Waist circumference in predicting gestational diabetes

The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20

Waist circumference in predicting gestational diabetes mellitus Cláudia Vicari Bolognani, Lilian Barros de Sousa Moreira Reis, Sulani Silva de Souza, Adriano Dias, Marilza Vieira Cunha Rudge & Iracema de Mattos Paranhos Calderon To cite this article: Cláudia Vicari Bolognani, Lilian Barros de Sousa Moreira Reis, Sulani Silva de Souza, Adriano Dias, Marilza Vieira Cunha Rudge & Iracema de Mattos Paranhos Calderon (2014) Waist circumference in predicting gestational diabetes mellitus, The Journal of Maternal-Fetal & Neonatal Medicine, 27:9, 943-948, DOI: 10.3109/14767058.2013.847081 To link to this article: https://doi.org/10.3109/14767058.2013.847081

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http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2014; 27(9): 943–948 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2013.847081

ORIGINAL ARTICLE

Waist circumference in predicting gestational diabetes mellitus Claúdia Vicari Bolognani1,2, Lilian Barros de Sousa Moreira Reis1,2, Sulani Silva de Souza1, Adriano Dias2, Marilza Vieira Cunha Rudge2, and Iracema de Mattos Paranhos Calderon2 1

Escola Superior de Cieˆncias da Sau´de, FEPECS, Brası´lia – DF, Brasil and 2Postgraduation Program in Gynecology, Obstetrics and Mastology, Botucatu Medical School, UNESP [MINTER/ESCS-BRASI´LIA /PG-GOM PROJECT], Botucatu, Brazil Abstract

Keywords

Background: To evaluate waist circumference (WC) measured at 20–24 weeks of gestation as a predictor of gestational diabetes mellitus (GDM). Methods: This cross-sectional study included 240 women at 20–24 weeks of gestation. At enrollment, WC was measured, and both prepregnancy and gestational body mass index (BMI) were estimated. According to the results of 75-g oral glucose tolerance test (OGTT) performed at 24–28 weeks, subjects were allocated into two groups, non-GDM and GDM. WC sensitivity and specificity, and odds ratios (OR) and 95% confidence intervals for BMI and WC were estimated, and a receiver operating characteristics curve was generated. Results: Of the 240 pregnant women enrolled, 31 (13%) had GDM. Prepregnancy BMI (OR ¼ 4.21), gestational BMI (OR ¼ 3.17) and WC at 20–24 weeks (OR ¼ 4.02) correlated with GDM risk. At 20–24 weeks, a WC of 85.5–88.5 cm was the optimal cutoff point for predicting GDM (Sens/Spec balance between 87.1/41.1% and 77.4/56.9%). Conclusion: At 20–24 weeks of gestation, WC values in the range of 86–88 cm showed to be a good performance in predicting GDM.

Gestational diabetes mellitus, risk factor, waist circumference

Introduction Metabolic syndrome (MS) consists of a cluster of coronary heart disease and diabetes mellitus risk factors. It is characterized by central obesity (defined for Brazilian women as waist circumference (WC) 80 cm or body mass index (BMI)430 kg/m2), associated with at least two of the following: raised triglycerides (4150 mg/dL or specific treatment for this abnormality), reduced high-density lipoprotein cholesterol (550 mg/dL or specific treatment for this abnormality), raised blood pressure (systolic 130 or diastolic 85 mmHg or treatment of previously diagnosed hypertension), raised fasting plasma glucose (100 mg/dl or previously diagnosed type 2 diabetes mellitus; DM2) [1]. The underlying cause of the MS continues to challenge the experts, but both insulin resistance and central obesity are considered significant factors [1]. Worldwide obesity levels and consequent insulin resistance are escalating. In Brazil alone, the rate of overweight women has increased from 28% in 1974–1975 to 48% in 2008–2009 [2]. Therefore, recent interest in MS has been expanding [3,4]. Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition Address for correspondence: Claúdia Vicari Bolognani, SQSW 306 Bloco C Apartamento 201 Sudoeste, Brası´lia – DF CEP 70673433, Brazil. Tel: +55 61 3222 0631. Fax: +55 61 3326 0119. E-mail: [email protected]

History Received 13 June 2013 Revised 13 September 2013 Accepted 17 September 2013 Published online 22 October 2013

during pregnancy. The definition applies whether or not the condition persists after pregnancy and does not exclude the possibility that unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy [5]. GDM history predicts DM2 risk. Women with GDM are up to six times more likely to develop DM2 than women with normal glucose tolerance during pregnancy [6]. Ten to 12 years after index pregnancy, DM2 has been confirmed in 16.7% of women with gestational hyperglycemia and in 23.6–44.8% of those with GDM [7]. GDM prevalence among Brazilian women attending the Public Unified Healthcare System (SUS) is 7.6% (95% confidence interval; 95% CI: 6.9–8.4), with 94% of them showing glucose intolerance, and only 6% meeting the diagnostic criteria for diabetes outside of pregnancy [8]. Insulin resistance and impaired insulin production and/or secretion are present in DM2, MS and GDM, which have similar prevalence and share similar risk factors. Moreover, some MS components, such as maternal weight gain (WG) and prepregnancy BMI, are also considered to be predictive of GDM [9,10]. WC, however, a renowned marker of diabetes outside of pregnancy [1,11,12], has not been used as a GDM predictor, and few studies have investigated its relationship with GDM. In a study conducted among Brazilian women, WC (measured at 20–28 weeks of gestation) greater than 82 cm showed a 63% sensitivity and a 57% specificity in predicting GDM [13].

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J Matern Fetal Neonatal Med, 2014; 27(9): 943–948

The increasing female prevalence of obesity and its potential links with insulin resistance [2–4] and subsequent development of GDM and/or mild gestational hyperglycemia (MGH) [5] is likely to significantly increase MS prevalence. Thus, investigating the associations of GDM/MGH with MS becomes more and more necessary, and gestation is the ideal diagnostic window for this purpose. Thus, the search for new markers of risk for GDM or gestational mild hyperglycemia, poor prognostic factors: maternal, placental and fetal [14–16]. The objective of this study was to assess the usefulness of WC measured at 20–24 weeks of gestation in predicting GDM. Our secondary aims included determining GDM prevalence and investigating the relationship of WC and BMI values with 75-g OGTT results in pregnant women attending public healthcare units in the Brazilian Federal District (DF, Brazil).

Subjects and methods Study design and study population This cross-sectional study involving the validation of a diagnostic tool was approved by the SES/DF Research Ethics Committee [274/09]; and written informed consent was obtained from all study participants. It was conducted between January and December 2010 and included pregnant women free of MGH or diabetes mellitus who received prenatal care at eight basic healthcare units located in Brasilia, Ceilaˆndia, Gama, Planaltina and Taguatinga/DF, Brazil. Assuming an odds ratio (OR) of 3.0 when predicting WC (83 cm) for GDM development [13], a type 1 error of 5% and a type 2 error of 20%, the minimum sample size was estimated as 188. Thus, 240 women at 20–24 weeks of pregnancy were enrolled. Pregnancy was confirmed by ultrasound examination. Women were excluded from the study in case of previous DM diagnosis, fetal malformation, twin gestation or use of hyperglycemiant agents (corticosteroids and thyroid hormones).

Measurements At enrollment, WC was measured, and both prepregnancy and gestational BMI were estimated. A data collection form, especially developed for this study, was completed with clinical and obstetric information on every participant, and a 75-g OGTT was scheduled to take place between 24 and 28 weeks of gestation. GDM was defined as fasting glycemia 110 mg/dL and/or 2-h postload glucose 140 mg/dL [8,17]. According to 75-g OGTT results, subjects were allocated into two groups: non-GDM (normal response, disease free) and GDM (abnormal response, confirmed disease). WC was measured, with the subject in the standing position, at the end of a normal expiration to the nearest 0.1 cm using an inelastic tape (0.5 cm 200 cm) placed at the midpoint between the lower margin of the last palpable rib and the top of the iliac crest [13,18]. BMI was calculated as weight/height2 (kg/m2), and subjects were classified as low weight (BMI518.5), normal weight (BMI ¼ 18.5–24.9), overweight (BMI ¼ 25–29.9) and obese (BMI 30) [11]. Prepregnancy BMI was estimated based on self-reported prepregnancy weight. When prepregnancy weight was unknown, the weight measurement taken at the first prenatal clinic visit was used. Gestational BMI was determined based on the weight measurement taken at enrollment (20–24 weeks of gestation). WG was defined as the weight at enrollment (gestational weight) minus prepregnancy weight. WG percentage (WG%) was calculated as [gestational weight – prepregnancy weight/ gestational weight] 100 [19]. Statistical analysis Statistical analyses were performed using SAS for Windows, version 9.2 (SAS Institute Inc., Cary, NC, USA). Means were compared using a generalized linear model for a Poisson distribution; and the p value was obtained by the likelihood ratio test. Proportions were compared using the Chi-square test or Firsher’s exact test, when applicable. Spearman’s correlation was used to evaluate associations of fasting and 2h 75-g OGTT results with the variables of interest (WC, BMI, WG and WG%). OR and 95% CI were calculated for

Table 1. Clinical and obstetric characteristics of the study participants by group (GDM and non-GDM). GDM (n ¼ 31)

Number of pregnancies Number of deliveries Number of abortions Gestational age (weeks) Height (m) Prepregnancy weight (kg) Gestational weight (kg) Prepregnancy BMI (kg/m2) Gestational BMI (kg/m2) Weight gain (kg) Weight gain (%) Waist circumference (cm) Glucose level/ 75-g OGTT Fasting (mg/dL) 2-h (mg/dL) a

Non-GDM (n ¼ 209)

m

dp

m

dp

pa

2.226 0.903 0.322 21.806 1.589 66.513 71.835 26.235 28.333 5.323 8.471 93.548

1.477 0.944 0.702 1.471 0.058 12.945 13.066 4.284 4.206 4.051 7.091 8.873

2.029 0.794 0.234 22.005 1.598 60.873 66.213 23.831 25.921 5.341 9.179 87.679

1.241 0.986 0.553 1.361 0.071 11.221 11.527 4.088 4.155 4.166 7.446 8.011

0.4217 0.5642 0.4254 0.4543 0.4721 0.0111 0.0135 0.0027 0.0029 0.9820 0.6196 0.0002

87.742 160.323

12.154 22.947

77.524 101.752

6.078 18.526

50.0001 50.0001

Generalized linear model (GLM) with Poisson distribution and p value obtained by the likelihood ratio test. Significant values are indicated with boldface.

Waist circumference in predicting GDM

DOI: 10.3109/14767058.2013.847081

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Table 2. Percent distribution (%) and odds ratios (OR) for BMI and WC values by group (GDM and non-GDM). GDM (n ¼ 31) n Prepregnancy BMI 525 kg/m2 25 kg/m2 Gestational BMI 525 kg/m2 25 kg/m2 Waist circumference 583 cm 83 cm

Non-GDM (n ¼ 209)

%

n

%

pa 0.0004

11 20

35.48 64.52

143 66

68.42 31.58

7 24

22.58 77.42

99 110

47.37 52.63

3 28

9.68 90.32

61 148

29.19 70.81

0.0095 0.0219 CI 95%

Prepregnancy BMI 25 kg/m2 Gestational BMI 25 kg/m2 WC 83 cm

OR

Minimum

Maximum

pb

4.209 3.166 4.018

1.833 1.302 1.117

9.407 7.699 13.784

0.0005 0.0110 0.0270

BMI ¼ body mass index; WC ¼ waist circumference. a Chi-square test or Fisher’s exact test. b Likelihood ratio test adjusted by gestational age. Significant values are indicated with boldface. Table 3. Correlations between maternal characteristics and 75-g OGTT resultsa.

75-g OGTT Fasting 2-h

r p r p

Fasting G

WC

PreBMI

GestBMI

WG

% WG

2-h G

1.00000 – 0.39788 50.0001

0.37329 50.0001 0.27179 50.0001

0.29533 50.0001 0.24253 0.0001

0.35008 50.0001 0.26291 50.0001

0.14805 0.0221 0.08469 0.1910

0.05073 0.4350 0.04574 0.4806

0.39788 50.0001 1.00000 –

Fasting G ¼ fasting glucose; 2-h G ¼ 2-h glucose; WC ¼ waist circumference; PreBMI ¼ prepregnancy body mass index; GestBMI ¼ gestational body mass index; WG ¼ weight gain. a Spearman’s correlation. Significant values are indicated with boldface. Table 4. Sensitivity and specificity of WC [20–24 weeks] and prepregnancy BMI to predict GDM among study participants.

WC (cm)a 76.5 77.5 78.5 79.5 80.5 81.5 82.5 83.5 84.5 85.5 86.5 87.5 88.5 BMI (kg/m2)b 24.6 24.7 24.8 24.9 25.0

Sensitivity

Specificity

0.935 0.935 0.935 0.935 0.935 0.903 0.903 0.903 0.871 0.871 0.774 0.774 0.774

0.062 0.091 0.115 0.134 0.211 0.211 0.292 0.330 0.383 0.411 0.459 0.502 0.569

0.710 0.710 0.710 0.645 0.645

0.660 0.670 0.680 0.680 0.690

a

WC ¼ waist circumference; bBMI ¼ prepregnancy body mass index.

prepregnancy and gestational BMI, and WC at 20–24 weeks of gestation, adjusted by gestational age. The sensitivity (S)

and specificity (E) of WC at 20–24 weeks of gestation were calculated, and WC predictive performance was assessed by using receiver operating characteristic curve analysis. Statistical significance was set at 95% (p50.05).

Results According to 75-g OGTT results, 31 (13%) of the 240 pregnant women enrolled had GDM, while 209 showed normal glucose levels (Non-GDM). Mean BMI analysis revealed that GDM women were overweight, both prepregnancy (26.23 4.28 kg/m2) and at 20–24 weeks of gestation (28.33 4.20 kg/m2). In the nonGDM group, although mean BMI indicated overweight during gestation (25.92 4.15 kg/m2), it was lower than in the GDM group (p ¼ 0.0029). Table 1 shows that mean WC was higher in the GDM group (93.55 8.87 cm) than in the non-GDM group (87.79 8.01 cm) (p ¼ 0.0002). WC 83 cm was observed in 90.32% of the GDM women in 70.81% of those in the non-GDM group (p ¼ 0.0219). The ORs for prepregnancy BMI 25 kg/m2 (p ¼ 0.0005), gestational BMI 25 kg/m2 (p ¼ 0.0110) and WC at 20–24 weeks (p ¼ 0.0270) were 4.21, 3.17, and 4.02, respectively (Table 2). WG showed a positive correlation with fasting glucose (r ¼ 0.1480, p ¼ 0.0221). Fasting and 2-h 75-g OGTT results positively correlated with WC (r ¼ 0.3733, p50.0001;

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r ¼ 0.2718, p50.0001, respectively), prepregnancy BMI (r ¼ 0.2953, p50.0001; r ¼ 0.2425, p ¼ 0.0001, respectively) and gestational BMI (r ¼ 0.3501, p50.0001; r ¼ 0.2629, p50.0001, respectively) (Table 3). At 20–24 weeks of gestation, the sensitivity of WC 83 cm to predict GDM was 90.3%, while the specificity ranged from 29.2 to 33.3%. Within this gestational age range, a WC cutoff between 85.5 and 88.5 cm offered a better sensitivity/specificity balance. To prepregnancy BMI, the better sensitivity/specificity balance was 24.8 kg/ m2 with sensitivity of 71% and specificity of 68% (Table 4; Figure 1).


Discussion This study demonstrated that the prevalence of GDM is 13% in the basic healthcare network of the Brazilian Federal District, confirmed that both prepregnancy and gestational BMI 25 kg/m2, as well as WC 83 cm (measured at 20–24 weeks of gestation), are associated with a three- to fourfold increase in the risk of developing GDM; and, finally, suggested new WC cutoff points (86–88 cm) for GDM prediction. The 13% GDM prevalence observed in our study population is high in comparison with those observed in previous local studies. According to the Brazilian Ministry of Health,

Figure 1. ROC curve sensitivity and specificity of WC [20–24 gestational weeks] and prepregnancy BMI to predict GDM.

Waist circumference in predicting GDM

DOI: 10.3109/14767058.2013.847081

GDM prevalence rate was 7.6% among the women attending the SUS across the country in 2005 [8]. In a survey conducted in 2008, GDM was found to be prevalent in 6.6% of the pregnant women attending a basic healthcare unit in Brası´lia/ DF [20]. Despite potential biases resulting from different methods for diagnosis, our findings indicate a rise in GDM prevalence that is likely to be related to the growing rate of obesity among Brazilian women [3], as well as to the fact that these women are getting pregnant later in life, which increases the risk of GDM [21,22]. Several studies have demonstrated that excessive gestational WG, especially early in pregnancy [23] or in women with prepregnancy BMI 30 kg/m2 [24,25], may increase a woman’s risk of GDM. In this study, no difference in WG was observed between the groups. Nonetheless, both body weight and BMI, which showed a positive correlation with GDM risk, were higher in the women with GDM. In the study, participants showing prepregnancy and/or gestational BMI 25 kg/m2, GDM risk was fourfold and threefold higher, respectively. These findings confirm that BMI is predictive of GDM risk as previously reported [9,13,15]. However, probably due to differences in the timing of WC measurement during pregnancy, controversy remains regarding the cutoff points. While some investigators suggest a threshold of 24.3 kg/m2 with 75% sensitivity and 86% specificity, others recommend a BMI of 23 kg/m2 with 61% sensitivity and 54% specificity [13,26]. The Brazilian Ministry of Health acknowledges BMI 25 kg/m2 as a risk factor for GDM [27]. Furthermore, according to the CARDIA study, not only obesity but also overweight may predict cardiovascular risk [28]. Consistently with the findings of Negrato et al. [9,29], a prepregnancy or gestational BMI 25 kg/m2 was predictive of MS associated with GDM/gestational hyperglycemia among our patients. A recent systematic review showed that increase in the risk for GDM is proportional to maternal BMI increase – OR values progressively rise according to BMI category (overweight, moderate and severe obesity) [30]. In this study, WC 83 cm at 20–24 weeks of gestation positively correlated with fasting glucose and 2-h 75-g OGTT values and was associated with a fourfold increase in the risk of developing GDM. Nonetheless, despite offering better sensitivity, this cutoff point showed lower specificity than that reported by Wendland et al. [13] in Brazilian women (57.0%). Between 20 and 24 weeks of gestation, our results indicate that WC ¼ 85.5–88.5 cm (sensitivity/specificity balance ranging from 87.1–41.1% to 77.4–56.9%) showed a better performance in predicting GDM. Such cutoff points are higher than that proposed by Wendland et al. [13] and closer to the 85.5 cm (with sensitivity of 75% and specificity 81.4%) found by Madhavan et al. [26] in 106 Asian Indian women at the first trimester of gestation. Our results confirm that, regardless of the cutoff point used, WC is a risk factor for developing GDM and corroborate findings previously reported by our research team [9]. Furthermore, this study suggests that WC cutoff points are gestational age-dependent; and that, at 20–24 weeks of gestation, a WC between 86 and 88 cm has the best predictive performance. The fact that such cutoff point is higher than both that recommended by IDF [1] for non-pregnant women

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(CC 80 cm) and that established at 20–28 weeks of gestation (CC 83 cm) [13] calls for further studies aiming at not only validating the cutoff points proposed here in (86–88 cm/20–24 weeks) but also at establishing WC reference values according to gestational age as previously done for BMI [8].

Acknowledgements The authors are grateful to (i) Sabin Laboratory and Sabin Institute Research Support Nucleus for the performance of the diagnostic tests and (ii) Research Support Group of Botucatu Medical School/UNESO for their guidance in statistical analysis.

Declaration of interest The authors declare that they have no conflicts of interest in this research. This study is part of a larger research project funded by Escola Superior de Cieˆncias da Sau´de (ESCS), supported by Fundaçaõ de Ensino e Pesquisa em Cieˆncias da Sau´de da Secretaria de Estado de sau´de do Distrito Federal (FEPECS/ SES-DF).

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