and in a random sample with normal glucose tolerance. Complete retinal data were available for 1,192 participants. Photographs were graded at two time points according to a simplified version of the Wisconsin grading system., Results: The 5-year incidences of retinopathy were 13.9 and 3.0% among those with known and newly diagnosed diabetes at baseline, respectively. Of those who developed incident newly diagnosed diabetes at follow-up, 11.9% had retinopathy at baseline compared with 5.6% of those who did not progress to incident newly diagnosed diabetes (P = 0.037). After adjustment for factors identified as risk factors for diabetes, individuals with retinopathy signs at baseline were twice as likely to develop incident newly diagnosed diabetes compared with those who did not have retinopathy signs at baseline., Conclusions: The 5-year incidence of retinopathy was 13.9% among individuals with known diabetes. Nondiabetic individuals with retinopathy signs at baseline had a twofold higher risk of developing incident newly diagnosed diabetes 5 years later. This result provides further evidence that mild retinopathy signs may be a preclinical marker of underlying microvascular disease and future diabetes risk.

Objective: To compare the different diagnostic criteria for gestational diabetes mellitus (GDM) proposed by the American Diabetes Association (ADA), World Health Organization (WHO), and Australian Diabetes in Pregnancy Society (ADIPS) in a 75-g, 2-hour oral glucose tolerance test (OGTT) and to investigate their effects on neonatal birth weight., Methods: Healthy pregnant women were enrolled in a cohort study to undergo a 75-g OGTT during 24 to 28 weeks of pregnancy and then followed up to delivery. ADA criteria and recommendations were used for the management of patients., Results: Among 670 pregnant women, GDM was diagnosed in 41 (6.1%), 81 (12.1%), and 126 (18.8%) on the basis of ADA, WHO, and ADIPS criteria, respectively. The kappa value was 0.38 (P<.0001) for the agreement between ADA and WHO criteria, 0.41 (P<.0001) for agreement between ADA and ADIPS criteria, and 0.64 (P<.0001) for agreement between WHO and ADIPS criteria. WHO-only "positive" women had significantly lower fasting plasma glucose (87.9 versus 102.2 mg/dL; P<.0001) and 1-hour plasma glucose levels (146.4 versus 200.5 mg/dL; P<.0001) but higher 2-hour plasma glucose levels (150.1 versus 109.1 mg/dL; P<.0001) than women diagnosed with GDM by only ADA criteria. The correlation coefficient between 1-hour glucose level and neonatal birth weight was 0.09 (P<.02). The adjusted odds ratio of macrosomia associated with GDM according to ADA criteria was 1.34 (95% confidence interval, 0.15 to 12)., Conclusion: The frequency of occurrence of GDM was 6.1% in a 75-g OGTT based on ADA criteria, and there was fair agreement between ADA and WHO criteria, moderate agreement between ADA and ADIPS criteria, and strong agreement between WHO and ADIPS criteria. A modest correlation was found between the 1-hour serum glucose value and neonatal birth weight.

Elevated 2-h plasma glucose concentration (2hPG) from an oral glucose tolerance (OGTT) test more strongly predicts risk of subsequent cardiovascular disease than fasting plasma glucose (FPG), but the association between these glucose measurements and hypertension risk is less clear. We examined the association between 2hPG, FPG and risk of hypertension. We conducted a prospective observational study (The Australian Diabetes, Obesity and Lifestyle Study-AusDiab) among 4413 Australian residents who attended a baseline (1999-2000) and follow-up (2004-2005) examinations. Measurements included blood pressure (mean of two readings), 75 g OGTT, fasting insulin, anthropometrics, dietary and alcohol intake, medical history and physical activity. Hypertension was defined as a systolic blood pressure (SBP)> or =140 or a diastolic blood pressure (DBP)> or =90 mm Hg or treatment with medication for hypertension. HOMA-S was calculated as a measure of insulin sensitivity using the HOMA2 calculator. Hypertension developed in 14% of the 4306 subjects available for this analysis. Higher 2hPG was significantly related to greater risk of hypertension after adjustment for age, gender, FPG, BMI (baseline and difference), waist circumference (baseline and difference), education, exercise, alcohol intake, baseline SBP and smoking (OR (95% CI) 1.12 (1.01 to 1.23)), but no significant association was seen between FPG and hypertension in this model (1.02 (0.88-1.19)). Further adjustment for HOMA-S did not change these findings. Higher baseline 2hPG was more strongly associated with an increase in SBP than in DBP over 5 years. We conclude that higher 2hPG predicted future hypertension occurrence in this population.

Aim: To determine the extent of gender-related differences in the prevalence of glucose intolerance for the Australian population and whether body size may explain such differences., Methods: Cross-sectional data were collected from a national cohort of 11 247 Australians aged > or = 25 years. Glucose tolerance status was assessed according to both fasting plasma glucose (FPG) and 2-h plasma glucose (2hPG) levels following a 75-g oral glucose tolerance test (OGTT). Anthropometric and glycated haemoglobin measurements were also made., Results: Undiagnosed diabetes and non-diabetic glucose abnormalities were more prevalent among men than women when based only on the FPG results (diabetes: men 2.2%, women 1.6%, P = 0.02; impaired fasting glycaemia: men 12.3%, women 6.6%, P < 0.001). In contrast 16.0% of women and 13.0% of men had a 2hPG abnormality (either diabetes or impaired glucose tolerance, P = 0.14). Women had a mean FPG 0.3 mmol/l lower than men (P < 0.001), but 2hPG 0.3 mmol/l higher (P = 0.002) and FPG-2hPG increment 0.5 mmol/l greater (P < 0.001). The gender difference in mean 2hPG and FPG-2hPG increment disappeared following adjustment for height. For both genders, those in the shortest height quartile had 2hPG levels 0.5 mmol/l higher than the tallest quartile, but height showed almost no relationship with the FPG., Conclusions: Men and women had different glycaemic profiles; women had higher mean 2hPG levels, despite lower fasting levels. It appeared that the higher 2hPG levels for women related to lesser height and may be a consequence of using a fixed glucose load in the OGTT, irrespective of body size.

Objective: This national, population-based study reports diabetes incidence based on oral glucose tolerance tests (OGTTs) and identifies risk factors for diabetes in Australians., Research Design and Methods: The Australian Diabetes, Obesity and Lifestyle Study followed-up 5,842 participants over 5 years. Normal glycemia, impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and diabetes were defined using World Health Organization criteria., Results: Age-standardized annual incidence of diabetes for men and women was 0.8% (95% CI 0.6-0.9) and 0.7% (0.5-0.8), respectively. The annual incidence was 0.2% (0.2-0.3), 2.6% (1.8-3.4), and 3.5% (2.9-4.2) among those with normal glycemia, IFG, and IGT, respectively, at baseline. Among those with IFG, the incidence was significantly higher in women (4.0 vs. 2.0%), while among those with IGT, it was significantly higher in men (4.4 vs. 2.9%). Using multivariate logistic regression, hypertension (odds ratio 1.64 [95% CI 1.17-2.28]), hypertriglyceridemia (1.46 [1.05-2.02]), log fasting plasma glucose (odds ratio per 1 SD 5.25 [95% CI 3.98-6.92]), waist circumference (1.26 [1.08-1.48]), smoking (1.70 [96% CI 1.11-2.63]), physical inactivity (1.56 [1.12-2.16]), family history of diabetes (1.82 [1.30-2.52]), and low education level (1.85 [1.04-3.31]) were associated with incident diabetes. In age- and sex-adjusted models, A1C was a predictor of diabetes in the whole population, in those with normal glycemia, and in those with IGT or IFG., Conclusions: Diabetes incidence is 10-20 times greater in those with IGT or IFG than those with normal glycemia. Measures of glycemia, A1C, metabolic syndrome components, education level, smoking, and physical inactivity are risk factors for diabetes.

Aim: To compare Austrian and Australian national guidelines for gestational and pre-gestational diabetes and estimate the level to which physicians comply with their country's guidelines., Methods: Austrian (ODG, Austrian Diabetes Society) and Australian guidelines (ADIPS, Australasian Diabetes in Pregnancy Society) for the treatment of gestational diabetes and pre-gestational diabetes were systematically reviewed. Current practices in two obstetric centers in Austria and Australia were assessed by interviewing key stakeholders through questionnaires assessing different components of diabetes care. For gestational diabetes, these components were screening, abnormal oral glucose tolerance test values (mmol/L), abnormal values for diagnosis, further management when abnormal values are detected, monitoring/glucose targets (mmol/L), further management and indications for insulin therapy, route and timing of delivery, and postpartum management and counseling. For pre-gestational diabetes, the components were management during the preconceptional period, glucose target values, medical surveillance, obstetric surveillance, medication used, route and timing of delivery, and postpartum management and counseling., Results: More variation was found in the management of gestational than pre-gestational diabetes. There were differences in oral glucose tolerance test and cut-off levels for diagnosing gestational diabetes in both centers and guidelines. Australian guidelines recommended two-stage screening for gestational diabetes, while Austrian guidelines recommended one-stage screening. At the Austrian obstetric center, amniocentesis was recommended for determining the start of insulin treatment in pregnant women with gestational diabetes. This approach was neither used at the Australian obstetric center nor recommended by any of the two guidelines., Conclusion: Our study showed that it was difficult to standardize screening criteria and diagnostic methods for gestational and pre-gestational diabetes. National and international consensus has yet to be achieved in the management of diabetes in pregnancy.

Background: Diabetes mellitus increases the risk of cardiovascular disease (CVD) and all-cause mortality. The relationship between milder elevations of blood glucose and mortality is less clear. This study investigated whether impaired fasting glucose and impaired glucose tolerance, as well as diabetes mellitus, increase the risk of all-cause and CVD mortality., Methods and Results: In 1999 to 2000, glucose tolerance status was determined in 10,428 participants of the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab). After a median follow-up of 5.2 years, 298 deaths occurred (88 CVD deaths). Compared with those with normal glucose tolerance, the adjusted all-cause mortality hazard ratios (HRs) and 95% confidence intervals (CIs) for known diabetes mellitus and newly diagnosed diabetes mellitus were 2.3 (1.6 to 3.2) and 1.3 (0.9 to 2.0), respectively. The risk of death was also increased in those with impaired fasting glucose (HR 1.6, 95% CI 1.0 to 2.4) and impaired glucose tolerance (HR 1.5, 95% CI 1.1 to 2.0). Sixty-five percent of all those who died of CVD had known diabetes mellitus, newly diagnosed diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance at baseline. Known diabetes mellitus (HR 2.6, 95% CI 1.4 to 4.7) and impaired fasting glucose (HR 2.5, 95% CI 1.2 to 5.1) were independent predictors for CVD mortality after adjustment for age, sex, and other traditional CVD risk factors, but impaired glucose tolerance was not (HR 1.2, 95% CI 0.7 to 2.2)., Conclusions: This study emphasizes the strong association between abnormal glucose metabolism and mortality, and it suggests that this condition contributes to a large number of CVD deaths in the general population. CVD prevention may be warranted in people with all categories of abnormal glucose metabolism.

Aims/hypothesis: We sought to determine the risk of diabetes and IGT/IFG with grand multiparity., Subjects, Materials and Methods: Women, aged > or =25 years, from the Australian Diabetes, Obesity and Lifestyle Study and the Crossroads Undiagnosed Disease Study (a rural study in Victoria, Australia), participated in a household census (response 67 and 70%, respectively), subsequently attending a biomedical examination that included an oral glucose tolerance test (58% [6198] and 69% [819])., Results: After adjusting for age, obesity and socio-economic status, diabetes, but not IGT/IFG, was less common among women with a parity of 1 to 2 (odds ratio [OR]=0.64 [0.48-0.84]) and 3 to 4 (OR=0.72 [0.53-0.96]) than in grand multiparous women. This relationship was unrelated to past hysterectomy, use of the oral contraceptive pill or menopausal status., Conclusions/interpretation: Grand multiparity is associated with an increased risk of diabetes but not of IGT/IFG. We postulate that parity accelerates transition from IGT/IFG to diabetes, more than it does transition from normal glucose tolerance to IGT/IFG.