BMJ: Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up

BMJ | November 2019 | Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up| 67| l6398

A study that looked at the associations between maternal diabetes (diagnosed prior to or during pregnancy) and early onset cardiovascular disease (CVD) in offspring during their first four decades of life adds to the evidence around non-genetic intergenerational connections between maternal illness and risk factors for CVD among offspring. The experts who authored the study looked at data from more than 2 million births in Denmark between 1977 and 2016. 

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The findings from this population based study indicate that the children of mothers with diabetes, especially mothers with CVD history or diabetic complications, had increased rates of early-onset CVD throughout the early decades of life. If the associations are causal, then preventing and treating diabetes in women of childbearing age could have a significant impact on the reduction of CVD incidence in the next generation.

The authors argue that their findings highlight the importance of effective strategies for screening and preventing diabetes in women of childbearing age (Source: BMJ).

 

 

Read the full Opinion from BMJ

Yongfu, Y. et al | 2019|  Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up|

Abstract

Objective To evaluate the associations between maternal diabetes diagnosed before or during pregnancy and early onset cardiovascular disease (CVD) in offspring during their first four decades of life.

Design Population based cohort study.

Setting Danish national health registries.

Participants All 2 432 000 liveborn children without congenital heart disease in Denmark during 1977-2016. Follow-up began at birth and continued until first time diagnosis of CVD, death, emigration, or 31 December 2016, whichever came first.

Exposures for observational studies Pregestational diabetes, including type 1 diabetes (n=22 055) and type 2 diabetes (n=6537), and gestational diabetes (n=26 272).

Main outcome measures The primary outcome was early onset CVD (excluding congenital heart diseases) defined by hospital diagnosis. Associations between maternal diabetes and risks of early onset CVD in offspring were studied. Cox regression was used to assess whether a maternal history of CVD or maternal diabetic complications affected these associations. Adjustments were made for calendar year, sex, singleton status, maternal factors (parity, age, smoking, education, cohabitation, residence at childbirth, history of CVD before childbirth), and paternal history of CVD before childbirth. The cumulative incidence was averaged across all individuals, and factors were adjusted while treating deaths from causes other than CVD as competing events.

 

Results During up to 40 years of follow-up, 1153 offspring of mothers with diabetes and 91 311 offspring of mothers who did not have diabetes were diagnosed with CVD. Offspring of mothers with diabetes had a 29% increased overall rate of early onset CVD ; cumulative incidence among offspring unexposed to maternal diabetes at 40 years of age 13.07%, difference in cumulative incidence between exposed and unexposed offspring 4.72% . The sibship design yielded results similar to those of the unpaired design based on the whole cohort. Both pregestational diabetes and gestational diabetes were associated with increased rates of CVD in offspring. We also observed varied increased rates of specific early onset CVDs, particularly heart failure, hypertensive disease, deep vein thrombosis, and pulmonary embolism. Increased rates of CVD were seen in different age groups from childhood to early adulthood until age 40 years. The increased rates were more pronounced among offspring of mothers with diabetic complications. A higher incidence of early onset CVD in offspring of mothers with diabetes and comorbid CVD was associated with the added influence of comorbid CVD but not due to the interaction between diabetes and CVD on the multiplicative scale.

 

Conclusions Children of mothers with diabetes, especially those mothers with a history of CVD or diabetic complications, have increased rates of early onset CVD from childhood to early adulthood. If maternal diabetes does have a causal association with increased CVD rate in offspring, the prevention, screening, and treatment of diabetes in women of childbearing age could help to reduce the risk of CVD in the next generation.

Offspring of mothers with diabetes, especially those mothers with a history of CVD or diabetic complications, have increased rates of early onset CVD from childhood to early adulthood

The article is available in full from The BMJ

Diabetes UK strategy 2020-2025

Diabetes UK has launched a new strategy called ‘A generation to end the harm: Diabetes UK Strategy 2020-2025’ coinciding with World Diabetes Day 2019 

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Image source: https://www.diabetes.org.uk/

There are an estimated 2.85 million people diagnosed with type 2 diabetes in England, and more than 850,000 living with the condition who do not know they have it because they have not yet been diagnosed − bringing the total up to 3.7 million.

The new strategy from Diabetes UK focuses on achieving five key outcomes by 2025:

  • more people with type 1, type 2 and all other forms of diabetes will benefit from new treatments that cure or prevent the condition
  • more people will be in remission from type 2 diabetes
  • more people will get the quality of care they need to manage their diabetes well
  • fewer people will get type 2 and gestational diabetes
  • more people will live better and more confident lives with diabetes, free from discrimination.

The charity said that more than half of all cases of type 2 diabetes could be prevented or delayed, and in turn, the risk of developing the related complications, by tackling overweight and obesity.

Full document: A generation to end the harm: Diabetes UK Strategy 2020-2025

See also: Obesity rate doubles over past 20 years | OnMedica

National Pregnancy in Diabetes Audit

National Pregnancy in Diabetes (NPID) audit report 2018 | The Healthcare Quality Improvement Partnership

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The National Pregnancy in Diabetes (NPID) audit measures the quality of antenatal care and pregnancy outcomes for women with pre-gestational diabetes.

This is the first year that a Quality Improvement Collaborative (QIC) has been incorporated into the NPID programme for 2018/19 with the aim of focusing on improvement activity.

Some of the key findings include:

  • Overall 7 out of 8 women were not well prepared for pregnancy
  • There has been an increase in the rate of admissions with hypoglycaemia for women with type 1 diabetes
  • Almost one in two babies had complications related to maternal diabetes which is mostly the result of large for gestational age (LGA) babies
  • Admissions to neonatal units are more common than in the general population.

Full report: National Pregnancy in Diabetes (NPID) Audit Report 2018

See also: NHS Digital resources

NHS spends around £3bn a year on ‘avoidable’ treatment for diabetes

ITV | September 2019 | NHS spends around £3bn a year on ‘avoidable’ treatment for diabetes

An analysis of hospital treatment in 2017/18 highlights that approximately £5.5bn each year is spent on treatment of diabetes, of this an estimated £3bn is on ‘potentially avoidable’ treatment. The authors of the research explain that this equates to around one-tenth of the NHS budget; compared to people without diabetes, the average annual cost of planned care was over twice as high for those with Type 2 diabetes and the average cost of emergency care was three times higher, once age was taken into account.

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Study author, Dr Adrian Heald from Salford Royal Hospital, said: “People with diabetes are admitted to hospital more often, especially as emergencies, and stay on average longer as inpatients.

“These increased hospital costs, 40% of which come from non-elective and emergency care, are three times higher than the current costs of diabetes medication.

“Improved management of diabetes by GPs and diabetes specialist care teams could improve the health of people with diabetes and substantially reduce the level of hospital care and costs.” (Source: ITV News)

The team’s finding will be presented this week at the European Association for the study of Diabetes (EASD)  annual meeting in Barcelona.

Read the full story from ITV News

See also:

BT NHS spends around £3bn a year on ‘avoidable’ treatment for diabetes

 

NICE: Dapagliflozin with insulin for treating type 1 diabetes

NICE | August 2019| Dapagliflozin with insulin for treating type 1 diabetes

Today (28 August 2019) has published  final guidance on an innovative treatment for type 1 diabetes. Dapagliflozin is the first licenced oral add-on therapy to insulin in type 1 diabetes

Dapagliflozin (brand name Forxiga) with insulin is available on the NHS. It is a possible treatment for type 1 diabetes in adults with a body mass index (BMI) of at least 27 kg/m2, when insulin alone does not control blood sugar levels well enough, if:

  • you are on insulin doses of more than 5 units per kilogram of body weight per day and
  • you have done a structured education programme that includes information about diabetic ketoacidosis, and
  • treatment is started and supervised by a consultant physician specialising in endocrinology and diabetes.

Further details are available from NICE

Fish oil pills ‘no benefit’ for type 2 diabetes

Brown, T., Brainard, J., Song, F., Wang, X., Abdelhamid, A. & Hooper, L. | 2019| Omega-3, omega-6, and total dietary polyunsaturated fat for prevention and treatment of type 2 diabetes mellitus: systematic review and meta-analysis of randomised controlled trials | BMJ|  366 | l4697|  doi: https://doi.org/10.1136/bmj.l4697 :

Research that investigated whether omega-3 and other fatty acids were beneficial to people with type 2 diabetes has found that increasing long chain omega-3 intake had little or no effect on diagnosis or glucose metabolism; the study’s authors also report that there may be  negative outcomes at high dose. 

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Abstract

Objective To assess effects of increasing omega-3, omega-6, and total polyunsaturated fatty acids (PUFA) on diabetes diagnosis and glucose metabolism.

Design Systematic review and meta-analyses.

Data sources Medline, Embase, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, and trials in relevant systematic reviews.

Eligibility criteria Randomised controlled trials of at least 24 weeks’ duration assessing effects of increasing α-linolenic acid, long chain omega-3, omega-6, or total PUFA, which collected data on diabetes diagnoses, fasting glucose or insulin, glycated haemoglobin (HbA1c), and/or homoeostatic model assessment for insulin resistance (HOMA-IR).

Data synthesis Statistical analysis included random effects meta-analyses using relative risk and mean difference, and sensitivity analyses. Funnel plots were examined and subgrouping assessed effects of intervention type, replacement, baseline risk of diabetes and use of antidiabetes drugs, trial duration, and dose. Risk of bias was assessed with the Cochrane tool and quality of evidence with GRADE.

Results 83 randomised controlled trials (mainly assessing effects of supplementary long chain omega-3) were included; 10 were at low summary risk of bias. Long chain omega-3 had little or no effect on likelihood of diagnosis of diabetes or measures of glucose metabolism. A suggestion of negative outcomes was observed when dose of supplemental long chain omega-3 was above 4.4 g/d. Effects of α-linolenic acid, omega-6, and total PUFA on diagnosis of diabetes were unclear (as the evidence was of very low quality), but little or no effect on measures of glucose metabolism was seen, except that increasing α-linolenic acid may increase fasting insulin (by about 7%). No evidence was found that the omega-3/omega-6 ratio is important for diabetes or glucose metabolism.

Conclusions This is the most extensive systematic review of trials to date to assess effects of polyunsaturated fats on newly diagnosed diabetes and glucose metabolism, including previously unpublished data following contact with authors. Evidence suggests that increasing omega-3, omega-6, or total PUFA has little or no effect on prevention and treatment of type 2 diabetes mellitus.

Systematic review registration PROSPERO CRD42017064110.

 

The full article is available from the  BMJ

In the news:

BBC News Fish oil pills ‘no benefit’ for type 2 diabetes

Using pharmacists to help improve care for people with type 2 diabetes

drug-1674890_1280The Royal Pharmaceutical Society (RPS) has published Using pharmacists to help improve care for people with type 2 diabetes.  This document is aimed at policy makers and education/service commissioners within the NHS in England and makes recommendations for how pharmacists can play an increasing role in the prevention, early detection, care and support of people with type 2 diabetes.

To improve care for people with type 2 diabetes, the RPS are calling for:

  1. Pharmacists should work in collaboration with other healthcare professionals to play a greater role in prevention and detection services for type 2 Diabetes
  2. Pharmacists should play an active role in optimising medicines, improving the health, wellbeing and safety of people with type 2 diabetes across the NHS
  3. Pharmacists in specialist and generalist roles should be given access to the most up to date education and training to support people with multiple conditions
  4. NHS organisations need to establish and embed the role of consultant pharmacists in diabetes across the NHS should ensure improved outcomes in the management of people with type 2 diabetes, promote collaborative practice, multidisciplinary team working, quality improvement and research.

Full detail at Royal Pharmaceutical Society

See also: Pharmacists must be integrated into diabetes care | RPS press release