Epidemiology/Health Services/Psychosocial Research ORIGINAL ARTICLE Impaired Fasting Glucose and Impaired Glucose Tolerance in Women With Prior Gestational Diabetes Are Associated With a Different Cardiovascular Profile 1 1 LUIS FELIPE PALLARDO, MD TERESA GARCIA-INGELMO, MD of abnormalities is associated with insulin 1 2 LUCRECIA HERRANZ, MD CRISTINA GRANDE, SCD resistance even in situations of normal 1 3 PILAR MARTIN-VAQUERO, BM MERCEDES JANEZ˜ , BM glucose tolerance (8,9). On the other hand, the establishment of two intermediate categories between normal glucose homeostasis and diabetes (impaired glucose tolerance [IGT] and OBJECTIVE — The purpose of this study was to investigate the association of cardiovascular impaired fasting glucose [IFG]) (10) has risk factors to impaired glucose tolerance (IGT) and to impaired fasting glucose (IFG) in women raised concern in which of these distur- with prior gestational diabetes mellitus (GDM). bances has a major role in predicting the RESEARCH DESIGN AND METHODS — We studied 838 women with prior GDM. development of type 2 diabetes or cardio- Postpartum glucose tolerance status was classified as normal, IFG, IGT, IFG plus IGT, and vascular disease. diabetes according to the World Health Organization criteria. Postpartum BMI, waist circum- The aim of this study was to investi- ference, blood pressure, triglyceride, cholesterol, and HDL cholesterol were assessed. gate the association of cardiovascular risk factors to IGT and IFG in the postpartum RESULTS — BMI and blood pressure were significantly higher in women with IFG than in evaluation of women with GDM. women with normal glucose status. BMI and waist circumference were significantly higher in women with IFG plus IGT than in women with normal glucose status. No differences were observed between women with IGT and normal glucose status. The prevalence of hypertension RESEARCH DESIGN AND and obesity was significantly increased in IFG compared with normal glucose status. The prev- METHODS — This research was con- alence of obesity and abnormal lipids was significantly increased in IFG plus IGT compared with ducted in the Diabetes and Pregnancy normal glucose status. IGT showed no increased prevalence of cardiovascular risk factors. Unit at the University Hospital La Paz in Madrid between 1992 and 2000. We CONCLUSIONS — Traditional cardiovascular risk factors have a stronger association with isolated IFG than with isolated IGT in women with prior GDM. studied 838 Caucasian women (mean age 32.4 Ϯ 4.6 years; mean parity 1.8 Ϯ 0.9) Diabetes Care 26:2318–2322, 2003 with singleton gestations complicated by GDM and who attended the initial post- partum assessment (3–6 months after de- livery) when lactation was concluded. omen with gestational diabetes creased LDL cholesterol and triglyceride The total number of women with single- mellitus (GDM) are at an in- levels and decreased HDL cholesterol lev- ton gestations who had a diagnosis of creased risk for the development els (2–4). Furthermore, changes in endo- W GDM during this period was 1,350. of diabetes (usually type 2) after preg- thelial function (5) and increased levels of Women who did not participate in the nancy (1). Likewise, women with prior adhesion molecules (6), together with a postpartum examination (37.9%) were GDM, when compared with women with higher prevalence of microalbuminuria similar to those who attended with regard no history of GDM, are found to have (7), abnormal electrocardiograms, and to age, parity, prepregnancy BMI, and de- higher BMI (2), higher blood pressure cardiovascular events (3) are observed in gree of glucose intolerance during preg- (3,4), and an altered lipid profile with in- women with prior GDM. This spectrum nancy. Ethical permission for the study ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● was received from the hospital ethical From the 1Department of Endocrinology, Division of Diabetes, Hospital Universitario La Paz, Madrid, Spain; committee, and informed consent was 2the Department of Biochemistry, Hospital Universitario La Paz, Madrid, Spain; and 3the Department of obtained from all subjects. Obstetrics and Gynecology, Hospital Universitario La Paz, Madrid, Spain. The diagnosis of GDM was made us- Address correspondence and reprint requests to Dr. L.F. Pallardo, Jefe de Servicio de Endocrinologı´a y ing the criteria of the National Diabetes Nutricio´n, Unidad de Diabetes, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain. E-mail: [email protected]. Data Group (11) after performing a fast- Received for publication 29 October 2002 and accepted in revised form 16 April 2003. ing 3-h, 100-g oral glucose tolerance test Abbreviations: dBP, diastolic blood pressure; GDM, gestational diabetes mellitus; IFG, impaired fasting (OGTT) in all pregnant women with a glucose; IGT, impaired glucose tolerance; OGTT, oral glucose tolerance test; sBP, systolic blood pressure; screening test (50-g oral glucose chal- WHR, waist-to-hip ratio. Ն A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion lenge) showing a 1-h glucose value 140 factors for many substances. mg/dl (7.8 mmol/l). The screening test © 2003 by the American Diabetes Association. was performed at the first prenatal visit if 2318 DIABETES CARE, VOLUME 26, NUMBER 8, AUGUST 2003 Pallardo and Associates Table 1—Potential cardiovascular risk factors by postpartum glucose tolerance status Parameter Normal IFG IGT IFG plus IGT Diabetes P n 681 40 62 25 30 BMI (kg/m2) 25.3 Ϯ 4.1*†‡ 27.9 Ϯ 6.0* 25.4 Ϯ 4.5§ 29.0 Ϯ 5.4†§ 29.3 Ϯ 7.5‡ Ͻ0.001 Waist circumference (cm) 79.7 Ϯ 9.5†‡ 83.8 Ϯ 12.9 79.9 Ϯ 9.5§࿣ 88.8 Ϯ 12.1†§ 88.8 Ϯ 16.1‡࿣ Ͻ0.001 Triglyceride (mmol/l) 1.00 Ϯ 0.57‡ 1.08 Ϯ 0.62 1.20 Ϯ 0.69 1.37 Ϯ 0.86 1.39 Ϯ 1.15‡ Ͻ0.001 Cholesterol (mmol/l) 4.96 Ϯ 1.00 4.93 Ϯ 0.98 5.06 Ϯ 0.99 5.04 Ϯ 0.65 4.68 Ϯ 1.13 0.560 HDL cholesterol (mmol/l) 1.44 Ϯ 0.32 1.39 Ϯ 0.32 1.42 Ϯ 0.31 1.21 Ϯ 0.25 1.35 Ϯ 0.39 0.064 sBP (mmHg) 112.0 Ϯ 14.7* 118.4 Ϯ 16.8* 113.9 Ϯ 14.7 112.9 Ϯ 16.9 118.7 Ϯ 15.5 0.017 dBP (mmHg) 69.5 Ϯ 10.5*‡ 74.3 Ϯ 11.1* 71.3 Ϯ 11.2 68.9 Ϯ 12.5 75.5 Ϯ 11.0‡ 0.002 Data are means Ϯ SD. Significance of differences among pairs of group means (P Ͻ 0.05): *Normal versus IFG; †normal versus IFG plus IGT; ‡normal versus diabetes; §IGT versus IFG plus IGT; ࿣IGT versus diabetes. clinical characteristics were consistent els. Systolic (sBP) and diastolic (dBP) one-way ANOVA was used (F test) and with a high risk of GDM (obesity, family blood pressures were recorded with the post hoc tests were performed using the history of diabetes, personal history of patient in a sitting position after at least 5 Bonferroni method. Categorical variables GDM, or poor obstetric outcome) or at min of rest, using a sphyngomanometer. were compared using ␹2 and Fisher’s ex- 24–28 weeks of gestation when these The average of two blood pressure mea- act tests of significance. Multiple-variable characteristics were not present. surements was used for the analysis. An- logistic regression models were used to All women with a diagnosis of GDM thropometric measurements included estimate adjusted ORs. Association be- received nutrition counseling with indi- weight, height, and waist and hip circum- tween variables was evaluated using lin- vidualized caloric intake and providing ferences (13). BMI (kg/m2) was computed ear correlation coefficients and stepwise 50% of calories from carbohydrates, 30% from current weight and height, and multiple linear regression analysis. A P from fat, and 20% from protein. Self- waist-to-hip ratio (WHR) was computed value Ͻ0.05 was considered significant. glucose monitoring was performed by the from waist and hip circumferences. patients on alternate days. Insulin ther- Postpartum area under the glucose apy, given on the basis of a fasting blood curve was calculated by the trapezoidal RESULTS — At postpartum assess- glucose Ն105 mg/dl (5.8 mmol/l) or a 2-h method. A woman was classified as hav- ment of the 838 women with GDM, 681 postprandial blood glucose Ն120 mg/dl ing abnormal lipids if she had any of the women (81.3%) had a normal glycemic (6.7 mmol/l) on two or more occasions, following characteristics: triglyceride lev- status, 30 (3.5%) had diabetes, 40 (4.8%) was needed in 386 women (46.1%). els Ն150 mg/dl (1.69 mmol/l), HDL cho- had IFG, 62 (7.4%) had IGT, and 25 (3%) At postpartum assessment, a standard lesterol levels Յ39 mg/dl (1.01 mmol/l), had IFG plus IGT. Mean age was 32.5 Ϯ 75-g OGTT was given to 834 women (4 or total cholesterol levels Ն200 mg/dl 4.2 years for women with normal glyce- women had fasting glucose values that (5.17 mmol/l). Obesity was defined as the mic status, 32.6 Ϯ 4.8 years for women were diagnostic of diabetes). Reclassifica- presence of BMI Ն30 kg/m2 and/or WHR with diabetes, 32.8 Ϯ 5.1 years for tion of glycemic status was done accord- Ն0.85. Hypertension was defined as the women with IFG, 32.7 Ϯ 4.7 years for ing to the criteria of the World Health presence of sBP Ն140 mmHg and/or dBP women with IGT, and 32.8 Ϯ 4.8 years Organization (12) with the following Ն90 mmHg.