Associação entre circunferência do pescoço na gestação com diabetes gestacional e grau de tolerância à glicose entre 2 e 6 meses pós-parto em mulheres com sobrepeso ou obesidade
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2021
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Carvalho, Camila, Rodrigues de Souza [UNIFESP]
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Almeida-Pititto, Bianca [UNIFESP]
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Introdução: O diabetes mellitus tipo 2 (DM2) e o diabetes gestacional (DMG) são
problemas de saúde prevalentes no mundo e no Brasil. O excesso de peso é um
fator de risco devido a sua função na fisiopatologia da resistência à insulina. É
importante identificar, dentre mulheres com excesso de peso, as que cursam com
DMG, bem como aquelas com maior risco de progredir para alterações do
metabolismo da glicose no pós-parto no intuito de direcionar medidas de prevenção
do diabetes. A circunferência do pescoço (CP) tem ganhado atenção como uma
boa medida antropométrica para predição de risco cardiometabólico. O objetivo
deste estudo foi avaliar a associação da CP medida durante primeiro e terceiro
trimestres da gestação com diagnóstico de DMG (Artigo1) e grau de tolerância à
glicose entre 2 e 6 meses no pós-parto (Artigo 2) em mulheres com com sobrepeso
ou obesidade, acompanhadas nos ambulatórios do Centro de Diabetes e da
Obstetrícia da Escola Paulista de Medicina da Universidade Federal de São Paulo
– UNIFESP. Métodos: Para o estudo atual, foram incluídas todas as mulheres que
aceitaram participar provenientes dos 2 ambulatórios assim que ingressaram no
sistema de atendimento entre dezembro de 2018 e dezembro de 2019. Foi
realizado questionário para obtenção de dados demográficos, socioeconômicos e
inquérito alimentar durante a gestação. Essa coleta de dados também foi realizada
entre 2 e 6 meses pós-parto quando foram feitas avaliação bioquímica das
participantes por coleta de sangue. As pacientes que aceitaram participar do estudo
assinaram o Termo de Consentimento Livre e Esclarecido (TCLE). A análise foi
realizada tendo como variável de exposição a circunferência do pescoço durante a
gestação e a de desfecho a presença de DMG e perfil glicêmico e de resistência à
insulina entre 2 e 6 meses pós-parto (glicemia de jejum, glicemia de 2 horas, HbA1c,
insulina de jejum e de 2 horas, HOMA-IR e TyG). Peso pré-gestacional, paridade,
ganho de peso durante a gestação, realização de atividade física, história familiar
de diabetes, dieta, uso de medicação hipoglicemiante durante a gestação foram
utilizadas como covariáveis. Resultados: (Artigo 1) - Mulheres com e sem DMG
apresentaram média (DP) de IMC pré-gestacional semelhante [30,3 (4,0) vs 29,4
(3,5) Kg / m2, p = 0,16]. Mulheres com DMG eram mais velhas [32 (6) vs 28 (6)
anos, p <0,001] e tinham maior CP [36,0 (2,7) vs 34,5 (1,8) cm, p <0,001]. CP foi
semelhante em mulheres com DMG no primeiro ou terceiro trimestre [p = 0,4] e foi
ix
correlacionado com glicemia de jejum [r0,29, p = 0,01] e com pressão arterial
sistólica [r0,28, p = 0,001] e diastólica [r0,25, p = 0,004]. CP foi associada com
diagnóstico de DMG [OR 1,25, IC 95% 1,03-1,52] ajustado para idade, atividade
física, escolaridade e histórico familiar de diabetes. Na análise ROC, a área sob a
curva foi de 0,655 e o valor de corte de 34,5cm teve 0,70 de sensibilidade e 0,51
de especificidade para a presença de DMG. Mulheres que tiveram CP ≥ 34,5 vs <
34,5 cm tiveram frequências mais altas de hipertensão na gravidez [32,3 vs 4,2%,
p = 0,01]. (Artigo 2) –Para as análises do artigo 2, a CP foi dividida em tercis (tercil
1: CP ≤33,3 cm, tercil 2: 33,4 a 36,3 cm e tercil 3: ≥36,4 cm). Encontramos
diferenças no IMC pós-parto (27,4 ± 3,1 vs. 29,4 ± 3,7 vs. 32,1 ± 3,6 kg / m², p
<0,001) e CP pós parto (33,16 ± 1,32 vs. 34,8 ± 2,0 vs. 37,4 ± 2,6 cm, p < 0,001)
de acordo com o primeiro, segundo e terceiro tercis, respectivamente. Em relação
ao metabolismo glicêmico no pós-parto, os níveis de HbA1c (5,3 ± 0,2 vs. 5,4 ± 0,3
vs. 5,6 ± 0,4 %, p = 0,006), insulina em jejum (9,5 ± 4,9 vs. 11,1 ± 5,8 vs. 13,2 ± 6,6
µUI/mL, p = 0,035), HOMA-IR (9,5 ± 4,9 vs. 2,5 ± 1,3 vs. 3,1 ± 1,7, p = 0,035) e
índice TyG (4,5 ± 0,3 vs. 4,5 ± 0,2 vs. 4,6 ± 0,2, p = 0,010) foram menores no
primeiro e segundo tercis do que no terceiro, respectivamente. Na análise de
regressão linear bruta, a CP durante a gravidez teve associação estatisticamente
significativa com os níveis de glicose plasmática de jejum, glicose de 2 horas,
HbA1c, Log HOMA-IR e índice de Tyg, mantendo a associação após ajuste para
idade, história familiar de diabetes e número de gravidezes. Quando ajustado para
IMC pré-gestacional e ganho de peso gestacional, a CP persistiu
independentemente associado à glicose plasmática em jejum e HbA1c. Ao ajustar
pela presença de DMG as associações perderam a significância estatistica.
Conclusão: Em um grupo de gestantes com sobrepeso ou obesidade, a CP
medida na gestação foi capaz de identificar o diagnóstico de DMG e pior perfil
metabólico da glicose no puerpério. Desta forma, a CP pode ser uma ferramenta
viável para a identificação precoce de mulheres com maior risco de desenvolver
DMG e DM2. Estudos prospectivos de mais longo prazo são necessários para
confirmar o valor preditivo da CP para DM2.
Introduction: Type 2 diabetes mellitus (DM2) and gestational diabetes (GDM) are prevalent health problems in the world and in Brazil. Excess weight is a risk factor due to its role in the pathophysiology of insulin resistance. It is important to identify, among women with excess weight and/or GDM, those at greater risk of progressing to changes in glucose metabolism in the postpartum period in order to guide measures to prevent DM2. Neck circumference (NC) has gained attention as a good anthropometric measure for predicting cardiometabolic risk. The aim of this study was to evaluate the association between NC measured during the first and third trimesters of pregnancy with a diagnosis of GDM and the degree of glucose tolerance between 2 and 6 months postpartum in women with overweight or obesity, followed up at the Diabetes Center outpatient clinics and Obstetrics at the São Paulo School of Medicine, Federal University of São Paulo – UNIFESP. Methods: For the current study, all women who agreed to participate from the clinics as soon as they entered the service system between December 2018 and December 2019 were included. A questionnaire was carried out to obtain demographic, socioeconomic and food survey data during the gestation. This data collection was also carried out between 2 and 6 months postpartum, when the participants were biochemically assessed by blood collection. Patients who agreed to participate in the study signed the Informed Consent Form. The analysis was performed using the neck circumference during pregnancy as an exposure variable and the outcome variable was the presence of GDM and glycemic profile and insulin resistance between 2 and 6 months postpartum (fasting glucose, 2-hour glucose, HbA1c, fasting and 2- hour insulin, HOMA-IR and TyG). Pre-gestational weight, parity, weight gain during pregnancy, physical activity, family history of diabetes, diet, use of hypoglycemic medication during pregnancy will be used as covariates. Results: (Paper 1): Women with and without GDM had similar mean (SD) pre-gestational BMI [30.3(4.0) vs 29.4(3.5)Kg/m2, p=0.16]. Women with GDM were older [32(6) vs 28(6)yrs, p<0.001] and had greater NC [36.0(2.7) vs 34.5(1.8)cm, p<0.001]. NC was similar in women with GDM diagnosed in first or third trimester [p=0.4] and was correlated with FPG [r0.29, p=0.01] and systolic [r0.28, p=0.001] and diastolic [r0.25, p=0.004] blood pressure. NC was associated with GDM [OR 1.25, 95%CI 1.03-1.52] adjusted for age, physical activity, schooling and familiar history of diabetes. In ROC analysis, xi the area under the curve was 0.655 and the cut-off value of 34.5cm had 0.70 of sensitivity and 0.51 of specificity for GDM. Women who had NC≥34.5 vs <34.5cm had higher frequencies of hypertension [32.3 vs 4.2%, p=0.01]. (Paper 2): NC was divided into tertiles (tertile 1: NC ≤33.3 cm, tertile 2: 33.4 to 36.3 cm and tertile 3: ≥36.4 cm). We found differences in postpartum BMI (27.4 ± 3.1 vs. 29.4 ± 3.7 vs. 32.1 ± 3.6 kg / m², p <0.001) and postpartum NC (33.16 ± 1, 32 vs. 34.8 ± 2.0 vs. 37.4 ± 2.6 cm, p < 0.001) according to the first, second and third tertiles, respectively. Regarding postpartum glycemic metabolism, HbA1c levels (5.3 ± 0.2 vs. 5.4 ± 0.3 vs. 5.6 ± 0.4 %, p = 0.006), fasting insulin (9.5 ± 4.9 vs. 11.1 ± 5.8 vs. 13.2 ± 6.6 µIU/mL, p = 0.035), HOMA-IR (9.5 ± 4.9 vs. 2, 5 ± 1.3 vs. 3.1 ± 1.7, p = 0.035) and TyG index (4.5 ± 0.3 vs. 4.5 ± 0.2 vs. 4.6 ± 0.2, p = 0.010) were lower in the first and second tertiles than in the third, respectively. In crude linear regression analysis, NC during pregnancy had a statistically significant association with fasting plasma glucose, 2-hour glucose, HbA1c, Log HOMA-IR and Tyg index, maintaining the association after adjustment for age, history family member of diabetes and number of pregnancies. When adjusted for pre-pregnancy BMI and gestational weight gain, NC persisted independently associated with fasting plasma glucose and HbA1c. When adjusting for the presence of GDM, the associations lost statistical significance. Conclusion: In a group of overweight or obese pregnant women, the PC measured during pregnancy was able to identify the diagnosis of GDM and a worse metabolic profile of glucose in the puerperium. In this way, NC can be a viable tool for the early identification of women at higher risk of developing GDM and T2DM. Longer-term prospective studies are needed to confirm the predictive value of NC for T2DM.
Introduction: Type 2 diabetes mellitus (DM2) and gestational diabetes (GDM) are prevalent health problems in the world and in Brazil. Excess weight is a risk factor due to its role in the pathophysiology of insulin resistance. It is important to identify, among women with excess weight and/or GDM, those at greater risk of progressing to changes in glucose metabolism in the postpartum period in order to guide measures to prevent DM2. Neck circumference (NC) has gained attention as a good anthropometric measure for predicting cardiometabolic risk. The aim of this study was to evaluate the association between NC measured during the first and third trimesters of pregnancy with a diagnosis of GDM and the degree of glucose tolerance between 2 and 6 months postpartum in women with overweight or obesity, followed up at the Diabetes Center outpatient clinics and Obstetrics at the São Paulo School of Medicine, Federal University of São Paulo – UNIFESP. Methods: For the current study, all women who agreed to participate from the clinics as soon as they entered the service system between December 2018 and December 2019 were included. A questionnaire was carried out to obtain demographic, socioeconomic and food survey data during the gestation. This data collection was also carried out between 2 and 6 months postpartum, when the participants were biochemically assessed by blood collection. Patients who agreed to participate in the study signed the Informed Consent Form. The analysis was performed using the neck circumference during pregnancy as an exposure variable and the outcome variable was the presence of GDM and glycemic profile and insulin resistance between 2 and 6 months postpartum (fasting glucose, 2-hour glucose, HbA1c, fasting and 2- hour insulin, HOMA-IR and TyG). Pre-gestational weight, parity, weight gain during pregnancy, physical activity, family history of diabetes, diet, use of hypoglycemic medication during pregnancy will be used as covariates. Results: (Paper 1): Women with and without GDM had similar mean (SD) pre-gestational BMI [30.3(4.0) vs 29.4(3.5)Kg/m2, p=0.16]. Women with GDM were older [32(6) vs 28(6)yrs, p<0.001] and had greater NC [36.0(2.7) vs 34.5(1.8)cm, p<0.001]. NC was similar in women with GDM diagnosed in first or third trimester [p=0.4] and was correlated with FPG [r0.29, p=0.01] and systolic [r0.28, p=0.001] and diastolic [r0.25, p=0.004] blood pressure. NC was associated with GDM [OR 1.25, 95%CI 1.03-1.52] adjusted for age, physical activity, schooling and familiar history of diabetes. In ROC analysis, xi the area under the curve was 0.655 and the cut-off value of 34.5cm had 0.70 of sensitivity and 0.51 of specificity for GDM. Women who had NC≥34.5 vs <34.5cm had higher frequencies of hypertension [32.3 vs 4.2%, p=0.01]. (Paper 2): NC was divided into tertiles (tertile 1: NC ≤33.3 cm, tertile 2: 33.4 to 36.3 cm and tertile 3: ≥36.4 cm). We found differences in postpartum BMI (27.4 ± 3.1 vs. 29.4 ± 3.7 vs. 32.1 ± 3.6 kg / m², p <0.001) and postpartum NC (33.16 ± 1, 32 vs. 34.8 ± 2.0 vs. 37.4 ± 2.6 cm, p < 0.001) according to the first, second and third tertiles, respectively. Regarding postpartum glycemic metabolism, HbA1c levels (5.3 ± 0.2 vs. 5.4 ± 0.3 vs. 5.6 ± 0.4 %, p = 0.006), fasting insulin (9.5 ± 4.9 vs. 11.1 ± 5.8 vs. 13.2 ± 6.6 µIU/mL, p = 0.035), HOMA-IR (9.5 ± 4.9 vs. 2, 5 ± 1.3 vs. 3.1 ± 1.7, p = 0.035) and TyG index (4.5 ± 0.3 vs. 4.5 ± 0.2 vs. 4.6 ± 0.2, p = 0.010) were lower in the first and second tertiles than in the third, respectively. In crude linear regression analysis, NC during pregnancy had a statistically significant association with fasting plasma glucose, 2-hour glucose, HbA1c, Log HOMA-IR and Tyg index, maintaining the association after adjustment for age, history family member of diabetes and number of pregnancies. When adjusted for pre-pregnancy BMI and gestational weight gain, NC persisted independently associated with fasting plasma glucose and HbA1c. When adjusting for the presence of GDM, the associations lost statistical significance. Conclusion: In a group of overweight or obese pregnant women, the PC measured during pregnancy was able to identify the diagnosis of GDM and a worse metabolic profile of glucose in the puerperium. In this way, NC can be a viable tool for the early identification of women at higher risk of developing GDM and T2DM. Longer-term prospective studies are needed to confirm the predictive value of NC for T2DM.
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Citation
CARVALHO, C.R.S..Associação da circunferência do pescoço na gestação com diabetes gestacional e grau de tolerância à glicose entre 2 e 6 meses pós-parto em mulheres com sobrepeso ou obesidade. São Paulo, 2021. 83F. Tese (Mestrado em Endocrinologia e Metabologia) - Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, 2021.