Diss. (sammanfattning) Uppsala : Univ., 2001. / Härtill 5 uppsatser.

Objectives. The Pregnancy, Nutrition & Diabetes (PND) study aimed to evaluate the dietary status of urban Black pregnant women attending the Antenatal Clinic at the Charlotte Maxeke (Johannesburg General) Hospital. In addition, the study investigated the effects of maternal dietary intake and hormonal levels during pregnancy on fetal growth, birth size and the early postnatal development of risk factors for future Type 2 diabetes. The study analysis precedes a detailed description of the study population, including its comparison with other populations. Methods. 126 women were enrolled in the study before 24 weeks of gestation. Twice during pregnancy (weeks 20-24 and 30-36, visits V1 and V2) and approximately six months after the delivery (visit V3), volunteers participated in a standard 75 g oral glucose tolerance test (OGTT). Blood pressure, anthropometric and socio-demographic data were taken and a food frequency questionnaire was administered at each visit. The daily maternal intakes of total energy and macronutrients expressed as a % of total energy intake (%E) were calculated and further evaluated. A comparison with the crude nutrients intakes was also performed. During both pregnancy visits, an ultrasound examination was carried out to obtain estimates of fetal biometry and fetal well-being and the postnatal anthropometric parameters were also measured. Blood samples were collected at fasting, 30min, 60min and 120min of the OGTT for the measurements of maternal glucose (GLC), insulin (INS), C-peptide (C-PEP) and proinsulin (PI) and fasting samples for the determination of placental lactogen (HPL), insulinlike growth factor 1 (IGF-1), insulin-like growth factor binding protein 1 (IGF-BP1), free thyroxin (FT4), cortisol (CORT) and leptin (LEPT). Infant fasting blood samples were used for the analysis of the GLC, INS, PI, IGF-BP3 and LEPT. The plasma glucose samples were analysed on the Beckman Glucose Analyser 2, whilst all the other analytes were measured by an immunoassay method on 96-well plates. Results – DESCRIPTIVE DATA. Study participants. The majority of the study participants had completed high school education, however were unemployed and of low and very poor socio-economic levels. In comparison with another study from the developing world, the Pune study in India, the women from the current study were older, heavier with greater body mass index (BMI) and they were also taller. They had higher head and arm circumference. Birth outcomes. The birth size of African babies in the current study, although smaller in all parameters, was still relatively closer to the size of the Caucasian babies seen within the Southampton (Godfrey et al. 1996) or Helsinki (Forsén et al. 1997) studies than to the birth size of the babies from Trivandrum (Jaya et al. 1995) or Pune (Rao et al. 2001) in India. These relatively smaller African babies have comparable (or even larger) maternal placental sizes in relation to the mothers of both European studies. However, in comparison with the small Indian babies, the major difference noted was a substantially smaller placental size of the Pune mothers. Compared to z-scores from the World Health Organization (WHO) child growth standards (WHO Anthropo 2010), the PND study babies were born lighter and shorter with a larger head circumference (HC). A growth delay observed near the neonatal visit was followed by catch up growth in weight for age, however no catch-up growth was observed for length for age by the second postnatal visit. Dietary intakes. The PND study women had pregnancy energy intakes slightly below the national level intakes (Steyn et al. 2006), except for the energy intake at V3, which exceeded the national level. The lower energy intake during pregnancy is attributable to a lower intake of dietary protein and total carbohydrate. The fat intake was substantially higher in the PND study, with levels almost double at the second postnatal visit. This discrepancy may be due to differences between investigated populations or due to increased requirements of energy during lactation. In comparison with the Recommended Dietary Allowances (RDA), during the pregnancy period women in the current study had lesser crude protein and higher carbohydrate intake. Intake of the crude protein after delivery was low in comparison to the RDA for lactating women. Total carbohydrate intake exceeded the RDA. The relation between the intake of macronutrients expressed as a percentage of total energy (%E) and RDA was similar. The current study participants had a lower intake of energy, especially during the pregnancy period, when compared to populations in the developed world. They had a lower intake of protein at all visits in comparison with the national average for women or with that found in the Southampton study or when compared to the usual American diet. The energyadjusted intake of fat and carbohydrate were comparable with the Southampton and American data. This population in our study was therefore more comparable to that of Pune than to American or Southampton populations. However, despite similar total energy intakes as the Pune Study, total protein and fat intakes were higher in the African mothers, which may explain their higher weights and birthweights of their babies. Results – ANALYTICAL DATA Dietary intakes. Maternal dietary intakes showed significant effects on the fetal biometrical measurements, mainly involving the fetal head, femur length and the size of abdomen. The outcomes also show a significant relationship between maternal protein intake and baby’s birth weight. Associations were also found for maternal dietary intakes and the neonatal length and BMI and the markers of the infant β-cell function. Intakes of the plant protein and polyunsaturated fat supported the linear growth. There was no correlation between maternal dietary intake and the fetal growth rate. Effects of the total energy intake and carbohydrate seemed to be direct, while the effect of protein and fat may be delayed, possibly involving metabolic adaptation of the mother and the partitioning of nutrients between the mother, placenta and fetus. (See Table: Associations between the maternal dietary intake and the neonatal INSF1 levels, Pg. xiv). Maternal hormones. The data of the current study show significant relationships between maternal pregnancy hormones and fetal growth rate and the postnatal growth rate, although maternal anthropometry and fetal gender and BMI are also significantly involved. The maternal thyroid hormones seem to play an important role in fetal and postnatal growth and insulin metabolism (N=76, p=0.002, ß=-0.343; AR2=0.106) in the association with the neonatal fasting insulin. Discussion. The outcomes of the current study show that the African pregnant women in the study had lower energy intakes attributable to a lower intake of dietary protein and total carbohydrate. Maternal dietary intakes showed significant effects on the fetal biometrical parameters. Protein dietary intake was positively associated with baby’s birth weight and was shown to be statistically significant. Associations were also found for maternal dietary intakes and the infant postnatal BMI and the markers of the infant β-cell function. Quality of the protein and fat has different effects on fetal/infant growth. Maternal hormones showed correlations with fetal growth rate and the outcomes of the current study also show that maternal hormones can affect neonatal and early postnatal infant glucose levels and β-cell function. They are also linked to the programming of early obesity. The maternal thyroid hormones seem to play an important role. The maternal low energy, protein (especially plant protein) and PUFA intakes during gestation may be the reasons for the lower z-score birth parameters of the infants in comparison with the World Health Organization (WHO) child growth standards (WHO Anthro 2010). The disproportionally larger head of the newborn may be an outcome of the brain sparing effect. A suggestion for an increased maternal dietary intake of energy, protein and PUFA has been made.

Diss. Stockholm : Karol. inst.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 7 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 5 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 5 uppsatser.

Thesis (M.Fam.Med.)--University of the Witwatersrand, Faculty of Health Sciences, 2014. / Background The combined influence of processes of care, lifestyle advice and drug treatment on glycaemic control in Type 2 diabetes in primary care settings is not well documented. Aim To describe the provision of lifestyle advice, selected processes of care and drug treatment to, and assess the influence of these factors on glycaemic control in, a sample of adults with type 2 diabetes mellitus attending the Johan Heyns Community Health Centre in Sedibeng District, Gauteng. Methods A cross-sectional design was used. Participants consisted of 200, consecutively chosen, adult volunteers with type 2 diabetes. Information on demographics, reported receipt of lifestyle advice and anthropomorphic measurements was collected through questionnaire-based interviews. This was followed by a record review of all participants’ clinic files for information on current drug management, co-morbid medical conditions and documentation of processes of care, in the preceding 12 months, in respect of HbA1c, blood pressure (BP), weight, waist circumference (WC) and body mass index (BMI) monitoring. HbA1c values were used to ascertain glycaemic control. Performance of processes of care was assessed in accordance with Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) guidelines. Parsimonious models for glycaemic control were constructed through multivariate logistic regression. Results Mean age of the sample was 58 years with 58% in the 50-64 year age group. Blacks (88%) and females (63%) were in the majority. Over two-thirds had diabetes for under 10 years and 98% had at least one co-morbid condition, mainly hypertension (92%). Obesity was noted in 65%, while 95% of females and 83% of males had a WC that conferred substantial cardio-metabolic risk. Receipt of advice on any of diet, exercise or weight control from a health professional in the preceding 12 months was reported by 79%, with 67% reporting receipt of advice on all three. Under 2% of patient records met the SEMDSA standard for processes of care for HbA1c, weight, WC and BMI monitoring, while 93% achieved the standard for BP monitoring. Exclusive oral treatment was prescribed in 62%, and the majority of these were on combined metformin and sulphonylurea; 5% were on insulin monotherapy. Optimal glycaemic control (HbA1c < 7%) was noted in only 25% of the sample. On multivariate analyses, the presence of CCF conferred higher odds of controlled glycaemia (OR = 3.17, P = 0.035). Compared with insulin monotherapy, treatment with either combined metformin and insulin (OR = 0.216, P = 0.02), or with the combination of all 3 drug classes ( metformin, sulphonylurea and insulin) (OR = 0.185, P = 0.027), conferred lower odds of glycaemic control. Conclusions This study highlights substantial shortcomings in the compliance with key processes of care and the achievement of optimal glycaemic control for type 2 diabetes mellitus in the current research setting. An inverse association was noted between glycaemic control and the use of combined oral and insulin drug therapy. Measured processes of care and reported receipt of lifestyle advice showed no association with glycaemic control. CCF co-morbidity conferred improved odds of controlled glycaemia.

Background: Type 2 diabetes mellitus (T2DM) is defined by an increase in serum glucose, however, this leads to the belief that only the serum glucose levels need be monitored and treated. Hence many other risk factors such as obesity, lipids and blood pressure which increase the risk of coronary heart disease, myocardial infarction, stroke and peripheral vascular disease are neglected. Consequently, T2DM patients that are at greater risk of developing cardiovascular disease (CVD), are often not receiving optimal comprehensive care. Aims: To identify the treatment gaps of cardiovascular risk factors in patients with T2DM using both national and international current treatment guidelines. Methods: Using a public sector database, data was obtained on the treatment of 666 T2DM patients. Records of patients were selected on the basis of established T2DM diagnoses, receiving oral hypoglycaemic and/or insulin therapy. The following patient data was recorded: demographics (age, gender, ethnicity), systolic blood pressure (SBP), diastolic blood pressure (DBP), glycated haemoglobin (HbA1c), total cholesterol (TC), triglycerides (TG), HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C) , family history, cardiovascular history and all chronic medications. The following parameters were applied to the cohort: SBP <130 mmHg, DBP <80 mmHg. In the event of proteinuria: SBP ≤120 mmHg, DBP ≤70 mmHg. HbA1c <7.0%, TC <4.5 mmol/L, LDL-C <2.5 mmol/L, HDL-C >1.0 mmol/L (males), HDL-C >1.2 mmol/L (females) and TG <1.7 mmol/L. In patients with established CVD, LDL-C target: ≤1.8 mmol/L. Results: The study cohort consisted of 666 T2DM-patients. 55% females. Mean age was 63 years (SD: 11.8), mean HbA1c was 8.7% (SD: 2.4). The mean SBP and DBP readings for the cohort were 133.66 (SD: 19.9) and 78.07 mmHg (SD: 11.6), respectively. Mean LDL-cholesterol was 2.6 mmol/L (SD: 0.9). 26.2% reached HbA1c of ≤7%, 45.8% reached ≤130/80 mm Hg blood pressure targets, 53.8% reached LDL-C of ≤2.5mmol/L and all 3 were reached by 7.5% of the cohort. TC ≤4.5 mmol/L was reached by 53.8%, 60.2% reached TG ≤1.7mmol/L, 58.6% males and 52.8% females reached HDL-C targets of ≥1.0 mmol/L and ≥1.2 mmol/L, respectively. There were 17.9% of patients with CVD reaching targets of LDL-C ≤1.8 mmol/L whilst 16.4% of patients with nephropathy reaching targets of ≤120/70 mm Hg. Almost half (48.2%) were not receiving lipid-lowering therapy, yet would be deemed eligible for therapy. Blood pressure targets may have been better reached with appropriate dosage reductions in addition to the introduction of further antihypertensive combination therapy. CVD was present in 15.5%. Conclusions: T2DM patients are at high-risk for CVD. Many trials have demonstrated the benefits of targeting CVD risk factors (HbA1c, blood pressure, serum lipids) in T2DM. Less than 10% of CVD risk factor targets were reached by the study cohort despite treatment guideline recommendations. The data from the study suggests poor control of modifiable cardiovascular risk factors and significant under treatment of T2DM in clinical practice. Whether improvement lies in the form of therapeutic titration adjustment or an increase in patient education, there needs to be a more aggressive multi-factorial therapeutic approach to treating this high risk group of patients in order to reduce overall morbidity, mortality and improve patient outcomes.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 6 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 5 uppsatser.