The Official Patient's Sourcebook on Gestational Diabetes

THE OFFICIAL PATIENT’S SOURCEBOOK

on

GESTATIONAL DIABETES J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

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ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright Ó2002 by ICON Group International, Inc. Copyright Ó2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher's note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your physician. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified physician. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The Official Patient’s Sourcebook on Gestational Diabetes: A Revised and Updated Directory for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83141-6 1. Gestational Diabetes-Popular works. I. Title.

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Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.

Copyright Notice If a physician wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this sourcebook.

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Dedication To the healthcare professionals dedicating their time and efforts to the study of gestational diabetes.

Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to gestational diabetes. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.

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About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

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About ICON Health Publications In addition to gestational diabetes, Official Patient’s Sourcebooks are available for the following related topics: ·

The Official Patient's Sourcebook on Antenatal Corticosteroid Therapy

·

The Official Patient's Sourcebook on Endometriosis

·

The Official Patient's Sourcebook on Uterine Fibroids

·

The Official Patient's Sourcebook on Vaginitis

To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

Contents vii

Table of Contents INTRODUCTION...................................................................................... 1

Overview............................................................................................................... 1 Organization......................................................................................................... 3 Scope ..................................................................................................................... 3 Moving Forward................................................................................................... 4

PART I: THE ESSENTIALS ................................................. 7 CHAPTER 1. THE ESSENTIALS ON GESTATIONAL DIABETES: GUIDELINES ........................................................................................... 9

Overview............................................................................................................... 9 What Is Gestational Diabetes? What Causes It? ............................................... 10 How Does Gestational Diabetes Differ from Other Types of Diabetes? ............ 12 Who Is at Risk for Developing Gestational Diabetes? How Is It Detected? ...... 13 How Does Gestational Diabetes Affect Pregnancy? .......................................... 14 What Can Be Done to Reduce Problems Associated with Gestational Diabetes? ............................................................................................................................ 16 What Is Self Blood Glucose Monitoring?........................................................... 17 How Often and When Should I Test? ................................................................ 17 How Should I Record My Test Results? ............................................................ 18 Are There Any Other Tests I Should Know About?.......................................... 18 How Do I Test for Ketones? ............................................................................... 18 When Do I Test for Ketones?.............................................................................. 19 Is It Ever Necessary to Take Insulin?................................................................. 19 Will My Baby Be Healthy?................................................................................. 19 Does Gestational Diabetes Affect Labor and Delivery? ..................................... 22 Should I Expect My Baby to Have Any Problems? ........................................... 23 Will I Develop Diabetes in the Future?.............................................................. 23 Why Is a Special Diet Recommended? ............................................................... 24 How Much Weight Should I Gain?.................................................................... 24 How Should I Eat during My Pregnancy? ........................................................ 26 Other Nutritional and Non-Nutritional Considerations................................... 29 What Food Patterns Help Keep Blood Sugar Levels Normal? ........................... 30 How Do I Plan Meals? ....................................................................................... 33 What Can Be Done to Slow Weight Gain during Pregnancy?.......................... 34 Is Breast-Feeding Recommended? ...................................................................... 36 Should I Exercise? .............................................................................................. 37 What Happens If Diet and Exercise Fail to Control My Blood Sugars? ........... 39 Can My Blood Sugar Level Go Too Low? .......................................................... 39 More Guideline Sources ..................................................................................... 40 Vocabulary Builder............................................................................................. 50

CHAPTER 2. SEEKING GUIDANCE ....................................................... 55

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Overview............................................................................................................. 55 Associations and Gestational Diabetes............................................................... 55 Finding More Associations................................................................................. 57 Finding Doctors.................................................................................................. 59 Finding an Obstetrician-Gynecologist ............................................................... 60 Selecting Your Doctor ........................................................................................ 61 Working with Your Doctor ................................................................................ 61 Broader Health-Related Resources ..................................................................... 63 Vocabulary Builder............................................................................................. 63

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL.................................................. 65 CHAPTER 3. STUDIES ON GESTATIONAL DIABETES ............................ 67

Overview............................................................................................................. 67 The Combined Health Information Database ..................................................... 67 Federally-Funded Research on Gestational Diabetes ......................................... 78 E-Journals: PubMed Central .............................................................................. 92 The National Library of Medicine: PubMed ...................................................... 92 Vocabulary Builder............................................................................................. 93

CHAPTER 4. PATENTS ON GESTATIONAL DIABETES ........................... 97

Overview............................................................................................................. 97 Patents on Gestational Diabetes ......................................................................... 98 Patent Applications on Gestational Diabetes ................................................... 100 Keeping Current ............................................................................................... 100

CHAPTER 5. BOOKS ON GESTATIONAL DIABETES ............................ 101

Overview........................................................................................................... 101 Book Summaries: Federal Agencies .................................................................. 101 Book Summaries: Online Booksellers ............................................................... 104 The National Library of Medicine Book Index ................................................. 104 Chapters on Gestational Diabetes..................................................................... 105 General Home References ................................................................................. 107 Vocabulary Builder........................................................................................... 108

CHAPTER 6. MULTIMEDIA ON GESTATIONAL DIABETES.................. 109

Overview........................................................................................................... 109 Video Recordings .............................................................................................. 109 Audio Recordings ............................................................................................. 112 Bibliography: Multimedia on Gestational Diabetes ......................................... 112 Vocabulary Builder........................................................................................... 113

CHAPTER 7. PHYSICIAN GUIDELINES AND DATABASES ................... 115

Overview........................................................................................................... 115 NIH Guidelines................................................................................................. 115 NIH Databases.................................................................................................. 116 Other Commercial Databases ........................................................................... 127

Contents

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The Genome Project and Gestational Diabetes................................................. 127 Specialized References....................................................................................... 132 Vocabulary Builder........................................................................................... 133

CHAPTER 8. DISSERTATIONS ON GESTATIONAL DIABETES .............. 135

Overview........................................................................................................... 135 Dissertations on Gestational Diabetes.............................................................. 135 Keeping Current ............................................................................................... 136

PART III. APPENDICES .................................................. 137 APPENDIX A. RESEARCHING YOUR MEDICATIONS.......................... 139

Overview........................................................................................................... 139 Your Medications: The Basics .......................................................................... 140 Learning More about Your Medications .......................................................... 142 Commercial Databases...................................................................................... 143 Contraindications and Interactions (Hidden Dangers) ................................... 144 A Final Warning .............................................................................................. 145 General References............................................................................................ 146

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ................... 149

Overview........................................................................................................... 149 What Is CAM? ................................................................................................. 149 What Are the Domains of Alternative Medicine?............................................ 150 Can Alternatives Affect My Treatment? ......................................................... 153 Finding CAM References on Gestational Diabetes .......................................... 154 Additional Web Resources................................................................................ 156 General References............................................................................................ 158 Vocabulary Builder........................................................................................... 159

APPENDIX C. RESEARCHING NUTRITION ......................................... 161

Overview........................................................................................................... 161 Food and Nutrition: General Principles........................................................... 162 Finding Studies on Gestational Diabetes ......................................................... 166 Federal Resources on Nutrition........................................................................ 172 Additional Web Resources................................................................................ 173 Vocabulary Builder........................................................................................... 174

APPENDIX D. FINDING MEDICAL LIBRARIES.................................... 177

Overview........................................................................................................... 177 Preparation ....................................................................................................... 177 Finding a Local Medical Library ...................................................................... 178 Medical Libraries Open to the Public............................................................... 178

APPENDIX E. YOUR RIGHTS AND INSURANCE ................................. 185

Overview........................................................................................................... 185 Your Rights as a Patient................................................................................... 185 Patient Responsibilities .................................................................................... 189 Choosing an Insurance Plan............................................................................. 190

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Medicare and Medicaid .................................................................................... 192 NORD’s Medication Assistance Programs ..................................................... 195 Additional Resources ........................................................................................ 196

APPENDIX F. MORE ON GESTATIONAL DIABETES ............................ 199

Overview........................................................................................................... 199 Why Do Some Women Get Gestational Diabetes?........................................... 200 How Do I Know If I'm at Risk? ....................................................................... 200 Should I Get Tested?......................................................................................... 200 What Is Involved in Getting Tested? ............................................................... 201 What If I Don't Get Treated for Gestational Diabetes? ................................... 201 What Should I Do If I Have Gestational Diabetes? ......................................... 202

ONLINE GLOSSARIES.................................................... 203 Online Dictionary Directories.......................................................................... 206

GESTATIONAL DIABETES GLOSSARY.................... 207 General Dictionaries and Glossaries ................................................................ 218 INDEX

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Introduction

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INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don't know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many physicians and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3

Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1 2

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Gestational Diabetes

Since the late 1990s, physicians have seen a general increase in patient Internet usage rates. Patients frequently enter their doctor's offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that doctors often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Gestational Diabetes has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to gestational diabetes, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on gestational diabetes. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on gestational diabetes should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique. Deciding on

Introduction

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appropriate options is always up to the patient in consultation with their physician and healthcare providers.

Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching gestational diabetes (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to gestational diabetes. It also gives you sources of information that can help you find a doctor in your local area specializing in treating gestational diabetes. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with gestational diabetes. Part II moves on to advanced research dedicated to gestational diabetes. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on gestational diabetes. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “free-to-use” options. Part III provides appendices of useful background reading for all patients with gestational diabetes or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with gestational diabetes. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with gestational diabetes.

Scope While this sourcebook covers gestational diabetes, your doctor, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that gestational diabetes is often considered a synonym or a condition closely related to the following: ·

Glucose Intolerance during Pregnancy

·

Glucose Intolerance of Pregnancy

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Gestational Diabetes

In addition to synonyms and related conditions, physicians may refer to gestational diabetes using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world's illnesses. Your physician may use this coding system as an administrative or tracking tool. The following classification is commonly used for gestational diabetes:4 ·

648.8 abnormal glucose tolerance - gestational diabetes

For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to gestational diabetes. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians.

Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses. Some are written by patients or their family members. These generally take a layperson's approach to understanding and coping with an illness or disorder. They can be uplifting, encouraging, and highly supportive. Other guides are authored by physicians or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian. Why “Internet age”? All too often, patients diagnosed with gestational diabetes will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with gestational diabetes is even indexed in search engines, a non-systematic 4 This list is based on the official version of the World Health Organization's 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”

Introduction

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approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. While we focus on the more scientific aspects of gestational diabetes, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors

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PART I: THE ESSENTIALS

ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on gestational diabetes. The essentials of a disease typically include the definition or description of the disease, a discussion of who it affects, the signs or symptoms associated with the disease, tests or diagnostic procedures that might be specific to the disease, and treatments for the disease. Your doctor or healthcare provider may have already explained the essentials of gestational diabetes to you or even given you a pamphlet or brochure describing gestational diabetes. Now you are searching for more in-depth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your doctor has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.

Guidelines

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CHAPTER 1. THE ESSENTIALS ON GESTATIONAL DIABETES: GUIDELINES Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on gestational diabetes. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on gestational diabetes can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them.

The National Institutes of Health (NIH)5 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on gestational diabetes. Originally founded in 1887, the NIH is one of the world's foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years include the world's most illustrious scientists and physicians. Among them are 97 scientists who have won the Nobel Prize for achievement in medicine.

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Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.

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There is no guarantee that any one Institute will have a guideline on a specific disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare diseases. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with gestational diabetes and associated conditions: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Child Health and Human Development (NICHD); guidelines available at http://www.nichd.nih.gov/publications/pubskey.cfm

Among those listed above, the National Institute of Child Health and Human Development (NICHD) is especially noteworthy. The mission of the NICHD, a part of the National Institutes of Health (NIH), is to support and conduct research on topics related to the health of children, adults, families, and populations. NICHD research focuses on the idea that events that happen prior to and throughout pregnancy as well as during childhood have a great impact on the health and well-being of adults. The following guideline is one the NICHD provides concerning gestational diabetes.6

What Is Gestational Diabetes? What Causes It?7 Approximately 3 to 5 percent of all pregnant women in the United States are diagnosed as having gestational diabetes. These women and their families have many questions about this disorder. Some of the most frequently asked questions are: What is gestational diabetes and how did I get it? How does it differ from other kinds of diabetes? Will it hurt my baby? Will my baby have diabetes? What can I do to control gestational diabetes? Will I need a special diet? Will gestational diabetes change the way or the time my baby is delivered? Will I have diabetes in the future?

6 This and other passages have been adapted from the NIH and NICHD: http://www.nichd.nih.gov/default.htm. “Adapted” signifies that the text has been reproduced with attribution, with some or no editorial adjustments. 7 Adapted from the National Institute of Child Health and Human Development (NICHD): http://www.nichd.nih.gov/publications/pubs/gesttoc.htm.

Guidelines 11

This guideline will address these and many other questions about diet, exercise, measurement of blood sugar levels, and general medical and obstetric care of women with gestational diabetes. It must be emphasized that these are general guidelines and only your health care professional(s) can tailor a program specific to your needs. You should feel free to discuss any concerns you have with your doctor or other health care provider, as no one knows more about you and the condition of your pregnancy. Diabetes (actual name is diabetes mellitus) of any kind is a disorder that prevents the body from using food properly. Normally, the body gets its major source of energy from glucose, a simple sugar that comes from foods high in simple carbohydrates (e.g., table sugar or other sweeteners such as honey, molasses, jams, and jellies, soft drinks, and cookies), or from the breakdown of complex carbohydrates such as starches (e.g., bread, potatoes, and pasta). After sugars and starches are digested in the stomach, they enter the blood stream in the form of glucose.8 The glucose in the blood stream becomes a potential source of energy for the entire body, similar to the way in which gasoline in a service station pump is a potential source of energy for your car. But, just as someone must pump the gas into the car, the body requires some assistance to get glucose from the blood stream to the muscles and other tissues of the body. In the body, that assistance comes from a hormone called insulin. Insulin is manufactured by the pancreas, a gland that lies behind the stomach. Without insulin, glucose cannot get into the cells of the body where it is used as fuel. Instead, glucose accumulates in the blood to high levels and is excreted or “spilled” into the urine through the kidneys.

Insulin: The Key to Turning Food into Energy 8

For the purpose of this brochure the words sugar and glucose are used synonymously.

12 Gestational Diabetes

When the pancreas of a child or young adult produces little or no insulin we call this condition juvenile-onset diabetes or Type I diabetes (insulindependent). This is not the type of diabetes you have. Unlike women with Type I diabetes, women with gestational diabetes have plenty of insulin. In fact, they usually have more insulin in their blood than women who are not pregnant. However, the effect of their insulin is partially blocked by a variety of other hormones made in the placenta, a condition often called insulin resistance. The placenta performs the task of supplying the growing fetus with nutrients and water from the mother's circulation. It also produces a variety of hormones vital to the preservation of the pregnancy. Ironically, several of these hormones such as estrogen, cortisol, and human placental lactogen (HPL) have a blocking effect on insulin, a “contra-insulin” effect. This contrainsulin effect usually begins about midway (20 to 24 weeks) through pregnancy. The larger the placenta grows, the more these hormones are produced, and the greater the insulin resistance becomes. In most women the pancreas is able to make additional insulin to overcome the insulin resistance. When the pancreas makes all the insulin it can and there still isn't enough to overcome the effect of the placenta's hormones, gestational diabetes results. If we could somehow remove all the placenta's hormones from the mother's blood, the condition would be remedied. This, in fact, usually happens following delivery.

How Does Gestational Diabetes Differ from Other Types of Diabetes? There are several different types of diabetes. Gestational diabetes begins during pregnancy and disappears following delivery. Another type is referred to as juvenile-onset diabetes (in children) or Type I (in young adults). These individuals usually develop their disease before age 20. People with Type I diabetes must take insulin by injection every day. Approximately 10 percent of all people with diabetes have Type I (also called insulin-dependent diabetes). Type II diabetes or noninsulin-dependent diabetes (formerly called adultonset diabetes) is also characterized by high blood sugar levels, but these patients are often obese and usually lack the classic symptoms (fatigue, thirst, frequent urination, and sudden weight loss) associated with Type I diabetes. Many of these individuals can control their blood sugar levels by following a careful diet and exercise program, by losing excess weight, or by

Guidelines 13

taking oral medication. Some, but not all, need insulin. People with Type II diabetes account for roughly 90 percent of all diabetics.

Who Is at Risk for Developing Gestational Diabetes? How Is It Detected? Any woman might develop gestational diabetes during pregnancy. Some of the factors associated with women who have an increased risk are obesity; a family history of diabetes; having given birth previously to a very large infant, a stillbirth, or a child with a birth defect; or having too much amniotic fluid (polyhydramnios). Also, women who are older than 25 are at greater risk than younger individuals. Although a history of sugar in the urine is often included in the list of risk factors, this is not a reliable indicator of who will develop diabetes during pregnancy. Some pregnant women with perfectly normal blood sugar levels will occasionally have sugar detected in their urine. The Council on Diabetes in Pregnancy of the American Diabetes Association strongly recommends that all pregnant women be screened for gestational diabetes. Several methods of screening exist. The most common is the 50gram glucose screening test. No special preparation is necessary for this test, and there is no need to fast before the test. The test is performed by giving 50 grams of a glucose drink and then measuring the blood sugar level l hour later. A woman with a blood sugar level of less than 140 milligrams per deciliter (mg/dl) at l hour is presumed not to have gestational diabetes and requires no further testing. If the blood sugar level is greater than 140 mg/dl the test is considered abnormal or “positive:” Not all women with a positive screening test have diabetes. Consequently, a 3hour glucose tolerance test must be performed to establish the diagnosis of gestational diabetes. If your physician determines that you should take the complete 3hour glucose tolerance test, you will be asked to follow some special instructions in preparation for the test. For 3 days before the test, eat a diet that contains at least 150 grams of carbohydrates each day. This can be accomplished by including one cup of pasta, two servings of fruit, four slices of bread, and three glasses of milk every day. For 10 to 14 hours before the test you should not eat and not drink anything but water. The test is usually done in the morning in your physician's office or in a laboratory. First, a blood sample will be drawn to measure your fasting blood sugar level. Then you will be asked to drink a full bottle of a glucose drink (100 grams). This glucose drink is extremely sweet and occasionally makes some people feel nauseated.

14 Gestational Diabetes

Finally, blood samples will be drawn every hour for 3 hours after the glucose drink has been consumed. If two or more of your blood sugar levels are higher than the diagnostic criteria, you have gestational diabetes. This testing is usually performed at the end of the second or the beginning of the third trimester (between the 24th and 28th weeks of pregnancy) when insulin resistance usually begins. If you had gestational diabetes in a previous pregnancy or there is some reason why your physician is unusually concerned about your risk of developing gestational diabetes, you may be asked to take the 50gram glucose screening test as early as the first trimester (before the 13th week). Remember, merely having sugar in your urine or even having an abnormal blood sugar on the 50gram glucose screening test does not necessarily mean you have gestational diabetes. The 3hour glucose tolerance test must be abnormal before the diagnosis is made.

How Does Gestational Diabetes Affect Pregnancy? The complications of gestational diabetes are manageable and preventable. The key to prevention is careful control of blood sugar levels just as soon as the diagnosis of gestational diabetes is made. You should be reassured that there are certain things gestational diabetes does not usually cause. Unlike Type I diabetes, gestational diabetes generally does not cause birth defects. For the most part, birth defects originate sometime during the first trimester (before the 13th week) of pregnancy. The insulin resistance from the contra-insulin hormones produced by the placenta does not usually occur until approximately the 24th week. Therefore, women with gestational diabetes generally have normal blood sugar levels during the critical first trimester.

Guidelines 15

The Role of High Maternal Glucose in Fetal Macrosomia

One of the major problems a woman with gestational diabetes faces is a condition the baby may develop called “macrosomia.” Macrosomia means “large body” and refers to a baby that is considerably larger than normal. All of the nutrients the fetus receives come directly from the mother's blood. If the maternal blood has too much glucose, the pancreas of the fetus senses the high glucose levels and produces more insulin in an attempt to use the glucose. The fetus converts the extra glucose to fat. Even when the mother has gestational diabetes, the fetus is able to produce all the insulin it needs. The combination of high blood glucose levels from the mother and high insulin levels in the fetus results in large deposits of fat which causes the fetus to grow excessively large, a condition known as macrosomia. Occasionally, the baby grows too large to be delivered through the vagina and a cesarean delivery becomes necessary. The obstetrician can often determine if the fetus is macrosomic by doing a physical examination. However, in many cases a special test called an ultrasound is used to measure the size of the fetus. This and other special tests will be discussed later. In addition to macrosomia, gestational diabetes increases the risk of hypoglycemia (low blood sugar) in the baby immediately after delivery. This problem occurs if the mother's blood sugar levels have been consistently high causing the fetus to have a high level of insulin in its circulation. After delivery the baby continues to have a high insulin level, but it no longer has the high level of sugar from its mother, resulting in the newborn's blood sugar level becoming very low. Your baby's blood sugar level will be checked in the newborn nursery and if the level is too low, it may be necessary to give the baby glucose intravenously. Infants of mothers with

16 Gestational Diabetes

gestational diabetes are also vulnerable to several other chemical imbalances such as low serum calcium and low serum magnesium levels. All of these are manageable and preventable problems. The key to prevention is careful control of blood sugar levels in the mother just as soon as the diagnosis of gestational diabetes is made. By maintaining normal blood sugar levels, it is less likely that a fetus will develop macrosomia, hypoglycemia, or other chemical abnormalities.

What Can Be Done to Reduce Problems Associated with Gestational Diabetes? In addition to your obstetrician, there are other health professionals who specialize in the management of diabetes during pregnancy including internists or diabetologists, registered dietitians, qualified nutritionists, and diabetes educators. Your doctor may recommend that you see one or more of these specialists during your pregnancy. In addition, a neonatologist (a doctor who specializes in the care of newborn infants) should also be called in to manage any complications the baby might develop after delivery. One of the essential components in the care of a woman with gestational diabetes is a diet specifically tailored to provide adequate nutrition to meet the needs of the mother and the growing fetus. At the same time the diet has to be planned in such a way as to keep blood glucose levels in the normal range (60 to 120 mg/dl). Specific details about diet during pregnancy are discussed later. An obstetrician, diabetes educator, or other health care practitioner can teach you how to measure your own blood glucose levels at home to see if levels remain in an acceptable range on the prescribed diet. The ability of patients to determine their own blood sugar levels with easy-to-use equipment represents a major milestone in the management of diabetes, especially during pregnancy. The technique called “self blood glucose monitoring” (discussed in detail later) allows you to check your blood sugar levels at home or at work without costly and time-consuming visits to your doctor. The values of your blood sugar levels also determine if you need to begin insulin therapy sometime during pregnancy. Short of frequent trips to a laboratory, this is the only way to see if blood glucose levels remain under good control.

Guidelines 17

What Is Self Blood Glucose Monitoring? Once you are diagnosed as having gestational diabetes, you and your health care providers will want to know more about your day-to-day blood sugar levels. It is important to know how your exercise habits and eating patterns affect your blood sugars. Also, as your pregnancy progresses, the placenta will release more of the hormones that work against insulin. Testing your blood sugar level at important times during the day will help determine if proper diet and weight gain have kept blood sugar levels normal or if extra insulin is needed to help keep the fetus protected. Self blood glucose monitoring is done by using a special device to obtain a drop of your blood and test it for your blood sugar level. Your doctor or other health care provider will explain the procedure to you. Make sure that you are shown how to do the testing before attempting it on your own. Some items you may use to monitor your blood sugar levels are: ·

Lancet–a disposable, sharp needle-like sticker for pricking the finger to obtain a drop of blood.

·

Lancet device–a spring-loaded finger sticking device.

·

Test strip–a chemically treated strip to which a drop of blood is applied.

·

Color chart–a chart used to compare against the color on the test strip for blood sugar level.

·

Glucose meter–a device which “reads” the test strip and gives you a digital number value.

Your health care provider can advise you where to obtain the selfmonitoring equipment in your area. You may want to inquire if any places rent or loan glucose meters, since it is likely you won't be needing it after your baby is born.

How Often and When Should I Test? You may need to test your blood several times a day. Generally, these times are fasting (first thing in the morning before you eat) and 2 hours after each meal. Occasionally, you may be asked to test more frequently during the day or at night. As each person is an individual, your health care provider can advise the schedule best for you.

18 Gestational Diabetes

How Should I Record My Test Results? Most manufacturers of glucose testing products provide a record diary, although some health care providers may have their own version. A Self Blood Glucose Monitoring Diary is included at the end of this book. You should record any test result immediately because it's easy to forget what the reading was during the course of a busy day. You should always have this diary with you when you visit your doctor or other health care provider or when you contact them by phone. These results are very important in making decisions about your health care.

Are There Any Other Tests I Should Know About? In addition to blood testing, you may be asked to check your urine for ketones. Ketones are by-products of the breakdown of fat and may be found in the blood and urine as a result of inadequate insulin or from inadequate calories in your diet. Although it is not known whether or not small amounts of ketones can harm the fetus, when large amounts of ketones are present they are accompanied by a blood condition, acidosis, which is known to harm the fetus. To be on the safe side, you should watch for them in your urine and report any positive results to your doctor.

How Do I Test for Ketones? To test the urine for ketones, you can use a test strip similar to the one used for testing your blood. This test strip has a special chemically treated pad to detect ketones in the urine. Testing is done by passing the test strip through the stream of urine or dipping the strip in and out of urine in a container. As your pregnancy progresses, you might find it easier to use the container method. All test strips are disposable and can be used only once. This applies to blood sugar test strips also. You cannot use your blood sugar test strips for urine testing, and you cannot use your urine ketone test strips for blood sugar testing.

Guidelines 19

When Do I Test for Ketones? Overnight is the longest fasting period, so you should test your urine first thing in the morning every day and any time your blood sugar level goes over 240 mg/dl on the blood glucose test. It is also important to test if you become ill and are eating less food than normal. Your health care provider can advise what's best for you.

Is It Ever Necessary to Take Insulin? Yes, despite careful attention to diet some women's blood sugars do not stay within an acceptable range. A pregnant woman free of gestational diabetes rarely has a blood glucose level that exceeds 100 mg/dl in the morning before breakfast (fasting) or 2 hours after a meal. The optimum goal for a gestational diabetic is blood sugar levels that are the same as those of a woman without diabetes. There is no absolute blood sugar level that necessitates beginning insulin injections. However, many physicians begin insulin if the fasting sugar exceeds 105 mg/dl or if the level 2 hours after a meal exceeds 120 mg/dl on two separate occasions. Blood sugar levels measured by you at home will help your doctor know when it is necessary to begin insulin. The ability to perform self blood glucose monitoring has made it possible to begin insulin therapy at the earliest sign of high sugar levels, thereby preventing the fetus from being exposed to high levels of glucose from the mother's blood.

Will My Baby Be Healthy? The ultimate concern of any expectant mother is, “Will my baby be all right?” There is an array of simple, safe tests used to assess the condition of the fetus before birth and these can be particularly valuable during a pregnancy complicated by gestational diabetes. Tests that may be given during your pregnancy include:

Ultrasound Ultrasound uses short pulses of high-frequency, low-intensity sound waves to create images. Unlike x-rays, there is no radiation exposure to the fetus. First used during World War II to detect enemy submarines below the

20 Gestational Diabetes

surface of the water, ultrasound has since been used safely in obstetrics. Occasionally, the date of your last menstrual period is not sufficient to determine a due date. Ultrasound can provide an accurate gestational age and due date that may be very important if it is necessary to induce labor early or perform a cesarean delivery. Ultrasound can also be used to determine the position of the placenta if it is necessary to perform an amniocentesis (another test discussed later). Fetal Movement Records Recording fetal movement is a test you can do by yourself to help determine the condition of the baby. Fetal activity is generally a reassuring sign of wellbeing. Women are often asked to count fetal movements regularly during the last trimester of pregnancy. You may be asked to set aside specific times to lie down on your back or side and count the number of times the baby moves or kicks. Three or more movements in a 2-hour period is considered normal. Contact your obstetrician if you feel fewer than three movements to determine if other tests are needed.

Fetal Monitoring Modern instruments make it possible to monitor the baby's heart rate before delivery. Currently, there are two types of fetal monitors — internal and external. The internal monitor consists of a small wire electrode attached directly to the scalp of the fetus after the membranes have ruptured. The external monitor uses transducers secured to the mother's abdomen by an elastic belt. One transducer records the baby's heart rate by a sensitive microphone called a doppler. The other transducer measures the firmness of the abdomen during a contraction of the uterus. It is a crude measure of the strength and frequency of contractions. Fetal monitoring is the basis for the non-stress test and the oxytocin challenge test described below.

Non-Stress Test The “non-stress” test refers to the fact that no medication is given to the mother to cause movement of the fetus or contraction of the uterus. It is often used to confirm the well-being of the fetus based on the principle that a healthy fetus will demonstrate an acceleration in its heart rate following movement. Fetal activity may be spontaneous or induced by external manipulation such as rubbing the mother's abdomen or making a loud noise

Guidelines 21

above the abdomen with a special device. When movement of the fetus is noted, a recording of the fetal heart rate is made. If the heart rate goes up, the test is normal. If the heart rate does not accelerate, the fetus may merely be “sleeping”; if, after stimulation, the fetus still does not react, it may be necessary to perform a “stress test” (oxytocin challenge test).

Stress Test (Oxytocin Challenge Test) Labor represents a stress to the fetus. Every time the uterus contracts, the fetus is momentarily deprived of its usual blood supply and oxygen. This is not a problem for most babies. However, some babies are not healthy enough to handle the stress and demonstrate an abnormal heart rate pattern. This test is often done if the non-stress test is abnormal. It involves giving the hormone oxytocin (secreted by every mother when normal labor begins) to the mother to stimulate uterine contractions. The contractions are a challenge to the baby, similar to the challenge of normal labor. If the baby's heart rate slows down rather than speeds up after a contraction, the baby may be in jeopardy. The stress test is considered more accurate than the non-stress test. Nevertheless, it is not 100 percent foolproof and your obstetrician may want to repeat it on another occasion to ensure its accuracy. Most women describe this test as mildly uncomfortable but not painful.

Amniocentesis Amniocentesis is a method of removing a small amount of fluid from the amniotic sac for analysis. Either the fluid itself or the cells shed by the fetus into the fluid can be studied. In mid-pregnancy the cells in amniotic fluid can be analyzed for genetic abnormalities such as Down syndrome. Many women over the age of 35 have amniocentesis for just this reason. Another important use for amniocentesis late in pregnancy is to study the fluid itself to determine if the lungs of the fetus are mature and able to withstand early delivery This information can be very important in deciding the best time for a woman with Type I diabetes to deliver. It is not done as frequently to women with gestational diabetes. Amniocentesis can be performed in an obstetrician's office or on an outpatient basis in a hospital. For genetic testing, amniocentesis is usually performed around the 16th week when the placenta and fetus can be located easily with ultrasound and a needle can be inserted safely into the amniotic sac. The overall complication rate for amniocentesis is less than 1 percent.

22 Gestational Diabetes

The risk is even lower during the third trimester when the amniotic sac is larger and easily identifiable.

Does Gestational Diabetes Affect Labor and Delivery? Most women with gestational diabetes can complete pregnancy and begin labor naturally. Any pregnant woman has a slight chance (about 5 percent) of developing preclampsia (toxemia), a sudden onset of high blood pressure associated with protein in the urine, occurring late in pregnancy. If preclampsia develops, your obstetrician may recommend an early delivery. When an early delivery is anticipated, an amniocentesis is usually performed to assess the maturity of the baby's lungs. Gestational diabetes, by itself, is not an indication to perform a cesarean delivery, but sometimes there are other reasons your doctor may elect to do a cesarean. For example, the baby may be too large (macrosomic) to deliver vaginally, or the baby may be in distress and unable to withstand vaginal delivery. You should discuss the various possibilities for delivery with your obstetrician so there are no surprises. Careful control of blood sugar levels remains important even during labor. If a mother's blood sugar level becomes elevated during labor, the baby's blood sugar level will also become elevated. High blood sugars in the mother produce high insulin levels in the baby. Immediately after delivery high insulin levels in the baby can drive its blood sugar level very low since it will no longer have the high sugar concentration from its mother's blood. Women whose gestational diabetes does not require that they take insulin during their pregnancy, will not need to take insulin during their labor or delivery. On the other hand, a woman who does require insulin during pregnancy may be given insulin by injection on the morning labor begins, or in some instances, it may be given intravenously throughout labor. For most women with gestational diabetes there is no need for insulin after the baby is born and blood sugar level returns to normal immediately. The reason for this sudden return to normal lies in the fact that when the placenta is removed the hormones it was producing (which caused the insulin resistance) are also removed. Thus, the mother's insulin is permitted to work normally without resistance. Your doctor may want to check your blood sugar level the next morning, but it will most likely be normal.

Guidelines 23

Should I Expect My Baby to Have Any Problems? One of the most frequently asked questions is, “Will my baby have diabetes?” Almost universally the answer is no. However, the baby is at risk for developing Type II diabetes later in life, and of having other problems related to gestational diabetes, such as hypoglycemia (low blood sugar) mentioned earlier. If your blood sugars were not elevated during the 24 hours before delivery, there is a good chance that hypoglycemia will not be a problem for your baby. Nevertheless, a neonatologist (a doctor who specializes in the care of newborn infants) or other doctor should check your baby's blood sugar level and give extra glucose if necessary. Another problem that may develop in the infant of a mother with gestational diabetes is jaundice. Jaundice occurs when extra red blood cells in the baby's circulation are destroyed, releasing a substance called bilirubin. Bilirubin is a pigment that causes a yellow discoloration of the skin (jaundice). A minor degree of jaundice is common in many newborns. However, the presence of large amounts of bilirubin in the baby's system can be harmful and requires placing the baby under special lights which help get rid of the pigment. In extreme cases, blood transfusions may be necessary.

Will I Develop Diabetes in the Future? For most women gestational diabetes disappears immediately after delivery. However, you should have your blood sugars checked after your baby is born to make sure your levels have returned to normal. Women who had gestational diabetes during one pregnancy are at greater risk of developing it in a subsequent pregnancy. It is important that you have appropriate screening tests for gestational diabetes during future pregnancies as early as the first trimester. Pregnancy is a kind of “stress test” that often predicts future diabetic problems. In one large study more than onehalf of all women who had gestational diabetes developed overt Type II diabetes within 15 years of pregnancy. Because of the risk of developing Type II diabetes in the future, you should have your blood sugar level checked when you see your doctor for your routine checkups. There is a good chance you will be able to reduce the risk of developing diabetes later in life by maintaining an ideal body weight and exercising regularly.

24 Gestational Diabetes

Why Is a Special Diet Recommended? A nutritionally balanced diet is always essential to maintaining a healthy mother and successful pregnancy. The foods you choose become the nutrient building blocks for the growth of the fetus. For a woman with , gestational diabetes, proper diet alone often keeps blood sugar levels in the normal range and is generally the first step to follow before resorting to insulin injections. Careful attention should be paid to the total calories eaten daily, to avoid foods which increase blood sugar levels, and to emphasize the use of foods which help the body maintain a normal blood sugar. A registered dietitian is the best person to help you with meal planning to meet your individual needs. Your physician can help you find a dietitian if this service is not a part of his or her office or clinic. Your local chapter of the American Dietetic Association or the American Diabetes Association can also help you locate a registered dietitian.

How Much Weight Should I Gain? Of all questions asked by pregnant women, this is the most common. The answer is particularly important for women with gestational diabetes. The weight that you gain is a rough indication of how much nutrition is available to the fetus for growth. An inadequate weight gain may result in a small baby who lacks protective calorie reserves at birth. This baby may have more illness during the first year of life. An excessive weight gain during pregnancy, however, has an insulin-resistant effect, just like the hormones produced by the placenta, and will make your blood sugar level higher. The “optimal” weight to gain depends on the weight that you are before becoming pregnant. Your pre-pregnancy weight is also a rough indication of how well-nourished you are before becoming pregnant. If you are at a desirable weight for your body size before you become pregnant, a weight gain of 24 to 27 pounds is recommended. If you are approximately 20 pounds or more above your desirable weight before pregnancy, a weight gain of 24 pounds is recommended. Many overweight women, however, have healthy babies and gain only 20 pounds. If you become pregnant when you are underweight, you need to gain more weight during the pregnancy to give your baby the extra nutrition he or she needs for the first year. You should gain 28 to 36 pounds, depending on how underweight you are before becoming pregnant. Your nutrition advisor or health care provider can recommend an appropriate weight gain.

Guidelines 25

Total recommended weight gain is often not as helpful as a weekly rate of gain. Most women gain 3 to 5 pounds during the first trimester (first 3 months) of pregnancy. During the second and third trimesters, a good rate of weight gain is about three-quarters of a pound to one pound per week. Gaining too much weight (2 or more pounds per week) results in putting on too much body fat. This extra body fat produces an insulin-resistant effect which requires the body to produce more insulin to keep blood sugar levels normal. An inability to produce more insulin, as in gestational diabetes, causes your blood sugar levels to rise above acceptable levels. If weight gain has been excessive, often limiting weight gain to approximately threequarters of a pound per week (3 pounds per month) can return blood sugar levels to normal. Fetal growth and development depend on proper nourishment and will be placed at risk by drastically reducing calories. However, you can limit weight gain by cutting back on excessive calories and by eating a nutritionally-sound diet that meets your needs and the needs of your baby. Remember that dieting and severely cutting back on weight gain may increase the risk of delivering prematurely. If blood sugar levels continue to go up and you are not gaining excessive weight or eating improperly, the safest therapy for the well-being of the fetus is insulin. Occasionally, your weight may go up rapidly in the last trimester (after 28 weeks) and you may notice an increase in water retention, such as swelling in the feet, fingers, and face. If there is any question as to whether the rapid weight gain is due to eating too many calories or too much water retention, keeping records of how much food you eat and your exercise patterns at this time will be very helpful. A Food and Exercise Record Sheet is included at the end of this book. By examining your Food and Exercise Record Sheet, your nutrition advisor can help you determine which is causing the rapid weight gain. In addition, by examining your legs and body for signs of fluid retention, your physician can help you to determine the cause of your weight gain. If your weight gain is due to water retention, cutting back drastically on calories may actually cause more fluid retention. Bed rest and resting on your side will help you to lose the build-up of fluid. Limit your intake of salt (sodium chloride) and very salty foods, as they tend to contribute to water retention. Marked fluid retention when combined with an increase in blood pressure and possibly protein in the urine are the symptoms of preeclampsia. This is a disorder of pregnancy that can be harmful to both the mother and baby. Inform your obstetrician of any rapid weight gain, especially if you are eating moderately and gaining more than 2 pounds per week. Should you develop preeclampsia, be especially careful to eat a well-balanced diet with adequate calories.

26 Gestational Diabetes

After being diagnosed as having gestational diabetes, many women notice a slower weight gain as they start cutting the various sources of sugar out of their diet. This seems to be harmless and lasts only 1 or 2 weeks. It may be that sweets were contributing a substantial amount of calories to the diet.

How Should I Eat during My Pregnancy? As with any pregnancy, it is important to eat the proper foods to meet the nutritional needs of the mother and fetus. An additional goal for women with gestational diabetes is to maintain a proper diet to keep blood sugars as normal as possible.

Protein Equivalents Grams of Protein Food 1 cup milk 8 1 cup plain nonfat yogurt 8 1 ounce American processed cheese 7 1 ounce low-fat cheese 7 1 tbsp. peanut butter 7 1/4 cup cottage cheese 7 1/2 cup cooked dried beans 7 1 slice whole wheat bread 3 1/2 cup flaked cereal bran or corn 3

The daily need for calories increases by 300 calories during the second and third trimesters of pregnancy. If non-pregnant calorie intake was 1800 calories per day and weight gain was maintained, a calorie intake of 2100 calories per day is usual from 14 weeks until delivery. This is the equivalent of an additional 8 ounce glass of 2milk and one-half of a sandwich (1 slice of bread, approximately 1 ounce of meat, and I teaspoon of margarine, mayonnaise, etc.) per day. The need for protein also increases during pregnancy. Make sure your diet includes foods high in protein, but not high in fat. Most vitamins and minerals are also needed in larger amounts during pregnancy. This can be attained by increasing dairy products, especially those low in fat, and making sure you include whole grain cereals and breads, as well as fruits and vegetables in your diet each day. To make sure you get enough folate (a B vitamin critical during pregnancy) and iron, your obstetrician will probably recommend a prenatal vitamin. Prenatal vitamins do not replace a good diet; they merely help you to get the nutrients you

Guidelines 27

need. To absorb the most iron from your prenatal vitamin, take it at night before going to bed, or in the morning on an empty stomach. The Daily Food Guide serves as a guideline for food sources that provide important vitamins and minerals, as well as carbohydrates, protein, and fiber during pregnancy. The recommended minimal servings per day appear in parenthesis after each food group listed. This guide emphasizes foods that are low in fat and in sugar.

Daily Food Guide (Each Item Equals One Serving) Milk and Milk Products (4 servings per day; high protein, calcium, and Vitamin D): ·

1 cup milk, skim or low-fat

·

1/3 cup powdered non-fat milk

·

1 cup reconstituted powdered non-fat milk

·

1-1/2 oz. Low-fat cheese9

Meat, Poultry, Fish, and Meat Substitutes (5-6 servings per day; high protein, B vitamins, and iron): ·

1 oz. Cooked poultry, fish, or lean meat (beef, lamb, pork)

·

1 tbsp. peanut butter

·

1 egg

·

1/4 cup low-fat cottage cheese

·

1/2 cup cooked dried beans or lentils

Breads, Cereals, and Other Starches (5-6 servings per day; high complex carbohydrates; emphasize whole grams, or use fortified or enriched; a good source of protein, B-vitamins, fiber and minerals): ·

1 slice whole grain bread

·

5 crackers

·

1 muffin, biscuit, pancake or waffle

1 oz. low-fat cheese can also be used as 1 serving from the Meat, Poultry, Fish, and Meat Substitutes group if sufficient calcium is already being provided from 4 servings. 9

28 Gestational Diabetes

·

3/4 cup dry cereal, unsweetened

·

1/2 cup pasta (macaroni, spaghetti), rice, mashed potatoes, or cooked cereal

·

1/3 cup sweet potatoes or yams

·

1/2 cup cooked dried beans or lentils

·

1/2 bagel, 1/2 english muffin, or l/2 flour tortilla

·

1 small baked potato

·

2 taco shells

Fruit (2 servings per day; fresh fruit provides fiber; include one vitamin C source daily): ·

1/2 cup fresh fruit,

·

1/2 banana, or 1 medium-sized fruit (apple, orange)

·

1/2 cup, orange, grapefruit, or other juice fortified with vitamin C

·

1/2 medium-sized grapefruit

·

1 cup strawberries

·

1/2 cup fresh apricots, nectarines, purple plums, cantaloupe or 4 halves dried apricots (vitamin A source)

Vegetables10 (2 servings per day; include good vitamin A sources at least every other day): ·

1/2 cup cooked or 1 cup raw broccoli, spinach, and carrots (vitamin A source)

·

1/3 cup mixed vegetables

Fats: ·

1 tsp. butter or margarine

·

1 tsp. oil or mayonnaise

·

1 tbsp. regular salad dressing

·

2 tbsp. low-calorie salad dressing

Starchy vegetables such as corn, peas, and potatoes are included in Breads, Cereals, and Other Starches list.

10

Guidelines 29

·

1/4 cup nuts or seeds

The food guide is divided into six groups: milk and milk products; meat, poultry, fish, and meat substitutes; breads, cereals, and other starches; fruits; vegetables; and fats. Each group provides its own combination of vitamins, minerals, and other nutrients which play an important part in nutrition during pregnancy. Omitting the foods from one group will leave your diet inadequate in other nutrients. Plan your meals using a variety of foods within each food group, in the amounts recommended, and you'll be most likely to get all the vitamins, minerals, and other nutrients the fetus needs for growth and development.

Other Nutritional and Non-Nutritional Considerations Alcohol There is no known safe level of alcohol to allow during pregnancy. Daily heavy alcohol intake causes severe defects in development of the body and brain of the fetus, called Fetal Alcohol Syndrome. Even moderate drinking is associated with delayed fetal growth, spontaneous abortions, and lowered birth weight in babies. The Surgeon General's office warns: “Women who are pregnant or even considering pregnancy should avoid alcohol completely and should be aware of the alcohol content of food and drugs.”

Salt Salt restriction is no longer routinely advised during pregnancy. Recent research shows that during pregnancy the body needs salt to help provide the proper fluid balance. Your health care provider may recommend that you use salt in moderation.

Caffeine Studies conflict on the potential danger of caffeine to the fetus. Caffeine is found primarily in coffee, tea, and some sodas. Moderation is recommended. Talk to your doctor or other health professional about the maximum amount of caffeine recommended.

30 Gestational Diabetes

Caffeine Comparisons Food Regular coffee Instant coffee Decaffeinated coffee Tea Carbonated drinks e.g. colas Hot chocolate

Serving 8 oz. 8 oz. 8 oz. 8 oz. 12oz. 8 oz.

Amount of Caffeine 80-200 ma. 60-100 ma. 3-5 ma. 60-65 ma. 30-65 mg. 13 ma.

Megavitamins Megavitamins are defined as 10 times the Recommended Dietary Allowance11 of vitamins and minerals and are not recommended for pregnant women. Although it is possible to get all of the necessary nutrients from food alone, your doctor may prescribe some prenatal vitamins and minerals. If taken regularly, along with a balanced diet, you will be getting all the vitamins and minerals needed during your pregnancy.

Smoking Research has shown without question that smoking during pregnancy increases the risk of fetal death and pre-term delivery, impairs fetal growth, and can lead to low birth weight. It is best to stop smoking entirely and permanently, or at the very least, to cut back drastically on the number of cigarettes you smoke.

What Food Patterns Help Keep Blood Sugar Levels Normal? The following outlines food patterns which help to keep blood sugar levels within an acceptable range. Avoid sugar and foods high in sugar. Most women with gestational diabetes, just like those without diabetes, have a desire for something sweet in their diet. In pregnant women, sugar is rapidly absorbed into the blood and requires a larger release of insulin to maintain normal blood sugar levels.

Dietary allowances established by the National Academy of Sciences-National Research Council.

11

Guidelines 31

Without the larger release of insulin, blood sugar levels will increase excessively when you eat sugar-containing foods. There are many forms of sugar such as table sugar, honey, brown sugar, corn syrup, maple syrup, turbinado sugar, high fructose corn syrup, and molasses. Generally, food that ends in “ose” is a sugar (e.g., sucrose, dextrose, and glucose). Foods that usually contain high amounts of sugar include pies, cakes, cookies, ice cream, candy, soft drinks, fruit drinks, fruit packed in syrup, commercially fruited yogurt, jams, jelly, doughnuts, and sweet rolls. Many of these foods are high in fat as well. Be sure to check the list of ingredients on food products. Ingredients are listed in order of amount. If an ingredient is first on the list, it is present in the highest amount. If some type of sugar is listed first, second, or third on the list of ingredients, the product should be avoided. If sugar is further down, fourth, fifth, or sixth, it probably will not cause your blood sugar levels to go up excessively. Fruit juices should only be taken with a meal and limited to 6 ounces. Tomato juice is a good choice because it is low in sugar. Six ounces of most other juice (apple, grapefruit, orange) with no sugar added still contain approximately 4 to 5 teaspoons of sugar. However, these do not contain much of the fiber of a piece of fruit which normally would act to slow the absorption of sugar into the blood. If you drink juice frequently to quench your thirst during the day, a high blood sugar level may result. Use only whole fruit for snacks. To help with the occasional sweet tooth that we all have, artificial sweeteners may be used in foods. Aspartame has been extensively tested for safety. Use during pregnancy has been approved by the Food and Drug Administration and by the American Medical Association's Review Board. However, aspartame has not been tested for long-term safety and has not been on the market very long. It may be best to avoid its use until more tests have been done. Saccharin is not advised during pregnancy. Likewise, use of mannitol, xylitol, sorbitol, or other artificial sweeteners is not recommended until further research is done. Fructose is a special type of sugar that is slowly absorbed into the system. A small amount of fructose can be used if your blood sugar levels are within

32 Gestational Diabetes

normal range. However, fructose still has 4 calories per gram, as much as table sugar. High fructose corn syrup is part fructose and part corn syrup, making it very similar to table sugar in composition. It will raise blood sugar levels and should definitely be avoided. Emphasize the use of complex carbohydrates. These include vegetables, cereal, grains, beans, peas, and other starchy foods. A well-balanced diet with plenty of fiber provided by vegetables, dried beans, cereals, and other starchy foods decreases the amount of insulin your body needs to keep blood sugars within a normal range. Anything that decreases the need for insulin is beneficial The American Diabetes Association recommends that at least one-half of your calories come from complex carbohydrates. Starchy foods include pasta, rice, grains, cereals, crackers, bread, potatoes, dried beans, peas, and legumes. Also, contrary to popular belief, carbohydrates are not highly fattening when eaten in moderate amounts and without the rich sauces and toppings often added. Emphasize foods high in dietary fiber. Fiber is the edible portion of foods of plant origin that is not digested (e.g., skins, membranes, seeds, bran). Foods with a high fiber content include whole grain cereals and breads, fruits, vegetables, and legumes (dried peas and beans). Fiber aids digestion and helps prevent constipation. The fiber found in fruits, vegetables, and legumes also helps keep your blood sugar level from becoming too high without requiring extra insulin. Keep your diet low in fat. Some fat is needed to help with the absorption of certain vitamins and to provide the essential fatty acids necessary for fetal growth. A diet which is high in fat causes the insulin to react in a less efficient manner, necessitating more insulin to keep blood sugar levels within normal range. Foods high in saturated fats such as fatty meats, butter, bacon, cream (light, coffee, sour cream, etc.), and whole milk cheeses are likely to be high in total fat. Most foods with saturated fat are also high in cholesterol because they are fats from animal origin. However, foods such as crackers made with coconut, palm, or palm kernel oil can be high in saturated fats as well. Read labels carefully. Unsaturated fats are found in foods such as fish, margarine and vegetable oils. Keep your use of salad dressings to a minimum and whenever possible use those prepared with olive oil. To help keep the diet lower in fat, avoid adding extra fats such as rich sauces and creamy desserts, and bake or broil foods instead of frying them. Replacing fatty foods with those high in complex carbohydrates is also helpful.

Guidelines 33

Include a bedtime snack that is a good source of protein and complex carbohydrates. Women with gestational diabetes have a tendency toward lower than normal blood sugar levels during the night. This causes the body to increase its utilization of fats as a fuel source. As fat is used, ketones (discussed later) are produced as a byproduct of the breakdown of fats, and in large amounts, may be harmful to the fetus. This can be prevented by having a bedtime snack that provides protein and complex carbohydrates such as starchy foods. Starch will stabilize your blood sugar level in the early night, while protein acts as a long-acting stabilizer. Examples of a bedtime snack are: ·

1 oz. Americanprocessed cheese + 5 crackers

·

1/2 chicken sandwich on whole wheat bread

·

3 cups unbuttered popcorn + 1/4 cup nuts

If you need to take insulin, a bedtime snack is critical and you should not omit it. When taken by injection, insulin acts to lower blood sugar level, even during the night when meals are not eaten. A bedtime snack is protective against low blood sugars while sleeping or upon arising. If a bedtime snack causes heartburn, sleep with your head raised on pillows, and be careful that you are not eating too large a bedtime snack.

How Do I Plan Meals? A registered dietitian or qualified nutritionist can help you plan a meal pattern that is right for you. Most women with gestational diabetes need three meals and a bedtime snack each day. It is unwise for anyone who is pregnant to go long periods of time (greater than 5 hours) without eating, as this will produce ketones. Extra snacks are necessary if your schedule results in a long time between meals. Blood sugars will be easier to keep in the normal range if meal times and amounts (total calories) are evenly spaced. It's more likely that a higher blood sugar will result if the majority of calories are eaten at dinner) than if they are distributed more evenly throughout the day. If insulin injections prove necessary, the time at which meals are eaten and the amounts eaten should be approximately the same from day to day. Do not skip meals and snacks, as this often results in hypoglycemia (low blood sugar), which may be harmful to the fetus and makes you feel irritable, shaky, or may result in a headache.

34 Gestational Diabetes

Sample Menu — 2000 Calories This diet is planned for women whose normal non-pregnant weight should be 130135 lbs. For women who weigh less than 130 before pregnancy, the diet should contain fewer calories. Women who are overweight are at higher risk for gestational diabetes. Your health care provider can discuss this and help you make necessary changes. BREAKFAST 1/2 grapefruit 3/4 cup oatmeal, cooked 1 tsp. raisins 1 whole wheat English muffin I tsp. margarine

AFTERNOON SNACK 2 rice cakes 6 oz. low-fat yogurt, plain 1/2 cup blueberries

LUNCH Salad with: 1 cup romaine lettuce 1/2 cup kidney beans, cooked 1/2 fresh tomato 1 oz. part skim mozzarella cheese 2 tbsp. low-calorie Italian dressing 1 bran muffin 1/2 cup cantaloupe chunks

DINNER 3/4 cup vegetable soup with 1/4 cup cooked barley 3 oz. chicken, without skin 1 baked potato 1/2 cup cooked broccoli 1 piece whole wheat bread 1 tbsp. Margarine 1 fresh peach

BEDTIME SNACK 1 apple 2 cups popcorn, plain 1/4 cup peanuts

What Can Be Done to Slow Weight Gain during Pregnancy? Gaining too much weight during pregnancy will make blood sugar levels higher than normal for women with gestational diabetes. Yet, for many pregnant women it is very difficult to gain weight slowly and still get all of the recommended nutrients. Luckily, fat, which is high in calories (9 calories per gram), is needed in only small amounts during pregnancy. Carbohydrates and protein, in contrast to fat, provide only 4 calories per gram. To cut calories without depriving the fetus of any necessary nutritional factors, it is best to avoid fats and fatty foods. ·

Avoid high-fat meats. Choose lean cuts of beef, pork, and lamb. Emphasize more fish and poultry (without the skin).

Guidelines 35

·

Avoid frying meat, fish, or poultry in added oil, shortening, or lard. Bake, broil, or roast instead.

·

Avoid foods fried in oil such as chips, french fries, and doughnuts. Substitute pretzels, unbuttered popcorn, or breadsticks instead.

·

Avoid using cream sauces and butter sauces, as well as salt pork for seasoning on vegetables. Season with herbs instead.

·

Avoid using the fat drippings from meat or poultry for gravy. Use broth or bouillon instead and thicken with cornstarch.

·

Avoid using mayonnaise or oil for salads. Use vinegar, lemon juice, or low-calorie salad dressings instead.

To help reduce calories choose low-fat dairy products. During pregnancy you need 1200 mg calcium daily to build the fetal skeleton without drawing from maternal calcium stores. The difference between 600 calories and 340 calories is only 260 calories and may seem insignificant. Yet, if your diet is cut by 260 calories daily for 1 week, your weight gain slows down by approximately 1/2 pound per week. In other words, instead of gaining 1-1/2 pounds per week you will only gain 1 pound per week. If cheese is a part of your daily diet, use low-fat cheeses such as low-fat cottage cheese, Neufchatel, mozzarella, farmers, and pot cheese. Avoid using cream cheese, as it has little protein and most of its calories come from fat. Even though pregnancy can be a very hectic time, with little time for meal preparation, eat less and less often at “fast food” restaurants. Studies have shown that some foods from fast food restaurants average 40 to 60 percent of their calories from fat, and are quite high in calories.12 For example, chicken and fish that are coated with batter and deep-fried in fat may contain more fat and calories than a hamburger or roast beef sandwich.

Calorie Comparisons Food 4-8 oz. glasses whole milk 4-8 oz. glasses 2milk 4-8 oz. glasses skim milk

Calories 600 480 340

Fast Food Facts: Nutritive and Exchange Values for Fast Food Restaurants. Marion J. Franz, International Diabetes Center. Minneapolis, Minnesota, 1987. 54 pp.

12

36 Gestational Diabetes

2-8 oz. glasses whole milk plus 3 oz. American processed cheese 2-8 oz. glasses 2milk plus 3 oz. American processed cheese 2-8 oz. glasses skim milk plus 3 oz. American processed cheese

600 540 470

Go lightly when using butter and margarine. Adding only an extra three pats of butter or margarine (same calories) daily could add an extra pound of weight gain next month. It may be better to emphasize the use of foods rich in complex carbohydrates that don't use butter, margarine, or cream sauce to make them palatable. Many people find rice, noodles, and spaghetti tasty without a lot of butter. Use a variety of spices and herbs (such as curry, garlic, and parsley) to flavor rice and tomato sauce to flavor pasta without additional fats. It is also a good idea to eat small amounts frequently, thereby keeping the edge off your appetite. This will assist your “self-control” in avoiding large portions of food that you should not have. Avoid skipping meals or trying to cut back drastically on breakfast or lunch. It will leave you too hungry for the next meal to exercise any control. Your doctor or dietitian can help you determine how you can cut extra calories. You may find it helpful to keep food records of what you eat, as most of us tend to forget or not realize the extent of our snacking. Recording everything you eat or drink tends to be a sobering and instructive experience. A Food and Exercise Record Sheet is included at the end of this book. Be careful to maintain a weight gain of at least 1/2 pound per week, over several weeks, if you are in the second trimester (14 weeks or more of gestation). Cutting back more than this may increase the risk of having a low-birth-weight infant.

Is Breast-Feeding Recommended? Breast-feeding is strongly encouraged. For most women this represents the easiest way back to pre-pregnancy weight after delivery. The body draws on the calories stored during the first part of pregnancy to use in milk production. Approximately 800 calories per day are used during the first 3 months of milk production, and even more during the next 3 months. By 6

Guidelines 37

weeks after delivery, women who breast-feed usually have lost 4 pounds more than women who bottle-feed. This can be a very important factor, as it is strongly recommended that women with gestational diabetes return to their desirable body weight 4 to 5 months postpartum. As previously mentioned, maintaining a weight appropriate for your height and frame may reduce the risk of developing diabetes later in life. In addition, breast-feeding has many advantages for your baby. Protection from infection and allergies are transferred to the baby through breast milk. This milk is also easier to digest than formula, and its minerals are better absorbed than those in formula.

Should I Exercise? A daily exercise program is an important part of a healthy pregnancy. Daily exercise helps you feel better and reduces stress. In addition, being physically fit protects against back pain, and maintains muscle tone, strength, and endurance. For women with gestational diabetes, exercise is especially important. Regular exercise increases the efficiency or potency of your body's own insulin. This may allow you to keep your blood sugar levels in the normal range while using less insulin. Moderate exercise also helps blunt your appetite, helping you to keep your weight gain down to normal levels. Maintaining the correct weight gain is very important in preventing high blood sugar levels. Talk with your doctor about what exercise program is right for you. Your doctor can advise you about limitations, warning signs, and any special considerations. Generally, you can continue any exercise program or sport you participated in prior to pregnancy. Use caution, however, and avoid sports or exercises where you might fall, or that involve jolting. Prepregnancy bicycling, jogging, and cross-country skiing are good exercises to continue during pregnancy. If you plan to start an exercise program during pregnancy, talk to your doctor before beginning and start slowly. Vigorous walking is good for women who need to start exercising and have not been active before pregnancy.

38 Gestational Diabetes

Exercising frequently, 4 to 5 days per week, is necessary to get the “blood sugar lowering” advantages of an exercise program. Don't omit a warm-up period of 5 to 10 minutes and a cool-down period of 5 to 10 minutes. Always stop exercising if you feel pain, dizziness, shortness of breath, faintness, palpitations, back or pelvic pain, or experience vaginal bleeding. Also, avoid vigorous exercise in hot, humid weather or if you have a fever. It is important to prevent dehydration during exercise, especially during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) recommends drinking fluids prior to and after exercise, and if necessary, during the activity to prevent dehydration. An ACOG report13 issued in 1985, warned that target heart rates for pregnant and postpartum women should be set approximately 25 to 30 percent lower than rates for non-pregnant women. It may be that exercising too vigorously will direct blood flow away from the uterus and fetus. ACOG recommends that pregnant women measure their heart rate during activity and that maternal heart rate not exceed 140 beats per minute. If you need to be on insulin during your pregnancy, take a few precautions. Because both insulin and exercise lower blood sugar levels, the combination can result in hypoglycemia or low blood sugar You need to be aware that this is a potential problem, and you should be familiar with the symptoms of hypoglycemia (confusion, extreme hunger, blurry vision, shakiness, sweating). When exercising, take along sugar in the form of hard, sugarsweetened candies just in case your blood sugar becomes too low. When on insulin, you should always carry some form of sugar for potential episodes of hypoglycemia. It may be necessary for you to eat small snacks between meals if the exercise results in low blood sugar levels: ·

One serving of fruit will keep blood sugars normal for most short-term activities (approximately 30 minutes).

·

One serving of fruit plus a serving of starch will be enough for activities that last longer (60 minutes or more).

·

If you exercise right after a meal, eat the snack after the exercise. If the exercise is 2 hours or more after a meal, eat the snack before the exercise.

Home Exercise Program: Exercise During Pregnancy and the Postnatal Period. American College of Obstetricians and Gynecologists May 1985 6 pp.

13

Guidelines 39

What Happens If Diet and Exercise Fail to Control My Blood Sugars? If your blood sugars tend to go over the acceptable levels (105 mg/dl or below for fasting, 120 mg/dl or below 2 hours after a meal) you may need to take insulin injections. Insulin is a protein and would be digested like any other protein in food if it were given orally. The needles used to inject insulin are extremely fine, so there is little discomfort. If insulin injections are necessary, you will be taught how to fill the syringe and how to do the injections yourself. Your physician will calculate the amount of insulin needed to keep blood sugar levels within the normal range. It is very likely that the amount or dosage of insulin needed to keep your levels of blood sugar normal will increase as your pregnancy advances. This does not mean your gestational diabetes is getting worse. As any healthy pregnancy progresses, the placenta will grow and produce progressively higher levels of contra-insulin hormones. As a result you will likely need to inject more insulin to overcome their effect. Some women may even require two injections each day. This does not imply anything about the severity of the problem or the outcome of the pregnancy. The goal is to maintain normal blood sugar levels with whatever dosage of insulin is needed.

Can My Blood Sugar Level Go Too Low? Occasionally, your blood sugar level may get too low if you are taking insulin. This can happen if you delay a meal or exercise more than usual, especially at the time your insulin is working at its peak. This low blood sugar is called “hypoglycemia” or an “insulin reaction.” This is a medical emergency and should be promptly treated, never ignored. The symptoms of insulin reaction vary from sweating, shakiness, or dizziness to feeling faint, disoriented, or a tingling sensation. Remember, if you take insulin injections, you need to keep some form of sugar-sweetened candy in your purse, at home, at work, and in your car. In case of an episode of hypoglycemia, you will be prepared to treat it immediately. Be sure to eat something more substantial afterward. Also, report any insulin reactions or high blood sugar levels to your doctor right away in case an adjustment in your treatment needs to be made.

40 Gestational Diabetes

As you can see from reading this booklet, extra care, work, and commitment on the part of you and your spouse or partner are required to provide the special medical care necessary. Don't worry if you occasionally go off your diet or miss a planned exercise program. Your doctor and other health care professionals will work along with you to make sure you receive the specialized care that has resulted in dramatically improved pregnancy outcome. An ounce of prevention is worth a pound of cure! Eat as directed. Exercise as directed. Monitor as directed. Do these things and you are doing your part toward a happy, healthy pregnancy. A Practical Guide to a Healthy Pregnancy U.S. Department of Healath and Human Services Public Health Service National Institutes of Health National Institute of Child Health and Human Development NIH Publication No. 93-2788 Reprinted February 1993

More Guideline Sources The guideline above on gestational diabetes is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to gestational diabetes. Many of the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with gestational diabetes. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly.

Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. From there you

Guidelines 41

can either search using the alphabetical index or browse by broad topic areas.

If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it only includes material linked within the MEDLINEplus system (mostly patient-oriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search.

The Combined Health Information Database (CHID) CHID Online is a reference tool that maintains a database directory of thousands of journal articles and patient education guidelines on gestational diabetes and related conditions. One of the advantages of CHID over other sources is that it offers summaries that describe the guidelines available, including contact information and pricing. CHID’s general Web site is http://chid.nih.gov/. To search this database, go to http://chid.nih.gov/detail/detail.html. In particular, you can use the advanced search options to look up pamphlets, reports, brochures, and information kits. The following was recently posted in this archive: ·

Gestational Diabetes: Diabetes When You're Pregnant Source: Santa Cruz, CA: ETR Associates. 2000. 6 p. Contact: Available from ETR Associates. P.O. Box 1830, Santa Cruz, CA 95061-1830. (800) 321-4407. Fax (800) 435-8433. Website: www.etr.org. PRICE: $16.00 for 50 copies; larger bulk orders available. Summary: This brochure focuses on gestational diabetes. This form of diabetes occurs during pregnancy if a woman has too much sugar in her blood. A one hour glucose test and a glucose tolerance test are used to diagnose gestational diabetes. The brochure provides a checklist of health risks for gestational diabetes and suggests ways women can manage gestational diabetes. Tips include eating healthy foods every day, eating small meals and snacks, drinking eight glasses of water per day, drinking caffeine free drinks, taking vitamin supplements, avoiding foods that increase blood sugar, avoiding alcoholic beverages, checking blood sugar levels, quitting smoking, being physically active, and keeping track of weight gain. Other topics include labor, delivery, and follow up.

42 Gestational Diabetes

·

Gestational Diabetes: All You Need to Know About You and Your Baby. [Diabetes Gestacional: Todo Lo Que Debe Saber Acerca de Usted y Su Bebe] Source: San Diego, CA: Sweet Success: California Diabetes and Pregnancy Program. 1998. 22 p. Contact: Available from Sweet Success: California Diabetes and Pregnancy Program. Resource Center, 4543 Ruffner Street, Suite 130, San Diego, CA 92111. (619) 467-4990. Fax (619) 467-4993. Website: www.llu.edu/llumc/sweetsuccess. PRICE: $3.50 each plus shipping and handling. Order number: SD9022 for English version; SD9023 for Spanish version; SD9024 for Vietnamese version. Summary: This booklet uses a question and answer format to provide information about gestational diabetes. Topics include reasons for high blood sugar, risk factors for gestational diabetes, the effects of gestational diabetes, the symptoms of high blood sugar, the role of each member of the health care team, the need for frequent visits to the health care team, ways to reduce stress, self care tips, the effect of diabetes on delivery, postpartum care, and breastfeeding. The booklet discusses the need to follow a meal plan, exercise, and test blood sugar and ketone levels. In addition, it advises women to take insulin if a physician has prescribed it to keep their blood sugar normal, identifies special tests to check the health of the fetus, and lists warning signs for all pregnant women. The booklet includes a sample meal plan, a personal food plan sheet, and a record sheet for monitoring blood sugar and urine ketone.

·

About Gestational Diabetes Source: South Deerfield, MA: Channing L. Bete Company, Inc. 1997. 15 p. Contact: Available from Channing L. Bete Company, Inc. 200 State Road, South Deerfield, MA 01373-0200. (800) 628-7733. Fax (800) 499-6464. PRICE: $0.89 each for 1-99 copies; discounts available for larger orders. Item number: 39495A396. Summary: This booklet provides basic information about gestational diabetes. Written in non-technical language, the booklet defines and describes gestational diabetes. Topics include risk factors for developing gestational diabetes; problems that gestational diabetes can cause in a fetus; and screening tests. The booklet also discusses the role of good nutrition as the basis of gestational diabetes management; recommendations for exercise; self-monitoring; insulin therapy; coping with the psychological stresses associated with gestational diabetes; tests used to monitor the fetus' health before delivery; and post-natal health care and the risk of the mother later developing type 2 diabetes. The

Guidelines 43

booklet concludes with a brief summary and section of questions and answers. The booklet is illustrated with cartoon drawings of patients and health care providers from a variety of ethnic groups. ·

Gestational Diabetes: Dealing with Diabetes During Pregnancy Source: San Diego, CA: Sweet Success: California Diabetes and Pregnancy Program. 1997. [2 p.]. Contact: Available from Sweet Success: California Diabetes and Pregnancy Program. Resource Center, 4543 Ruffner Street, Suite 130, San Diego, CA 92111. (619) 467-4990. Fax (619) 467-4993. Website: www.llu.edu/llumc/sweetsuccess. PRICE: $0.50. Order number: SS2400. Summary: This pamphlet offers advice on coping with gestational diabetes. The pamphlet identifies the members of a health care team for women with gestational diabetes, highlights feelings and body changes that women may experience during pregnancy, notes the effects of these changes, and outlines steps that women diagnosed with gestational diabetes need to take to have a healthy pregnancy.

·

Gestational Diabetes: When You and Your Baby Need Special Care Source: San Bruno, CA: Krames Communications. 1996. 16 p. Contact: Available from Krames Communications. Order Department, 1100 Grundy Lane, San Bruno, CA 94066. (800) 333-3032. Fax (650) 2444512. PRICE: $1.35; discounts available for larger quantities. Order number 1784 (English) or 1792 (Spanish). Summary: This brochure familiarizes readers with gestational diabetes, a type of diabetes that happens only during pregnancy. Topics include understanding how the body uses energy, and problems resulting from high blood glucose levels; nutrition and diet therapy; the role of exercise; testing one's blood glucose levels; insulin therapy; monitoring the baby; labor and delivery considerations; and postnatal care for the mother, particularly that designed to reduce the risk of subsequent diabetes. The brochure is written in nontechnical language and features full-color line drawings, charts and graphs illustrating the concepts presented. The brochure depicts men and women of different ethnicities, and is available in English or Spanish. 3 references.

·

Diabetes Health Care Facts: Gestational Diabetes Source: Tarrytown, NY: Bayer Corporation. 1996. 4 p.

44 Gestational Diabetes

Contact: Available from Bayer Corporation. Diagnostics Division, 511 Benedict Avenue, Tarrytown, NY 10591-5097. (800) 445-5901. PRICE: Single copy free. Summary: This brochure, which is presented in question and answer format, provides information about gestational diabetes. According to the brochure, a family history of diabetes, obesity, a previous pregnancy with delivery of a large baby (10 pounds or more), and previous miscarriages or stillbirths tend to increase the risk of developing gestational diabetes. Topics include the causes of gestational diabetes, common problems of gestational diabetes, treatment, and insulin. The authors point out that a pregnant woman with diabetes can increase her chances of having a healthy pregnancy and baby by testing her blood glucose and urine ketones daily and following her meal plan closely. A list of products concludes the brochure. (AA-M). ·

Gestational Diabetes and You Source: Olathe, KS: Nutrition Counseling/Education Services (NCES). 1995. 28 p. Contact: Available from Nutrition Counseling/Education Services (NCES). 1904 East 123rd Street, Olathe, KS 66061. (800) 445-5653 for orders, or (913) 782-4385. Fax (913) 782-8230. PRICE: $2.95 each; $16.95 for 10 copies (as of 1995). Summary: This patient education booklet on gestational diabetes (GDM) provides detailed information in an easy-to-read, accessible format. Topics include a definition of GDM; the causes of GDM; how GDM affects the fetus; normal blood glucose levels; recording blood glucose levels, insulin, and exercise; the use of a food diary; meal planning; the use of exchange lists; weight loss; meal planning considerations for patients using insulin; emotional adjustment; breastfeeding; and optimizing choices for a healthy baby. The booklet is illustrated with line drawings depicting both Caucasian and African-American pregnant women. The booklet is available in English or Spanish.

·

Gestational Diabetes: Caring for Yourself and Your Baby Source: Minneapolis, MN: International Diabetes Center, Park Nicollet Medical Foundation. 1995. 29 p. Contact: Available from HealthSource. 3800 Park Nicollet Boulevard, Minneapolis, MN 55416-9963. (800) 372-7776. PRICE: $2.95. ISBN: 1885115210.

Guidelines 45

Summary: This brochure provides basic information about gestational diabetes. It covers caring for mother and baby with blood glucose control and monitoring; emotional balance; nutrition needs during pregnancy, including carbohydrate, protein, fat, making food choices, caloric intake, and weight gain; food and blood glucose control; physical activity and blood glucose control; taking insulin; testing guidelines and goals, including those for blood glucose and ketones; record-keeping; and postpregnancy considerations. The booklet features lists of practical suggestions for implementing each recommendation. The booklet also includes blank forms for readers to use for keeping blood glucose records. Simple charts and line drawings illustrate the booklet. ·

How to Manage Gestational Diabetes Source: Indianapolis, IN: Eli Lilly and Company. 1994. 11 p. Contact: Available from Eli Lilly and Company. Lilly Corporate Center, Indianapolis, IN 46285. (800) 545-5979 or (317) 276-2000. PRICE: Single copy free. Summary: This brochure describes gestational diabetes mellitus (GDM) and its effect on pregnant women and fetuses. Because GDM usually has no symptoms, all pregnant women should have their blood tested between the 24th and 28th weeks of pregnancy, or earlier if they had GDM in an previous pregnancy. The brochure advises that women who develop gestational diabetes work with a health care team follow special meal plans devised by a registered dietitian, test their blood sugar and urine ketones, keep accurate records, maintain a healthy weight, and exercise in accordance with their doctor's advice. The brochure also describes the use of insulin in GDM, tests doctors may perform to measure the growth of the fetus, and the post-partum effects of GDM.

·

Gestational Diabetes: You're in Control Source: Cypress, CA: Medcom, Inc. 1994. (videocassette and booklet). Contact: Available from Medcom, Inc. P.O. Box 6003, Cypress, CA 90630. (800) 320-1444. Fax (714) 898-4852. PRICE: $19.95 plus shipping (as of 1995). Summary: This patient education kit, consisting of a videotape program and pocket sized guide, is designed to ease the fears associated with gestational diabetes by providing the tools necessary to control the disease. The program answers common questions and reassures pregnant women with gestational diabetes that a safe pregnancy and the delivery of a healthy baby are possible. The program explains how diabetes develops; provides answers to myths about diabetes and insulin;

46 Gestational Diabetes

emphasizes the need for women to work with their health care providers; lists five things pregnant women must do to take control of their disease state; discusses the risk factors for developing permanent diabetes after pregnancy; and provides information to empower women to take control of their disease state. The content is based on the latest medical information available on diabetes and was reviewed by a consulting staff of nurses, nurse practitioners, registered dietitians, and diabetic educators. The accompanying booklet provides written reinforcement of the concepts presented in the video, and includes a daily food and blood glucose diary for patient recordkeeping. (AA-M). ·

Taking Care of Gestational Diabetes. [El Cuidado de la Diabetes Gestacional] Source: Minneapolis, MN: International Diabetes Center. 1992. 44 p. Contact: Available from International Diabetes Center. Attention: IDC Publishing. 3800 Park Nicollet Boulevard, Minneapolis, MN 55416. (612) 993-3874. PRICE: $2.95. Summary: This patient education booklet is designed to explain the basics of gestational diabetes in clear, easy-to-understand language. Topics covered include a review of gestational diabetes; how it can affect the pregnant woman and fetus; normal blood glucose levels; how to control blood glucose levels; the emotions that may arise when a woman learns she has gestational diabetes; desirable weight gain during pregnancy; nutrition during pregnancy, including guidelines for meal planning and food groups and exchanges; types of insulin and how it is administered; problems with low blood sugar; what happens after pregnancy; and breastfeeding. Numerous line drawings illustrate the concepts presented. The booklet is available in English or Spanish.

·

Gestational Diabetes Mellitus Source: Dallas, TX: Methodist Medical Center. 1991. 22 p. Contact: Available from Methodist Medical Center. Women's Center, 301 West Colorado, Dallas, TX 75208. (214) 944-7160. PRICE: $2 for 1-120, $1.75 for 11-49, $1.50 for 50 or more. Summary: A booklet for pregnant women provides information on the characteristics, potential causes, diagnosis, treatment, and potential consequences of gestational diabetes. Answers are given to a variety of typical questions covering pregnancy, delivery, and after birth. Dietary information, diet tips, and a sample menu are included for managing gestational diabetes.

Guidelines 47

·

How to Have a Healthy Baby: Gestational Diabetes Source: Albuquerque, NM: Indian Health Service. 1991. 24 p. Contact: Available from IHS HQW Diabetes Program. 5300 Homestead Road, NE, Albuquerque, NM 78110. (505) 837-4182. Fax (505) 837-4188. PRICE: Materials are available only to health care professionals serving American Indian populations; contact the IHS Diabetes Program for list of currently available materials. Summary: This brochure, written for Native American women with gestational diabetes, explains steps to take to increase the chances of a healthy pregnancy and a healthy baby. Topics include pregnancy and high blood glucose, problems that high blood glucose can cause during pregnancy, healthy food choices, exercise during pregnancy, selfmonitoring of blood glucose (SMBG), and special diagnostic tests that may be used. This brochure is written in clear, easy-to-understand language, with culturally relevant line drawings illustrating the concepts presented. Space is included for specific clinic information and phone numbers and for patient notes.

·

Gestational Diabetes: How You Can Deal With It Source: Lexington, KY: Lexington-Fayette County Health Department. 199x. 9 p. Contact: Available from Lexington-Fayette County Health Department. Division of Nutrition and Health Education, 650 Newtown Pike, Lexington, KY 40508. (606) 288-2333. Fax (606) 288-2359. PRICE: $38.00 per 25 copies plus shipping. Summary: This guide to gestational diabetes is one in a series of 22 diabetes education materials that combine practical tips and humorous drawings with current diabetes information. The series is written at a sixth grade reading level and is designed to teach and motivate patients to take good care of themselves. The booklet provides specific suggestions for readers to implement in their everyday diabetes management. Gestational diabetes is defined as high blood glucose levels during pregnancy. The booklet provides information about the causes of gestational diabetes, how gestational diabetes can affect the fetus and baby, how to keep blood glucose levels normal, what to eat, snack ideas, sweets and desserts, and what happens after the baby is born. The booklet also provides a sample 1-day, 2,000-calorie menu designed for a person with gestational diabetes. Readers are cautioned against smoking and alcohol use.

48 Gestational Diabetes

·

Gestational Diabetes Source: Montgomery, AL: Alabama Department of Public Health Diabetes Program. 199x. [7 p.]. Contact: Available from Alabama Department of Public Health Diabetes Program. 201 Monroe Street, Suite 1460, P.O. Box 30317, Montgomery, AL 36130-3017. (334) 206-2060. Fax (334) 206-2064. E-mail: [email protected]. Website: www.alapubhealth.org. PRICE: Single copy free. Summary: This booklet uses a question and answer format to provide women with information on gestational diabetes, which occurs during pregnancy and usually goes away after the baby is born. Topics include risk factors for gestational diabetes; the diagnosis; the complications of gestational diabetes for the baby and mother such as macrosomia, polyhydramnios, toxemia, and edema; and the maintenance of excellent blood sugar control during pregnancy through diet, increased physical activity, and medication. In addition, the booklet provides general guidelines on dietary management of gestational diabetes, explains the process of self monitoring of blood glucose levels, and discusses the need for insulin in controlling blood sugar in some cases. The booklet concludes with information on tests to monitor the baby's development, delivery, and postpartum care.

·

Diabetes Day-by-Day Source: Alexandria, VA: American Diabetes Association. 199x. [168 p.]. Contact: Available from American Diabetes Association, Inc. Order Fulfillment Department, P.O. Box 930850, Atlanta, GA 31193-0850. (800) 232-6733. Fax (770) 442-9742. PRICE: $9.95 (members), $11.95 (nonmembers) for 50 copies of each fact sheet in the series; single copies free. Summary: This information package consists of 42 fact sheets about daily living and coping with diabetes. The series emphasizes self care and the value of a positive attitude. Topics include sugars and artificial sweeteners; nutrition; eating out; alcohol and smoking; weight loss and exercise; health care and the patient care team; diagnosis; insulin; tight diabetes control; oral diabetes medications; drug interactions; blood glucose and urine self testing; hypoglycemia; the glycated hemoglobin test; sexual health; pregnancy; gestational diabetes; genetics; information for parents and teens; discrimination; emotions and stress; traveling; skin, foot, and mouth care; complications; transplantation; and cardiovascular health. The fact sheets are written in nontechnical language and provide starting points for exploring important diabetes topics. Each fact sheet

Guidelines 49

refers readers to others in the series that may be useful, as well as to other American Diabetes Association materials.

The National Guideline Clearinghouse™ The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “gestational diabetes” or synonyms. The following was recently posted: ·

Gestational diabetes mellitus. Source: American Diabetes Association.; 1986 (revised 2000; republished 2002 Jan); 3 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 2364&sSearch_string=gestational+diabetes

·

Gestational diabetes practice guidelines. Source: International Diabetes Center.; 2000; 33 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1789&sSearch_string=gestational+diabetes Healthfinder™

Healthfinder™ is an additional source sponsored by the U.S. Department of Health and Human Services which offers links to hundreds of other sites that contain healthcare information. This Web site is located at http://www.healthfinder.gov. Again, keyword searches can be used to find guidelines. The following was recently found in this database: ·

Understanding Gestational Diabetes Summary: This document answers many questions that women and their families have about gestational diabetes including diet, measurement of blood sugar levels, and general medical and obstetric care of women Source: National Institute of Child Health and Human Development, National Institutes of Health http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=839

50 Gestational Diabetes

The NIH Search Utility After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to gestational diabetes. The drawbacks of this approach are that the information is not organized by theme and that the references are often a mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for relatively rare or specific disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html.

Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats

·

drkoop.comÒ: http://www.drkoop.com/conditions/ency/index.html

·

Family Village: http://www.familyvillage.wisc.edu/specific.htm

·

Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/

·

Med Help International: http://www.medhelp.org/HealthTopics/A.html

·

Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/

·

Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/

·

WebMDÒHealth: http://my.webmd.com/health_topics

Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter:

Guidelines 51

Acidosis: A pathologic condition resulting from accumulation of acid or depletion of the alkaline reserve (bicarbonate content) in the blood and body tissues, and characterized by an increase in hydrogen ion concentration. [EU] Amniocentesis: Percutaneous transabdominal puncture of the uterus during pregnancy to obtain amniotic fluid. It is commonly used for fetal karyotype determination in order to diagnose abnormal fetal conditions. [NIH] Aspartame: Flavoring agent sweeter than sugar, metabolized as phenylalanine and aspartic acid. [NIH] Bilirubin: A bile pigment that is a degradation product of heme. [NIH] Calcium: A mineral that the body needs for strong bones and teeth. Calcium may form stones in the kidney. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Dehydration: The condition that results from excessive loss of body water. Called also anhydration, deaquation and hypohydration. [EU] Digestion: The process of breakdown of food for metabolism and use by the body. [NIH] Dizziness: An imprecise term which may refer to a sense of spatial disorientation, motion of the environment, or lightheadedness. [NIH] Edema: Excessive amount of watery fluid accumulated in the intercellular spaces, most commonly present in subcutaneous tissue. [NIH] Elastic: Susceptible of resisting and recovering from stretching, compression or distortion applied by a force. [EU] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond

52 Gestational Diabetes

that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Heartburn: Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. [NIH] Hormone: A natural chemical produced in one part of the body and released into the blood to trigger or regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down urine production. [NIH] Hunger: The desire for food generated by a sensation arising from the lack of food in the stomach. [NIH] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Jaundice: A clinical manifestation of hyperbilirubinemia, consisting of deposition of bile pigments in the skin, resulting in a yellowish staining of the skin and mucous membranes. [NIH] Mannitol: A diuretic and renal diagnostic aid related to sorbitol. It has little significant energy value as it is largely eliminated from the body before any metabolism can take place. It can be used to treat oliguria associated with kidney failure or other manifestations of inadequate renal function and has been used for determination of glomerular filtration rate. Mannitol is also commonly used as a research tool in cell biological studies, usually to control osmolarity. [NIH] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Molasses: The syrup remaining after sugar is crystallized out of sugar cane or sugar beet juice. It is also used in animal feed, and in a fermented form, is used to make industrial ethyl alcohol and alcoholic beverages. [NIH] Obstetrics: A medical-surgical specialty concerned with management and care of women during pregnancy, parturition, and the puerperium. [NIH] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Oxytocin: A nonapeptide posterior pituitary hormone that causes uterine contractions and stimulates lactation. [NIH] Palpitation: A subjective sensation of an unduly rapid or irregular heart beat. [EU] Pancreas: A mixed exocrine and endocrine gland situated transversely across the posterior abdominal wall in the epigastric and hypochondriac

Guidelines 53

regions. The endocrine portion is comprised of the islets of langerhans, while the exocrine portion is a compound acinar gland that secretes digestive enzymes. [NIH] Placenta: A highly vascular fetal organ through which the fetus absorbs oxygen and other nutrients and excretes carbon dioxide and other wastes. It begins to form about the eighth day of gestation when the blastocyst adheres to the decidua. [NIH] Polyhydramnios: Excess of amniotic fluid greater than 2,000 ml. It is a common obstetrical complication whose major causes include maternal diabetes, chromosomal disorders, isoimmunological disease, congenital abnormalities, and multiple gestations. [NIH] Postnatal: Occurring after birth, with reference to the newborn. [EU] Preeclampsia: A toxaemia of late pregnancy characterized by hypertension, edema, and proteinuria, when convulsions and coma are associated, it is called eclampsia. [EU] Prenatal: Existing or occurring before birth, with reference to the fetus. [EU] Pulse: The rhythmical expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle of the heart as it contracts. [NIH] Saccharin: Flavoring agent and non-nutritive sweetener. [NIH] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Sorbitol: A polyhydric alcohol with about half the sweetness of sucrose. Sorbitol occurs naturally and is also produced synthetically from glucose. It was formerly used as a diuretic and may still be used as a laxative and in irrigating solutions for some surgical procedures. It is also used in many manufacturing processes, as a pharmaceutical aid, and in several research applications. [NIH] Spices: The dried seeds, bark, root, stems, buds, leaves, or fruit of aromatic plants used to season food. [NIH] Toxemia: A generalized intoxication produced by toxins and other substances elaborated by an infectious agent. [NIH] Transfusion: The introduction of whole blood or blood component directly into the blood stream. [EU] Urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder, and expelled from the body through the urethra by the act of voiding or urinating. [NIH]

54 Gestational Diabetes

Uterus: The hollow muscular organ in female mammals in which the fertilized ovum normally becomes embedded and in which the developing embryo and fetus is nourished. In the nongravid human, it is a pear-shaped structure; about 3 inches in length, consisting of a body, fundus, isthmus, and cervix. Its cavity opens into the vagina below, and into the uterine tube on either side at the cornu. It is supported by direct attachment to the vagina and by indirect attachment to various other nearby pelvic structures. Called also metra. [EU] Vagina: The tube in a woman's body that runs beside the urethra and connects the womb (uterus) to the outside of the body. Sometimes called the birth canal. [NIH]

Seeking Guidance 55

CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with gestational diabetes. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.14 In addition to support groups, your physician can be a valuable source of guidance and support. Therefore, finding a physician that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with gestational diabetes. The chapter ends with a discussion on how to find a doctor that is right for you.

Associations and Gestational Diabetes As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of an illness can be as taxing as the physical side.15 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, your expectations, and how well you cope with your condition can all Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 15 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 14

56 Gestational Diabetes

influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. In addition to associations or groups that your doctor might recommend, we suggest that you consider the following list (if there is a fee for an association, you may want to check with your insurance provider to find out if the cost will be covered): ·

Diabetes Insipidus Foundation, Inc Address: Diabetes Insipidus Foundation, Inc. 4533 Ridge Drive, Baltimore, MD 21229 Telephone: (410) 247-3953 E-mail: [email protected] Website: http://diabetesinsipidus.maxinter.net Email: [email protected] Web Site: http://diabetesinsipidus.maxinter.net Background: The Diabetes Insipidus Foundation is concerned with all forms of diabetes insipidus (DI), namely neurogenic, nephrogenic, gestagenic (gestational DI), and dipsogenic. The three major goals of the Foundation include promoting research, providing information, and offering support to affected individuals and their families. In the area of research, the Foundation strives to increase research dollars by educating the biomedical community about the prevalence of diabetes insipidus and its numerous extra- urinary manifestations. The Foundation also strives for more accurate diagnosis, more specific therapy, and, ultimately, the prevention and cure of diabetes insipidus. In addition, the Foundation strives for greater public awareness and understanding of the disease by promoting public education and offering informational material such as a quarterly newsletter.

·

JDF The Diabetes Research Foundation Address: JDF The Diabetes Research Foundation 89 Granton Avenue, Richmond Hill, Ontario, L4B 2N5, Canada Telephone: (905) 889- 4171 Toll-free: (800) 287-2533 Fax: (905) 889-4209 Email: [email protected] Web Site: http://www.jdfc.ca

Seeking Guidance 57

Background: JDF The Diabetes Research Foundation is an international not-for- profit organization in Canada dedicated to raising funds to support and promote diabetes research. Diabetes is a chronic metabolic disorder that affects the body's ability to properly manufacture or utilize insulin, a hormone necessary for the body to transport food glucose into cells for energy. There are several types of diabetes including InsulinDependent Diabetes Mellitus, IDDM (also known as Juvenile Diabetes); Non-Insulin Dependent (Type II, also known as Adult-Onset Diabetes); and Gestational Diabetes. Established in 1974 and consisting of 14 chapters, JDF supports research advances in therapies to reduce the risk of diabetes- caused blindness, decrease the number of amputations due to diabetes, and control high blood pressure associated with diabetes; disease management practices that help maintain tight control of glucose levels to prevent or delay complications of diabetes; and practices that afford women with diabetes the opportunity for safe pregnancies and healthy children. JDF also supports advancements in methods to detect the earliest signs of diabetes; therapeutic treatments to prevent or delay the disease's onset; experimental techniques for programming cells from outside the pancreas to produce insulin; and research that has contributed to the increased understanding of transplantation immunology, which has helped to make transplantation of pancreatic tissue a reality. JDF publishes a quarterly magazine entitled 'Countdown Canada,' regularly produces 'Research News Updates,' and has a web site on the Internet at http://www.jdfc.ca.

Finding More Associations There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information than what is listed above, by consulting all of them, you will have nearly exhausted all sources for patient associations.

The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about gestational diabetes. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797.

58 Gestational Diabetes

DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “gestational diabetes” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations.

The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “gestational diabetes”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then, select your preferred language and the format option “Organization Resource Sheet.” By making these selections and typing in “gestational diabetes” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with gestational diabetes. You should check back periodically with this database since it is updated every 3 months. The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option called “Organizational Database (ODB)” and type “gestational diabetes” (or a synonym) in the search box. Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMDÒ, for example, offers such a service at their Web site:

Seeking Guidance 59

http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your doctor or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective.

Finding Doctors One of the most important aspects of your treatment will be the relationship between you and your doctor or specialist. All patients with gestational diabetes must go through the process of selecting a physician. While this process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:16 ·

If you are in a managed care plan, check the plan's list of doctors first.

·

Ask doctors or other health professionals who work with doctors, such as hospital nurses, for referrals.

·

Call a hospital’s doctor referral service, but keep in mind that these services usually refer you to doctors on staff at that particular hospital. The services do not have information on the quality of care that these doctors provide.

·

Some local medical societies offer lists of member doctors. Again, these lists do not have information on the quality of care that these doctors provide.

Additional steps you can take to locate doctors include the following: ·

Check with the associations listed earlier in this chapter.

·

Information on doctors in some states is available on the Internet at http://www.docboard.org. This Web site is run by “Administrators in Medicine,” a group of state medical board directors.

·

The American Board of Medical Specialties can tell you if your doctor is board certified. “Certified” means that the doctor has completed a training program in a specialty and has passed an exam, or “board,” to assess his or her knowledge, skills, and experience to provide quality patient care in that specialty. Primary care doctors may also be certified as specialists. The AMBS Web site is located at

16

This section is adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

60 Gestational Diabetes

http://www.abms.org/newsearch.asp.17 You can also contact the ABMS by phone at 1-866-ASK-ABMS. ·

You can call the American Medical Association (AMA) at 800-665-2882 for information on training, specialties, and board certification for many licensed doctors in the United States. This information also can be found in “Physician Select” at the AMA's Web site: http://www.amaassn.org/aps/amahg.htm.

If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of doctors with expertise in various rare diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.

Finding an Obstetrician-Gynecologist The American College of Obstetricians and Gynecologists (ACOG) provides a searchable Physician Directory at http://www.acog.org/memberlookup/disclaimer.cfm. The directory is provided as a public service to help women find obstetrician-gynecologists in their area. The ACOG’s database includes over 43,000 of its members who practice obstetrics and/or gynecology in the U.S., Canada, and internationally. The Physician Directory is searchable by physician name, state, country, or zip code. Some of the topics covered can include information about each physician’s practice, such as office hours, affiliated hospitals, and languages spoken. A green icon next to a physician’s name denotes that information about this practice is available. By clicking on a linked name, you will be redirected to the associated physician’s home page.

While board certification is a good measure of a doctor's knowledge, it is possible to receive quality care from doctors who are not board certified. 17

Seeking Guidance 61

Selecting Your Doctor18 When you have compiled a list of prospective doctors, call each of their offices. First, ask if the doctor accepts your health insurance plan and if he or she is taking new patients. If the doctor is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen physician. During the first visit you will have the opportunity to evaluate your doctor and to find out if you feel comfortable with him or her. Ask yourself, did the doctor: ·

Give me a chance to ask questions about gestational diabetes?

·

Really listen to my questions?

·

Answer in terms I understood?

·

Show respect for me?

·

Ask me questions?

·

Make me feel comfortable?

·

Address the health problem(s) I came with?

·

Ask me my preferences about different kinds of treatments for gestational diabetes?

·

Spend enough time with me?

Trust your instincts when deciding if the doctor is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your doctor to get to know each other.

Working with Your Doctor19 Research has shown that patients who have good relationships with their doctors tend to be more satisfied with their care and have better results. Here are some tips to help you and your doctor become partners: ·

You know important things about your symptoms and your health history. Tell your doctor what you think he or she needs to know.

·

It is important to tell your doctor personal information, even if it makes you feel embarrassed or uncomfortable.

18 This

section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm. 19 This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

62 Gestational Diabetes

·

Bring a “health history” list with you (and keep it up to date).

·

Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications.

·

Tell your doctor about any natural or alternative medicines you are taking.

·

Bring other medical information, such as x-ray films, test results, and medical records.

·

Ask questions. If you don't, your doctor will assume that you understood everything that was said.

·

Write down your questions before your visit. List the most important ones first to make sure that they are addressed.

·

Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers.

·

Ask your doctor to draw pictures if you think that this would help you understand.

·

Take notes. Some doctors do not mind if you bring a tape recorder to help you remember things, but always ask first.

·

Let your doctor know if you need more time. If there is not time that day, perhaps you can speak to a nurse or physician assistant on staff or schedule a telephone appointment.

·

Take information home. Ask for written instructions. Your doctor may also have brochures and audio and videotapes that can help you.

·

After leaving the doctor's office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your doctor, call for your test results. If your doctor recommended that you have certain tests, schedule an appointment to get them done. If your doctor said you should see an additional specialist, make an appointment.

By following these steps, you will enhance the relationship you will have with your physician.

Seeking Guidance 63

Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:20 ·

Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html

·

Choosing a Doctor or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html

·

Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html

Vocabulary Builder The following vocabulary builder provides definitions of words used in this chapter that have not been defined in previous chapters: Blindness: The inability to see or the loss or absence of perception of visual stimuli. This condition may be the result of eye diseases; optic nerve diseases; optic chiasm diseases; or brain diseases affecting the visual pathways or occipital lobe. [NIH] Chronic: Lasting a long time. Chronic diseases develop slowly. Chronic renal failure may develop over many years and lead to end-stage renal disease. [NIH] Gynecology: A medical-surgical specialty concerned with the physiology and disorders primarily of the female genital tract, as well as female endocrinology and reproductive physiology. [NIH] Nephrogenic: Constant thirst and frequent urination because the kidney tubules cannot respond to antidiuretic hormone and therefore pass too much water. [NIH] Neurogenic: Loss of bladder control caused by damage to the nerves controlling the bladder. [NIH] You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.

20

64 Gestational Diabetes

65

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL

ABOUT PART II In Part II, we introduce you to additional resources and advanced research on gestational diabetes. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on gestational diabetes. In Part II, as in Part I, our objective is not to interpret the latest advances on gestational diabetes or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with gestational diabetes is suggested.

Studies 67

CHAPTER 3. STUDIES ON GESTATIONAL DIABETES Overview Every year, academic studies are published on gestational diabetes or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or physicians. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on gestational diabetes. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on gestational diabetes and teach you how to keep current on new studies as they are published or undertaken by the scientific community.

The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and gestational diabetes, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the

68 Gestational Diabetes

format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type in “gestational diabetes” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is a sample of what you can expect from this type of search: ·

Screening for MODY Mutations, GAD Antibodies, and Type 1 Diabetes-Associated HLA Genotypes in Women with Gestational Diabetes Mellitus Source: Diabetes Care. 25(1): 68-71. January 2002. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This article reports on a study undertaken to investigate whether genetic susceptibility to type 1 diabetes or maturity onset diabetes of the young (MODY) increases susceptibility to gestational diabetes mellitus (GDM). The authors studied mutations in MODY1-4 genes, the presence of GAD antibodies, and HLA DQB1 risk genotypes in 66 Swedish women with GDM and a family history of diabetes. An oral glucose tolerance test (OGTT) was repeated in 46 women at 1 year postpartum. There was no increase in type 1 diabetes associated HLADQB1 alleles or GAD antibodies when compared with a group of patients with type 2 diabetes (n = 82) or healthy control subjects (n = 86). Mutations in known MODY genes were identified in 3 of the 66 subjects. Of the 46 GDM subjects, 2 had diabetes (4 percent) and 17 had impaired glucose tolerance (IGT, 37 percent) at 1 year postpartum. The authors conclude that MODY mutations but not autoimmunity contribute to GDM in Swedish women with a family history of diabetes and increase the risk of subsequent diabetes. 2 tables. 25 references.

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Gestational Diabetes Mellitus: Diagnosis, Treatment, and Beyond Source: Diabetes Educator. 27(1): 69-72, 74. January-February 2001. Contact: Available from American Association of Diabetes Educators. 100 West Monroe Street, 4th Floor, Chicago, IL 60603-1901. (312) 424-2426. Summary: This article discusses the diagnosis and treatment of gestational diabetes mellitus (GDM). Early recognition and treatment are critical to a successful outcome for both mother and infant. GDM is

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defined by the American Diabetes Association (ADA) as any degree of glucose intolerance with onset or first recognition during pregnancy. A risk assessment for GDM during the first prenatal visit is important. The ADA recommends screening and the 100-gram oral glucose tolerance test for diagnosing GDM. Daily self monitoring of blood glucose can be used to determine the effectiveness of diet, exercise, and insulin in maintaining target blood glucose goals. Medical nutrition therapy is used to ensure that the woman is consuming adequate calories and nutrients for maternal and fetal health. An individualized meal plan can be developed by the patient and a registered dietitian. Exercise is vital for maintaining euglycemia because regular exercise enhances insulin sensitivity and glucose utilization. Human insulin is the only pharmacologic treatment recommended to lower blood glucose during pregnancy. Postpartum care is important because approximately 40 percent to 60 percent of women with GDM will develop type 2 diabetes. 4 tables. 4 references. ·

Gestational Diabetes Mellitus Diagnosed with a 2-h 75-g Oral Glucose Tolerance Test and Adverse Pregnancy Outcomes Source: Diabetes Care. 24(7): 1151-1155. July 2001. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This review article describes a cohort study that evaluated American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes. Although the ADA recommends a 3 hour 100 gram oral glucose tolerance test (OGTT) for the diagnosis of GDM, it has also recently included in its recommendations the use of a 2 hour 75 gram OGTT. GDM is defined by the new ADA test recommendations for the two hour 75 gram OGTT as at least two values greater than a fasting glucose of 5.3 mmol per liter, a 1 hour glucose of 10 mmol per liter, and a 2 hour glucose of 8.6 mmol per liter. WHO criteria require a fasting plasma glucose of equal to or greater than 7.0 mmol per liter or a 2 hour glucose of equal to or greater than 7.8 mmol per liter. The study population consisted of 4,977 Brazilian adult women attending general prenatal clinics who underwent a standardized 2 hour 75 gram OGTT between their estimated 24th to 28th gestational weeks. Among the women, 2.4 percent presented with GDM by ADA criteria and 7.2 percent by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia, preeclampsia, and perinatal death. Similarly, GDM by WHO criteria predicted increased risk for macrosomia, preeclampsia, and

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perinatal death. Of women positive by WHO criteria, 260 were negative by ADA criteria. Conversely, 22 women positive by ADA criteria were negative by WHO criteria. The article concludes that GDM based on a 2 hour 75 gram OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes. Thus, until consensual criteria are reached, these two criteria are valid options for the detection of a glucose tolerance state predictive of adverse pregnancy outcomes. 1 appendix. 1 figure. 2 tables. 18 references. (AA-M). ·

Gestational Diabetes: Clinical Management Guidelines for Obstetrician-Gynecologists Source: Obstetrics and Gynecology. 98(3): 525-538. September 2001. Contact: Available from Elsevier Science, Inc. 655 Avenue of the Americas, New York, NY 10010. (212) 989-5800. Summary: Gestational diabetes mellitus (GDM) is one of the most common clinical issues facing obstetricians and their patients. A lack of data from well-designed studies has contributed to the controversy surrounding the diagnosis and management of this condition. This document provides a brief overview of the understanding of GDM and then provides management guidelines that have been validated by appropriately conducted clinical research. When outcomes based research is not available, expert opinion is provided to aid the practitioner. The background section covers definition and prevalence, maternal and fetal complications of GDM, and controversies regarding current screening practices and treatment benefits. Clinical considerations and recommendations are provided for: screening for GDM, gestational age at which laboratory screening should be performed, the use of venous versus capillary blood, appropriate threshold values for laboratory screening tests, the diagnosis of GDM, monitoring blood glucose values in women with GDM, the role of diet therapy in the treatment of GDM, the role of insulin in the treatment of GDM, the role of exercise and oral antidiabetic agents in the treatment of GDM, fetal assessment in pregnancies complicated by GDM, childbirth considerations in pregnancies complicated by GDM, and postpartum follow up of women who had GDM during their pregnancy. The article concludes with a summary of recommendations, categorized by those based on research studies and those based on consensus and expert opinion. 2 tables. 105 references.

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Comparison of Glyburide and Insulin in Women with Gestational Diabetes Mellitus Source: New England Journal of Medicine. 343(16): 1134-1138. October 19, 2000. Summary: This article describes a study that compared glyburide and insulin in the treatment of women with gestational diabetes. The study population consisted of 404 women with singleton pregnancies and gestational diabetes that required treatment. The women were randomly assigned between 11 and 33 weeks of gestation to receive glyburide or insulin according to an intensified treatment protocol. The primary end point was achievement of the desired level of glycemic control Secondary end points included maternal and neonatal complications. The study found that the mean pretreatment blood glucose concentration as measured at home for one week was 114 plus or minus 19 milligrams (mg) per deciliter (dl) in the glyburide group and 116 plus or minus 22 mg per dl in the insulin group. The mean concentrations during treatment were 105 plus or minus 16 mg/dl in the glyburide group and 105 plus or minus 18 mg per dl in the insulin group. Eight women in the glyburide group required insulin therapy. There were no significant differences between the glyburide and insulin groups in the percentage of infants who were large for gestational age, who had macrosomia, who had lung complications, who had hypoglycemia, who were admitted to a neonatal intensive care unit, or who had fetal anomalies. The cord serum insulin concentrations were similar in the two groups, and glyburide was not detected in the cord serum of any infant in the glyburide group. The article concludes that, in women with gestational diabetes, glyburide is a clinically effective alternative to insulin therapy. 4 tables. 49 references. (AA-M).

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Oral Hypoglycemic Drugs for Gestational Diabetes (editorial) Source: New England Journal of Medicine. 343(16): 1178-1179. October 19, 2000. Summary: This editorial comments on the use of oral hypoglycemic drugs for the treatment of gestational diabetes. Early use of first generation sulfonylurea drugs was not effective, as many women delivered infants with profound and prolonged hyperinsulinemic hypoglycemia. The observation that sulfonylurea drugs could cross the placenta and stimulate fetal insulin secretion was another cause for concern about their use in pregnancy. The risk of late fetal death for women with gestational diabetes is another concern that has been debated. Lastly, there has been concern about the possibility of congenital malformations in women taking sulfonylurea drugs during pregnancy.

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However, a recent randomized, controlled trial comparing the sulfonylurea drug glyburide with traditional insulin therapy found that only 4 percent of women in the glyburide group failed to achieve adequate blood glucose control. In addition, there was no evidence of any of complications resulting from fetal or neonatal hyperinsulinemia due to transplacental passage of the drug. The editorial considers the implications of these findings for clinical practice. 10 references. ·

Carbohydrate and Lipid Metabolism in Pregnancy: Normal Compared with Gestational Diabetes Mellitus Source: American Journal of Clinical Nutrition. 71(5 Supplement): 1256S1261S. May 2000. Contact: Available from American Journal of Clinical Nutrition. Production Office, 9650 Rockville Pike, Bethesda, MD 20814. (301) 5307038. Fax (301) 571-8303. Website: www.ajcn.org. Summary: This article reviews maternal metabolic strategies for accommodating fetal nutrient requirements in normal pregnancy and in gestational diabetes mellitus (GDM). Pregnancy is characterized by a progressive increase in nutrient stimulated insulin responses despite an only minor deterioration in glucose (sugar) tolerance, consistent with progressive insulin resistance. The hyperinsulinemic (too much insulin in the blood) euglycemic (ideal levels of blood glucose) glucose clamp technique and intravenous glucose tolerance test have indicated that insulin action in late normal pregnancy is 50 to 70 percent lower than in nonpregnant women. Metabolic adaptations do not fully compensate in GDM and glucose intolerance ensures. GDM may reflect a predisposition to type 2 diabetes or may be an extreme manifestation of metabolic alterations that normally occur in pregnancy. Recent advances in understanding carbohydrate metabolism during pregnancy suggest that preventive measures should be aimed at improving insulin sensitivity in women predisposed to GDM. Further research is needed to elucidate the mechanisms and consequences of alterations in lipid (fats) metabolism during pregnancy. 49 references.

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Nutritional Management of Gestational Diabetes and Nutritional Management of Women with a History of Gestational Diabetes: Two Different Therapies or the Same? Source: Clinical Diabetes. 17(4): 170-176. 1999. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org.

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Summary: This article offers practical suggestions for the nutritional management of gestational diabetes mellitus (GDM) and nutritional management of women with a history of GDM. GDM, which is the most common medical complication of pregnancy, is defined as carbohydrate intolerance of varying degrees of severity with onset or first recognition during pregnancy. Women who have GDM have a significant risk of developing GDM with a subsequent pregnancy and of developing type 2 diabetes later in life. Nutritional management is the cornerstone of treatment for GDM. Medical nutrition therapy for GDM is discussed in terms of optimal maternal weight gain; ideal caloric intake; and amount, timing, and distribution of carbohydrate intake. Other topics include self monitoring of blood glucose, testing for ketones, keeping records of all food and caloric beverages consumed, exercising, breastfeeding, and following up 6 to 12 weeks postpartum. In addition, the article addresses the issues of caring for women with a history of GDM and identifying nutritional factors influencing recurrence of GDM and progression to type 2 diabetes. The article recommends that nutrition therapy start with a modest carbohydrate level distributed among three meals and three snacks, exercise be used as an adjunct to treatment if possible to help maintain maternal euglycemia, and insulin be added to the treatment regimen if necessary. In addition, the article advises that practitioners who have chosen to use a carbohydrate level of less than 45 percent of kcal be sure to educate and evaluate postpartum whether the woman has switched to a low fat diet and has maintained the low fat diet. 1 figure. 4 tables. 37 references. ·

Nutritional Guidelines for Women with Gestational Diabetes Source: Clinical Diabetes. 17(4): 177. 1999. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This article provides nutritional guidelines for women who have gestational diabetes. Guidelines include eating three meals and three snacks per day, omitting foods high in sugar and concentrated sweets, eating whole pieces of fruit instead of drinking fruit juices, spreading carbohydrates out throughout the day, eating foods high in fiber and low in fat, limiting foods from fast food restaurants, and gaining at least 1/2 pound per week.

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Gestational Diabetes: What It Means for You and Your Baby Source: American Family Physician. 60(3): 1009-1010. September 1, 1999.

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Contact: Available from American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (800) 274-2237. Website: www.aafp.org. Summary: This article uses a question and answer format to provide women with information on gestational diabetes. This type of diabetes occurs during pregnancy, and affects about 3 percent of all pregnant women. Gestational diabetes can cause a baby to grow somewhat larger than a normal baby and can cause hypoglycemia or jaundice in the baby at birth. Between the 24th and 28th week of pregnancy, women may undergo blood glucose testing to monitor blood glucose levels. Women diagnosed with gestational diabetes need to eat well-balanced meals with plenty of fruits, vegetables, and grains, and participate in a safe form of moderate exercise. Gestational diabetes usually goes away following the baby's birth; however, it may return during a subsequent pregnancy. Most babies born to mothers with gestational diabetes do not have diabetes after birth, but they may be at higher risk of getting type 2 diabetes as adults. ·

Sweet Taste and Intake of Sweet Foods in Normal Pregnancy and Pregnancy Complicated by Gestational Diabetes Mellitus Source: American Journal of Clinical Nutrition. 70(2): 277-284. August 1999. Contact: Available from American Journal of Clinical Nutrition. Production Office, 9650 Rockville Pike, Bethesda, MD 20814. (301) 5307038. Fax (301) 571-8303. Website: www.ajcn.org. Summary: Dietary compliance in gestational diabetes mellitus (GDM) is poor. Changes in sweet taste perception might alter food preferences in GDM, making dietary compliance difficult to achieve. This study documented changes in sweet taste perception and dietary intakes in pregnancy women with and without GDM and determined whether these differences persisted postpartum (after the pregnancy). Subjects were 30 pregnant women without GDM, 25 pregnancy women with recently diagnosed GDM, and 12 nonpregnancy control subjects. Pregnancy women were tested at 28 to 32 weeks gestations and retested 12 weeks postpartum. Subjects evaluated the taste of strawberry flavored milks with different sucrose (0 to 10 percent) and fat (0 to 10 percent) contents and glucose solutions. Women with GDM showed no differences in liking for the milk samples across test sessions and their liking ratings were not significantly different from those of nonpregnant control subjects. Women without GDM liked the 10 percent sucrose sweetened milk samples less during pregnancy that at 12 weeks postpartum, at which time their ratings were not significantly different

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from those of nonpregnant control subjects. In women with GDM, plasma glucose after a 50 gram glucose load was correlated with both increased liking for the taste of glucose and higher consumption of fruit and fruit juices. The authors summarize that normal pregnancy was associated with a lower preference for 10 percent sucrose sweetened milk samples late in gestation than postpartum, whereas GDM was associated with no such differences. Plasma glucose in women with GDM was related to a higher preference for the sweet taste of glucose and higher dietary sweet food intakes from fruit and fruit juices. These findings have important implications for the dietary management of GDM. 3 figures. 2 tables. 37 references. ·

Maternal Plasma Phospholipid Polyunsaturated Fatty Acids in Pregnancy with and without Gestational Diabetes Mellitus: Relations with Maternal Factors Source: American Journal of Clinical Nutrition. 70(1): 53-61. July 1999. Contact: Available from American Journal of Clinical Nutrition. Production Office, 9650 Rockville Pike, Bethesda, MD 20814. (301) 5307038. Fax (301) 571-8303. Website: www.ajcn.org. Summary: The fatty acids arachidonic acid (AA) and docosahexaenoic acid (DHA) are essential for fetal grown and development, but their metabolism may be altered in insulin resistance. This article reports on a study of maternal plasma (blood) phospholipid polyunsaturated fatty acid concentrations in pregnancy women receiving diet therapy for gestational diabetes mellitus (GDM, n = 15); the study identified maternal factors associated with plasma phospholipid AA and DHA concentrations in the third trimester. The study included a control group of 15 healthy, pregnancy women without GDM. Maternal plasma phospholipid linoleic acid, AA, and 22:5n-6 (another fatty acid) did not differ significantly between women with GDM and control subjects. The other n-6 long chain polyunsaturated fatty acids were lower in GDM subjects than in control subjects. Plasma phospholipid and summed precursors of DHA were lower and DHA adjusted for dietary DHA intake, was 13 percent higher in GDM subjects than in control subjects. Maternal blood hemoglobin A1c (glycosylated hemoglobin, a measure of blood glucose levels over time) was inversely related to plasma phospholipid AA in control subjects and positively associated with plasma phospholipid AA in women with GDM. Pregravid (before pregnancy) body mass index was negatively associated with plasma phospholipid DHA in control subjects and in women with GDM with a body mass index less than 30. The authors conclude that, in pregnancy women, both with and without GDM, maternal glycemic control and

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pregravid BMI appear to be significant predictors of plasma phospholipid AA and DHA, respectively, during the third trimester. Additionally, dietary DHA significantly affects phospholipid DHA concentrations. 5 tables. 34 references. ·

Gestational Diabetes: Detection, Management and Implications Source: Clinical Diabetes. 16(1): 4-11. January-February 1998. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This review article addresses the detection, management, and implications of gestational diabetes. The authors note that gestational diabetes is the most common medical complication and metabolic disorder of pregnancy. It is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. Topics include pathophysiology; maternal morbidity; perinatal morbidity and mortality; diagnosis; management; delivery timing; and postpartum follow up. Treatment for gestational diabetes includes diet therapy, glucose monitoring, and exercise. The article notes that oral hypoglycemic agents are not currently used in treating gestational diabetes. Because women with gestational diabetes have a significant risk for developing diabetes later in life, it is imperative that these women be identified. If diagnostic criteria and management based on maternal and fetal outcomes are to be established, continued research is necessary. 1 figure. 5 tables. 65 references. (AA-M).

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Gestational Diabetes: Antepartum Characteristics That Predict Postpartum Glucose Intolerance and Type 2 Diabetes in Latino Women Source: Diabetes. 47(8): 1302-1310. August 1998. Summary: This article describes a study that examined antepartum clinical characteristics along with measures of glucose tolerance, insulin sensitivity, pancreatic beta cell function, and body composition in Latino women with gestational diabetes mellitus (GDM) for their ability to predict type 2 diabetes or impaired glucose tolerance (IGT) within 6 months after delivery. A total of 122 islet cell antibody-negative women underwent an oral glucose tolerance test (OGTT) and an intravenous glucose tolerance test (IVGTT), hyperinsulinemic-euglycemic clamps, and measurement of body fat between 29 and 36 weeks of gestation and returned between 1 and 6 months postpartum for a 75-gram OGTT. Logistic regression analysis was used to examine the relationship between antepartum variables and glucose tolerance status postpartum.

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Results revealed that, at postpartum testing, 40 percent of the cohort had normal glucose tolerance, 50 percent had IGT, and 10 percent had diabetes by American Diabetes Association criteria. Independent antepartum predictors of postpartum diabetes were the 30-minute incremental insulin:glucose ratio during a 75-gram OGTT and the total area under the diagnostic 100-gram glucose tolerance curve. Independent predictors of postpartum IGT were a low first-phase IVGTT insulin response, a diagnosis of GDM before 22 weeks of gestation, and weight gain between prepregnancy and the postpartum examination. All subjects had low insulin sensitivity during late pregnancy, but neither glucose clamp nor minimal model measures of insulin sensitivity in the third trimester were associated with the risk of IGT or diabetes within 6 months after delivery. Results highlight the importance of pancreatic beta cell dysfunction, detectable under conditions of marked insulin resistance in late pregnancy, to predict abnormalities of glucose tolerance soon after delivery in pregnancies complicated by GDM. Moreover, the association of postpartum IGT with weight gain and an early gestational age at diagnosis of GDM suggests a role for chronic insulin resistance in mediating hyperglycemia outside the third trimester in women with such a beta cell defect. 1 appendix. 5 figures. 3 tables. 36 references. (AA-M). ·

Is Self-Monitoring of Blood Glucose Necessary in the Management of Gestational Diabetes Mellitus? Source: Diabetes Care. 21(Supplement 2): B118-B122. August 1998. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This article addresses the issue of whether self-monitoring of blood glucose (SMBG) is necessary for managing gestational diabetes mellitus (GDM). Controversy continues over the role of blood glucose monitoring in the management of pregnant women with GDM, specifically with regard to the use of capillary versus venous samples, as well as the frequency and timing of blood glucose determinants. At the Third International Workshop Conference, it was noted that selfmonitoring has allowed women to participate in their own care but that its utility in mild GDM not requiring the use of insulin has not been formally proved. The article reviews the existing evidence in the literature on the impact of SMBG on outcomes in pregnancies complicated by GDM. This evidence suggests a role for the selfmonitoring of capillary blood glucose in pregnancies complicated by even mild GDM. The article also presents data on the optimal timing, accuracy, costs, and psychosocial effects of self-monitored glucose

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determinations and concludes that SMBG provides important information on guiding and assessing dietary and insulin therapy in pregnancies complicated by GDM. Furthermore, it enhances patient education, facilitates lifestyle modifications, and allows women to actively participate in their own care. SMBG has been shown to improve neonatal outcomes in pregnancies complicated by GDM without apparently causing undue stress for the mother and at a potentially lower cost. However, the optimal management scheme of blood glucose monitoring and the appropriate threshold of glucose values for initiating insulin therapy have yet to be firmly established. 38 references. (AA-M).

Federally-Funded Research on Gestational Diabetes The U.S. Government supports a variety of research studies relating to gestational diabetes and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.21 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site at http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to gestational diabetes and related conditions. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore gestational diabetes and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for gestational diabetes: ·

Project Title: Fetal Metabolic Consenquences Of Spontaneous Gestational Diabetes Mellitus Principal Investigator & Institution: Friedman, Jacob E.; ; Case Western Reserve University 10900 Euclid Ave Cleveland, Oh 44106 Timing: Fiscal Year 2000

21 Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).

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Summary: The long-term goal of these studies is to understand how defects in maternal insulin transduction contribute to gestational diabetes mellitus (GDM) and the mechanisms leading to fetal macrosomia and obesity. Metabolic imprinting suggests the transmission of diabetic susceptibility genes from moth to offspring is less important than the maternal environment in producing second-generation insulin resistance, obesity, and diabetes. This proposal will use a series of established heterozygous transgenic mouse models will combined gene knockouts in the insulin receptor (IR/+), insulin receptor substrate-1 (IRS-1/+), and leptin receptor (db/+) genes to establish how genetic defects in insulin signaling and the hormones of pregnancy interact to provoke abnormalities in insulin signal transduction, beta-cell hypertrophy, and spontaneous hyperglycemia during pregnancy. Our studies will also determine how modifying maternal insulin resistance during pregnancy decreases hyperglycemia and the development of fetal macrosomia by studying db/+ mice that over-express the human GLUT4 gene. The association between maternal hyperglycemia and fetal genotype on fetal over/under growth and expression of insulin signaling proteins in liver and skeletal muscle will be determined during the perinatal period. The last goal will be to determine whether insulin resistance and obesity in early and later life is modified by inheritance of an abnormal genotype or the consequences of epigenetics (i.e. information that is heritable and alters the phenotype of offspring but is not encoded specifically in the genetic code of DNA. One of the immediate benefits of these models is that they provide information on the role of biochemical defects expressed against a constant genetic background, thus enabling us to observe epigenetic transmission of an altered metabolic phenotype originally induced by a genetic event (inheritance of the IR/IRS-1 or leptin receptor mutation). Because many metabolic disorders, such as diabetes, have both genetic and epigenetic components, this approach offers an opportunity to identify metabolic alterations that may be unique to genetic or epigenetic effects. The outcome of these studies will have important implications for the prevention and treatment of GDM. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Gestational Diabetes: Diagnostic Criteria and Outcomes Principal Investigator & Institution: Ferrara, Assiamira; Kaiser Foundation Research Institute 1800 Harrison St, 16Th Fl Oakland, Ca 94612 Timing: Fiscal Year 2000; Project Start 1-SEP-2000; Project End 1-AUG2004

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Summary: (Adapted from Investigator's Abstract) Gestational diabetes mellitus (GDM) is associated with increased risk of several adverse infant and maternal outcomes and its clinical recognition can reduce these risks. There is concern that the current criteria for GDM may be to restrictive and that residual excess risk of perinatal complications exists below present cutoff values. The proposed study will evaluate whether among women without GDM (as defined by current criteria), increasing levels of maternal glycemia are associated with increased risk of selected perinatal complications: infant severe macrosomia, severe hyperbilirubinemia, hypoglycemia, respiratory distress syndrome, and maternal preeclampsia/eclampsia. To accomplish this, the investigators propose to conduct five nested case-control studies, one for each of the complications of interest, within a large multiethnic cohort of approximately 74,000 women who were screened at 24 to 28 weeks of gestation at Kaiser Permanente, Northern California between 1995 and 1998. In this setting nearly 94 percent of the pregnant women are screened for GDM by a 50 gm., 1 hr. oral glucose tolerance test (50 g, 1-h OGTT) and approximately 15 percent have are abnormal screening and go on to receive the diagnostic (100-g, 3-h OGTT) test. Potential cases of each type of complication will be identified by searching computerized hospitalization and laboratory databases. For each of the infant complications, 500 cases will be randomly selected without knowledge of the maternal glucose values. A single control group for the infant complication case groups will be 1,000 infants randomly selected from all births and frequency matched on gestational age to the distribution of the combined case group. Five hundred women with either preeclampsia or eclampsia and 500 age-matched controls will be randomly selected. The medical records of the 3,000 mother-infant pairs in the four case-control studies on infant complications, and 1,000 women for the case-control study of preeclampsia/eclampsia, will be abstracted to confirm eligibility, and, if so, to ascertain data on possible maternal and infant covariates. Logistic regression will be used to estimate the odds ratios associated with several levels of pregnancy glycemia and perinatal complications. The investigators state that the proposed study will provide important knowledge about the magnitude of the risk of severe perinatal complications associated with degrees of maternal hyperglycemia below the glucose cutpoints currently used to diagnose GDM. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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Project Title: Molecular Genetics of Gestational Diabetes Mellitus--A Genetic Predisposition Principal Investigator & Institution: Lowe, William; ; Northwestern University 303 E Chicago Ave Chicago, Il 60611 Timing: Fiscal Year 2000 Summary: Women who develop gestational diabetes mellitus (GDM) progress to diabetes outside of pregnancy at a rate >5%/yr and account, therefore, for a sizable proportion of people with non-insulin dependent diabetes mellitus (NIDDM) whose mean age at diagnosis is relatively young. Moreover, impaired b-cell function is an important early predictor of the risk of developing DM among women with GDM. For these reasons, we have hypothesized that women with gestational diabetes mellitus (GDM) share a unique set of genetic characteristics apart from other presentations of NIDDM. The proposed studies are designed to create a bank of genomic DNA from and phenotypic information on several groups of participants, including (i)women with NIDDM subsequent to a history of GDM, (ii)women with a history of GDM who have normal glucose tolerance, (iii)women who do not have a history of GDM, (iv)individuals with typical, late-onset NIDDM (defined as onset after age 50), and (v)a reference group of individuals with normal glucose tolerance but who are at risk factor for late-onset NIDDM based upon a family history of a first degree relative with NIDDM, age over 50, or ethnicity (African-American, Hispanic, or Native American). This DNA and phenotypic information will be used to address our hypothesis in the present and future studies by examining the frequency of polymorphisms/mutations in previously identified genes that predispose to the development of maturity onset diabetes of the young (MODY), NIDDM, and obesity (a risk factor for NIDDM) in the different groups of participants and the association of those polymorphisms/mutations with alterations in the different phenotypic characteristics. These studies will be conducted using the about 1000 people who are currently undergoing oral glucose tolerance tests to determine their eligibility for participation in the Diabetes Prevention Program at Northwestern University Medical School and about 450 people who will be enrolled in another CRC-approved study ("Are Polymorphic Variants of the Leptin Receptor Gene Associated with Obesity and Gestational Diabetes Mellitus" - Protocol 597). The specific analysis that will be conducted in the proposed study will be to determine the prevalence rate of mutations in the transcription factor hepatocyte nuclear factor-1a in women with NIDDM subsequent to a history of GDM compared to the other four groups. Mutations in this

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gene result in maturity-onset diabetes of the young (MODY) and are, thus, associated with onset of diabetes at a young age. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Nutrition Practice Guidelines for Gestational Diabetes Principal Investigator & Institution: Pleuss, Joan; ; Medical College of Wisconsin 8701 Watertown Plank Rd Milwaukee, Wi 53226 Timing: Fiscal Year 2000; Project Start 1-DEC-1991; Project End 0-NOV2001 Summary: The purpose of this study is to compare two types of nutrition care provided to women with gestational diabetes (GDM) by registered dietitians. The study will answer the question: Does nutrition care delivered according to new nutrition practice guidelines result in better pregnancy outcomes than usual nutrition care delivered according to new practice guidelines provided by registered dietitians? Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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Project Title: Troglitazone in Women with Prior Gestational Diabetes Mellitus Principal Investigator & Institution: Buchanan, Thomas A.; Professor; University of Southern California University Park Los Angeles, Ca 90007 Timing: Fiscal Year 2000 Summary: This is a 5-year trial to test whether improvements in whole body insulin sensitivity can prevent or delay the development of noninsulin-dependent diabetes mellitus to Hispanic women identified to be at high risk for diabetes by history of gestational diabetes and by their oral glucose tolerance test profile when not pregnant. This investigatorinitiated project is a direct result of information obtained on the prediction and mechanisms of NIDDM in women with GDM from a current NIH-funded cohort study (GCRC Protocol #626). Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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Project Title: Birthweight and Gestational Age and Chronic Disease Risk Principal Investigator & Institution: Byers, Tim E.; Professor of Preventive Medicine; Preventive Med and Biometrics; University of Colorado Hlth Sciences Ctr 4200 E 9Th Ave Denver, Co 80262 Timing: Fiscal Year 2000; Project Start 1-AUG-1999; Project End 1-MAR2002

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Summary: Several studies have shown that people born small or thin have increased risk for developing Insulin Resistance Syndrome (IRS), non-insulin dependent diabetes mellitus (NIDDM), and cardiovascular disease (CVD) as adults. These observations have led to the "fetal origins" hypothesis - that susceptibility to these chronic adult conditions may be programmed in utero. The profound metabolic and hemodynamic changes that occur in gestation make pregnancy a physiologic stress test for glucose intolerance, hypertension, and other IRS-related abnormalities. Gestational diabetes (GDM) and pregnancy-induced hypertension (PIH) are two common complications of pregnancy that share many characteristics of IRS, and also predict a woman's risk for the later development of NIDDM and CVD. We propose to investigate the effects of a woman's growth before her own birth (indicated by her own birthweight and gestational age) on her risk in young adulthood for PIH or GDM. Apart from promising preliminary work we have recently completed in Colorado, this is an area of investigation that has not previously been explored. The proposal is to conduct a case-control study based on birth registry and hospital discharge data from New York State and New York City, computer-linked across a generation. Subjects will be women who were born in NY after 1959 and delivered a live singleton infant in New York between 1990 and 1996. Cases will be subjects who had PIH and/or GDM diagnosed during a recent pregnancy (1990-1996), while controls will be subjects frequency matched to cases on hospital and year of delivery, but without a diagnosis of PIH or GDM. The records of each subject's recent pregnancy (1990-1996) will be matched to those of her own birth (12-36 years earlier). We will use multiple logistic regression to estimate the independent effects of a mother's own early growth, as indicated by birth weight and gestational age, on her later risk of developing GDM or PIH. The analysis will account for potential confounding and effect-modifying factors, including race/ethnicity, maternal age, and smoking. We will also conduct a sub-study of the validity of the diagnoses of GDM and PIH on the birth records. This study will thus offer a powerful and cost-efficient way to investigate the hypothesis of the fetal origins of GDM and PIH, two common but still poorly understood complications of pregnancy which are associated with increased risk for chronic disease later in life. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Diabetes Prevention Program (DDP-2) Principal Investigator & Institution: Kitabchi, Abbas E.; Medicine; University of Tennessee Health Sci Ctr Health Science Center Memphis, Tn 38163

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Timing: Fiscal Year 2000; Project Start 0-AUG-1994; Project End 0-JUN2003 Summary: Non-insulin dependent diabetes mellitus (NIDDM) has reached an epidemic proportion in the United States. Although NIDDM, cardiovascular diseases, and cancer account for two-thirds of all deaths in the United States, there is strong evidence to indicate that these diseases may be related to the lifestyle of the patients. There is no compelling evidence in the literature that the following are combined, or independent risk factors for development of NIDDM: (a) obesity, (b) family history of NIDDM, (c) upper body adiposity, (d) ethnicity, (e) hyperinsulinemia, (f) impaired glucose tolerance, (g) gestational diabetes, (h) sex hormone binding globulin (SHBG), (i) sedentary life. We hypothesize that in such individuals with high risk, alteration of lifestyle, such as dietary modification and physical exercise, will ameliorate or delay development of NIDDM. We, therefore, propose the following specific aims for this multicenter primary prevention trial: 1. To recruit a cohort of subjects at high risk for NIDDM consisting of 100 persons with previous history of gestational diabetes, most of whom will be African American, and 100 other persons who are hyperinsulinemic with upper body adiposity, insulin resistant, impaired glucose tolerant and strong family history of diabetes. Some of the patients will be undiagnosed NIDDM with fasting blood glucose of < 140 mg/dl. 2. To randomize these subjects into intensive therapy group versus usual care group (attention control). 3. The intensive therapy group will be designed to accomplish the following aims: (a) to modify the diets in these high risk subjects to reduce total fat to less than 30% of total calories and saturated fat to less than 10%, (b) to increase energy expenditure from physical activity to 2000 Kcal per week, (c) to combine dietary therapy with effective moderate exercise therapy to achieve a reduction of body weight of greater than 10% per individual which will be maintained over time, (d) to design these dietary and exercise interventions so they are flexible enough that they can be modified for the different target ethnic, gender, educational level, and other subgroups, and (e) to design a long term adherence program that will maximize adherence to prescribed therapies while minimizing drop outs and therapeutic cross overs. 4. To provide baseline and semi-annual evaluations of glycemic control and insulin resistance in all groups of patients, and repetition of all initial laboratory and physical examination data on an annual basis. We estimate 75% of our study population will be African American, and 25% will be Caucasian. Both male and female populations will be represented, with the majority being female, as 50% of our patients will consist of those persons with gestational diabetes. We understand the final protocol will

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be based on the decision arrived at by the Steering Committee, and may involve the use of insulin-resistance-modifying drugs. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Diabetes Prevention Program (DPP) Principal Investigator & Institution: Shamoon, Harry; Professor and Dcrc Program Director; Medicine; Yeshiva University 500 W 185Th St New York, Ny 10033 Timing: Fiscal Year 2000; Project Start 5-AUG-1994; Project End 0-JUN2003 Summary: There is increasing evidence that the development of noninsulin dependent diabetes mellitus (NIDDM) is presaged many years earlier by the presence of biochemical and other phenotypic features in susceptible individuals. Earlier intervention in such individuals may prevent or slow the occurrence of overt hyperglycemia which, in turn, may limit the morbidity and mortality associated with diabetes. By selecting populations at higher than average risk for the ultimate development of NIDDM, we propose to be able to practically test the following hypothesis: The reduction in risk of developing NIDDM in persons at high risk for the development of diabetes will be dependent on treatment which affects insulin resistance, islet B-cell dysfunction, and/or hepatic glucose production. Interventions which include diet, exercise sulfonylurea drugs, and metformin in a factorial design can address this hypothesis. The Diabetes Center at the Albert Einstein College of Medicine is a multidisciplinary aggregation of scientists and clinicians actively involved in various aspects of diabetes. With the resources and expertise available among individuals in the Center, we will participate in a multicenter NIDDM Prevention Trial. The Albert Einstein Center would be able to contribute to the success of such a Trial for the following reasons: l) a Diabetes Research and Training Center underpinning and the Institutional commitment to addressing issues in underserved populations of New York City; 2) our participation in the Diabetes Control and Complications Trial as a clinical center; 3) the availability of a large, identified population of individuals from racial and ethnic minority groups in the Bronx and Westchester Counties who receive their medical care in Einstein-affiliated programs; 4) an identified and well characterized population of women who had gestational diabetes diagnosed between 1988 and the present, and an annual accrual of an additional cohort of women with gestational diabetes; 5) expertise in the design and implementation of clinical trials; 6) strong research foci of the principal and co-investigators in areas such as pathophysiology and diagnosis as well as nutritional and pharmacologic treatment of

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NIDDM; 7) members of the treatment team with specific competence in diabetes in Hispanic and in African-American individuals; 8) a new outpatient facility in which to conduct a clinical trial; 9) expertise in related areas such as hypertension control, cardiovascular risk reduction, and behavioral techniques intended to achieve therapeutic goals; and lO) a track record of participating in constructive collaborative efforts to achieve the goals of NIH-initiated multicenter projects. We will participate in the Trial by providing personnel, resources, and study volunteers to achieve the aims of the planning, implementation, and data analysis phases of the proposed 7-year study. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Glucose and Amino Acid Metabolism in Pregnancy Principal Investigator & Institution: Kalhan, Satish C.; Professor; Case Western Reserve University 10900 Euclid Ave Cleveland, Oh 44106 Timing: Fiscal Year 2000 Summary: The objectives of the proposed studies are to quantify longitudinally maternal metabolic responses to progressions of pregnancy and growth of the fetus. Specifically, the impact of pregnancy and alterations in fetal growth, e.g. in diabetes, upon whole body amino acid and glucose metabolism will be quantified using stable isotope tracer method. Data from our previous studies in human pregnancy have shown that while changes in energy delivering substrates, e.g. glucose and fatty acids, during pregnancy occur parallel with the energy requirements of the mother and growing conceptus, adaptive responses in protein/nitrogen metabolism appear in anticipation of the fetal needs. In addition, preliminary data suggest that (a) liver/splanchnic tissue may be an important organ system involved in the pregnancy related adaptation, and (b) amino acid transamination may be an important component of nitrogen conservation and accretion. The proposed studies are aimed at testing these two hypotheses. Multiple isotope tracers will be used simultaneously to quantify splanchnic extraction and metabolism of essential amino acids. Whole body kinetics of glutamine, a major nitrogen source for urea and for the fetus and its nitrogen source will be quantified. Since fetal macrosomia has continued to be a persistent problem in gestational diabetes despite rigorous intervention strategies, this clinical model of abnormal fetal growth will be evaluated for the changes in gluconeogenesis and amino acid metabolism. A recently developed novel method employing labeling of body water which has already been applied to normal pregnancy will be used to quantify gluconeogenesis in gestational diabetes. These studies will quantify kinetics of key nutrients and substrates in the whole body (mother and

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fetus) which can impact fetal growth. It is anticipated that these data will permit the development of intervention strategies for amelioration of aberrant fetal growth. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: HAPO: Data Coordinating Center Principal Investigator & Institution: Dyer, Alan R.; Professor; Preventive Medicine; Northwestern University 303 E Chicago Ave Chicago, Il 60611 Timing: Fiscal Year 2000; Project Start 4-MAY-1999; Project End 1-MAR2004 Summary: There is a consensus that overt diabetes mellitus (DM), whether or not accompanied by symptoms or signs of metabolic decompensation, is associated with a significant risk of adverse pregnancy outcome. On the other hand, the risk of adverse outcome associated with degrees of glucose intolerance less severe than overt DM is controversial. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study is a basic epidemiologic investigation aiming to clarify unanswered questions on the association of various levels of glucose intolerance during the third trimester of pregnancy and risk of adverse outcomes. Its General Aim -- by means of an international cooperative study involving 16 centers and approximately 25,000 pregnant women -is to achieve a major advance in knowledge on levels of glucose during pregnancy that place the mother, fetus, and neonate at increased risk. The primary hypothesis is that hyperglycemia during pregnancy, less severe than overt DM, is associated with increased risk of adverse maternal, fetal, and neonatal outcome that is independently related to the degree of metabolic disturbance. Specific Aims of HAPO are: 1. to examine glucose tolerance in a large, heterogeneous, multinational, multicultural, ethnically diverse cohort of women in the third trimester of gestation with medical caregivers "blinded" to status of glucose tolerance (except in those instances where fasting and/or two hour OGTT plasma glucose concentration exceeds a predefined cutoff value); and 2. to derive internationally acceptable criteria for the diagnosis and classification of gestational diabetes mellitus (GDM) based on the specific relationships between maternal glycemia and the risk of specific adverse outcomes that are established through this study. The study is to be accomplished with high quality standardized data collection on the women during the third trimester of gestation (including the OGTT) and at time of delivery for assessment of adverse outcomes, including operative delivery (caesarean section), increased fetal size (macrosomia/obesity), neonatal morbidity (hypoglycemia), and fetal hyperinsulinism. HAPO is to include a Clinical Coordinating Center and Data Coordinating Center, both located at the

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Northwestern University Medical School in Chicago, as well as a Central Laboratory located in Belfast, United Kingdom. This application requests support for the Data Coordinating Center for HAPO. Cost effectiveness for HAPO is enhanced through cost sharing by colleagues in non-U.S. centers. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Insulin Resistance and Glucose Metabolism in Pregnancy Principal Investigator & Institution: Catalano, Patrick M.; ; Case Western Reserve University 10900 Euclid Ave Cleveland, Oh 44106 Timing: Fiscal Year 2000 Summary: The long term objectives are to understand the relationship of pregavid maternal lipid metabolism and maternal metabolic adaptations during pregnancy at the system and cellular level. The specific aims of this proposal are to : evaluate the longitudinal changes in maternal insulin sensitivity as it relates to maternal lipid metabolism and fat accretion in lean and obese women with normal glucose tolerance and gestational diabetes; evaluate the alterations in maternal lipid metabolism in late pregnancy in relationship to neonatal body composition; and, identify the cellular mechanisms underlying decreased insulin sensitivity in adipose tissue during late gestation in normal glucose tolerance and gestational diabetes. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

·

Project Title: Niddm Primary Prevention Trial (DPT 2) Principal Investigator & Institution: Goldstein, Barry J.; Director; Medicine; Thomas Jefferson University 1020 Walnut St Philadelphia, Pa 19107 Timing: Fiscal Year 2001; Project Start 5-AUG-1994; Project End 0-JUN2003 Summary: The objective of this multicenter clinical trial is to develop interventions to prevent the development of NIDDM in people with a history of gestational diabetes (GDM) and impaired glucose tolerance (IGT) (Cohort I primary prevention) and the worsening of glucose tolerance in people with newly diagnosed NIDDM with an FPG less than 140 mg/dl (Cohort II, secondary prevention). The central hypothesis of this application is that improvement of insulin resistance will delay the onset of NIDDM in individuals at risk. Therefore, we propose a five year randomized non-pharmacological and pharmacological factorial treatment design aimed to improve insulin resistance: Stratification will assure an overall trial representation of Black (0.4), Hispanic (0.2), Native

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American (0.2), GDM (0.2) and other races including Caucasian (1.0) Power calculations indicate that 20 centers contributing with 200 patients each will be necessary to fulfill the goal of the study. We will recruit the study subjects from among the Thomas Jefferson University employees. From a preliminary survey of the 7,294 full-time employees with a response rate of 58% revealed that 52% of the employees are at risk for NIDDM and that 76% have indicated interest in a NIDDM prevention trial, if available. It is hoped that the screening treatment follow-up and outcome measures methods will be translated to the society at large. To this end, it is important that both community and work-site models be developed. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Niddm Primary Prevention Trial (DPT 2) Principal Investigator & Institution: Bray, George A.; Director; None; Lsu Pennington Biomedical Research Ctr 6400 Perkins Rd Baton Rouge, La 70808 Timing: Fiscal Year 2000; Project Start 5-AUG-1994; Project End 0-JUN2003 Summary: Non-insulin Dependent Diabetes Mellitus develops in individuals who have peripheral tissue resistance to the action of insulin. These individuals often make normal or increased amounts of insulin but are unable to maintain physiologic blood glucose concentrations because of this defect. Women who develop gestational diabetes mellitus manifest this peripheral insulin resistance and 30% go on to develop non-insulin dependent diabetes within five years of the diagnosis of gestational diabetes mellitus. Women with increased risk for developing NIDDM will be identified as high risk at the Genesis Obstetrical Center in Tampa. These women will be evaluated after pregnancy and divided into two categories based upon fasting plasma glucose values. The first will be those women with fasting plasma glucose values less than 110 mg/ dl. The second will be women with fasting plasma glucose equal to or greater than 110 mg/ dl but less than 140 mg/dl. These individuals will have serum islet cell antibodies, insulin autoantibodies, tested to determine that they do not have autoimmune diabetes mellitus. They will then have an oral glucose tolerance test to determine whether they have normal or impaired glucose tolerance or diabetes mellitus as defined by the National Diabetes Data Group. These individuals will then be randomized into four intervention groups. Each individual will have peripheral insulin sensitivity determined with a glucose clamp experiment. The first group will be placed on a calorically restricted diet (1600-1800 Kcal/day) and started on an aerobic exercise program

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designed to reduce body mass index. The next group will receive one of a number of oral agents (sulfonylureas, thiozolidinolione, or magnesium chloride) with potential for reducing peripheral insulin resistance will be evaluated. The third group will have intensified insulin therapy provided 5 days annually since this has been shown in insulin dependent diabetes to reduce peripheral insulin resistance. The fourth group will receive an oral placebo and serve as controls. Each of these individuals will be seen on a quarterly basis to measure their height, weight, blood pressure, fasting plasma glucose levels, glycosylated hemoglobin, sex hormone binding protein, serum insulin and urinary C-peptide levels. Each of these individuals will have a glucose clamp experiment performed to determine the degree of insulin resistance and oral glucose tolerance test as an indicator of glucose homeostasis on an annual basis. This protocol will require two years to enroll the study subjects and 5-6 years of followup to determine the role of peripheral insulin resistance and the above interventions for the delay or prevention of NIDDM. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Niddm Primary Prevention Trial (DPT-2) Principal Investigator & Institution: Goldberg, Ronald B.; Medicine; University of Miami Box 016159 Miami, Fl 33101 Timing: Fiscal Year 2000; Project Start 0-AUG-1994; Project End 0-JUN2003 Summary: The objectives of this research proposal is to participate as a clinical center in a multicenter trial to determine whether the development of non- insulin dependent diabetes (NIDDM) can be prevented. We propose to identify 200 subjects at high risk for developing NIDDM over a 12-month period. Group I subjects with impaired glucose tolerance (IGT) will be identified from the AfricanAmerican minority group by oral glucose tolerance testing (OGTT) and Group Il subjects with IGT will be identified from a large data base of women who have had post-gestational diabetes. In the course of screening these populations, it is anticipated that a proportion of subjects with undiagnosed diabetes will be identified by OGTT. Those without fasting hyperglycemia (<140 mg/dl) represent a very high risk group for progression to fasting hyperglycemia and will be included in the trial (Group III). Recruited subjects will be randomized either into a usual referred care (RC) group and a special intervention (SI) group aimed at achieving dietary modification (4% weight loss) and increased physical activity (600 Kcal/week) for a 4-5 year period. Half of the SI group will in addition receive the antihyperglycemic drug, Metformin (850 mg b.i.d.), and the other half placebo. Performance of yearly OGTT's will be used to

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compare rates of deterioration to fasting hyperglycemia in each of the three treatment groups, in addition to changes in insulin and cardiovascular risk factors. Subjects with IGT will be analyzed separately from those originally found to have diabetes, since the natural history and response to treatment may differ between the two. It is anticipated that intervention in patients at high risk for diabetes, with diet, physical activity or pharmacologic agents may slow or prevent their deterioration to NIDDM and offer a new approach to the treatment of this disease. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Treatment

Pregnant

Black

Diabetic

Women--Adherence

To

Principal Investigator & Institution: Brooks, Latina M.; None; Case Western Reserve University 10900 Euclid Ave Cleveland, Oh 44106 Timing: Fiscal Year 2001; Project Start 5-NOV-2000 Summary: Diabetes during pregnancy is a major health problem. Pregnant women with diabetes are at risk for acute and chronic complications while their infants are at high risk for morbidity and mortality. African American childbearing women have higher rates of diabetes, higher maternal complication rates and higher rates of low birthweight infants. These combined factors make study of pregnant African American women with diabetes a very timely and important group to study. The purpose of the proposed research is to examine barriers to treatment adherence in African American women whose pregnancies have been complicated by gestational diabetes. Using focus groups, modification of the Barriers to Self-Care Scale, and the Diabetes Compliance Questionnaire, the proposed study will examine: 1) what aspects of the diabetes treatment regimen are most difficult to adhere to; 2) environmental and social factors that act as barriers to adherence; 3) whether barriers and measures of adherence vary according to age, parity, or level of education; and 4) environmental and social factors that may be related to adherence among African American women with gestational diabetes. This information is basic to developing acceptable and effective plans of care for this group. The major long-term goal of this program of research is to develop acceptable, and effective treatment plans that improve pregnancy outcomes for African American women whose pregnancies are complicated by diabetes. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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E-Journals: PubMed Central22 PubMed Central (PMC) is a digital archive of life sciences journal literature developed and managed by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).23 Access to this growing archive of e-journals is free and unrestricted.24 To search, go to http://www.pubmedcentral.nih.gov/index.html#search, and type “gestational diabetes” (or synonyms) into the search box. This search gives you access to full-text articles. The following is a sample of items found for gestational diabetes in the PubMed Central database: ·

Birth characteristics of women who develop gestational diabetes: population based study by Grace M Egeland, Rolv Skjaerven, and Lorentz M Irgens; 2000 September 2 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=27469

·

Intervening to reduce weight gain in pregnancy and gestational diabetes mellitus in Cree communities: an evaluation by Katherine Gray-Donald, Elizabeth Robinson, Aileen Collier, Kinga David, Lise Renaud, and Shaila Rodrigues; 2000 November 14 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=80308

·

Using fasting plasma glucose concentrations to screen for gestational diabetes mellitus: prospective population based study by Daniele Perucchini, Ursin Fischer, Giatgen A Spinas, Renate Huch, Albert Huch, and Roger Lehmann; 1999 September 25 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=28232

The National Library of Medicine: PubMed One of the quickest and most comprehensive ways to find academic studies in both English and other languages is to use PubMed, maintained by the National Library of Medicine. The advantage of PubMed over previously mentioned sources is that it covers a greater number of domestic and foreign

Adapted from the National Library of Medicine: http://www.pubmedcentral.nih.gov/about/intro.html. 23 With PubMed Central, NCBI is taking the lead in preservation and maintenance of open access to electronic literature, just as NLM has done for decades with printed biomedical literature. PubMed Central aims to become a world-class library of the digital age. 24 The value of PubMed Central, in addition to its role as an archive, lies the availability of data from diverse sources stored in a common format in a single repository. Many journals already have online publishing operations, and there is a growing tendency to publish material online only, to the exclusion of print. 22

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references. It is also free to the public.25 If the publisher has a Web site that offers full text of its journals, PubMed will provide links to that site, as well as to sites offering other related data. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals. To generate your own bibliography of studies dealing with gestational diabetes, simply go to the PubMed Web site at www.ncbi.nlm.nih.gov/pubmed. Type “gestational diabetes” (or synonyms) into the search box, and click “Go.” The following is the type of output you can expect from PubMed for “gestational diabetes” (hyperlinks lead to article summaries): ·

Thiamine supplementation to prevent induction of low birth weight by conventional therapy for gestational diabetes mellitus. Author(s): Bakker SJ, ter Maaten JC, Gans RO. Source: Medical Hypotheses. 2000 July; 55(1): 88-90. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11021334&dopt=Abstract

Vocabulary Builder Alleles: Mutually exclusive forms of the same gene, occupying the same locus on homologous chromosomes, and governing the same biochemical and developmental process. [NIH] Antibody: An immunoglobulin molecule that has a specific amino acid sequence by virtue of which it interacts only with the antigen that induced its synthesis in cells of the lymphoid series (especially plasma cells), or with antigen closely related to it. Antibodies are classified according to their ode of action as agglutinins, bacteriolysins, haemolysins, opsonins, precipitins, etc. [EU] Antidiabetic: An agent that prevents or alleviates diabetes. [EU] Antigen: Any substance which is capable, under appropriate conditions, of inducing a specific immune response and of reacting with the products of that response, that is, with specific antibody or specifically sensitized Tlymphocytes, or both. Antigens may be soluble substances, such as toxins PubMed was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at Web sites of participating publishers. Publishers that participate in PubMed supply NLM with their citations electronically prior to or at the time of publication.

25

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and foreign proteins, or particulate, such as bacteria and tissue cells; however, only the portion of the protein or polysaccharide molecule known as the antigenic determinant (q.v.) combines with antibody or a specific receptor on a lymphocyte. Abbreviated Ag. [EU] Autoantigens: Endogenous tissue constituents that have the ability to interact with autoantibodies and cause an immune response. [NIH] Autoimmunity: Process whereby the immune system reacts against the body's own tissues. Autoimmunity may produce or be caused by autoimmune diseases. [NIH] Capillary: Any one of the minute vessels that connect the arterioles and venules, forming a network in nearly all parts of the body. Their walls act as semipermeable membranes for the interchange of various substances, including fluids, between the blood and tissue fluid; called also vas capillare. [EU]

Cardiomyopathy: A general diagnostic term designating primary myocardial disease, often of obscure or unknown etiology. [EU] Coronary: Encircling in the manner of a crown; a term applied to vessels; nerves, ligaments, etc. The term usually denotes the arteries that supply the heart muscle and, by extension, a pathologic involvement of them. [EU] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any disease, injury, or other health-related event occurring in such outbreaks. [EU] Epidemiological: Relating to, or involving epidemiology. [EU] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Glyburide: An antidiabetic sulfonylurea derivative with actions similar to those of chlorpropamide. [NIH] Hepatic: Pertaining to the liver. [EU] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Immunotherapy: Manipulation of the host's immune system in treatment of disease. It includes both active and passive immunization as well as immunosuppressive therapy to prevent graft rejection. [NIH] Induction: The act or process of inducing or causing to occur, especially the production of a specific morphogenetic effect in the developing embryo through the influence of evocators or organizers, or the production of anaesthesia or unconsciousness by use of appropriate agents. [EU]

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Ischemia: Deficiency of blood in a part, due to functional constriction or actual obstruction of a blood vessel. [EU] Lipid: Any of a heterogeneous group of flats and fatlike substances characterized by being water-insoluble and being extractable by nonpolar (or fat) solvents such as alcohol, ether, chloroform, benzene, etc. All contain as a major constituent aliphatic hydrocarbons. The lipids, which are easily stored in the body, serve as a source of fuel, are an important constituent of cell structure, and serve other biological functions. Lipids may be considered to include fatty acids, neutral fats, waxes, and steroids. Compound lipids comprise the glycolipids, lipoproteins, and phospholipids. [EU] Lipoprotein: Any of the lipid-protein complexes in which lipids are transported in the blood; lipoprotein particles consist of a spherical hydrophobic core of triglycerides or cholesterol esters surrounded by an amphipathic monolayer of phospholipids, cholesterol, and apolipoproteins; the four principal classes are high-density, low-density, and very-lowdensity lipoproteins and chylomicrons. [EU] Malformation: A morphologic defect resulting from an intrinsically abnormal developmental process. [EU] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Monocytes: Large, phagocytic mononuclear leukocytes produced in the vertebrate bone marrow and released into the blood; contain a large, oval or somewhat indented nucleus surrounded by voluminous cytoplasm and numerous organelles. [NIH] Myocardium: The muscle tissue of the HEART composed of striated, involuntary muscle known as cardiac muscle. [NIH] Neonatal: Pertaining to the first four weeks after birth. [EU] Nephropathy: Disease of the kidneys. [EU] Parenteral: Not through the alimentary canal but rather by injection through some other route, as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intrasternal, intravenous, etc. [EU] Perinatal: Pertaining to or occurring in the period shortly before and after birth; variously defined as beginning with completion of the twentieth to twenty-eighth week of gestation and ending 7 to 28 days after birth. [EU] Pharmacologic: Pertaining to pharmacology or to the properties and reactions of drugs. [EU] Phenotype: The outward appearance of the individual. It is the product of interactions between genes and between the genotype and the environment. This includes the killer phenotype, characteristic of YEASTS. [NIH]

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Precursor: Something that precedes. In biological processes, a substance from which another, usually more active or mature substance is formed. In clinical medicine, a sign or symptom that heralds another. [EU] Predisposition: A latent susceptibility to disease which may be activated under certain conditions, as by stress. [EU] Reperfusion: Restoration of blood supply to tissue which is ischemic due to decrease in normal blood supply. The decrease may result from any source including atherosclerotic obstruction, narrowing of the artery, or surgical clamping. It is primarily a procedure for treating infarction or other ischemia, by enabling viable ischemic tissue to recover, thus limiting further necrosis. However, it is thought that reperfusion can itself further damage the ischemic tissue, causing reperfusion injury. [NIH] Retinopathy: 1. retinitis (= inflammation of the retina). 2. retinosis (= degenerative, noninflammatory condition of the retina). [EU] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Sedentary: 1. sitting habitually; of inactive habits. 2. pertaining to a sitting posture. [EU] Substrate: A substance upon which an enzyme acts. [EU]

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CHAPTER 4. PATENTS ON GESTATIONAL DIABETES Overview You can learn about innovations relating to gestational diabetes by reading recent patents and patent applications. Patents can be physical innovations (e.g. chemicals, pharmaceuticals, medical equipment) or processes (e.g. treatments or diagnostic procedures). The United States Patent and Trademark Office defines a patent as a grant of a property right to the inventor, issued by the Patent and Trademark Office.26 Patents, therefore, are intellectual property. For the United States, the term of a new patent is 20 years from the date when the patent application was filed. If the inventor wishes to receive economic benefits, it is likely that the invention will become commercially available to patients with gestational diabetes within 20 years of the initial filing. It is important to understand, therefore, that an inventor’s patent does not indicate that a product or service is or will be commercially available to patients with gestational diabetes. The patent implies only that the inventor has “the right to exclude others from making, using, offering for sale, or selling” the invention in the United States. While this relates to U.S. patents, similar rules govern foreign patents. In this chapter, we show you how to locate information on patents and their inventors. If you find a patent that is particularly interesting to you, contact the inventor or the assignee for further information.

26Adapted

from The U. S. Patent and Trademark Office: http://www.uspto.gov/web/offices/pac/doc/general/whatis.htm.

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Patents on Gestational Diabetes By performing a patent search focusing on gestational diabetes, you can obtain information such as the title of the invention, the names of the inventor(s), the assignee(s) or the company that owns or controls the patent, a short abstract that summarizes the patent, and a few excerpts from the description of the patent. The abstract of a patent tends to be more technical in nature, while the description is often written for the public. Full patent descriptions contain much more information than is presented here (e.g. claims, references, figures, diagrams, etc.). We will tell you how to obtain this information later in the chapter. The following is an example of the type of information that you can expect to obtain from a patent search on gestational diabetes: ·

Method of diagnosing gestational diabetes Inventor(s): Peterson; Charles M. (Santa Barbara, CA), Peterson; Lois G. (Santa Barbara, CA), Peterson; Charles M. (Santa Barbara, CA), Peterson; Lois G. (Santa Barbara, CA) Assignee(s): Sansum Medical Research Foundation (Santa Barbara, CA), Sansum Medical Research Foundation (Santa Barbara, CA) Patent Number: 5,670,377 Date filed: March 14, 1996 Abstract: Methods of diagnosis of gestational diabetes mellitus are disclosed. In preferred embodiments, a blood sample is obtained from a pregnant female in the 24th to 28th week of pregnancy after an overnight fast, after a 1-hour 50-gram glucose challenge test, or at the 1-hour time point during a 3-hour 100-gram oral glucose tolerance test. The concentrations of fasting plasma glucose and glycosylated plasma proteins in this blood sample are then determined. A fasting plasma glucose concentration equal to or exceeding 90 mg/dL is 100% sensitive and 64% specific in predicting glucose-related macrosomia (i.e., birth weight above 4000 grams). A glycosylated plasma protein concentration equal to or exceeding 23% is 100% sensitive and 52% specific in predicting glucose-related macrosomia. A fasting plasma protein value equal to or exceeding 90 mg/dL and a glycosylated plasma protein value equal to or exceeding 23% is 100% sensitive and 93% specific in predicting glucose-related macrosomia. Excerpt(s): The present invention is broadly concerned with methods of diagnosing gestational diabetes mellitus (GDM). More particularly, in these methods, the concentrations of fasting plasma glucose (FPG) and

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glycosylated plasma protein (GPP) in the blood of a female in the 24th to 28th week of pregnancy are determined; concentrations of FPG and GPP equal to or exceeding 90 mg/dL and 23%, respectively, indicate that the pregnant female may be suffering from GDM and is therefore at risk of giving birth to a macrosomic infant. ... The present invention is broadly concerned with methods of diagnosing gestational diabetes mellitus (GDM). More particularly, in these methods, the concentrations of fasting plasma glucose (FPG) and glycosylated plasma protein (GPP) in the blood of a female in the 24th to 28th week of pregnancy are determined; concentrations of FPG and GPP equal to or exceeding 90 mg/dL and 23%, respectively, indicate that the pregnant female may be suffering from GDM and is therefore at risk of giving birth to a macrosomic infant. ... In an obstetrics clinic, 160 pregnant women at 24 to 28 weeks' gestation were given a 1-hour 50-gram GCT according to the recommendation of the Third International Gestational Diabetes Workshop (1). If this glucose challenge resulted in a plasma glucose concentration greater than 140 mg/dL, the patient underwent a formal 3-hour 100-gram OGTT after an overnight fast (1). All blood glucose concentrations were determined in the Santa Barbara County Health Services laboratories using a hexokinase method (Boehringer-Mannheim-Hitachi Systems, Indianapolis, Ind.). At the time of the GCT, two additional tubes of blood were drawn at the 1hour time point for determination of GSP, GPP, and GHb concentrations by boronate-affinity high-performance liquid chromatography (Primus, Kansas City, Mo.). The normal concentration range is 13.0 to 21.0% for GSP, 17.0 to 23.6 for GPP, and 4.1 to 6.1% for GHb. Inter- and intra-assay levels of precision (coefficients of variation) for each assay were less than 3%. For example, with a maximum coefficient of variation of 3% for a GPP concentration of 20%, the coefficient of variation is .+-.0.6% with a range of 19.4 to 20.6%. ... In an obstetrics clinic, 160 pregnant women at 24 to 28 weeks' gestation were given a 1-hour 50-gram GCT according to the recommendation of the Third International Gestational Diabetes Workshop (1). If this glucose challenge resulted in a plasma glucose concentration greater than 140 mg/dL, the patient underwent a formal 3hour 100-gram OGTT after an overnight fast (1). All blood glucose concentrations were determined in the Santa Barbara County Health Services laboratories using a hexokinase method (Boehringer-MannheimHitachi Systems, Indianapolis, Ind.). At the time of the GCT, two additional tubes of blood were drawn at the 1-hour time point for determination of GSP, GPP, and GHb concentrations by boronate-affinity high-performance liquid chromatography (Primus, Kansas City, Mo.). The normal concentration range is 13.0 to 21.0% for GSP, 17.0 to 23.6 for GPP, and 4.1 to 6.1% for GHb. Inter- and intra-assay levels of precision (coefficients of variation) for each assay were less than 3%. For example,

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with a maximum coefficient of variation of 3% for a GPP concentration of 20%, the coefficient of variation is .+-.0.6% with a range of 19.4 to 20.6%. ... 1. Third International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes 1985; 34 (suppl 2):123-62. ... 1. Third International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes 1985; 34 (suppl 2):123-62. Web site: http://www.delphion.com/details?pn=US05670377__

Patent Applications on Gestational Diabetes As of December 2000, U.S. patent applications are open to public viewing.27 Applications are patent requests which have yet to be granted (the process to achieve a patent can take several years).

Keeping Current In order to stay informed about patents and patent applications dealing with gestational diabetes, you can access the U.S. Patent Office archive via the Internet at no cost to you. This archive is available at the following Web address: http://www.uspto.gov/main/patents.htm. Under “Services,” click on “Search Patents.” You will see two broad options: (1) Patent Grants, and (2) Patent Applications. To see a list of granted patents, perform the following steps: Under “Patent Grants,” click “Quick Search.” Then, type “gestational diabetes” (or synonyms) into the “Term 1” box. After clicking on the search button, scroll down to see the various patents which have been granted to date on gestational diabetes. You can also use this procedure to view pending patent applications concerning gestational diabetes. Simply go back to http://www.uspto.gov/main/patents.htm. Under “Services,” click on “Search Patents.” Select “Quick Search” under “Patent Applications.” Then proceed with the steps listed above.

27

This has been a common practice outside the United States prior to December 2000.

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CHAPTER 5. BOOKS ON GESTATIONAL DIABETES Overview This chapter provides bibliographic book references relating to gestational diabetes. You have many options to locate books on gestational diabetes. The simplest method is to go to your local bookseller and inquire about titles that they have in stock or can special order for you. Some patients, however, feel uncomfortable approaching their local booksellers and prefer online sources (e.g. www.amazon.com and www.bn.com). In addition to online booksellers, excellent sources for book titles on gestational diabetes include the Combined Health Information Database and the National Library of Medicine. Once you have found a title that interests you, visit your local public or medical library to see if it is available for loan.

Book Summaries: Federal Agencies The Combined Health Information Database collects various book abstracts from a variety of healthcare institutions and federal agencies. To access these summaries, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. You will need to use the “Detailed Search” option. To find book summaries, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer. For the format option, select “Monograph/Book.” Now type “gestational diabetes” (or synonyms) into the “For these words:” box. You will only receive results on books. You should check back periodically with this database which is updated every 3 months. The following is a typical result when searching for books on gestational diabetes:

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·

Managing Your Gestational Diabetes: A Guide for You and Your Baby's Good Health Source: Minneapolis, MN: Chronimed Publishing. 1994. 132 p. Contact: Available from Chronimed Publishing. P.O. Box 59032, Minnetonka, MN 55459-0032. (800) 848-2793. PRICE: $9.95. ISBN: 1565610520. Summary: This book provides pregnant women with information about gestational diabetes. Women diagnosed with gestational diabetes should follow a special meal plan and self-monitor blood glucose. They also may need to follow a regular exercise program and inject insulin each day. Fourteen chapters address an introduction to diabetes, emotions, gestational diabetes treatment, meal planning, exercise, insulin and insulin reactions, self monitoring of blood glucose and urine ketone testing, stress management, delivery, breastfeeding, and planning for the future. The author notes that meal planning is central to controlling gestational diabetes and ensuring delivery of a healthy baby. All other parts of the treatment program hinge on successfully following an appropriate meal plan. A list of meal planning publications, a glossary, biographical information, sample record pages, a comparison of American and Canadian food group exchanges, and a subject index conclude the book. (AA-M).

·

Understanding Gestational Diabetes: A Practical Guide to a Healthy Pregnancy. Revised ed Source: Bethesda, MD: National Institute of Child Health and Human Development. 1993. 46 p. Contact: Available from National Diabetes Information Clearinghouse (NDIC). 1 Information Way, Bethesda, MD 20892-3560. (800) 860-8747 or (301) 654-3327. E-mail: [email protected]. PRICE: Single copy free. Bulk copies available from National Institute of Child Health and Human Development. 31 Center Drive, MSC 2425, Building 31, Room 2A32, Bethesda, MD 20892. (301) 496-5133. Also available at http://www.niddk.nih.gov/. Summary: This booklet for pregnant women and their families explains gestational diabetes and its impact on the health of mother and baby. It addresses many questions about diet, exercise, measurement of blood glucose levels, and general medical and obstetric care of women with gestational diabetes. Screening methods for gestational diabetes are discussed. The primary focus of this health guide is on diet and weight gain. Several tables are included to assist the pregnant woman in following a nutritionally sound diet that fosters an appropriate weight

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gain and that keeps blood glucose levels as normal as possible. Footnotes cite 4 bibliographic citations and a brief glossary is included. Blank Self Blood Glucose Monitoring Diary and Food and Exercise Record Sheet charts are appended. ·

Best for You and Your Baby: Answers About Gestational Diabetes Source: Indianapolis, IN: Boehringer Mannheim Corporation. 1993. 40 p. Contact: Available from Boehringer Mannheim Corporation. Medical Services Department. 9115 Hague Road, Indianapolis, IN 46250. (800) 428-5076. PRICE: Single copy free. Summary: This easy-to-read patient education booklet offers general information about gestational diabetes. Topics include the patient care team and the patient's role in it; a definition of gestational diabetes; the causes of high blood glucose levels; complications to the fetus and the mother caused by hyperglycemia; monitoring fetal health; selfmonitoring of blood glucose (SMBG); meal planning; the use of insulin; the role of exercise; emotional support; labor and delivery; postpartum problems with diabetes; and breastfeeding. Written in clear, basic language, the booklet features charcoal drawing illustrations and sidebars that highlight the important points on each page. The booklet concludes with a glossary of relevant terms. It is also available in Spanish (Lo Mejor para Usted y su Bebe: Respuestas Sobre la Diabetes del Embarazo).

·

Gestational Diabetes: What to Expect Source: Alexandria, VA: American Diabetes Association. 1992. 76 p. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-6733. PRICE: $7.95 for ADA members; $9.95 for nonmembers (as of 1995). ISBN: 0945448104. Order Number CPREGD. Summary: This book, from the American Diabetes Association, provides a comprehensive guide for the pregnant woman who has gestational diabetes. The authors explain proper care during pregnancy, including nutrition, exercise, insulin therapy, and blood glucose monitoring. Other subjects related to pregnancy are discussed, including stages of a fetus' development, tests to expect during pregnancy, labor and delivery, and birth control. An extensive glossary of terms is included, and a subject index concludes the book.

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Book Summaries: Online Booksellers Commercial Internet-based booksellers, such as Amazon.com and Barnes & Noble.com, offer summaries which have been supplied by each title’s publisher. Some summaries also include customer reviews. Your local bookseller may have access to in-house and commercial databases that index all published books (e.g. Books in PrintÒ). The following have been recently listed with online booksellers as relating to gestational diabetes (sorted alphabetically by title; follow the hyperlink to view more details at Amazon.com): ·

Diabetes Sourcebook : Basic Information About Insulin-Dependent and Noninsulin-Dependent Diabetes Mellitus, Gestational Diabetes, and Diabetic complic by Karen Bellenir (Editor), Peter D. Dresser (Editor) (1995); ISBN: 1558887512 http://www.amazon.com/exec/obidos/ASIN/1558887512/icongroupin terna

·

Managing Your Gestational Diabetes : A Guide for You and Your Baby's Good Health by Lois Jovanovic-Peterson, Morton Stone (1998); ISBN: 0471346845 http://www.amazon.com/exec/obidos/ASIN/0471346845/icongroupin terna

·

Gestational Diabetes: What to Expect, McGraw Hill – NTC (2001); ISBN: 1580400728 http://www.amazon.com/exec/obidos/ASIN/1580400728/icongroupin terna

The National Library of Medicine Book Index The National Library of Medicine at the National Institutes of Health has a massive database of books published on healthcare and biomedicine. Go to the following Internet site, http://locatorplus.gov/, and then select “Search LOCATORplus.” Once you are in the search area, simply type “gestational diabetes” (or synonyms) into the search box, and select “books only.” From

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there, results can be sorted by publication date, author, or relevance. The following was recently catalogued by the National Library of Medicine:28 ·

Diabetes sourcebook: basic information about insulin-dependent and noninsulin-dependent diabetes mellitus, gestational diabetes, and diabetic complications, symptoms, treatments, and research results ... Author: edited by Karen Bellenir and Peter D.Dresser; Year: 1994; Detroit, MI: Omnigraphics, 1994; ISBN: 1558887512 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/1558887512/icongroupin terna

·

Gestational diabetes: guidelines for a safe pregnancy and a healthy baby. Author: Marion Franz, Nancy Cooper, and Lucy Mullen; Year: 1985; Minneapolis, MI.: <STRONG>Diabetes Center, 1986, c1985; ISBN: 093772114X (pbk.) http://www.amazon.com/exec/obidos/ASIN/093772114X/icongroupi nterna

·

Gestational diabetes. Author: Peter A.M. Weiss, Donald R. Coustan (eds.); Year: 1988; Wien; New York: Springer-Verlag, c1988; ISBN: 0387820078 (U.S.) http://www.amazon.com/exec/obidos/ASIN/0387820078/icongroupin terna

Chapters on Gestational Diabetes Frequently, gestational diabetes will be discussed within a book, perhaps within a specific chapter. In order to find chapters that are specifically dealing with gestational diabetes, an excellent source of abstracts is the Combined Health Information Database. You will need to limit your search to book chapters and gestational diabetes using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find book chapters, use the drop boxes at the bottom of the search page where “You may refine your search In addition to LOCATORPlus, in collaboration with authors and publishers, the National Center for Biotechnology Information (NCBI) is adapting biomedical books for the Web. The books may be accessed in two ways: (1) by searching directly using any search term or phrase (in the same way as the bibliographic database PubMed), or (2) by following the links to PubMed abstracts. Each PubMed abstract has a “Books” button that displays a facsimile of the abstract in which some phrases are hypertext links. These phrases are also found in the books available at NCBI. Click on hyperlinked results in the list of books in which the phrase is found. Currently, the majority of the links are between the books and PubMed. In the future, more links will be created between the books and other types of information, such as gene and protein sequences and macromolecular structures. See http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Books.

28

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by.” Select the dates and language you prefer, and the format option “Book Chapter.” By making these selections and typing in “gestational diabetes” (or synonyms) into the “For these words:” box, you will only receive results on chapters in books. The following is a typical result when searching for book chapters on gestational diabetes: ·

Exercise and Gestational Diabetes Source: in Devlin, J.T. and Schneider, S.H., eds. Handbook of Exercise in Diabetes. Alexandria, VA: American Diabetes Association. 2002. p.533545. Contact: Available from American Diabetes Association (ADA). Order Fulfillment Department, P.O. Box 930850, Atlanta, GA 31193-0850. (800) 232-6733. Fax (770) 442-9742. Website: www.diabetes.org. PRICE: $69.95 plus shipping and handling. ISBN: 1580400191. Summary: Exercise can play an important role in attaining and maintaining target levels of glycemia during pregnancy in women with gestational diabetes mellitus (GDM). This chapter on exercise and gestational diabetes is from a book that provides a practical, comprehensive guide to diabetes and exercise for health care professionals involved in patient care. Regular, light exercise (e.g., walking for 20 to 30 minutes daily) is a rational component of the initial management regimen regardless of maternal regimen regardless of maternal glycemia. Intensification of the exercise prescription (e.g., to 25 to 40 minutes of exercise of 50 percent of calculated maximal aerobic capacity three times per week) can help to achieve safe levels of glycemia when diet and light exercise fail to do so. Pregnancy-induced hypertension (high blood pressure), preterm rupture of membranes, preterm labor in current or past pregnancies, incompetent cervix, persistent vaginal bleeding, or evidence for intrauterine growth retardation are contraindications to exercise during pregnancy. Women with a history of GDM are at high risk of developing diabetes, especially type 2 diabetes, after pregnancy. Insulin resistance appears to be an important component of and risk factor for progression to type 2 diabetes. Recommendations for behaviors, such as regular exercise, that reduce insulin resistance and help in attaining ideal body weight are an important part of postpartum management in women with GDM. 35 references.

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Testing for Gestational Diabetes Source: in Reece, E.A. and Coustan, D.R., eds. Diabetes Mellitus in Pregnancy. 2nd ed. New York, NY: Churchill Livingstone. 1995. p. 261275.

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Contact: Available from Churchill Livingstone. 300 Lighting Way, Secaucus, NJ 07094. (800) 553-5426. PRICE: $92.00. ISBN: 0443089795. Summary: This chapter covers diagnostic criteria for the oral glucose tolerance test and for the intravenous glucose tolerance test (IVGTT) in testing for gestational diabetes. In addition, the author examines proposed screening tests, including historical factors, glycosylated hemoglobin and other blood protein levels, and other oral challenge tests. The diagnostic use of amniotic fluid glucose, insulin, and C-peptide, as well as postpartum evaluation of women with suspected diabetic fetopathy, are also discussed. 6 tables. 90 references. (AA-M). ·

Management of Gestational Diabetes Source: in Reece, E.A.; Coustan, D.R., eds. Diabetes Mellitus in Pregnancy. 2nd ed. New York, NY: Churchill Livingstone. 1995. p. 277286. Contact: Available from Churchill Livingstone. 300 Lighting Way, Secaucus, NJ 07094. (800) 553-5426. PRICE: $92.00. ISBN: 0443089795. Summary: This chapter, from a medical textbook on diabetes mellitus in pregnancy, discusses the management of gestational diabetes (GDM). The author stresses that the most important step in the management of GDM is its diagnosis. Once this has been achieved, almost every type of management protocol has been associated with a reduction in the perinatal mortality rate. The author briefly discusses the goals of management, then outlines a plan for achieving these goals. Steps in the plan include dietary therapy, glucose monitoring, oral hypoglycemic agents, insulin therapy, and the use of insulin to prevent morbidity (prophylactic insulin). The author concludes the chapter with a discussion of recommended fetal evaluation tests, and delivery considerations. The author stresses that all women diagnosed with GDM should be given dietary counseling and should be monitored at least weekly for fasting and postprandial hyperglycemia. Should hyperglycemia occur, insulin should be administered to restore glucose homeostasis and reduce perinatal mortality risks. Intervention to reduce perinatal morbidity is less clear. 1 figure. 2 tables. 53 references.

General Home References In addition to references for gestational diabetes, you may want a general home medical guide that spans all aspects of home healthcare. The following

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list is a recent sample of such guides (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · Female Reproductive Health by N. Manassiev (Editor), M. Whitehead (Editor); Hardcover - 300 pages, 1st edition (May 15, 2002), CRC PressParthenon Publishers; ISBN: 1850704910; http://www.amazon.com/exec/obidos/ASIN/1850704910/icongroupinterna · Handbook of Women's Sexual and Reproductive Health by Gina M. Wingood (Editor), Ralph J. Diclemente (Editor); Hardcover - 472 pages (January 1, 2002), Plenum Publishing Corp.; ISBN: 0306466511; http://www.amazon.com/exec/obidos/ASIN/0306466511/icongroupinterna · Your Guy's Guide to Gynecology by Bruce Bekkar M.D., Udo Wahn M.D.; Hardcover - 288 pages (March 2000), North Star Publications Inc.; ISBN: 0965506746; http://www.amazon.com/exec/obidos/ASIN/0965506746/icongroupinterna

Vocabulary Builder Aerobic: 1. having molecular oxygen present. 2. growing, living, or occurring in the presence of molecular oxygen. 3. requiring oxygen for respiration. [EU] Contraception: The prevention of conception or impregnation. [EU] Demography: Statistical interpretation and description of a population with reference to distribution, composition, or structure. [NIH] Homeostasis: A tendency to stability in the normal body states (internal environment) of the organism. It is achieved by a system of control mechanisms activated by negative feedback; e.g. a high level of carbon dioxide in extracellular fluid triggers increased pulmonary ventilation, which in turn causes a decrease in carbon dioxide concentration. [EU] Triage: The sorting out and classification of patients or casualties to determine priority of need and proper place of treatment. [NIH]

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CHAPTER 6. MULTIMEDIA ON GESTATIONAL DIABETES Overview Information on gestational diabetes can come in a variety of formats. Among multimedia sources, video productions, slides, audiotapes, and computer databases are often available. In this chapter, we show you how to keep current on multimedia sources of information on gestational diabetes. We start with sources that have been summarized by federal agencies, and then show you how to find bibliographic information catalogued by the National Library of Medicine. If you see an interesting item, visit your local medical library to check on the availability of the title.

Video Recordings Most diseases do not have a video dedicated to them. If they do, they are often rather technical in nature. An excellent source of multimedia information on gestational diabetes is the Combined Health Information Database. You will need to limit your search to “video recording” and “gestational diabetes” using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find video productions, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Videorecording (videotape, videocassette, etc.).” By making these selections and typing “gestational diabetes” (or synonyms) into the “For these words:” box, you will only receive results on video productions. The following is a typical result when searching for video recordings on gestational diabetes:

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Gestational Diabetes: Your Questions Answered Source: Madison, WI: University of Wisconsin Hospitals and Clinics, Department of Outreach Education. 1996. (videocassette). Contact: Available from University of Wisconsin Hospital and Clinics. Picture of Health, 702 North Blackhawk Avenue, Suite 215, Madison, WI 53705-3357. (800) 757-4354 or (608) 263-6510. Fax (608) 262-7172. PRICE: $19.95 plus shipping and handling; bulk copies available. Order number 093096B. Summary: This videotape answers frequently asked questions about gestational diabetes. A moderator asks an obstetrician-gynecologist and a dietitian about various aspects of gestational diabetes. Topics include what gestational diabetes is and what causes it, how it differs from other kinds of diabetes, and how it will affect a baby. Gestational diabetes, which usually develops between 24 to 26 weeks of gestation, is caused when the placenta produces chemicals that interfere with insulin and the mother's body cannot compensate for this change. Risk factors for gestational diabetes include being over 30 years old and overweight, having a family history of diabetes, and having had a baby over 9.5 pounds or a stillborn infant. Most women have no symptoms so blood tests are usually performed between 24 and 28 weeks of gestation. Many women who have gestational diabetes can manage the disease with diet and exercise. However, some women may need insulin to manage their diabetes. If a woman needs insulin, she needs to self monitor her blood glucose levels, give herself insulin injections, have her pregnancy monitored more closely, do urine tests to monitor ketones, and have tests to make sure the baby is developing properly. Participants also answer questions about the effect of gestational diabetes on the baby, the impact of gestational diabetes on delivery, and other pregnancy complications. The videotape concludes by identifying sources of additional information.

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Gestational Diabetes: Common Sense Guide for Expectant Moms Source: Evanston, IL: Altschul Group Corporation. 1994. Contact: Available from Altschul Group Corporation. 1560 Sherman Avenue, Suite 100, Evanston, IL 60201. (800) 421-2363 or (708) 328-6700. Fax (708) 328-6706. PRICE: $295 (as of 1995). Order no. 7843. Summary: This videotape program is one of a series of six videotapes that present a common sense approach for living with and controlling diabetes mellitus. This program is for pregnant women who have been diagnosed with gestational diabetes. The program emphasizes a team approach to control diabetes through blood glucose monitoring, meal

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planning, exercising, and insulin injections. The program reiterates that knowing what to expect and how to care for oneself can lessen the fears of women who have gestational diabetes. (AA-M). ·

Nutrition Plan for Gestational Diabetes Source: Dallas, TX: St. Paul Medical Center, Diabetes Management Institute. 1993. Contact: Available from St. Paul Medical Center, Diabetes Management Institute, 2010 Record Crossing, Dallas, TX 75235. (214) 879-3285. PRICE: $39.95 plus $3.50 shipping and handling (as of 1995). Summary: This videotape program is designed to help viewers newly diagnosed with gestational diabetes (GDM) learn about nutrition. Topics covered include a brief discussion of the emotional aspects of GDM; how the disease occurs; the control of GDM with diet therapy, notably selecting the right foods at the right time in the right amounts; monitoring one's blood glucose levels; the basics of the GDM diet; working with dietitians; and the use of artificial sweeteners. Also included is a detailed, step-by-step guide to avoiding table sugar, incorporating three meals and three snacks per day, food selection, and the exchange list system of food groups for diabetes.

·

University of Minnesota case studies: Iron deficiency anemia, gestational diabetes Source: Minneapolis, MN: Division of Epidemiology, Public Health Nutrition, University of Minnesota. 1995. 2 videotapes (37:38 minutes). Contact: Available from Margie Konopliv, University of Minnesota, Division of Epidemiology, Public Health Nutrition, 1300 South Second Street, Suite 300, Minneapolis, MN 55454-1015. Telephone: (612) 626-7933 / fax: (612) 624-0315 / e-mail: [email protected]. $25 each videotape. Summary: This set of two videotapes explores two complications of pregnancy. Both videotapes are accompanied by a teaching guide. Gestational diabetes covers definition, prevalence, significance, screening, diagnosis, nutritional management, dietary strategies, monitoring and postpartum follow-up. Iron deficiency covers definition, prevalence, prevention, and treatment. Both of the guides contain references. [Funded by the Maternal and Child Health Bureau].

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Audio Recordings The Combined Health Information Database contains abstracts on audio productions. To search CHID, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find audio productions, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Sound Recordings.” By making these selections and typing “gestational diabetes” (or synonyms) into the “For these words:” box, you will only receive results on sound recordings (again, most diseases do not have results, so do not expect to find many). The following is a typical result when searching for sound recordings on gestational diabetes: ·

Happy, Healthy Babies: Gestational Source: Van Nuys, CA: Prana Publications. 1995. (audiocassette). Contact: Available from Prana Publications. 5623 Matilija Avenue, Van Nuys, CA 91401. (800) 735-7726 or (818) 780-1308. Fax (818) 786-7359. EMail [email protected]. PRICE: $11.95 plus $3.25 shipping and handling (as of 1995). Order Number A11. Summary: This audiocassette program features Dr. Lois JovanovicPeterson discussing gestational diabetes mellitus (GDM). Topics include testing blood glucose, diet, taking insulin if necessary, exercising safely, labor and delivery, and breast feeding. Dr. Jovanovic-Peterson also has diabetes. (AA-M).

Bibliography: Multimedia on Gestational Diabetes The National Library of Medicine is a rich source of information on healthcare-related multimedia productions including slides, computer software, and databases. To access the multimedia database, go to the following Web site: http://locatorplus.gov/. Select “Search LOCATORplus.” Once in the search area, simply type in gestational diabetes (or synonyms). Then, in the option box provided below the search box, select “Audiovisuals and Computer Files.” From there, you can choose to sort results by publication date, author, or relevance. The following multimedia has been indexed on gestational diabetes. For more information, follow the hyperlink indicated: ·

Gestational diabetes. Source: produced in cooperation with the American Association of Diabetes Educators; produced by Milner-

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Fenwick; Year: 2002; Format: Videorecording; Timonium, MD: MilnerFenwick, [2002] ·

Gestational diabetic patient : identification and treatment. Source: with Susan M. Palmer; Year: 1989; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, c1989

Vocabulary Builder Anemia: A reduction in the number of circulating erythrocytes or in the quantity of hemoglobin. [NIH] Embryo: In animals, those derivatives of the fertilized ovum that eventually become the offspring, during their period of most rapid development, i.e., after the long axis appears until all major structures are represented. In man, the developing organism is an embryo from about two weeks after fertilization to the end of seventh or eighth week. [EU] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Nadir: The lowest point; point of greatest adversity or despair. [EU] Ophthalmology: A surgical specialty concerned with the structure and function of the eye and the medical and surgical treatment of its defects and diseases. [NIH] Otolaryngology: A surgical specialty concerned with the study and treatment of disorders of the ear, nose, and throat. [NIH] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU]

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CHAPTER 7. PHYSICIAN GUIDELINES AND DATABASES Overview Doctors and medical researchers rely on a number of information sources to help patients with their conditions. Many will subscribe to journals or newsletters published by their professional associations or refer to specialized textbooks or clinical guides published for the medical profession. In this chapter, we focus on databases and Internet-based guidelines created or written for this professional audience.

NIH Guidelines For the more common diseases, The National Institutes of Health publish guidelines that are frequently consulted by physicians. Publications are typically written by one or more of the various NIH Institutes. For physician guidelines, commonly referred to as “clinical” or “professional” guidelines, you can visit the following Institutes: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Institute of General Medical Sciences (NIGMS); fact sheets available at http://www.nigms.nih.gov/news/facts/

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines: http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Child Health and Human Development (NICHD); guidelines available at http://www.nichd.nih.gov/publications/pubskey.cfm

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NIH Databases In addition to the various Institutes of Health that publish professional guidelines, the NIH has designed a number of databases for professionals.29 Physician-oriented resources provide a wide variety of information related to the biomedical and health sciences, both past and present. The format of these resources varies. Searchable databases, bibliographic citations, full text articles (when available), archival collections, and images are all available. The following are referenced by the National Library of Medicine:30 ·

Bioethics: Access to published literature on the ethical, legal and public policy issues surrounding healthcare and biomedical research. This information is provided in conjunction with the Kennedy Institute of Ethics located at Georgetown University, Washington, D.C.: http://www.nlm.nih.gov/databases/databases_bioethics.html

·

HIV/AIDS Resources: Describes various links and databases dedicated to HIV/AIDS research: http://www.nlm.nih.gov/pubs/factsheets/aidsinfs.html

·

NLM Online Exhibitions: Describes “Exhibitions in the History of Medicine”: http://www.nlm.nih.gov/exhibition/exhibition.html. Additional resources for historical scholarship in medicine: http://www.nlm.nih.gov/hmd/hmd.html

·

Biotechnology Information: Access to public databases. The National Center for Biotechnology Information conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information for the better understanding of molecular processes affecting human health and disease: http://www.ncbi.nlm.nih.gov/

·

Population Information: The National Library of Medicine provides access to worldwide coverage of population, family planning, and related health issues, including family planning technology and programs, fertility, and population law and policy: http://www.nlm.nih.gov/databases/databases_population.html

·

Cancer Information: Access to caner-oriented databases: http://www.nlm.nih.gov/databases/databases_cancer.html

Remember, for the general public, the National Library of Medicine recommends the databases referenced in MEDLINEplus (http://medlineplus.gov/ or http://www.nlm.nih.gov/medlineplus/databases.html). 30 See http://www.nlm.nih.gov/databases/databases.html. 29

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·

Profiles in Science: Offering the archival collections of prominent twentieth-century biomedical scientists to the public through modern digital technology: http://www.profiles.nlm.nih.gov/

·

Chemical Information: Provides links to various chemical databases and references: http://sis.nlm.nih.gov/Chem/ChemMain.html

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Clinical Alerts: Reports the release of findings from the NIH-funded clinical trials where such release could significantly affect morbidity and mortality: http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html

·

Space Life Sciences: Provides links and information to space-based research (including NASA): http://www.nlm.nih.gov/databases/databases_space.html

·

MEDLINE: Bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the healthcare system, and the pre-clinical sciences: http://www.nlm.nih.gov/databases/databases_medline.html

·

Toxicology and Environmental Health Information (TOXNET): Databases covering toxicology and environmental health: http://sis.nlm.nih.gov/Tox/ToxMain.html

·

Visible Human Interface: Anatomically detailed, three-dimensional representations of normal male and female human bodies: http://www.nlm.nih.gov/research/visible/visible_human.html

While all of the above references may be of interest to physicians who study and treat gestational diabetes, the following are particularly noteworthy.

The Combined Health Information Database A comprehensive source of information on clinical guidelines written for professionals is the Combined Health Information Database. You will need to limit your search to “Brochure/Pamphlet,” “Fact Sheet,” or “Information Package” and gestational diabetes using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For the publication date, select “All Years,” select your preferred language, and the format option “Fact Sheet.” By making these selections and typing “gestational diabetes” (or synonyms) into the “For these words:” box above, you will only receive results on fact sheets dealing with gestational diabetes. The following is a sample result:

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·

Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus Source: Diabetes Care. 23(Supplement 1): S4-S19. January 2000. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus aims to define and describe diabetes as it is currently understood, present a classification scheme that reflects the etiology or pathogenesis of the disease, provide diagnostic criteria for diabetes mellitus, and develop recommendations for testing that can help reduce the morbidity and mortality associated with diabetes. Diabetes mellitus is a group of metabolic disorders characterized by hyperglycemia that results from defects in insulin secretion, insulin action, or both. The pathogenic processes involved in the development of diabetes range from autoimmune destruction of the beta cells of the pancreas to abnormalities that result in resistance to insulin action. The classification of diabetes published in 1979 divided diabetes into insulin dependent diabetes mellitus (IDDM), noninsulin dependent diabetes mellitus (NIDDM), gestational diabetes mellitus, malnutrition-related diabetes, and other types. The Expert Committee is proposing changes to this classification scheme. One of the major changes is the elimination of the terms IDDM and NIDDM and the retention of the terms type 1 diabetes and type 2 diabetes. The report presents the features of immune mediated and idiopathic type 1 diabetes; type 2 diabetes; gestational diabetes; and other specific types of diabetes caused by genetic defects of the beta cell, genetic defects in insulin action, endocrinopathies, drugs, infections, and other genetic syndromes. The report also presents the rationale for revising the diagnostic criteria for diabetes and discusses the new criteria for diagnosing diabetes. The report concludes with criteria for testing for diabetes in asymptomatic, undiagnosed people. 2 figures. 6 tables. 143 references.

·

Self-Monitoring of Blood Glucose Source: Diabetes Care. 17(1): 81-86. January 1994. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This article discusses the consensus statement arising from a Consensus Development Conference on Self-Monitoring of Blood Glucose (SMBG), held in September 1993. The conference consisted of 24

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invited presentations and contributions from a large audience of health care professionals and representatives from industry. The consensus panel reached a consensus on the answers to five questions: What is the epidemiology of SMBG?; Who should self-monitor?; What is the current technology?; How should the data obtained from self-monitoring be used?; and What is the future of self-monitoring? This article briefly reports on each of these five areas. Specific topics include the achievement and maintenance of a specific level of glycemic control; the prevention and detection of hypoglycemia; the avoidance of severe hyperglycemia; adjusting care in response to changes in life-style; determining the need for initiating insulin therapy in gestational diabetes mellitus (GDM); measurement principles and limitations of SMBG systems; performance of SMBG systems; the assessment of clinically significant error; and quality assurance. 10 references. ·

Prevention of Diabetes Mellitus: Report of a WHO Study Group Source: Geneva, Switzerland, World Health Organization, WHO Technical Report Series, No. 844, 100 p., 1994. Contact: World Health Organization, Publications Center USA, 49 Sheridan Avenue, Albany, NY 12210. Summary: Prevention of Diabetes Mellitus: Report of a WHO Study Group presents the collective views of an international group of experts who met in Geneva in November 1992 to (1) review current possibilities for the prevention of diabetes and its consequences, (2) consider the development of national prevention and control programs, and (3) identify areas for further research. Chapters include (1) Introduction, which discusses the nature of the problem and prevention strategies and principles; (2) definition, classification, and diagnostic criteria; (3) primary prevention of insulin-dependent diabetes mellitus (IDDM), which addresses pathogenesis and prevention strategies; (4) primary prevention of noninsulin-dependent diabetes mellitus (NIDDM) and related disorders, which describes prevention strategies for NIDDM, impaired glucose tolerance, malnutrition-related diabetes, gestational diabetes mellitus, and gestational impaired glucose tolerance; (5) secondary prevention, which covers screening for both NIDDM and IDDM; (6) tertiary prevention, which discusses acute and chronic complications of diabetes; (7) diabetes prevention and control programs, which describes the socioeconomic impact of diabetes, the need for program monitoring and evaluation, obstacles that may be encountered during the implementation of diabetes control programs, monitoring the incidence of diabetes in the community, and integrating diabetes prevention and control programs with programs for other

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noncommunicable diseases; (8) research needs, which suggests areas for further examination in basic, epidemiological, intervention, and health services research; and (9) recommendations by the Study Group for the establishment of diabetes prevention and control programs. Appendixes include descriptions of (1) the oral glucose tolerance test, (2) field survey methods for diabetes, (3) characteristics of diabetes screening programs, and (4) a suggested outline for the development of a national program for diabetes prevention and control. ·

Gestational Diabetes Mellitus Cooperative Study Source: Diabetes Control Program, Washington State Department of Social and Health Services, Mail Stop LK-13, Olympia, WA 98504. (206) 586-2708. Summary: The objective of the gestational diabetes cooperative study was to determine the effect of varying degrees of maternal hyperglycemia on birth-weight and perinatal morbidity. The study was population-based and done in collaboration with Southern Illinois University School of Medicine and Brown University School of Medicine. Two populations were studied in the Washington Component--Group Health of Puget Sound and a University of Washington clinic-based population. Screening for glucose tolerance was performed at 24 and 28 weeks of gestation. A total of 2,136 women were screened in the Group Health population and 21.3 percent had abnormal 1-hour glucose values. Of these 102 (4.8 percent) had abnormal oral glucose tolerance tests indicative of gestational diabetes. Eighteen additional women with gestational diabetes were identified in the university population. The most striking finding in the study was the ability to demonstrate clear differences in the study populations with regard to biochemical abnormalities (insulin, triglycerides, glycosylated hemoglobin, and protein) without being able to show clinically significant outcome differences (macrosomia, shoulder dystocia, cesarean section rate).

·

Inside Look at Managing Diabetes Source: South Deerfield, MA: Channing L. Bete Co., Inc. 2000. 15 p. Contact: Available from Channing L. Bete, Co., Inc. 200 State Road, South Deerfield, MA 01373-0200. (800) 628-7733. Fax (800) 499-6464. PRICE: $1.60 each; plus shipping and handling; quantity discounts available. Order number 75226. Summary: This booklet provides an overview of diabetes management. The booklet begins by explaining how glucose gets into cells in a person who is healthy. This is followed by a description of type 1, type 2, and

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gestational diabetes. Risk factors for each type of diabetes are identified. The booklet then discusses the laboratory tests that can confirm a diagnosis of diabetes, including the fasting plasma glucose test, the random plasma glucose test, and the oral glucose tolerance test. Other topics include the effects of damage to the heart and large blood vessels and impact of damage to the small blood vessels. Small blood vessel damage can lead to eye and kidney disease, reduced circulation to the feet and legs, and nerve damage. In addition, the booklet presents steps that people who have diabetes can take to improve their quality of life, including following a healthy meal plan, engaging in regular physical activity, controlling their weight, performing regular self tests of blood glucose, and testing for ketones. The booklet concludes with information on the use of insulin and diabetes pills to manage the disease and other ways to determine the effectiveness of a treatment and self care plan. ·

Diabetes: Learn the Facts Source: South Deerfield, MA: Channing L. Bete Co., Inc. 1998. 7 p. Contact: Available from Channing L. Bete, Co., Inc. 200 State Road, South Deerfield, MA 01373-0200. (800) 628-7733. PRICE: $0.89 each for 1-99 copies; $0.64 each for 100-499 copies; $0.59 each for 500 or more copies. Order number: 72256A798. Summary: This illustrated booklet presents an overview of diabetes, a disease that affects the way the body uses food for energy. The booklet describes type 1 and type 2 diabetes, outlines the serious health problems that uncontrolled diabetes may cause, lists the symptoms of and risk factors for diabetes, and identifies the blood tests used to diagnose diabetes. Other topics include the screening of pregnant women for gestational diabetes and controlling diabetes through a healthy meal plan, weight management, regular physical exercise, regular self monitoring of blood glucose, and medication. The booklet also includes sources of additional information about diabetes.

·

Diabetes: Should I Worry? Source: Santa Cruz, CA: ETR Associates. 1997. 2 p. Contact: Available from ETR Associates. P.O. Box 1830, Santa Cruz, CA 95061-1830. (800) 321-4407. PRICE: $16.00 for 50 copies. Summary: This brochure provides introductory information about diabetes. Diabetes symptoms may include frequent urination; tiredness and weakness; an ill feeling; unusual thirst; weight loss; blurred vision; slow healing of cuts, sores, or infections; hunger most of the time; and dry, itchy skin. Topics include insulin, risk factors, the three types of

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diabetes, prevention, and monitoring. The author notes that the risk for developing diabetes increases if a person has an immediate family member with diabetes; is 20 percent or more over ideal weight; is over 40; is Native American, African American, Asian American, or Hispanic; or has had gestational diabetes. In order to reduce the risk for developing diabetes, a person should maintain body weight in the normal range; lose weight if he or she is 20 percent over ideal weight; exercise to control weight and more effectively use insulin; and get regular health checkups. Health care professionals should help people with diabetes monitor ideal weight, diet, exercise, blood glucose levels, medication, and regular health care. Contact information for four diabetes organizations concludes the brochure. (AA-M). ·

Carbohydrate Counting: Moving On (Level 2) Source: Alexandria, VA, and Chicago, IL: American Diabetes Association and The American Dietetic Association. 1995. 32 p. Contact: Available from American Diabetes Association. Order Fulfillment Department, P.O. Box 930850, Atlanta, GA 31193-0850. (800) 232-6733. Fax (404) 442-9742. PRICE: $15 (members) or $18 (nonmembers) for package of 10 booklets plus accompanying professional information (2 pages). Order Number CCCL2. Also available from The American Dietetic Association. 216 W. Jackson Boulevard, Chicago, IL 60606-6995. (800) 877-1600, ext. 5000. Summary: This booklet, the second in a series of three, builds on the basic concepts of carbohydrate counting as introduced in the first booklet. Readers develop their record keeping skills and learn to identify patterns in their blood glucose levels that are related to the food they eat, diabetes medications, and their physical activity levels. This technique, called pattern management, is presented in detail. Topics include food labels and carbohydrate counting; eating at restaurants; considerations about fat and protein; weight gain and hypoglycemia; and dietary fiber. The booklet includes examples and practice exercises for readers to practice their skills at pattern management. The series is designed for people with IDDM, NIDDM, and gestational diabetes mellitus (GDM). 9 references.

·

Carbohydrate Counting: Using Carbohydrate/Insulin Ratios (Level 3) Source: Alexandria, VA, and Chicago, IL: American Diabetes Association and The American Dietetic Association. 1995. 32 p. Contact: Available from American Diabetes Association. Order Fulfillment Department, P.O. Box 930850, Atlanta, GA 31193-0850. (800) 232-6733. Fax (404) 442-9742. PRICE: $15 (members) or $18 (nonmembers)

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for package of 10 booklets plus accompanying professional information (2 pages). Order Number CCCL3. Also available from The American Dietetic Association. 216 W. Jackson Boulevard, Chicago, IL 60606-6995. (800) 877-1600, ext. 5000. Summary: This booklet, the most advanced in a series of three, builds on the basic concepts of carbohydrate counting and pattern management as introduced in the first two booklets. This booklet is designed for people who take insulin and who have chosen intensive diabetes management, using multiple daily injections (MDI) or an insulin pump. The booklet describes how the carbohydrate counting and pattern management skills can be used to adjust short-acting (Regular) insulin according to the carbohydrate eaten and physical activity. Topics include determining if the carbohydrate/insulin ratios system is appropriate for a particular individual; developing carbohydrate/insulin ratios; adjusting the carbohydrate/insulin ratios over time; adjusting insulin for dietary fats, fiber, and protein intake; and what to expect from the Registered Dietitian on the health care team. The booklet concludes with practice worksheets. The series is designed for people with IDDM, NIDDM, and gestational diabetes mellitus (GDM). 9 references. ·

Diabetes and Pregnancy Source: Washington, DC: American College of Obstetricians and Gynecologists. 1995. 4 p. Contact: Available from American College of Obstetricians and Gynecologists. 409 12th Street, SW, Washington, DC 20024-2188. (800) 762-2264, ext. 197. PRICE: $15.00 for 50 copies. Summary: This brochure provides information about both gestational diabetes and pregnancy for women who have pre-existing diabetes. The brochure notes that good control of glucose levels before and during pregnancy can lower the risk of complications. Topics include the causes of diabetes, the effects of diabetes during pregnancy, preparing for pregnancy, diabetes control, prenatal care, delivery, and postpartum care. Complications that may arise include birth defects, macrosomia, preeclampsia, hydramnios, urinary tract infections, and respiratory distress syndrome (RDS). Blood glucose can be controlled with diet and exercise and, in some cases, by taking insulin. While insulin shots can be safely used during pregnancy to control diabetes, diabetes pills are not recommended. The brochure includes three illustrations. A glossary concludes the brochure. (AA-M).

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·

What is Diabetes? Source: Hollywood, FL: Diabetes Research Institute. 1992. 4 p. Contact: Available from Diabetes Research Institute. 3440 Hollywood Boulevard, Suite 100, Hollywood, Fl 33021. (800) 321-3437 or (305) 9644040. PRICE: Single copy free (donations accepted). Summary: This brochure describes diabetes mellitus. Written in a question-and-answer format, the brochure discusses how diabetes affects the body's ability to make or use insulin; insulin-dependent diabetes (IDDM); who gets IDDM; the etiology of IDDM; IDDM symptoms; the role of insulin; noninsulin-dependent diabetes (NIDDM); who gets NIDDM; the symptoms of NIDDM; how NIDDM is treated; other forms of diabetes, including gestational diabetes; pancreatitis and how it differs from diabetes; and the complications of diabetes.

·

Diabetes: The Bittersweet Truth Source: Trenton, NJ: New Jersey State Department of Health, Diabetes Control Program. 1990. 4 p. Contact: Available from New Jersey State Department of Health. Diabetes Control Program, University Office Plaza, CN 369, Trenton, NJ 086250369. (609) 588-7479. PRICE: Single copy free. Summary: This brochure reviews basic information about diabetes, including insulin-dependent diabetes, noninsulin-dependent diabetes, and gestational diabetes. For each type of diabetes, the brochure details the symptoms, diagnosis, and treatment currently used. Additional sections report epidemiological information about diabetes in New Jersey and list the activities of the Diabetes Control Program of the New Jersey Department of Health. Contact information for a variety of diabetes resource organizations in New Jersey is included.

·

Tests For Diabetes Source: San Diego, CA: Sweet Success: California Diabetes and Pregnancy Program. 1990. 6 p. Contact: Available from Education Programs Associates,Inc. 1 West Campbell Avenue, Building D, Campbell, CA 95008. (408) 374-3720. PRICE: $.35 for CDAPP members or $.50 for non-members. Summary: This simple, fold-out informational booklet briefly reviews the diagnostic test for gestational diabetes that may be performed during pregnancy. Written in clear, easy-to-understand language, the booklet outlines the procedures followed during the 3-hour glucose tolerance

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test. Simple drawings illustrate the topics covered. Space is included for patient notes. This booklet is also available in Spanish (See DMBR01820).

The NLM Gateway31 The NLM (National Library of Medicine) Gateway is a Web-based system that lets users search simultaneously in multiple retrieval systems at the U.S. National Library of Medicine (NLM). It allows users of NLM services to initiate searches from one Web interface, providing “one-stop searching” for many of NLM's information resources or databases.32 One target audience for the Gateway is the Internet user who is new to NLM's online resources and does not know what information is available or how best to search for it. This audience may include physicians and other healthcare providers, researchers, librarians, students, and, increasingly, patients, their families, and the public.33 To use the NLM Gateway, simply go to the search site at http://gateway.nlm.nih.gov/gw/Cmd. Type “gestational diabetes” (or synonyms) into the search box and click “Search.” The results will be presented in a tabular form, indicating the number of references in each database category. Results Summary Category Items Found Journal Articles 4300 Books / Periodicals / Audio Visual 50 Consumer Health 12 Meeting Abstracts 8 Other Collections 1 Total 4371

Adapted from NLM: http://gateway.nlm.nih.gov/gw/Cmd?Overview.x. The NLM Gateway is currently being developed by the Lister Hill National Center for Biomedical Communications (LHNCBC) at the National Library of Medicine (NLM) of the National Institutes of Health (NIH). 33 Other users may find the Gateway useful for an overall search of NLM's information resources. Some searchers may locate what they need immediately, while others will utilize the Gateway as an adjunct tool to other NLM search services such as PubMed® and MEDLINEplus®. The Gateway connects users with multiple NLM retrieval systems while also providing a search interface for its own collections. These collections include various types of information that do not logically belong in PubMed, LOCATORplus, or other established NLM retrieval systems (e.g., meeting announcements and pre-1966 journal citations). The Gateway will provide access to the information found in an increasing number of NLM retrieval systems in several phases. 31 32

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HSTAT34 HSTAT is a free, Web-based resource that provides access to full-text documents used in healthcare decision-making.35 HSTAT's audience includes healthcare providers, health service researchers, policy makers, insurance companies, consumers, and the information professionals who serve these groups. HSTAT provides access to a wide variety of publications, including clinical practice guidelines, quick-reference guides for clinicians, consumer health brochures, evidence reports and technology assessments from the Agency for Healthcare Research and Quality (AHRQ), as well as AHRQ's Put Prevention Into Practice.36 Simply search by “gestational diabetes” (or synonyms) at the following Web site: http://text.nlm.nih.gov. Coffee Break: Tutorials for Biologists37 Some patients may wish to have access to a general healthcare site that takes a scientific view of the news and covers recent breakthroughs in biology that may one day assist physicians in developing treatments. To this end, we recommend “Coffee Break,” a collection of short reports on recent biological discoveries. Each report incorporates interactive tutorials that demonstrate how bioinformatics tools are used as a part of the research process. Currently, all Coffee Breaks are written by NCBI staff.38 Each report is about 400 words and is usually based on a discovery reported in one or more articles from recently published, peer-reviewed literature.39 This site has new articles every few weeks, so it can be considered an online magazine of sorts, Adapted from HSTAT: http://www.nlm.nih.gov/pubs/factsheets/hstat.html. The HSTAT URL is http://hstat.nlm.nih.gov/. 36 Other important documents in HSTAT include: the National Institutes of Health (NIH) Consensus Conference Reports and Technology Assessment Reports; the HIV/AIDS Treatment Information Service (ATIS) resource documents; the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (SAMHSA/CSAT) Treatment Improvement Protocols (TIP) and Center for Substance Abuse Prevention (SAMHSA/CSAP) Prevention Enhancement Protocols System (PEPS); the Public Health Service (PHS) Preventive Services Task Force's Guide to Clinical Preventive Services; the independent, nonfederal Task Force on Community Services Guide to Community Preventive Services; and the Health Technology Advisory Committee (HTAC) of the Minnesota Health Care Commission (MHCC) health technology evaluations. 37 Adapted from http://www.ncbi.nlm.nih.gov/Coffeebreak/Archive/FAQ.html. 38 The figure that accompanies each article is frequently supplied by an expert external to NCBI, in which case the source of the figure is cited. The result is an interactive tutorial that tells a biological story. 39 After a brief introduction that sets the work described into a broader context, the report focuses on how a molecular understanding can provide explanations of observed biology and lead to therapies for diseases. Each vignette is accompanied by a figure and hypertext links that lead to a series of pages that interactively show how NCBI tools and resources are used in the research process. 34 35

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and intended for general background information. You can access the Coffee Break Web site at http://www.ncbi.nlm.nih.gov/Coffeebreak/.

Other Commercial Databases In addition to resources maintained by official agencies, other databases exist that are commercial ventures addressing medical professionals. Here are a few examples that may interest you: ·

CliniWeb International: Index and table of contents to selected clinical information on the Internet; see http://www.ohsu.edu/cliniweb/.

·

Image Engine: Multimedia electronic medical record system that integrates a wide range of digitized clinical images with textual data stored in the University of Pittsburgh Medical Center's MARS electronic medical record system; see the following Web site: http://www.cml.upmc.edu/cml/imageengine/imageEngine.html.

·

Medical World Search: Searches full text from thousands of selected medical sites on the Internet; see http://www.mwsearch.com/.

·

MedWeaver: Prototype system that allows users to search differential diagnoses for any list of signs and symptoms, to search medical literature see http://www.med.virginia.edu/~wmd4n/medweaver.html.

·

Metaphrase: Middleware component intended for use by both caregivers and medical records personnel. It converts the informal language generally used by caregivers into terms from formal, controlled vocabularies; see http://www.lexical.com/Metaphrase.html.

The Genome Project and Gestational Diabetes With all the discussion in the press about the Human Genome Project, it is only natural that physicians, researchers, and patients want to know about how human genes relate to gestational diabetes. In the following section, we will discuss databases and references used by physicians and scientists who work in this area.

Online Mendelian Inheritance in Man (OMIM) The Online Mendelian Inheritance in Man (OMIM) database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere. OMIM was

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developed for the World Wide Web by the National Center for Biotechnology Information (NCBI).40 The database contains textual information, pictures, and reference information. It also contains copious links to NCBI's Entrez database of MEDLINE articles and sequence information. Go to http://www.ncbi.nlm.nih.gov/Omim/searchomim.html to search the database. Type “gestational diabetes” (or synonyms) in the search box, and click “Submit Search.” If too many results appear, you can narrow the search by adding the word “clinical.” Each report will have additional links to related research and databases. By following these links, especially the link titled “Database Links,” you will be exposed to numerous specialized databases that are largely used by the scientific community. These databases are overly technical and seldom used by the general public, but offer an abundance of information. The following is an example of the results you can obtain from the OMIM for gestational diabetes: ·

Albright Hereditary Osteodystrophy; Aho Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?103580

·

Beckwith-wiedemann Syndrome Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?130650

·

Beta-3-adrenergic Receptor Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?109691

·

Bloom Syndrome Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?210900

·

Coagulation Factor Ii Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?176930

·

Diabetes Mellitus, Insulin-resistant, with Acanthosis Nigricans and Hypertension Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?604367

Adapted from http://www.ncbi.nlm.nih.gov/. Established in 1988 as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information--all for the better understanding of molecular processes affecting human health and disease.

40

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·

Dystrophia Myotonica 1 Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?160900

·

Glucokinase Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?138079

·

Insulin Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?176730

·

Insulin Promoter Factor 1 Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?600733

Genes and Disease (NCBI - Map) The Genes and Disease database is produced by the National Center for Biotechnology Information of the National Library of Medicine at the National Institutes of Health. This Web site categorizes each disorder by the system of the body associated with it. Go to http://www.ncbi.nlm.nih.gov/disease/, and browse the system pages to have a full view of important conditions linked to human genes. Since this site is regularly updated, you may wish to re-visit it from time to time. The following systems and associated disorders are addressed: ·

Cancer: Uncontrolled cell division. Examples: Breast And Ovarian Cancer, Burkitt lymphoma, chronic myeloid leukemia, colon cancer, lung cancer, malignant melanoma, multiple endocrine neoplasia, neurofibromatosis, p53 tumor suppressor, pancreatic cancer, prostate cancer, Ras oncogene, RB: retinoblastoma, von Hippel-Lindau syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Cancer.html

·

Immune System: Fights invaders. Examples: Asthma, autoimmune polyglandular syndrome, Crohn's disease, DiGeorge syndrome, familial Mediterranean fever, immunodeficiency with Hyper-IgM, severe combined immunodeficiency. Web site: http://www.ncbi.nlm.nih.gov/disease/Immune.html

·

Muscle and Bone: Movement and growth. Examples: Duchenne muscular dystrophy, Ellis-van Creveld syndrome, Marfan syndrome, myotonic dystrophy, spinal muscular atrophy. Web site: http://www.ncbi.nlm.nih.gov/disease/Muscle.html

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·

Signals: Cellular messages. Examples: Ataxia telangiectasia, Baldness, Cockayne syndrome, Glaucoma, SRY: sex determination, Tuberous sclerosis, Waardenburg syndrome, Werner syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Signals.html

·

Transporters: Pumps and channels. Examples: Cystic Fibrosis, deafness, diastrophic dysplasia, Hemophilia A, long-QT syndrome, Menkes syndrome, Pendred syndrome, polycystic kidney disease, sickle cell anemia, Wilson's disease, Zellweger syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Transporters.html

Entrez Entrez is a search and retrieval system that integrates several linked databases at the National Center for Biotechnology Information (NCBI). These databases include nucleotide sequences, protein sequences, macromolecular structures, whole genomes, and MEDLINE through PubMed. Entrez provides access to the following databases: ·

PubMed: Biomedical literature (PubMed), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

·

Nucleotide Sequence Database (Genbank): Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Nucleotide

·

Protein Sequence Database: Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Protein

·

Structure: Three-dimensional macromolecular structures, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Structure

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Genome: Complete genome assemblies, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Genome

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PopSet: Population study data sets, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Popset

·

OMIM: Online Mendelian Inheritance in Man, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM

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Taxonomy: Organisms in GenBank, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Taxonomy

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Books: Online books, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=books

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·

ProbeSet: Gene Expression Omnibus (GEO), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

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3D Domains: Domains from Entrez Structure, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

NCBI's Protein Sequence Information Survey Results: Web site: http://www.ncbi.nlm.nih.gov/About/proteinsurvey/

To access the Entrez system at the National Center for Biotechnology Information, go to http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=genom e, and then select the database that you would like to search. The databases available are listed in the drop box next to “Search.” In the box next to “for,” enter “gestational diabetes” (or synonyms) and click “Go.”

Jablonski's Multiple Congenital Anomaly/Mental Retardation (MCA/MR) Syndromes Database41 This online resource can be quite useful. It has been developed to facilitate the identification and differentiation of syndromic entities. Special attention is given to the type of information that is usually limited or completely omitted in existing reference sources due to space limitations of the printed form. At the following Web site you can also search across syndromes using an alphabetical index: http://www.nlm.nih.gov/mesh/jablonski/syndrome_toc/toc_a.html. You can search by keywords at this Web site: http://www.nlm.nih.gov/mesh/jablonski/syndrome_db.html. The Genome Database42 Established at Johns Hopkins University in Baltimore, Maryland in 1990, the Genome Database (GDB) is the official central repository for genomic mapping data resulting from the Human Genome Initiative. In the spring of 1999, the Bioinformatics Supercomputing Centre (BiSC) at the Hospital for Sick Children in Toronto, Ontario assumed the management of GDB. The Adapted from the National Library of Medicine: http://www.nlm.nih.gov/mesh/jablonski/about_syndrome.html. 42 Adapted from the Genome Database: http://gdbwww.gdb.org/gdb/aboutGDB.html#mission. 41

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Human Genome Initiative is a worldwide research effort focusing on structural analysis of human DNA to determine the location and sequence of the estimated 100,000 human genes. In support of this project, GDB stores and curates data generated by researchers worldwide who are engaged in the mapping effort of the Human Genome Project (HGP). GDB's mission is to provide scientists with an encyclopedia of the human genome which is continually revised and updated to reflect the current state of scientific knowledge. Although GDB has historically focused on gene mapping, its focus will broaden as the Genome Project moves from mapping to sequence, and finally, to functional analysis. To access the GDB, simply go to the following hyperlink: http://www.gdb.org/. Search “All Biological Data” by “Keyword.” Type “gestational diabetes” (or synonyms) into the search box, and review the results. If more than one word is used in the search box, then separate each one with the word “and” or “or” (using “or” might be useful when using synonyms). This database is extremely technical as it was created for specialists. The articles are the results which are the most accessible to nonprofessionals and often listed under the heading “Citations.” The contact names are also accessible to non-professionals.

Specialized References The following books are specialized references written for professionals interested in gestational diabetes (sorted alphabetically by title, hyperlinks provide rankings, information, and reviews at Amazon.com): · Comprehensive Gynecology by Morton A. Stenchever, M.D. (Editor), et al; Hardcover - 1325 pages, 4th edition (April 27, 2001), Mosby, Inc.; ISBN: 032301402X; http://www.amazon.com/exec/obidos/ASIN/032301402X/icongroupinterna · Current Clinical Strategies: Gynecology and Obstetrics 2002: With ACOG Guidelines by Paul D. Chan, Christopher R. Winkle; Paperback 140 pages, 6th edition (January 15, 2002), Current Clinical Strategies; ISBN: 192962204X; http://www.amazon.com/exec/obidos/ASIN/192962204X/icongroupinterna · Danforth's Handbook of Obstetrics and Gynecology by James R. Scott, M.D., et al; Paperback, 2nd edition (April 15, 2003), Lippincott, Williams & Wilkins Publishers; ISBN: 0781723647; http://www.amazon.com/exec/obidos/ASIN/0781723647/icongroupinterna

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· Gynecologic Oncology; Hardcover, 1st edition (December 2002), Landes Bioscience; ISBN: 1570595828; http://www.amazon.com/exec/obidos/ASIN/1570595828/icongroupinterna · The Johns Hopkins Manual of Gynecology and Obstetrics (The Spiral Manual Series) by Brandon J. Bankowski (Editor); Paperback, 2nd edition (June 2002), Lippincott, Williams & Wilkins Publishers; ISBN: 0781735955; http://www.amazon.com/exec/obidos/ASIN/0781735955/icongroupinterna · Novak's Gynecology by Jonathan S. Berek, Paula A. Hillard; Hardcover, 13th edition (July 26, 2002), Lippincott, Williams & Wilkins Publishers; ISBN: 078173262X; http://www.amazon.com/exec/obidos/ASIN/078173262X/icongroupinterna · Obstetrics and Gynecology on Call by Horowitz; Paperback, 2nd edition (December 31, 2003), Appleton & Lange; ISBN: 0838571417; http://www.amazon.com/exec/obidos/ASIN/0838571417/icongroupinterna · Solving Patient Problems in Ob/Gyn: The Clerkship Series by Philippe H. Girerd, Tom Peng; Paperback, 1st edition (September 2002), Fence Creek Publishing; ISBN: 1889325082; http://www.amazon.com/exec/obidos/ASIN/1889325082/icongroupinterna · Textbook of Gynecology : An Evidence Based Approach by F. Sanfillipo; Hardcover (June 2002), CRC Press-Parthenon Publishers; ISBN: 184214040X; http://www.amazon.com/exec/obidos/ASIN/184214040X/icongroupinterna

Vocabulary Builder Adrenergic: Activated by, characteristic of, or secreting epinephrine or substances with similar activity; the term is applied to those nerve fibres that liberate norepinephrine at a synapse when a nerve impulse passes, i.e., the sympathetic fibres. [EU] Asymptomatic: Showing or causing no symptoms. [EU] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU]

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Dystocia: Difficult childbirth or labor. [NIH] Idiopathic: Of the nature of an idiopathy; self-originated; of unknown causation. [EU] Indicative: That indicates; that points out more or less exactly; that reveals fairly clearly. [EU] Osteodystrophy: Defective bone formation. [EU] Pancreatitis: Acute or chronic inflammation of the pancreas, which may be asymptomatic or symptomatic, and which is due to autodigestion of a pancreatic tissue by its own enzymes. It is caused most often by alcoholism or biliary tract disease; less commonly it may be associated with hyperlipaemia, hyperparathyroidism, abdominal trauma (accidental or operative injury), vasculitis, or uraemia. [EU] Proportional: Being in proportion : corresponding in size, degree, or intensity, having the same or a constant ratio; of, relating to, or used in determining proportions. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU]

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CHAPTER 8. DISSERTATIONS ON GESTATIONAL DIABETES Overview University researchers are active in studying almost all known diseases. The result of research is often published in the form of Doctoral or Master's dissertations. You should understand, therefore, that applied diagnostic procedures and/or therapies can take many years to develop after the thesis that proposed the new technique or approach was written. In this chapter, we will give you a bibliography on recent dissertations relating to gestational diabetes. You can read about these in more detail using the Internet or your local medical library. We will also provide you with information on how to use the Internet to stay current on dissertations.

Dissertations on Gestational Diabetes ProQuest Digital Dissertations is the largest archive of academic dissertations available. From this archive, we have compiled the following list covering dissertations devoted to gestational diabetes. You will see that the information provided includes the dissertation’s title, its author, and the author’s institution. To read more about the following, simply use the Internet address indicated. The following covers recent dissertations dealing with gestational diabetes: ·

A Pilot Study on the Effectiveness of Medical Nutrition Therapy in the Treatment of Gestational Diabetes Mellitus by Crishi, Barbara L.; Ms from Texas Woman's University, 2000, 57 pages http://wwwlib.umi.com/dissertations/fullcit/1402183

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·

A Randomized Trial to Examine the Effects of Type of Maternal Metabolic Monitoring (self-blood Glucose and Periodic Monitoring) on Self-efficacy and Pregnancy Outcomes in Women with Diet-controlled Gestational Diabetes Mellitus by Homko, Carol J.; Phd from Temple University, 2000, 121 pages http://wwwlib.umi.com/dissertations/fullcit/9969893

·

Asa Classification Assigned to the Healthy Pregnant Patient Compared to the Asa Classification Assigned to the Pregnant Patient Presenting with Gestational Diabetes or Asthma by Dean, Jacqueline Suzanne; Msn from California State University, Long Beach, 2000, 53 pages http://wwwlib.umi.com/dissertations/fullcit/1401610

·

Coping Style and Locus of Control: Predicting Daily Adherence to Self-monitoring of Blood Glucose in Women with Gestational Diabetes Mellitus by Habboushe, Dina Frieda; Phd from Mcp Hahnemann University, 2000, 221 pages http://wwwlib.umi.com/dissertations/fullcit/3013817

Keeping Current As previously mentioned, an effective way to stay current on dissertations dedicated to gestational diabetes is to use the database called ProQuest Digital Dissertations via the Internet, located at the following Web address: http://wwwlib.umi.com/dissertations. The site allows you to freely access the last two years of citations and abstracts. Ask your medical librarian if the library has full and unlimited access to this database. From the library, you should be able to do more complete searches than with the limited 2-year access available to the general public.

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PART III. APPENDICES

ABOUT PART III Part III is a collection of appendices on general medical topics which may be of interest to patients with gestational diabetes and related conditions.

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APPENDIX A. RESEARCHING YOUR MEDICATIONS Overview There are a number of sources available on new or existing medications which could be prescribed to patients with gestational diabetes. While a number of hard copy or CD-Rom resources are available to patients and physicians for research purposes, a more flexible method is to use Internetbased databases. In this chapter, we will begin with a general overview of medications. We will then proceed to outline official recommendations on how you should view your medications. You may also want to research medications that you are currently taking for other conditions as they may interact with medications for gestational diabetes. Research can give you information on the side effects, interactions, and limitations of prescription drugs used in the treatment of gestational diabetes. Broadly speaking, there are two sources of information on approved medications: public sources and private sources. We will emphasize free-to-use public sources.

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Your Medications: The Basics43 The Agency for Health Care Research and Quality has published extremely useful guidelines on how you can best participate in the medication aspects of gestational diabetes. Taking medicines is not always as simple as swallowing a pill. It can involve many steps and decisions each day. The AHCRQ recommends that patients with gestational diabetes take part in treatment decisions. Do not be afraid to ask questions and talk about your concerns. By taking a moment to ask questions early, you may avoid problems later. Here are some points to cover each time a new medicine is prescribed: ·

Ask about all parts of your treatment, including diet changes, exercise, and medicines.

·

Ask about the risks and benefits of each medicine or other treatment you might receive.

·

Ask how often you or your doctor will check for side effects from a given medication.

Do not hesitate to ask what is important to you about your medicines. You may want a medicine with the fewest side effects, or the fewest doses to take each day. You may care most about cost, or how the medicine might affect how you live or work. Or, you may want the medicine your doctor believes will work the best. Telling your doctor will help him or her select the best treatment for you. Do not be afraid to “bother” your doctor with your concerns and questions about medications for gestational diabetes. You can also talk to a nurse or a pharmacist. They can help you better understand your treatment plan. Feel free to bring a friend or family member with you when you visit your doctor. Talking over your options with someone you trust can help you make better choices, especially if you are not feeling well. Specifically, ask your doctor the following: ·

The name of the medicine and what it is supposed to do.

·

How and when to take the medicine, how much to take, and for how long.

·

What food, drinks, other medicines, or activities you should avoid while taking the medicine.

·

What side effects the medicine may have, and what to do if they occur.

43

This section is adapted from AHCRQ: http://www.ahcpr.gov/consumer/ncpiebro.htm.

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·

If you can get a refill, and how often.

·

About any terms or directions you do not understand.

·

What to do if you miss a dose.

·

If there is written information you can take home (most pharmacies have information sheets on your prescription medicines; some even offer large-print or Spanish versions).

Do not forget to tell your doctor about all the medicines you are currently taking (not just those for gestational diabetes). This includes prescription medicines and the medicines that you buy over the counter. Then your doctor can avoid giving you a new medicine that may not work well with the medications you take now. When talking to your doctor, you may wish to prepare a list of medicines you currently take, the reason you take them, and how you take them. Be sure to include the following information for each: ·

Name of medicine

·

Reason taken

·

Dosage

·

Time(s) of day

Also include any over-the-counter medicines, such as: ·

Laxatives

·

Diet pills

·

Vitamins

·

Cold medicine

·

Aspirin or other pain, headache, or fever medicine

·

Cough medicine

·

Allergy relief medicine

·

Antacids

·

Sleeping pills

·

Others (include names)

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Learning More about Your Medications Because of historical investments by various organizations and the emergence of the Internet, it has become rather simple to learn about the medications your doctor has recommended for gestational diabetes. One such source is the United States Pharmacopeia. In 1820, eleven physicians met in Washington, D.C. to establish the first compendium of standard drugs for the United States. They called this compendium the “U.S. Pharmacopeia (USP).” Today, the USP is a non-profit organization consisting of 800 volunteer scientists, eleven elected officials, and 400 representatives of state associations and colleges of medicine and pharmacy. The USP is located in Rockville, Maryland, and its home page is located at www.usp.org. The USP currently provides standards for over 3,700 medications. The resulting USP DIÒ Advice for the PatientÒ can be accessed through the National Library of Medicine of the National Institutes of Health. The database is partially derived from lists of federally approved medications in the Food and Drug Administration's (FDA) Drug Approvals database.44 While the FDA database is rather large and difficult to navigate, the Phamacopeia is both user-friendly and free to use. It covers more than 9,000 prescription and over-the-counter medications. To access this database, simply type the following hyperlink into your Web browser: http://www.nlm.nih.gov/medlineplus/druginformation.html. To view examples of a given medication (brand names, category, description, preparation, proper use, precautions, side effects, etc.), simply follow the hyperlinks indicated within the United States Pharmacopoeia (USP). It is important to read the disclaimer by the USP (http://www.nlm.nih.gov/medlineplus/drugdisclaimer.html) before using the information provided. Of course, we as editors cannot be certain as to what medications you are taking. Therefore, we have compiled a list of medications associated with the treatment of gestational diabetes. Once again, due to space limitations, we only list a sample of medications and provide hyperlinks to ample documentation (e.g. typical dosage, side effects, drug-interaction risks, etc.). The following drugs have been mentioned in the Pharmacopeia and other sources as being potentially applicable to gestational diabetes:

Though cumbersome, the FDA database can be freely browsed at the following site: www.fda.gov/cder/da/da.htm.

44

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Insulin ·

Systemic - U.S. Brands: Humulin 50/50; Humulin 70/30; Humulin 70/30 Pen; Humulin L; Humulin N; Humulin N Pen; Humulin R; Humulin R, Regular U-500 (Concentrated); Humulin U; Lente; Lente Iletin II; Novolin 70/30; Novolin 70/30 PenFill; Novolin 70/30 Prefilled; Novolin L; Novoli http://www.nlm.nih.gov/medlineplus/druginfo/insulinsystemic 203298.html

Commercial Databases In addition to the medications listed in the USP above, a number of commercial sites are available by subscription to physicians and their institutions. You may be able to access these sources from your local medical library or your doctor's office.

Reuters Health Drug Database The Reuters Health Drug Database can be searched by keyword at the hyperlink: http://www.reutershealth.com/frame2/drug.html. The following medications are listed in the Reuters' database as associated with gestational diabetes (including those with contraindications):45 ·

Tolazamide http://www.reutershealth.com/atoz/html/Tolazamide.htm

Mosby's GenRx Mosby's GenRx database (also available on CD-Rom and book format) covers 45,000 drug products including generics and international brands. It provides prescribing information, drug interactions, and patient information. Information can be obtained at the following hyperlink: http://www.genrx.com/Mosby/PhyGenRx/group.html. Physicians Desk Reference The Physicians Desk Reference database (also available in CD-Rom and book format) is a full-text drug database. The database is searchable by brand 45

Adapted from A to Z Drug Facts by Facts and Comparisons.

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name, generic name or by indication. It features multiple drug interactions reports. Information can be obtained at the following hyperlink: http://physician.pdr.net/physician/templates/en/acl/psuser_t.htm. Other Web Sites A number of additional Web sites discuss drug information. As an example, you may like to look at www.drugs.com which reproduces the information in the Pharmacopeia as well as commercial information. You may also want to consider the Web site of the Medical Letter, Inc. which allows users to download articles on various drugs and therapeutics for a nominal fee: http://www.medletter.com/.

Contraindications and Interactions (Hidden Dangers) Some of the medications mentioned in the previous discussions can be problematic for patients with gestational diabetes--not because they are used in the treatment process, but because of contraindications, or side effects. Medications with contraindications are those that could react with drugs used to treat gestational diabetes or potentially create deleterious side effects in patients with gestational diabetes. You should ask your physician about any contraindications, especially as these might apply to other medications that you may be taking for common ailments. Drug-drug interactions occur when two or more drugs react with each other. This drug-drug interaction may cause you to experience an unexpected side effect. Drug interactions may make your medications less effective, cause unexpected side effects, or increase the action of a particular drug. Some drug interactions can even be harmful to you. Be sure to read the label every time you use a nonprescription or prescription drug, and take the time to learn about drug interactions. These precautions may be critical to your health. You can reduce the risk of potentially harmful drug interactions and side effects with a little bit of knowledge and common sense. Drug labels contain important information about ingredients, uses, warnings, and directions which you should take the time to read and understand. Labels also include warnings about possible drug interactions. Further, drug labels may change as new information becomes available. This is why it's especially important to read the label every time you use a

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medication. When your doctor prescribes a new drug, discuss all over-thecounter and prescription medications, dietary supplements, vitamins, botanicals, minerals and herbals you take as well as the foods you eat. Ask your pharmacist for the package insert for each prescription drug you take. The package insert provides more information about potential drug interactions.

A Final Warning At some point, you may hear of alternative medications from friends, relatives, or in the news media. Advertisements may suggest that certain alternative drugs can produce positive results for patients with gestational diabetes. Exercise caution--some of these drugs may have fraudulent claims, and others may actually hurt you. The Food and Drug Administration (FDA) is the official U.S. agency charged with discovering which medications are likely to improve the health of patients with gestational diabetes. The FDA warns patients to watch out for46: ·

Secret formulas (real scientists share what they know)

·

Amazing breakthroughs or miracle cures (real breakthroughs don't happen very often; when they do, real scientists do not call them amazing or miracles)

·

Quick, painless, or guaranteed cures

·

If it sounds too good to be true, it probably isn't true.

If you have any questions about any kind of medical treatment, the FDA may have an office near you. Look for their number in the blue pages of the phone book. You can also contact the FDA through its toll-free number, 1888-INFO-FDA (1-888-463-6332), or on the World Wide Web at www.fda.gov.

This section has been adapted from http://www.fda.gov/opacom/lowlit/medfraud.html.

46

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General References In addition to the resources provided earlier in this chapter, the following general references describe medications (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

New Pharmacological Approaches to Reproductive Health and Healthy Ageing : Symposium on the Occasion of the 80th Birthday of Professor Egon diczfalusy by Werner-Karl Raff (Editor), et al; Hardcover (December 2001), Springer Verlag; ISBN: 354042234X; http://www.amazon.com/exec/obidos/ASIN/354042234X/icongroupinterna

·

Complete Guide to Prescription and Nonprescription Drugs 2001 (Complete Guide to Prescription and Nonprescription Drugs, 2001) by H. Winter Griffith, Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/039952634X/icongroupinterna

·

The Essential Guide to Prescription Drugs, 2001 by James J. Rybacki, James W. Long; Paperback - 1274 pages (2001), Harper Resource; ISBN: 0060958162; http://www.amazon.com/exec/obidos/ASIN/0060958162/icongroupinterna

·

Handbook of Commonly Prescribed Drugs by G. John Digregorio, Edward J. Barbieri; Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/0942447417/icongroupinterna

·

Johns Hopkins Complete Home Encyclopedia of Drugs 2nd ed. by Simeon Margolis (Ed.), Johns Hopkins; Hardcover - 835 pages (2000), Rebus; ISBN: 0929661583; http://www.amazon.com/exec/obidos/ASIN/0929661583/icongroupinterna

·

Medical Pocket Reference: Drugs 2002 by Springhouse Paperback 1st edition (2001), Lippincott Williams & Wilkins Publishers; ISBN: 1582550964; http://www.amazon.com/exec/obidos/ASIN/1582550964/icongroupinterna

·

PDR by Medical Economics Staff, Medical Economics Staff Hardcover 3506 pages 55th edition (2000), Medical Economics Company; ISBN: 1563633752; http://www.amazon.com/exec/obidos/ASIN/1563633752/icongroupinterna

·

Pharmacy Simplified: A Glossary of Terms by James Grogan; Paperback 432 pages, 1st edition (2001), Delmar Publishers; ISBN: 0766828581; http://www.amazon.com/exec/obidos/ASIN/0766828581/icongroupinterna

Researching Your Medications 147

·

Physician Federal Desk Reference by Christine B. Fraizer; Paperback 2nd edition (2001), Medicode Inc; ISBN: 1563373971; http://www.amazon.com/exec/obidos/ASIN/1563373971/icongroupinterna

·

Physician's Desk Reference Supplements Paperback - 300 pages, 53 edition (1999), ISBN: 1563632950; http://www.amazon.com/exec/obidos/ASIN/1563632950/icongroupinterna

Researching Alternative Medicine 149

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE Overview Complementary and alternative medicine (CAM) is one of the most contentious aspects of modern medical practice. You may have heard of these treatments on the radio or on television. Maybe you have seen articles written about these treatments in magazines, newspapers, or books. Perhaps your friends or doctor have mentioned alternatives. In this chapter, we will begin by giving you a broad perspective on complementary and alternative therapies. Next, we will introduce you to official information sources on CAM relating to gestational diabetes. Finally, at the conclusion of this chapter, we will provide a list of readings on gestational diabetes from various authors. We will begin, however, with the National Center for Complementary and Alternative Medicine's (NCCAM) overview of complementary and alternative medicine.

What Is CAM?47 Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices which are not taught in medical schools, used in hospitals, or reimbursed by medical insurance companies. Many CAM therapies are termed “holistic,” which generally means that the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual health. Some of these therapies are also known as “preventive,” which means that the practitioner educates and 47

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/faq/index.html#what-is.

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treats the person to prevent health problems from arising, rather than treating symptoms after problems have occurred. People use CAM treatments and therapies in a variety of ways. Therapies are used alone (often referred to as alternative), in combination with other alternative therapies, or in addition to conventional treatment (sometimes referred to as complementary). Complementary and alternative medicine, or “integrative medicine,” includes a broad range of healing philosophies, approaches, and therapies. Some approaches are consistent with physiological principles of Western medicine, while others constitute healing systems with non-Western origins. While some therapies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine. Complementary and alternative therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of complementary or alternative therapy include mind/body control interventions such as visualization and relaxation, manual healing including acupressure and massage, homeopathy, vitamins or herbal products, and acupuncture.

What Are the Domains of Alternative Medicine?48 The list of CAM practices changes continually. The reason being is that these new practices and therapies are often proved to be safe and effective, and therefore become generally accepted as “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologicallybased treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this sourcebook. Thus, only limited examples are provided within each. Alternative Medical Systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of, and often prior to, conventional biomedical approaches. Many are traditional systems of medicine that are

48

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/classify/index.html.

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practiced by individual cultures throughout the world, including a number of venerable Asian approaches. Traditional oriental medicine emphasizes the balance or disturbances of qi (pronounced chi) or vital energy in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a thin needle. Ayurveda is India's traditional system of medicine. Ayurvedic medicine (meaning “science of life”) is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit. Ayurveda strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Other traditional healing systems have been developed by the world’s indigenous populations. These populations include Native American, Aboriginal, African, Middle Eastern, Tibetan, and Central and South American cultures. Homeopathy and naturopathy are also examples of complete alternative medicine systems. Homeopathic medicine is an unconventional Western system that is based on the principle that “like cures like,” i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic health practitioners believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body's defense mechanisms and healing processes in order to treat illness. Naturopathic medicine is based on the theory that disease is a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including the following: diet and clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy (the use of water in a range of temperatures and methods of applications), spinal and soft-tissue manipulation, physical therapies (such as those involving electrical currents, ultrasound, and light), therapeutic counseling, and pharmacology.

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Mind-Body Interventions Mind-body interventions employ a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms. Only a select group of mind-body interventions having well-documented theoretical foundations are considered CAM. For example, patient education and cognitive-behavioral approaches are now considered “mainstream.” On the other hand, complementary and alternative medicine includes meditation, certain uses of hypnosis, dance, music, and art therapy, as well as prayer and mental healing.

Biological-Based Therapies This category of CAM includes natural and biological-based practices, interventions, and products, many of which overlap with conventional medicine's use of dietary supplements. This category includes herbal, special dietary, orthomolecular, and individual biological therapies. Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and/or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.

Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure and function, primarily pertaining to the spine, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. In contrast, osteopaths place particular emphasis on the musculoskeletal system and practice osteopathic manipulation. Osteopaths believe that all of the body's systems work together and that disturbances in one system may have an impact upon function elsewhere in the body. Massage therapists manipulate the soft tissues of the body to normalize those tissues.

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Energy Therapies Energy therapies focus on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields). Biofield therapies are intended to affect energy fields (the existence of which is not yet experimentally proven) that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, improve blood circulation, and enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that, by channeling spiritual energy through the practitioner, the spirit is healed and, in turn, heals the physical body. Therapeutic Touch is derived from the ancient technique of “laying-on of hands.” It is based on the premises that the therapist’s healing force affects the patient's recovery and that healing is promoted when the body's energies are in balance. By passing their hands over the patient, these healers identify energy imbalances. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Can Alternatives Affect My Treatment? A critical issue in pursuing complementary alternatives mentioned thus far is the risk that these might have undesirable interactions with your medical treatment. It becomes all the more important to speak with your doctor who can offer advice on the use of alternatives. Official sources confirm this view. Though written for women, we find that the National Women’s Health Information Center’s advice on pursuing alternative medicine is appropriate for patients of both genders and all ages.49

49

Adapted from http://www.4woman.gov/faq/alternative.htm.

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Is It Okay to Want Both Traditional and Alternative Medicine? Should you wish to explore non-traditional types of treatment, be sure to discuss all issues concerning treatments and therapies with your healthcare provider, whether a physician or practitioner of complementary and alternative medicine. Competent healthcare management requires knowledge of both conventional and alternative therapies you are taking for the practitioner to have a complete picture of your treatment plan. The decision to use complementary and alternative treatments is an important one. Consider before selecting an alternative therapy, the safety and effectiveness of the therapy or treatment, the expertise and qualifications of the healthcare practitioner, and the quality of delivery. These topics should be considered when selecting any practitioner or therapy.

Finding CAM References on Gestational Diabetes Having read the previous discussion, you may be wondering which complementary or alternative treatments might be appropriate for gestational diabetes. For the remainder of this chapter, we will direct you to a number of official sources which can assist you in researching studies and publications. Some of these articles are rather technical, so some patience may be required. The Combined Health Information Database For a targeted search, The Combined Health Information Database is a bibliographic database produced by health-related agencies of the Federal Government (mostly from the National Institutes of Health). This database is updated four times a year at the end of January, April, July, and October. Check the titles, summaries, and availability of CAM-related information by using the “Simple Search” option at the following Web site: http://chid.nih.gov/simple/simple.html. In the drop box at the top, select “Complementary and Alternative Medicine.” Then type “gestational diabetes” (or synonyms) in the second search box. We recommend that you select 100 “documents per page” and to check the “whole records” options.

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National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (http://nccam.nih.gov) has created a link to the National Library of Medicine's databases to allow patients to search for articles that specifically relate to gestational diabetes and complementary medicine. To search the database, go to the following Web site: www.nlm.nih.gov/nccam/camonpubmed.html. Select “CAM on PubMed.” Enter “gestational diabetes” (or synonyms) into the search box. Click “Go.” The following references provide information on particular aspects of complementary and alternative medicine (CAM) that are related to gestational diabetes: ·

A high-fibre diet in gestational diabetes--wheat fibre, leguminous fibre or both? Author(s): Paisey RB, Hartog M, Savage P. Source: Hum Nutr Appl Nutr. 1987 April; 41(2): 146-9. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3032872&dopt=Abstract

·

Amylophagia presenting as gestational diabetes. Author(s): Jackson WC, Martin JP. Source: Archives of Family Medicine. 2000 July; 9(7): 649-52. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10910314&dopt=Abstract

·

Do fiber-enriched diabetic diets have glucose-lowering effects in pregnancy? Author(s): Reece EA, Hagay Z, Caseria D, Gay LJ, DeGennaro N. Source: American Journal of Perinatology. 1993 July; 10(4): 272-4. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8397560&dopt=Abstract

·

Fasting plasma glucose as a screening test for gestational diabetes in a multi-ethnic, high-risk population. Author(s): Agarwal MM, Hughes PF, Punnose J, Ezimokhai M. Source: Diabetic Medicine : a Journal of the British Diabetic Association. 2000 October; 17(10): 720-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11110505&dopt=Abstract

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·

Long-term high fibre, low fat diet in gestational diabetes. Author(s): Paisey RB, Savage P, Marsland I, Cooke P. Source: Diabetic Medicine : a Journal of the British Diabetic Association. 1985 July; 2(4): 286-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3030616&dopt=Abstract

·

Long-term implications of gestational diabetes for the mother. Author(s): Henry OA, Beischer NA. Source: Baillieres Clin Obstet Gynaecol. 1991 June; 5(2): 461-83. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1954723&dopt=Abstract

·

Management of the woman with gestational diabetes mellitus. Author(s): Jones MW, Stone LC. Source: J Perinat Neonatal Nurs. 1998 March; 11(4): 13-24. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9592458&dopt=Abstract

·

Thiamine supplementation to prevent induction of low birth weight by conventional therapy for gestational diabetes mellitus. Author(s): Bakker SJ, ter Maaten JC, Gans RO. Source: Medical Hypotheses. 2000 July; 55(1): 88-90. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11021334&dopt=Abstract

Additional Web Resources A number of additional Web sites offer encyclopedic information covering CAM and related topics. The following is a representative sample: ·

Alternative Medicine Foundation, Inc.: http://www.herbmed.org/

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AOL: http://search.aol.com/cat.adp?id=169&layer=&from=subcats

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Chinese Medicine: http://www.newcenturynutrition.com/

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drkoop.comÒ: http://www.drkoop.com/InteractiveMedicine/IndexC.html

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Family Village: http://www.familyvillage.wisc.edu/med_altn.htm

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Google: http://directory.google.com/Top/Health/Alternative/

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Open Directory Project: http://dmoz.org/Health/Alternative/

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·

TPN.com: http://www.tnp.com/

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Yahoo.com: http://dir.yahoo.com/Health/Alternative_Medicine/

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WebMDÒHealth: http://my.webmd.com/drugs_and_herbs

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WellNet: http://www.wellnet.ca/herbsa-c.htm

The following is a specific Web list relating to gestational diabetes; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation: ·

Related Conditions Diabetes Source: Prima Communications, Inc. Hyperlink: http://www.personalhealthzone.com/pg000285.html Diabetes Mellitus Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Diabet esMellituscc.html Obesity Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Obesit ycc.html Preeclampsia Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Preeclampsia.htm Pregnancy and Postpartum Support Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Pregnancy.htm

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General References A good place to find general background information on CAM is the National Library of Medicine. It has prepared within the MEDLINEplus system an information topic page dedicated to complementary and alternative medicine. To access this page, go to the MEDLINEplus site at: www.nlm.nih.gov/medlineplus/alternativemedicine.html. This Web site provides a general overview of various topics and can lead to a number of general sources. The following additional references describe, in broad terms, alternative and complementary medicine (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): ·

Ayurveda for Women: A Guide to Vitality and Health by Robert E. Svoboda; Paperback - 176 pages (November 2000), Inner Traditions Int’l Ltd.; ISBN: 0892819391; http://www.amazon.com/exec/obidos/ASIN/0892819391/icongroupinterna

·

The Path of Practice: A Woman's Book of Healing with Food, Breath, and Sound by Bri Maya Tiwari; Hardcover - 320 pages (October 31, 2000), Ballantine Books; ISBN: 0345430301; http://www.amazon.com/exec/obidos/ASIN/0345430301/icongroupinterna

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Reclaiming Our Health : Exploding the Medical Myth and Embracing the Sources of True Healing by John Robbins, Marianne Williamson; Paperback - 432 pages (February 1998), H J Kramer; ISBN: 0915811804; http://www.amazon.com/exec/obidos/ASIN/0915811804/icongroupinterna

·

Taking Charge of Your Fertility: The Definitive Guide to Natural Birth Control, Pregnancy Achievement, and Reproductive Health (Revised Edition) by Toni Weschler; Paperback - 496 pages, Revised edition (November 13, 2001), Quill; ISBN: 0060937645; http://www.amazon.com/exec/obidos/ASIN/0060937645/icongroupinterna

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Women's Encyclopedia of Natural Medicine by Tori Hudson, Christiane Northrup; Paperback - 358 pages, 1st edition (April 11, 1999), McGraw Hill - NTC; ISBN: 0879837888; http://www.amazon.com/exec/obidos/ASIN/0879837888/icongroupinterna

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Woman Heal Thyself : An Ancient Healing System for Contemporary Women by Jeanne Elizabeth Blum; Paperback - 328 pages, Revised edition (September 1996), Charles Tuttle Co.; ISBN: 0804831017; http://www.amazon.com/exec/obidos/ASIN/0804831017/icongroupinterna

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For additional information on complementary and alternative medicine, ask your doctor or write to: National Institutes of Health National Center for Complementary and Alternative Medicine Clearinghouse P. O. Box 8218 Silver Spring, MD 20907-8218

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Hyperglycaemia: Abnormally increased content of sugar in the blood. [EU] Midwifery: The practice of assisting women in childbirth. [NIH] Perineal: Pertaining to the perineum. [EU] Phallic: Pertaining to the phallus, or penis. [EU] Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU]

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APPENDIX C. RESEARCHING NUTRITION Overview Since the time of Hippocrates, doctors have understood the importance of diet and nutrition to patients’ health and well-being. Since then, they have accumulated an impressive archive of studies and knowledge dedicated to this subject. Based on their experience, doctors and healthcare providers may recommend particular dietary supplements to patients with gestational diabetes. Any dietary recommendation is based on a patient's age, body mass, gender, lifestyle, eating habits, food preferences, and health condition. It is therefore likely that different patients with gestational diabetes may be given different recommendations. Some recommendations may be directly related to gestational diabetes, while others may be more related to the patient's general health. These recommendations, themselves, may differ from what official sources recommend for the average person. In this chapter we will begin by briefly reviewing the essentials of diet and nutrition that will broadly frame more detailed discussions of gestational diabetes. We will then show you how to find studies dedicated specifically to nutrition and gestational diabetes.

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Food and Nutrition: General Principles What Are Essential Foods? Food is generally viewed by official sources as consisting of six basic elements: (1) fluids, (2) carbohydrates, (3) protein, (4) fats, (5) vitamins, and (6) minerals. Consuming a combination of these elements is considered to be a healthy diet: ·

Fluids are essential to human life as 80-percent of the body is composed of water. Water is lost via urination, sweating, diarrhea, vomiting, diuretics (drugs that increase urination), caffeine, and physical exertion.

·

Carbohydrates are the main source for human energy (thermoregulation) and the bulk of typical diets. They are mostly classified as being either simple or complex. Simple carbohydrates include sugars which are often consumed in the form of cookies, candies, or cakes. Complex carbohydrates consist of starches and dietary fibers. Starches are consumed in the form of pastas, breads, potatoes, rice, and other foods. Soluble fibers can be eaten in the form of certain vegetables, fruits, oats, and legumes. Insoluble fibers include brown rice, whole grains, certain fruits, wheat bran and legumes.

·

Proteins are eaten to build and repair human tissues. Some foods that are high in protein are also high in fat and calories. Food sources for protein include nuts, meat, fish, cheese, and other dairy products.

·

Fats are consumed for both energy and the absorption of certain vitamins. There are many types of fats, with many general publications recommending the intake of unsaturated fats or those low in cholesterol.

Vitamins and minerals are fundamental to human health, growth, and, in some cases, disease prevention. Most are consumed in your diet (exceptions being vitamins K and D which are produced by intestinal bacteria and sunlight on the skin, respectively). Each vitamin and mineral plays a different role in health. The following outlines essential vitamins: ·

Vitamin A is important to the health of your eyes, hair, bones, and skin; sources of vitamin A include foods such as eggs, carrots, and cantaloupe.

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Vitamin B1, also known as thiamine, is important for your nervous system and energy production; food sources for thiamine include meat, peas, fortified cereals, bread, and whole grains.

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Vitamin B2, also known as riboflavin, is important for your nervous system and muscles, but is also involved in the release of proteins from

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nutrients; food sources for riboflavin include dairy products, leafy vegetables, meat, and eggs. ·

Vitamin B3, also known as niacin, is important for healthy skin and helps the body use energy; food sources for niacin include peas, peanuts, fish, and whole grains

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Vitamin B6, also known as pyridoxine, is important for the regulation of cells in the nervous system and is vital for blood formation; food sources for pyridoxine include bananas, whole grains, meat, and fish.

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Vitamin B12 is vital for a healthy nervous system and for the growth of red blood cells in bone marrow; food sources for vitamin B12 include yeast, milk, fish, eggs, and meat.

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Vitamin C allows the body's immune system to fight various diseases, strengthens body tissue, and improves the body's use of iron; food sources for vitamin C include a wide variety of fruits and vegetables.

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Vitamin D helps the body absorb calcium which strengthens bones and teeth; food sources for vitamin D include oily fish and dairy products.

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Vitamin E can help protect certain organs and tissues from various degenerative diseases; food sources for vitamin E include margarine, vegetables, eggs, and fish.

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Vitamin K is essential for bone formation and blood clotting; common food sources for vitamin K include leafy green vegetables.

·

Folic Acid maintains healthy cells and blood and, when taken by a pregnant woman, can prevent her fetus from developing neural tube defects; food sources for folic acid include nuts, fortified breads, leafy green vegetables, and whole grains.

It should be noted that one can overdose on certain vitamins which become toxic if consumed in excess (e.g. vitamin A, D, E and K). Like vitamins, minerals are chemicals that are required by the body to remain in good health. Because the human body does not manufacture these chemicals internally, we obtain them from food and other dietary sources. The more important minerals include: ·

Calcium is needed for healthy bones, teeth, and muscles, but also helps the nervous system function; food sources for calcium include dry beans, peas, eggs, and dairy products.

·

Chromium is helpful in regulating sugar levels in blood; food sources for chromium include egg yolks, raw sugar, cheese, nuts, beets, whole grains, and meat.

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·

Fluoride is used by the body to help prevent tooth decay and to reinforce bone strength; sources of fluoride include drinking water and certain brands of toothpaste.

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Iodine helps regulate the body's use of energy by synthesizing into the hormone thyroxine; food sources include leafy green vegetables, nuts, egg yolks, and red meat.

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Iron helps maintain muscles and the formation of red blood cells and certain proteins; food sources for iron include meat, dairy products, eggs, and leafy green vegetables.

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Magnesium is important for the production of DNA, as well as for healthy teeth, bones, muscles, and nerves; food sources for magnesium include dried fruit, dark green vegetables, nuts, and seafood.

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Phosphorous is used by the body to work with calcium to form bones and teeth; food sources for phosphorous include eggs, meat, cereals, and dairy products.

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Selenium primarily helps maintain normal heart and liver functions; food sources for selenium include wholegrain cereals, fish, meat, and dairy products.

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Zinc helps wounds heal, the formation of sperm, and encourage rapid growth and energy; food sources include dried beans, shellfish, eggs, and nuts.

The United States government periodically publishes recommended diets and consumption levels of the various elements of food. Again, your doctor may encourage deviations from the average official recommendation based on your specific condition. To learn more about basic dietary guidelines, visit the Web site: http://www.health.gov/dietaryguidelines/. Based on these guidelines, many foods are required to list the nutrition levels on the food’s packaging. Labeling Requirements are listed at the following site maintained by the Food and Drug Administration: http://www.cfsan.fda.gov/~dms/labcons.html. When interpreting these requirements, the government recommends that consumers become familiar with the following abbreviations before reading FDA literature:50 ·

DVs (Daily Values): A new dietary reference term that will appear on the food label. It is made up of two sets of references, DRVs and RDIs.

·

DRVs (Daily Reference Values): A set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium.

50

Adapted from the FDA: http://www.fda.gov/fdac/special/foodlabel/dvs.html.

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·

RDIs (Reference Daily Intakes): A set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals and, in selected groups, protein. The name “RDI” replaces the term “U.S. RDA.”

·

RDAs (Recommended Dietary Allowances): A set of estimated nutrient allowances established by the National Academy of Sciences. It is updated periodically to reflect current scientific knowledge. What Are Dietary Supplements?51

Dietary supplements are widely available through many commercial sources, including health food stores, grocery stores, pharmacies, and by mail. Dietary supplements are provided in many forms including tablets, capsules, powders, gel-tabs, extracts, and liquids. Historically in the United States, the most prevalent type of dietary supplement was a multivitamin/mineral tablet or capsule that was available in pharmacies, either by prescription or “over the counter.” Supplements containing strictly herbal preparations were less widely available. Currently in the United States, a wide array of supplement products are available, including vitamin, mineral, other nutrients, and botanical supplements as well as ingredients and extracts of animal and plant origin. The Office of Dietary Supplements (ODS) of the National Institutes of Health is the official agency of the United States which has the expressed goal of acquiring “new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold.”52 According to the ODS, dietary supplements can have an important impact on the prevention and management of disease and on the maintenance of health.53 The ODS notes that considerable research on the effects of dietary supplements has been conducted in Asia and Europe where the use of plant products, in particular, has a long tradition. However, the overwhelming majority of supplements have not been studied scientifically. This discussion has been adapted from the NIH: http://ods.od.nih.gov/whatare/whatare.html. 52 Contact: The Office of Dietary Supplements, National Institutes of Health, Building 31, Room 1B29, 31 Center Drive, MSC 2086, Bethesda, Maryland 20892-2086, Tel: (301) 435-2920, Fax: (301) 480-1845, E-mail: [email protected]. 53 Adapted from http://ods.od.nih.gov/about/about.html. The Dietary Supplement Health and Education Act defines dietary supplements as “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, mineral, amino acid, herb or other botanical; or a dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above; and intended for ingestion in the form of a capsule, powder, softgel, or gelcap, and not represented as a conventional food or as a sole item of a meal or the diet.” 51

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To explore the role of dietary supplements in the improvement of health care, the ODS plans, organizes, and supports conferences, workshops, and symposia on scientific topics related to dietary supplements. The ODS often works in conjunction with other NIH Institutes and Centers, other government agencies, professional organizations, and public advocacy groups. To learn more about official information on dietary supplements, visit the ODS site at http://ods.od.nih.gov/whatare/whatare.html. Or contact: The Office of Dietary Supplements National Institutes of Health Building 31, Room 1B29 31 Center Drive, MSC 2086 Bethesda, Maryland 20892-2086 Tel: (301) 435-2920 Fax: (301) 480-1845 E-mail: [email protected]

Finding Studies on Gestational Diabetes The NIH maintains an office dedicated to patient nutrition and diet. The National Institutes of Health’s Office of Dietary Supplements (ODS) offers a searchable bibliographic database called the IBIDS (International Bibliographic Information on Dietary Supplements). The IBIDS contains over 460,000 scientific citations and summaries about dietary supplements and nutrition as well as references to published international, scientific literature on dietary supplements such as vitamins, minerals, and botanicals.54 IBIDS is available to the public free of charge through the ODS Internet page: http://ods.od.nih.gov/databases/ibids.html. After entering the search area, you have three choices: (1) IBIDS Consumer Database, (2) Full IBIDS Database, or (3) Peer Reviewed Citations Only. We recommend that you start with the Consumer Database. While you may not find references for the topics that are of most interest to you, check back periodically as this database is frequently updated. More studies can be found by searching the Full IBIDS Database. Healthcare professionals and Adapted from http://ods.od.nih.gov. IBIDS is produced by the Office of Dietary Supplements (ODS) at the National Institutes of Health to assist the public, healthcare providers, educators, and researchers in locating credible, scientific information on dietary supplements. IBIDS was developed and will be maintained through an interagency partnership with the Food and Nutrition Information Center of the National Agricultural Library, U.S. Department of Agriculture.

54

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researchers generally use the third option, which lists peer-reviewed citations. In all cases, we suggest that you take advantage of the “Advanced Search” option that allows you to retrieve up to 100 fully explained references in a comprehensive format. Type “gestational diabetes” (or synonyms) into the search box. To narrow the search, you can also select the “Title” field. The following is a typical result when searching for recently indexed consumer information on gestational diabetes: ·

A longitudinal study of plasma insulin and glucagon in women with previous gestational diabetes. Author(s): Department of Obstetrics and Gynecology, Rigshospitalet, University of Copenhagen, Denmark. Source: Damm, P Kuhl, C Hornnes, P Molsted Pedersen, L Diabetes-Care. 1995 May; 18(5): 654-65 0149-5992

·

American Diabetes Association's Fourth International WorkshopConference on Gestational Diabetes Mellitus: summary and discussion. Therapeutic interventions. Author(s): Sansum Medical Research Foundation, Santa Barbara, California 93105, USA. [email protected] Source: Jovanovic, L Diabetes-Care. 1998 August; 21 Suppl 2B131-7 01495992

·

Antepartum management protocol. Timing and mode of delivery in gestational diabetes. Author(s): Department of Obstetrics and Gynecology, Rabin Medical Center, Tel Aviv, Israel. [email protected] Source: Hod, M Bar, J Peled, Y Fried, S Katz, I Itzhak, M Ashkenazi, S Schindel, B Ben Rafael, Z Diabetes-Care. 1998 August; 21 Suppl 2B113-7 0149-5992

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Assessment of costs and benefits of management of gestational diabetes mellitus. Author(s): Division of Maternal-Fetal Medicine, Good Samaritan Hospital, San Jose, California, USA. Source: Kitzmiller, J L Elixhauser, A Carr, S Major, C A de Veciana, M Dang Kilduff, L Weschler, J M Diabetes-Care. 1998 August; 21 Suppl 2B123-30 0149-5992

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Birth weight of women with gestational diabetes. Author(s): Illawarra Area Health Service, Wollongong, New South Wales, Australia. [email protected] Source: Moses, R G Moses, J Knights, S Diabetes-Care. 1999 July; 22(7): 1059-62 0149-5992

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·

Care of diabetic pregnant women by primary-care physicians. Reported strategies for managing pregestational and gestational diabetes. Author(s): Department of Medicine, Regenstrief Institute, Indianapolis, IN 46202. Source: Marrero, D G Moore, P Langefeld, C D Golichowski, A Clark, C M Diabetes-Care. 1992 January; 15(1): 101-7 0149-5992

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Early postpartum metabolic assessment in women with prior gestational diabetes. Author(s): Department of Endocrinology, Hospital La Paz, Madrid, Spain. Source: Pallardo, F Herranz, L Garcia Ingelmo, T Grande, C Martin Vaquero, P Janez, M Gonzalez, A Diabetes-Care. 1999 July; 22(7): 1053-8 0149-5992

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Effects of maternal gestational diabetes and adiposity on neonatal adiposity and blood pressure. Author(s): Department of Pediatrics, Miriam Hospital, Providence, Rhode Island, USA. Source: Vohr, B R McGarvey, S T Coll, C G Diabetes-Care. 1995 April; 18(4): 467-75 0149-5992

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Glucocorticoid-induced ketoacidosis in gestational diabetes: sequela of the acute treatment of preterm labor. A case report. Author(s): Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA. Source: Bedalov, A Balasubramanyam, A Diabetes-Care. 1997 June; 20(6): 922-4 0149-5992

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Glucose and amino acid turnover in untreated gestational diabetes. Author(s): Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis 46202-5210, USA. Source: Zimmer, D M Golichowski, A M Karn, C A Brechtel, G Baron, A D Denne, S C Diabetes-Care. 1996 June; 19(6): 591-6 0149-5992

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Impact of social support and stress on compliance in women with gestational diabetes. Author(s): Brown University Program in Medicine, Rhode Island Hospital, Providence. Source: Ruggiero, L Spirito, A Bond, A Coustan, D McGarvey, S DiabetesCare. 1990 April; 13(4): 441-3 0149-5992

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Insulin antibody response to a short course of human insulin therapy in women with gestational diabetes. Author(s): Division of Endocrinology, Diabetes and Nutrition, Hospital de Sant Pau, Universitat Autonoma de Barcelona, Spain.

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Source: Balsells, M Corcoy, R Mauricio, D Morales, J Garcia Patterson, A Carreras, G Puig Domingo, M de Leiva, A Diabetes-Care. 1997 July; 20(7): 1172-5 0149-5992 ·

Maternal glycemic criteria for insulin therapy in gestational diabetes mellitus. Author(s): Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio 78284-7836, USA. Source: Langer, O Diabetes-Care. 1998 August; 21 Suppl 2B91-8 0149-5992

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Metabolic and immunologic effects of insulin lispro in gestational diabetes. Author(s): Sansum Medical Research Institute, Santa Barbara, California 93105, USA. [email protected] Source: Jovanovic, L Ilic, S Pettitt, D J Hugo, K Gutierrez, M Bowsher, R R Bastyr, E J Diabetes-Care. 1999 September; 22(9): 1422-7 0149-5992

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Prevention of perinatal morbidity by tight metabolic control in gestational diabetes mellitus. Author(s): Department of Medicine, University of Innsbruck, Austria. Source: Drexel, H Bichler, A Sailer, S Breier, C Lisch, H J Braunsteiner, H Patsch, J R Diabetes-Care. 1988 Nov-December; 11(10): 761-8 0149-5992

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Protein and nitrogen metabolism in gestational diabetes. Author(s): Case Western Reserve University, School of Medicine, Cleveland, OH. Source: Kalhan, S.C. Diabetes-care (USA). (August 1998). volume 21(suppl.2) page B75-B84. diabetes pregnancy protein metabolism nitrogen metabolism leucine phenylalanine women 0149-5992

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Protein metabolism in insulin-treated gestational diabetes. Author(s): U.S. Department of Agriculture/Agricultural Research Services, (USDA/ARS) Children's Nutrition Research Center, Houston, Texas 77030, USA. [email protected] Source: Butte, N F Hsu, H W Thotathuchery, M Wong, W W Khoury, J Reeds, P Diabetes-Care. 1999 May; 22(5): 806-11 0149-5992

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Risk and prevention of type 2 diabetes in women with gestational diabetes. Author(s): Department of Metabolic Medicine, Imperial College School of Medicine, Hammersmith Hospital, London, U.K. [email protected] Source: Dornhorst, A Rossi, M Diabetes-Care. 1998 August; 21 Suppl 2B43-9 0149-5992

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The following information is typical of that found when using the “Full IBIDS Database” when searching using “gestational diabetes” (or a synonym): ·

A proposal for detecting and managing gestational diabetes by coordinating existing services. Source: Macupa, L. Public-Health-Rep. Washington, D.C. : Public Health Service. Jan/February 1986. volume 101 (1) page 94-97. 0090-2818

·

A randomized controlled trial using glycemic plus fetal ultrasound parameters versus glycemic parameters to determine insulin therapy in gestational diabetes with fasting hyperglycemia. Author(s): Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California, USA. [email protected] Source: Kjos, S L Schaefer Graf, U Sardesi, S Peters, R K Buley, A Xiang, A H Bryne, J D Sutherland, C Montoro, M N Buchanan, T A Diabetes-Care. 2001 November; 24(11): 1904-10 0149-5992

·

ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes. Source: Obstet-Gynecol. 2001 September; 98(3): 525-38 0029-7844

·

Alternative therapies for the management of gestational diabetes. Author(s): Santa Barbara Cottage Hospital, California. Source: Mulford, M I Jovanovic Peterson, L Peterson, C M Clin-Perinatol. 1993 September; 20(3): 619-34 0095-5108

·

Can a diagnosis of gestational diabetes be an advantage to the outcome of pregnancy? Author(s): Diabetes Education Centre, Wollongong, Australia. Source: Moses, R G Griffiths, R D J-Soc-Gynecol-Investig. 1995 May-June; 2(3): 523-5 1071-5576

·

Clinically useful estimates of insulin sensitivity during pregnancy: validation studies in women with normal glucose tolerance and gestational diabetes mellitus. Author(s): Department of Reproductive Biology, Case Western Reserve University School of Medicine at MetroHealth Medical Center, Bell Greve Building, 2500 MetroHealth Dr., Cleveland, OH 44109-1998, USA. [email protected] Source: Kirwan, J P Huston Presley, L Kalhan, S C Catalano, P M Diabetes-Care. 2001 September; 24(9): 1602-7 0149-5992

Researching Nutrition 171

·

DIABNET: a qualitative model-based advisory system for therapy planning in gestational diabetes. Author(s): Grupo de Bioingenieria y Telemedicina, ETSI de Telecommunication, Unversidad Politecnica de Madrid, Spain. Source: Hernando, M E Gomez, E J del Pozo, F Corcoy, R Med-Inform(Lond). 1996 Oct-December; 21(4): 359-74 0307-7640

·

Diagnosis of gestational diabetes in early pregnancy. Author(s): Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH. Source: Super, D M Edelberg, S C Philipson, E H Hertz, R H Kalhan, S C Diabetes-Care. 1991 April; 14(4): 288-94 0149-5992

·

Effect of 1,25-dihydroxycholecalciferol on glucose metabolism in gestational diabetes mellitus. Author(s): Department of Obstetrics and Gynecology, Rigshospitalet, University of Copenhagen, Denmark. Source: Rudnicki, P M Molsted Pedersen, L Diabetologia. 1997 January; 40(1): 40-4 0012-186X

·

Effects of gestational diabetes on junctional adhesion molecules in human term placental vasculature. Author(s): School of Biomedical Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, UK. Source: Babawale, M O Lovat, S Mayhew, T M Lammiman, M J James, D K Leach, L Diabetologia. 2000 September; 43(9): 1185-96 0012-186X

·

Euglycemic control of gestational diabetes mellitus by specific dietary manipulation: a case study presentation. Source: Mahaffey, P J Podell, S K Diabetes-Educ. 1991 Nov-December; 17(6): 460-5 0145-7217

·

Exercise as a treatment modality to maintain normoglycemia in gestational diabetes. Source: Rosas, T Constantino, N J-Perinat-Neonatal-Nurs. 1992 June; 6(1): 14-24 0893-2190

·

From diagnosis to home management: nutritional considerations for women with gestational diabetes. Source: Armstrong, C L Brown, L P York, R Robbins, D Swank, A Diabetes-Educ. 1991 Nov-December; 17(6): 455-9 0145-7217

·

Gestational diabetes diagnosed in third trimester pregnancy and pregnancy outcome. Author(s): Department of Obstetrics & Gynaecology, Tsan Yuk Hospital, Hong Kong SAR, China. Source: Lao, T T Tam, K F Acta-Obstet-Gynecol-Scand. 2001 November; 80(11): 1003-8 0001-6349

172 Gestational Diabetes

·

Gestational diabetes mellitus. Source: Fagen, C Diabetes-Educ. 1991 Nov-December; 17(6): 447-8, 450 0145-7217

·

Gestational diabetes. Ensuring optimal outcome for mother and child. Author(s): International Diabetes Center, Minneapolis, MN 55416. Source: Hollander, P Postgrad-Med. 1988 June; 83(8): 48-52, 57, 61 00325481

·

Gestational diabetes. What are the implications? Source: Corcoy, R Cabero, L de Leiva, A Postgrad-Med. 1992 April; 91(5): 393-402 0032-5481

·

Glucose-induced release of tumour necrosis factor-alpha from human placental and adipose tissues in gestational diabetes mellitus. Author(s): Department of Obstetrics and Gynaecology, The University of Melbourne, Mercy Hospital for Women, East Melbourne, Australia. [email protected] Source: Coughlan, M T Oliva, K Georgiou, H M Permezel, J M Rice, G E Diabet-Med. 2001 November; 18(11): 921-7 0742-3071

·

Hair chromium content of women with gestational diabetes compared with nondiabetic pregnant women. Source: Aharoni, A. Tesler, B. Paltieli, Y. Tal, J. Dori, Z. Sharf, M. Am-JClin-Nutr. Baltimore, Md. : American Society for Clinical Nutrition. January 1992. volume 55 (1) page 104-107. charts. 0002-9165

Federal Resources on Nutrition In addition to the IBIDS, the United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) provide many sources of information on general nutrition and health. Recommended resources include: ·

healthfinder®, HHS's gateway to health information, including diet and nutrition: http://www.healthfinder.gov/scripts/SearchContext.asp?topic=238&page=0

·

The United States Department of Agriculture's Web site dedicated to nutrition information: www.nutrition.gov

·

The Food and Drug Administration's Web site for federal food safety information: www.foodsafety.gov

·

The National Action Plan on Overweight and Obesity sponsored by the United States Surgeon General: http://www.surgeongeneral.gov/topics/obesity/

Researching Nutrition 173

·

The Center for Food Safety and Applied Nutrition has an Internet site sponsored by the Food and Drug Administration and the Department of Health and Human Services: http://vm.cfsan.fda.gov/

·

Center for Nutrition Policy and Promotion sponsored by the United States Department of Agriculture: http://www.usda.gov/cnpp/

·

Food and Nutrition Information Center, National Agricultural Library sponsored by the United States Department of Agriculture: http://www.nal.usda.gov/fnic/

·

Food and Nutrition Service sponsored by the United States Department of Agriculture: http://www.fns.usda.gov/fns/

Additional Web Resources A number of additional Web sites offer encyclopedic information covering food and nutrition. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=174&layer=&from=subcats

·

Family Village: http://www.familyvillage.wisc.edu/med_nutrition.html

·

Google: http://directory.google.com/Top/Health/Nutrition/

·

Healthnotes: http://www.thedacare.org/healthnotes/

·

Open Directory Project: http://dmoz.org/Health/Nutrition/

·

Yahoo.com: http://dir.yahoo.com/Health/Nutrition/

·

WebMDÒHealth: http://my.webmd.com/nutrition

·

WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

The following is a specific Web list relating to gestational diabetes; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation: ·

Vitamins Vitamin B6 Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Supp/Vitamin_B6.htm

174 Gestational Diabetes

Vitamin B6 Source: Prima Communications, Inc. Hyperlink: http://www.personalhealthzone.com/pg000225.html ·

Minerals Chromium Source: Prima Communications, Inc. Hyperlink: http://www.personalhealthzone.com/pg000131.html

·

Food and Diet Diabetes Source: Healthnotes, Inc.; www.healthnotes.com Hyperlink: http://www.thedacare.org/healthnotes/Concern/Diabetes.htm

Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Endocrinology: A subspecialty of internal medicine concerned with the metabolism, physiology, and disorders of the endocrine system. [NIH] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Ketoacidosis: Acidosis accompanied by the accumulation of ketone bodies (ketosis) in the body tissues and fluids, as in diabetic acidosis. [EU] Leucine: An essential branched-chain amino acid important for hemoglobin formation. [NIH]

Researching Nutrition 175

Morale: The prevailing temper or spirit of an individual or group in relation to the tasks or functions which are expected. [NIH] Necrosis: The sum of the morphological changes indicative of cell death and caused by the progressive degradative action of enzymes; it may affect groups of cells or part of a structure or an organ. [EU] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Nitrogen: An element with the atomic symbol N, atomic number 7, and atomic weight 14. Nitrogen exists as a diatomic gas and makes up about 78% of the earth's atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Phenylalanine: An aromatic amino acid that is essential in the animal diet. It is a precursor of melanin, dopamine, noradrenalin, and thyroxine. [NIH] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Sequela: Any lesion or affection following or caused by an attack of disease. [EU]

Thermoregulation: Heat regulation. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Tumour: 1. swelling, one of the cardinal signs of inflammations; morbid

176 Gestational Diabetes

enlargement. 2. a new growth of tissue in which the multiplication of cells is uncontrolled and progressive; called also neoplasm. [EU]

Finding Medical Libraries 177

APPENDIX D. FINDING MEDICAL LIBRARIES Overview At a medical library you can find medical texts and reference books, consumer health publications, specialty newspapers and magazines, as well as medical journals. In this Appendix, we show you how to quickly find a medical library in your area.

Preparation Before going to the library, highlight the references mentioned in this sourcebook that you find interesting. Focus on those items that are not available via the Internet, and ask the reference librarian for help with your search. He or she may know of additional resources that could be helpful to you. Most importantly, your local public library and medical libraries have Interlibrary Loan programs with the National Library of Medicine (NLM), one of the largest medical collections in the world. According to the NLM, most of the literature in the general and historical collections of the National Library of Medicine is available on interlibrary loan to any library. NLM's interlibrary loan services are only available to libraries. If you would like to access NLM medical literature, then visit a library in your area that can request the publications for you.55

55

Adapted from the NLM: http://www.nlm.nih.gov/psd/cas/interlibrary.html.

178 Gestational Diabetes

Finding a Local Medical Library The quickest method to locate medical libraries is to use the Internet-based directory published by the National Network of Libraries of Medicine (NN/LM). This network includes 4626 members and affiliates that provide many services to librarians, health professionals, and the public. To find a library in your area, simply visit http://nnlm.gov/members/adv.html or call 1-800-338-7657.

Medical Libraries Open to the Public In addition to the NN/LM, the National Library of Medicine (NLM) lists a number of libraries that are generally open to the public and have reference facilities. The following is the NLM’s list plus hyperlinks to each library Web site. These Web pages can provide information on hours of operation and other restrictions. The list below is a small sample of libraries recommended by the National Library of Medicine (sorted alphabetically by name of the U.S. state or Canadian province where the library is located):56 ·

Alabama: Health InfoNet of Jefferson County (Jefferson County Library Cooperative, Lister Hill Library of the Health Sciences), http://www.uab.edu/infonet/

·

Alabama: Richard M. Scrushy Library (American Sports Medicine Institute), http://www.asmi.org/LIBRARY.HTM

·

Arizona: Samaritan Regional Medical Center: The Learning Center (Samaritan Health System, Phoenix, Arizona), http://www.samaritan.edu/library/bannerlibs.htm

·

California: Kris Kelly Health Information Center (St. Joseph Health System), http://www.humboldt1.com/~kkhic/index.html

·

California: Community Health Library of Los Gatos (Community Health Library of Los Gatos), http://www.healthlib.org/orgresources.html

·

California: Consumer Health Program and Services (CHIPS) (County of Los Angeles Public Library, Los Angeles County Harbor-UCLA Medical Center Library) - Carson, CA, http://www.colapublib.org/services/chips.html

·

California: Gateway Health Library (Sutter Gould Medical Foundation)

·

California: Health Library (Stanford University Medical Center), http://www-med.stanford.edu/healthlibrary/

56

Abstracted from http://www.nlm.nih.gov/medlineplus/libraries.html.

Finding Medical Libraries 179

·

California: Patient Education Resource Center - Health Information and Resources (University of California, San Francisco), http://sfghdean.ucsf.edu/barnett/PERC/default.asp

·

California: Redwood Health Library (Petaluma Health Care District), http://www.phcd.org/rdwdlib.html

·

California: San José PlaneTree Health Library, http://planetreesanjose.org/

·

California: Sutter Resource Library (Sutter Hospitals Foundation), http://go.sutterhealth.org/comm/resc-library/sac-resources.html

·

California: University of California, Davis. Health Sciences Libraries

·

California: ValleyCare Health Library & Ryan Comer Cancer Resource Center (ValleyCare Health System), http://www.valleycare.com/library.html

·

California: Washington Community Health Resource Library (Washington Community Health Resource Library), http://www.healthlibrary.org/

·

Colorado: William V. Gervasini Memorial Library (Exempla Healthcare), http://www.exempla.org/conslib.htm

·

Connecticut: Hartford Hospital Health Science Libraries (Hartford Hospital), http://www.harthosp.org/library/

·

Connecticut: Healthnet: Connecticut Consumer Health Information Center (University of Connecticut Health Center, Lyman Maynard Stowe Library), http://library.uchc.edu/departm/hnet/

·

Connecticut: Waterbury Hospital Health Center Library (Waterbury Hospital), http://www.waterburyhospital.com/library/consumer.shtml

·

Delaware: Consumer Health Library (Christiana Care Health System, Eugene du Pont Preventive Medicine & Rehabilitation Institute), http://www.christianacare.org/health_guide/health_guide_pmri_health _info.cfm

·

Delaware: Lewis B. Flinn Library (Delaware Academy of Medicine), http://www.delamed.org/chls.html

·

Georgia: Family Resource Library (Medical College of Georgia), http://cmc.mcg.edu/kids_families/fam_resources/fam_res_lib/frl.htm

·

Georgia: Health Resource Center (Medical Center of Central Georgia), http://www.mccg.org/hrc/hrchome.asp

·

Hawaii: Hawaii Medical Library: Consumer Health Information Service (Hawaii Medical Library), http://hml.org/CHIS/

180 Gestational Diabetes

·

Idaho: DeArmond Consumer Health Library (Kootenai Medical Center), http://www.nicon.org/DeArmond/index.htm

·

Illinois: Health Learning Center of Northwestern Memorial Hospital (Northwestern Memorial Hospital, Health Learning Center), http://www.nmh.org/health_info/hlc.html

·

Illinois: Medical Library (OSF Saint Francis Medical Center), http://www.osfsaintfrancis.org/general/library/

·

Kentucky: Medical Library - Services for Patients, Families, Students & the Public (Central Baptist Hospital), http://www.centralbap.com/education/community/library.htm

·

Kentucky: University of Kentucky - Health Information Library (University of Kentucky, Chandler Medical Center, Health Information Library), http://www.mc.uky.edu/PatientEd/

·

Louisiana: Alton Ochsner Medical Foundation Library (Alton Ochsner Medical Foundation), http://www.ochsner.org/library/

·

Louisiana: Louisiana State University Health Sciences Center Medical Library-Shreveport, http://lib-sh.lsuhsc.edu/

·

Maine: Franklin Memorial Hospital Medical Library (Franklin Memorial Hospital), http://www.fchn.org/fmh/lib.htm

·

Maine: Gerrish-True Health Sciences Library (Central Maine Medical Center), http://www.cmmc.org/library/library.html

·

Maine: Hadley Parrot Health Science Library (Eastern Maine Healthcare), http://www.emh.org/hll/hpl/guide.htm

·

Maine: Maine Medical Center Library (Maine Medical Center), http://www.mmc.org/library/

·

Maine: Parkview Hospital, http://www.parkviewhospital.org/communit.htm#Library

·

Maine: Southern Maine Medical Center Health Sciences Library (Southern Maine Medical Center), http://www.smmc.org/services/service.php3?choice=10

·

Maine: Stephens Memorial Hospital Health Information Library (Western Maine Health), http://www.wmhcc.com/hil_frame.html

·

Manitoba, Canada: Consumer & Patient Health Information Service (University of Manitoba Libraries), http://www.umanitoba.ca/libraries/units/health/reference/chis.html

·

Manitoba, Canada: J.W. Crane Memorial Library (Deer Lodge Centre), http://www.deerlodge.mb.ca/library/libraryservices.shtml

Finding Medical Libraries 181

·

Maryland: Health Information Center at the Wheaton Regional Library (Montgomery County, Md., Dept. of Public Libraries, Wheaton Regional Library), http://www.mont.lib.md.us/healthinfo/hic.asp

·

Massachusetts: Baystate Medical Center Library (Baystate Health System), http://www.baystatehealth.com/1024/

·

Massachusetts: Boston University Medical Center Alumni Medical Library (Boston University Medical Center), http://medlibwww.bu.edu/library/lib.html

·

Massachusetts: Lowell General Hospital Health Sciences Library (Lowell General Hospital), http://www.lowellgeneral.org/library/HomePageLinks/WWW.htm

·

Massachusetts: Paul E. Woodard Health Sciences Library (New England Baptist Hospital), http://www.nebh.org/health_lib.asp

·

Massachusetts: St. Luke's Hospital Health Sciences Library (St. Luke's Hospital), http://www.southcoast.org/library/

·

Massachusetts: Treadwell Library Consumer Health Reference Center (Massachusetts General Hospital), http://www.mgh.harvard.edu/library/chrcindex.html

·

Massachusetts: UMass HealthNet (University of Massachusetts Medical School), http://healthnet.umassmed.edu/

·

Michigan: Botsford General Hospital Library - Consumer Health (Botsford General Hospital, Library & Internet Services), http://www.botsfordlibrary.org/consumer.htm

·

Michigan: Helen DeRoy Medical Library (Providence Hospital and Medical Centers), http://www.providence-hospital.org/library/

·

Michigan: Marquette General Hospital - Consumer Health Library (Marquette General Hospital, Health Information Center), http://www.mgh.org/center.html

·

Michigan: Patient Education Resouce Center - University of Michigan Cancer Center (University of Michigan Comprehensive Cancer Center), http://www.cancer.med.umich.edu/learn/leares.htm

·

Michigan: Sladen Library & Center for Health Information Resources Consumer Health Information, http://www.sladen.hfhs.org/library/consumer/index.html

·

Montana: Center for Health Information (St. Patrick Hospital and Health Sciences Center), http://www.saintpatrick.org/chi/librarydetail.php3?ID=41

182 Gestational Diabetes

·

National: Consumer Health Library Directory (Medical Library Association, Consumer and Patient Health Information Section), http://caphis.mlanet.org/directory/index.html

·

National: National Network of Libraries of Medicine (National Library of Medicine) - provides library services for health professionals in the United States who do not have access to a medical library, http://nnlm.gov/

·

National: NN/LM List of Libraries Serving the Public (National Network of Libraries of Medicine), http://nnlm.gov/members/

·

Nevada: Health Science Library, West Charleston Library (Las Vegas Clark County Library District), http://www.lvccld.org/special_collections/medical/index.htm

·

New Hampshire: Dartmouth Biomedical Libraries (Dartmouth College Library), http://www.dartmouth.edu/~biomed/resources.htmld/conshealth.htmld/

·

New Jersey: Consumer Health Library (Rahway Hospital), http://www.rahwayhospital.com/library.htm

·

New Jersey: Dr. Walter Phillips Health Sciences Library (Englewood Hospital and Medical Center), http://www.englewoodhospital.com/links/index.htm

·

New Jersey: Meland Foundation (Englewood Hospital and Medical Center), http://www.geocities.com/ResearchTriangle/9360/

·

New York: Choices in Health Information (New York Public Library) NLM Consumer Pilot Project participant, http://www.nypl.org/branch/health/links.html

·

New York: Health Information Center (Upstate Medical University, State University of New York), http://www.upstate.edu/library/hic/

·

New York: Health Sciences Library (Long Island Jewish Medical Center), http://www.lij.edu/library/library.html

·

New York: ViaHealth Medical Library (Rochester General Hospital), http://www.nyam.org/library/

·

Ohio: Consumer Health Library (Akron General Medical Center, Medical & Consumer Health Library), http://www.akrongeneral.org/hwlibrary.htm

·

Oklahoma: Saint Francis Health System Patient/Family Resource Center (Saint Francis Health System), http://www.sfhtulsa.com/patientfamilycenter/default.asp

Finding Medical Libraries 183

·

Oregon: Planetree Health Resource Center (Mid-Columbia Medical Center), http://www.mcmc.net/phrc/

·

Pennsylvania: Community Health Information Library (Milton S. Hershey Medical Center), http://www.hmc.psu.edu/commhealth/

·

Pennsylvania: Community Health Resource Library (Geisinger Medical Center), http://www.geisinger.edu/education/commlib.shtml

·

Pennsylvania: HealthInfo Library (Moses Taylor Hospital), http://www.mth.org/healthwellness.html

·

Pennsylvania: Hopwood Library (University of Pittsburgh, Health Sciences Library System), http://www.hsls.pitt.edu/chi/hhrcinfo.html

·

Pennsylvania: Koop Community Health Information Center (College of Physicians of Philadelphia), http://www.collphyphil.org/kooppg1.shtml

·

Pennsylvania: Learning Resources Center - Medical Library (Susquehanna Health System), http://www.shscares.org/services/lrc/index.asp

·

Pennsylvania: Medical Library (UPMC Health System), http://www.upmc.edu/passavant/library.htm

·

Quebec, Canada: Medical Library (Montreal General Hospital), http://ww2.mcgill.ca/mghlib/

·

South Dakota: Rapid City Regional Hospital - Health Information Center (Rapid City Regional Hospital, Health Information Center), http://www.rcrh.org/education/LibraryResourcesConsumers.htm

·

Texas: Houston HealthWays (Houston Academy of Medicine-Texas Medical Center Library), http://hhw.library.tmc.edu/

·

Texas: Matustik Family Resource Center (Cook Children's Health Care System), http://www.cookchildrens.com/Matustik_Library.html

·

Washington: Community Health Library (Kittitas Valley Community Hospital), http://www.kvch.com/

·

Washington: Southwest Washington Medical Center Library (Southwest Washington Medical Center), http://www.swmedctr.com/Home/

Your Rights and Insurance 185

APPENDIX E. YOUR RIGHTS AND INSURANCE Overview Any patient with gestational diabetes faces a series of issues related more to the healthcare industry than to the medical condition itself. This appendix covers two important topics in this regard: your rights and responsibilities as a patient, and how to get the most out of your medical insurance plan.

Your Rights as a Patient The President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry has created the following summary of your rights as a patient.57 Information Disclosure Consumers have the right to receive accurate, easily understood information. Some consumers require assistance in making informed decisions about health plans, health professionals, and healthcare facilities. Such information includes: ·

Health plans. Covered benefits, cost-sharing, and procedures for resolving complaints, licensure, certification, and accreditation status, comparable measures of quality and consumer satisfaction, provider network composition, the procedures that govern access to specialists and emergency services, and care management information.

57Adapted

from Consumer Bill of Rights and Responsibilities: http://www.hcqualitycommission.gov/press/cbor.html#head1.

186 Gestational Diabetes

·

Health professionals. Education, board certification, and recertification, years of practice, experience performing certain procedures, and comparable measures of quality and consumer satisfaction.

·

Healthcare facilities. Experience in performing certain procedures and services, accreditation status, comparable measures of quality, worker, and consumer satisfaction, and procedures for resolving complaints.

·

Consumer assistance programs. Programs must be carefully structured to promote consumer confidence and to work cooperatively with health plans, providers, payers, and regulators. Desirable characteristics of such programs are sponsorship that ensures accountability to the interests of consumers and stable, adequate funding.

Choice of Providers and Plans Consumers have the right to a choice of healthcare providers that is sufficient to ensure access to appropriate high-quality healthcare. To ensure such choice, the Commission recommends the following: ·

Provider network adequacy. All health plan networks should provide access to sufficient numbers and types of providers to assure that all covered services will be accessible without unreasonable delay -including access to emergency services 24 hours a day and 7 days a week. If a health plan has an insufficient number or type of providers to provide a covered benefit with the appropriate degree of specialization, the plan should ensure that the consumer obtains the benefit outside the network at no greater cost than if the benefit were obtained from participating providers.

·

Women's health services. Women should be able to choose a qualified provider offered by a plan -- such as gynecologists, certified nurse midwives, and other qualified healthcare providers -- for the provision of covered care necessary to provide routine and preventative women's healthcare services.

·

Access to specialists. Consumers with complex or serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within a plan's network of providers. Authorizations, when required, should be for an adequate number of direct access visits under an approved treatment plan.

·

Transitional care. Consumers who are undergoing a course of treatment for a chronic or disabling condition (or who are in the second or third trimester of a pregnancy) at the time they involuntarily change health

Your Rights and Insurance 187

plans or at a time when a provider is terminated by a plan for other than cause should be able to continue seeing their current specialty providers for up to 90 days (or through completion of postpartum care) to allow for transition of care. ·

Choice of health plans. Public and private group purchasers should, wherever feasible, offer consumers a choice of high-quality health insurance plans.

Access to Emergency Services Consumers have the right to access emergency healthcare services when and where the need arises. Health plans should provide payment when a consumer presents to an emergency department with acute symptoms of sufficient severity--including severe pain--such that a “prudent layperson” could reasonably expect the absence of medical attention to result in placing that consumer's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Participation in Treatment Decisions Consumers have the right and responsibility to fully participate in all decisions related to their healthcare. Consumers who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators. Physicians and other health professionals should: ·

Provide patients with sufficient information and opportunity to decide among treatment options consistent with the informed consent process.

·

Discuss all treatment options with a patient in a culturally competent manner, including the option of no treatment at all.

·

Ensure that persons with disabilities have effective communications with members of the health system in making such decisions.

·

Discuss all current treatments a consumer may be undergoing.

·

Discuss all risks, nontreatment.

·

Give patients the opportunity to refuse treatment and to express preferences about future treatment decisions.

benefits,

and

consequences

to

treatment

or

188 Gestational Diabetes

·

Discuss the use of advance directives -- both living wills and durable powers of attorney for healthcare -- with patients and their designated family members.

·

Abide by the decisions made by their patients and/or their designated representatives consistent with the informed consent process.

Health plans, health providers, and healthcare facilities should: ·

Disclose to consumers factors -- such as methods of compensation, ownership of or interest in healthcare facilities, or matters of conscience -that could influence advice or treatment decisions.

·

Assure that provider contracts do not contain any so-called “gag clauses” or other contractual mechanisms that restrict healthcare providers' ability to communicate with and advise patients about medically necessary treatment options.

·

Be prohibited from penalizing or seeking retribution against healthcare professionals or other health workers for advocating on behalf of their patients.

Respect and Nondiscrimination Consumers have the right to considerate, respectful care from all members of the healthcare industry at all times and under all circumstances. An environment of mutual respect is essential to maintain a quality healthcare system. To assure that right, the Commission recommends the following: ·

Consumers must not be discriminated against in the delivery of healthcare services consistent with the benefits covered in their policy, or as required by law, based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.

·

Consumers eligible for coverage under the terms and conditions of a health plan or program, or as required by law, must not be discriminated against in marketing and enrollment practices based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment. Confidentiality of Health Information

Consumers have the right to communicate with healthcare providers in confidence and to have the confidentiality of their individually identifiable

Your Rights and Insurance 189

healthcare information protected. Consumers also have the right to review and copy their own medical records and request amendments to their records. Complaints and Appeals Consumers have the right to a fair and efficient process for resolving differences with their health plans, healthcare providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review. A free copy of the Patient's Bill of Rights is available from the American Hospital Association.58

Patient Responsibilities Treatment is a two-way street between you and your healthcare providers. To underscore the importance of finance in modern healthcare as well as your responsibility for the financial aspects of your care, the President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry has proposed that patients understand the following “Consumer Responsibilities.”59 In a healthcare system that protects consumers' rights, it is reasonable to expect and encourage consumers to assume certain responsibilities. Greater individual involvement by the consumer in his or her care increases the likelihood of achieving the best outcome and helps support a quality-oriented, cost-conscious environment. Such responsibilities include: ·

Take responsibility for maximizing healthy habits such as exercising, not smoking, and eating a healthy diet.

·

Work collaboratively with healthcare providers in developing and carrying out agreed-upon treatment plans.

·

Disclose relevant information and clearly communicate wants and needs.

·

Use your health insurance plan's internal complaint and appeal processes to address your concerns.

·

Avoid knowingly spreading disease.

58 To order your free copy of the Patient's Bill of Rights, telephone 312-422-3000 or visit the American Hospital Association’s Web site: http://www.aha.org. Click on “Resource Center,” go to “Search” at bottom of page, and then type in “Patient's Bill of Rights.” The Patient’s Bill of Rights is also available from Fax on Demand, at 312-422-2020, document number 471124. 59 Adapted from http://www.hcqualitycommission.gov/press/cbor.html#head1.

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·

Recognize the reality of risks, the limits of the medical science, and the human fallibility of the healthcare professional.

·

Be aware of a healthcare provider's obligation to be reasonably efficient and equitable in providing care to other patients and the community.

·

Become knowledgeable about your health plan’s coverage and options (when available) including all covered benefits, limitations, and exclusions, rules regarding use of network providers, coverage and referral rules, appropriate processes to secure additional information, and the process to appeal coverage decisions.

·

Show respect for other patients and health workers.

·

Make a good-faith effort to meet financial obligations.

·

Abide by administrative and operational procedures of health plans, healthcare providers, and Government health benefit programs.

Choosing an Insurance Plan There are a number of official government agencies that help consumers understand their healthcare insurance choices.60 The U.S. Department of Labor, in particular, recommends ten ways to make your health benefits choices work best for you.61 1. Your options are important. There are many different types of health benefit plans. Find out which one your employer offers, then check out the plan, or plans, offered. Your employer's human resource office, the health plan administrator, or your union can provide information to help you match your needs and preferences with the available plans. The more information you have, the better your healthcare decisions will be. 2. Reviewing the benefits available. Do the plans offered cover preventive care, well-baby care, vision or dental care? Are there deductibles? Answers to these questions can help determine the out-of-pocket expenses you may face. Matching your needs and those of your family members will result in the best possible benefits. Cheapest may not always be best. Your goal is high quality health benefits.

More information about quality across programs is provided at the following AHRQ Web site: http://www.ahrq.gov/consumer/qntascii/qnthplan.htm. 61 Adapted from the Department of Labor: http://www.dol.gov/dol/pwba/public/pubs/health/top10-text.html. 60

Your Rights and Insurance 191

3. Look for quality. The quality of healthcare services varies, but quality can be measured. You should consider the quality of healthcare in deciding among the healthcare plans or options available to you. Not all health plans, doctors, hospitals and other providers give the highest quality care. Fortunately, there is quality information you can use right now to help you compare your healthcare choices. Find out how you can measure quality. Consult the U.S. Department of Health and Human Services publication “Your Guide to Choosing Quality Health Care” on the Internet at www.ahcpr.gov/consumer. 4. Your plan's summary plan description (SPD) provides a wealth of information. Your health plan administrator can provide you with a copy of your plan’s SPD. It outlines your benefits and your legal rights under the Employee Retirement Income Security Act (ERISA), the federal law that protects your health benefits. It should contain information about the coverage of dependents, what services will require a co-pay, and the circumstances under which your employer can change or terminate a health benefits plan. Save the SPD and all other health plan brochures and documents, along with memos or correspondence from your employer relating to health benefits. 5. Assess your benefit coverage as your family status changes. Marriage, divorce, childbirth or adoption, and the death of a spouse are all life events that may signal a need to change your health benefits. You, your spouse and dependent children may be eligible for a special enrollment period under provisions of the Health Insurance Portability and Accountability Act (HIPAA). Even without life-changing events, the information provided by your employer should tell you how you can change benefits or switch plans, if more than one plan is offered. If your spouse's employer also offers a health benefits package, consider coordinating both plans for maximum coverage. 6. Changing jobs and other life events can affect your health benefits. Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), you, your covered spouse, and your dependent children may be eligible to purchase extended health coverage under your employer's plan if you lose your job, change employers, get divorced, or upon occurrence of certain other events. Coverage can range from 18 to 36 months depending on your situation. COBRA applies to most employers with 20 or more workers and requires your plan to notify you of your rights. Most plans require eligible individuals to make their COBRA election within 60 days of the plan's notice. Be sure to follow up with your plan sponsor if you don't receive notice, and make sure you respond within the allotted time.

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7. HIPAA can also help if you are changing jobs, particularly if you have a medical condition. HIPAA generally limits pre-existing condition exclusions to a maximum of 12 months (18 months for late enrollees). HIPAA also requires this maximum period to be reduced by the length of time you had prior “creditable coverage.” You should receive a certificate documenting your prior creditable coverage from your old plan when coverage ends. 8. Plan for retirement. Before you retire, find out what health benefits, if any, extend to you and your spouse during your retirement years. Consult with your employer's human resources office, your union, the plan administrator, and check your SPD. Make sure there is no conflicting information among these sources about the benefits you will receive or the circumstances under which they can change or be eliminated. With this information in hand, you can make other important choices, like finding out if you are eligible for Medicare and Medigap insurance coverage. 9. Know how to file an appeal if your health benefits claim is denied. Understand how your plan handles grievances and where to make appeals of the plan's decisions. Keep records and copies of correspondence. Check your health benefits package and your SPD to determine who is responsible for handling problems with benefit claims. Contact PWBA for customer service assistance if you are unable to obtain a response to your complaint. 10. You can take steps to improve the quality of the healthcare and the health benefits you receive. Look for and use things like Quality Reports and Accreditation Reports whenever you can. Quality reports may contain consumer ratings -- how satisfied consumers are with the doctors in their plan, for instance-- and clinical performance measures -- how well a healthcare organization prevents and treats illness. Accreditation reports provide information on how accredited organizations meet national standards, and often include clinical performance measures. Look for these quality measures whenever possible. Consult “Your Guide to Choosing Quality Health Care” on the Internet at www.ahcpr.gov/consumer.

Medicare and Medicaid Illness strikes both rich and poor families. For low-income families, Medicaid is available to defer the costs of treatment. The Health Care Financing Administration (HCFA) administers Medicare, the nation's largest health insurance program, which covers 39 million Americans. In the following pages, you will learn the basics about Medicare insurance as well as useful

Your Rights and Insurance 193

contact information on how to find more in-depth information about Medicaid.62

Who is Eligible for Medicare? Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. You might also qualify for coverage if you are under age 65 but have a disability or EndStage Renal disease (permanent kidney failure requiring dialysis or transplant). Here are some simple guidelines: You can get Part A at age 65 without having to pay premiums if: ·

You are already receiving retirement benefits from Social Security or the Railroad Retirement Board.

·

You are eligible to receive Social Security or Railroad benefits but have not yet filed for them.

·

You or your spouse had Medicare-covered government employment.

If you are under 65, you can get Part A without having to pay premiums if: ·

You have received Social Security or Railroad Retirement Board disability benefit for 24 months.

·

You are a kidney dialysis or kidney transplant patient.

Medicare has two parts: ·

Part A (Hospital Insurance). Most people do not have to pay for Part A.

·

Part B (Medical Insurance). Most people pay monthly for Part B. Part A (Hospital Insurance)

Helps Pay For: Inpatient hospital care, care in critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas) and skilled nursing facilities, hospice care, and some home healthcare.

This section has been adapted from the Official U.S. Site for Medicare Information: http://www.medicare.gov/Basics/Overview.asp.

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Cost: Most people get Part A automatically when they turn age 65. You do not have to pay a monthly payment called a premium for Part A because you or a spouse paid Medicare taxes while you were working. If you (or your spouse) did not pay Medicare taxes while you were working and you are age 65 or older, you still may be able to buy Part A. If you are not sure you have Part A, look on your red, white, and blue Medicare card. It will show “Hospital Part A” on the lower left corner of the card. You can also call the Social Security Administration toll free at 1-800-772-1213 or call your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772. For more information, call your Fiscal Intermediary about Part A bills and services. The phone number for the Fiscal Intermediary office in your area can be obtained from the following Web site: http://www.medicare.gov/Contacts/home.asp. Part B (Medical Insurance) Helps Pay For: Doctors, services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home healthcare. Part B helps pay for covered services and supplies when they are medically necessary. Cost: As of 2001, you pay the Medicare Part B premium of $50.00 per month. In some cases this amount may be higher if you did not choose Part B when you first became eligible at age 65. The cost of Part B may go up 10% for each 12-month period that you were eligible for Part B but declined coverage, except in special cases. You will have to pay the extra 10% cost for the rest of your life. Enrolling in Part B is your choice. You can sign up for Part B anytime during a 7-month period that begins 3 months before you turn 65. Visit your local Social Security office, or call the Social Security Administration at 1-800-7721213 to sign up. If you choose to enroll in Part B, the premium is usually taken out of your monthly Social Security, Railroad Retirement, or Civil Service Retirement payment. If you do not receive any of the above payments, Medicare sends you a bill for your part B premium every 3 months. You should receive your Medicare premium bill in the mail by the 10th of the month. If you do not, call the Social Security Administration at 1800-772-1213, or your local Social Security office. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772. For more information, call your Medicare carrier about bills and services. The

Your Rights and Insurance 195

phone number for the Medicare carrier in your area can be found at the following Web site: http://www.medicare.gov/Contacts/home.asp. You may have choices in how you get your healthcare including the Original Medicare Plan, Medicare Managed Care Plans (like HMOs), and Medicare Private Fee-for-Service Plans.

Medicaid Medicaid is a joint federal and state program that helps pay medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state. People on Medicaid may also get coverage for nursing home care and outpatient prescription drugs which are not covered by Medicare. You can find more information about Medicaid on the HCFA.gov Web site at http://www.hcfa.gov/medicaid/medicaid.htm. States also have programs that pay some or all of Medicare's premiums and may also pay Medicare deductibles and coinsurance for certain people who have Medicare and a low income. To qualify, you must have: ·

Part A (Hospital Insurance),

·

Assets, such as bank accounts, stocks, and bonds that are not more than $4,000 for a single person, or $6,000 for a couple, and

·

A monthly income that is below certain limits.

For more information on these programs, look at the Medicare Savings Programs brochure, http://www.medicare.gov/Library/PDFNavigation/PDFInterim.asp?Langua ge=English&Type=Pub&PubID=10126. There are also Prescription Drug Assistance Programs available. Find information on these programs which offer discounts or free medications to individuals in need at http://www.medicare.gov/Prescription/Home.asp.

NORD’s Medication Assistance Programs Finally, the National Organization for Rare Disorders, Inc. (NORD) administers medication programs sponsored by humanitarian-minded pharmaceutical and biotechnology companies to help uninsured or underinsured individuals secure life-saving or life-sustaining drugs.63 NORD Adapted from NORD: http://www.rarediseases.org/cgibin/nord/progserv#patient?id=rPIzL9oD&mv_pc=30.

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programs ensure that certain vital drugs are available “to those individuals whose income is too high to qualify for Medicaid but too low to pay for their prescribed medications.” The program has standards for fairness, equity, and unbiased eligibility. It currently covers some 14 programs for nine pharmaceutical companies. NORD also offers early access programs for investigational new drugs (IND) under the approved “Treatment INDs” programs of the Food and Drug Administration (FDA). In these programs, a limited number of individuals can receive investigational drugs that have yet to be approved by the FDA. These programs are generally designed for rare diseases or disorders. For more information, visit www.rarediseases.org.

Additional Resources In addition to the references already listed in this chapter, you may need more information on health insurance, hospitals, or the healthcare system in general. The NIH has set up an excellent guidance Web site that addresses these and other issues. Topics include:64 ·

Health Insurance: http://www.nlm.nih.gov/medlineplus/healthinsurance.html

·

Health Statistics: http://www.nlm.nih.gov/medlineplus/healthstatistics.html

·

HMO and Managed Care: http://www.nlm.nih.gov/medlineplus/managedcare.html

·

Hospice Care: http://www.nlm.nih.gov/medlineplus/hospicecare.html

·

Medicaid: http://www.nlm.nih.gov/medlineplus/medicaid.html

·

Medicare: http://www.nlm.nih.gov/medlineplus/medicare.html

·

Nursing Homes and Long-term Care: http://www.nlm.nih.gov/medlineplus/nursinghomes.html

·

Patient's Rights, Confidentiality, Informed Consent, Ombudsman Programs, Privacy and Patient Issues: http://www.nlm.nih.gov/medlineplus/patientissues.html

You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.

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Your Rights and Insurance 197

·

Veteran's Health, Persian Gulf War, Gulf War Syndrome, Agent Orange: http://www.nlm.nih.gov/medlineplus/veteranshealth.html

More on Gestational Diabetes 199

APPENDIX F. MORE ON GESTATIONAL DIABETES Overview Gestational diabetes (pronounced jess-tay-shun-ul die-uh-beet-eez) is a type of diabetes, or high blood sugar, that only pregnant women get. In fact, the word gestational means pregnant. If a woman gets high blood sugar when she's pregnant, but she never had high blood sugar before, she has gestational diabetes. Nearly 135,000 pregnant women get the condition every year, making it one of the top health concerns related to pregnancy. 65 If not treated, gestational diabetes can cause problems for mothers and babies. Some of these problems can be serious.

But There Is Some Good News Most of the time, gestational diabetes goes away after the baby is born. The changes in your body that cause gestational diabetes normally occur only when you are pregnant. After the baby is born, your body goes back to normal and the condition goes away. Gestational diabetes is treatable, especially if you find out about it early in your pregnancy. The best way to control gestational diabetes is to find out you have it early and start treatment quickly. Treating gestational diabetes greatly lowers the baby's chances of having problems. Adapted from The National Institute of Child Health and Human Development (NICHD): http://www.nichd.nih.gov/publications/pubs/gest_diabetes.htm.

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Why Do Some Women Get Gestational Diabetes? Usually, the body breaks down much of the food you eat into a type of sugar, called glucose (pronounced gloo-kos). Because glucose moves from the stomach into the blood, some people use the term blood sugar, instead of glucose. Your body makes a hormone called insulin (pronounced in-suh-lin) that moves glucose out of the blood and into the cells of the body. In women with gestational diabetes, the glucose can't get into the cells, so the amount of glucose in the blood gets higher and higher. This is called high blood sugar or diabetes.

How Do I Know If I'm at Risk? Answer the questions below to learn your risk level for gestational diabetes. ·

Are you a member of a high-risk ethnic group (Hispanic, African American, Native American, South or East Asian, Pacific Islander, or Indigenous Australian)?

·

Are you overweight or very overweight?

·

Are you related to anyone who has diabetes now or had diabetes in their lifetime?

·

Are you older than 25?

·

Did you have gestational diabetes with a past pregnancy?

·

Have you had a stillbirth or a very large baby with a past pregnancy?

If you answered YES to TWO or more of these questions, you are at HIGH RISK for gestational diabetes. If you answered YES to ONLY ONE of these questions, you are at AVERAGE RISK for gestational diabetes. If you answered NO to ALL of these questions, you are at LOW RISK for gestational diabetes.

Should I Get Tested? If you are at high risk: ·

Get tested as soon as you know you are pregnant.

·

If your first test is negative, get tested again when you are between 24 and 28 weeks pregnant.

More on Gestational Diabetes 201

If you are at average risk: ·

Get tested when you are between 24 and 28 weeks pregnant.

If you are at lower risk: ·

Don't get tested unless your doctor or nurse tells you that you should.

Keep in mind that every pregnancy is different. Even if you didn't have gestational diabetes when you were pregnant before, you might get it during your current pregnancy. Or, if you had gestational diabetes before, you may not get it with this pregnancy. Follow your doctor's or nurse's advice about your risk level and getting tested.

What Is Involved in Getting Tested? Tests for gestational diabetes have two parts. First, you drink about one full glass of a sugar drink. Then, after a certain amount of time, a doctor, nurse, or other healthcare worker takes a sample of your blood and tests the blood to see how much sugar is in it (called a blood sugar test). If the level of sugar in your blood is normal, then you probably don't have gestational diabetes. If your blood sugar level is high, then you might have gestational diabetes. Your doctor or nurse may want you to take another blood test if your blood sugar level is high. Your doctor or nurse will tell you more about the test before you take it. You may have to follow a special diet for a few days or fast (not eat or drink anything but water) for a few hours before you take the test. Ask your doctor or nurse if you have to follow any special instructions before you get tested.

What If I Don't Get Treated for Gestational Diabetes? Most women with gestational diabetes have healthy pregnancies and healthy babies because they control their condition. Without treatment, mothers with this condition could have very large babies. These mothers may have a harder time with labor and natural delivery (through the vagina). Some mothers need surgery to deliver their bigger babies, which can increase the mother's risk of infection. Mothers who have their babies by surgery also take a longer time to recover.

202 Gestational Diabetes

Children whose mothers had gestational diabetes are at higher risk for certain health problems: ·

As babies, they are at higher risk for Respiratory Distress Syndrome (RDS), a disease that makes it hard for the baby to breathe.

·

They are more likely to be obese (very overweight) as children or adults, which can lead to other health problems.

·

They are at higher risk for getting diabetes, or high blood sugar, as they get older.

What Should I Do If I Have Gestational Diabetes? If your doctor or nurse tells you that you have gestational diabetes, you will need to follow a treatment plan to keep the condition under control. Most treatment plans include testing your blood sugar level, eating a healthy diet, and getting regular physical activity. Some women also need to take insulin as part of their treatment plan. More and more women with gestational diabetes have healthy pregnancies and healthy babies because they follow their treatment plan and control their blood sugar level. Managing Gestational Diabetes: Your Guide to a Healthy Pregnancy, a booklet from the National Institute of Child Health and Human Development (NICHD), talks about general ways to stay healthy with gestational diabetes. The booklet combines advice from experts who treat gestational diabetes with nearly 40 years of scientific research on the health of mothers, children, and families. It tells you and your family what causes gestational diabetes, what having it means for you and your baby, and what you can do if you have it. You can learn more about gestational diabetes and how to stay healthy during your pregnancy from the NICHD booklet, Understanding Gestational Diabetes: A Practical Guide to a Healthy Pregnancy. To get your free copy of the booklet, contact the NICHD Clearinghouse at: 1-800-370-2943 Fax: (301) 984-1473 E-mail: [email protected] http://www.nichd.nih.gov

Online Glossaries 203

ONLINE GLOSSARIES The Internet provides access to a number of free-to-use medical dictionaries and glossaries. The National Library of Medicine has compiled the following list of online dictionaries: ·

ADAM Medical Encyclopedia (A.D.A.M., Inc.), comprehensive medical reference: http://www.nlm.nih.gov/medlineplus/encyclopedia.html

·

MedicineNet.com Medical Dictionary (MedicineNet, Inc.): http://www.medterms.com/Script/Main/hp.asp

·

Merriam-Webster Medical Dictionary (Inteli-Health, Inc.): http://www.intelihealth.com/IH/

·

Multilingual Glossary of Technical and Popular Medical Terms in Eight European Languages (European Commission) - Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish: http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html

·

On-line Medical Dictionary (CancerWEB): http://www.graylab.ac.uk/omd/

·

Technology Glossary (National Library of Medicine) - Health Care Technology: http://www.nlm.nih.gov/nichsr/ta101/ta10108.htm

·

Terms and Definitions (Office of Rare Diseases): http://rarediseases.info.nih.gov/ord/glossary_a-e.html

Beyond these, MEDLINEplus contains a very user-friendly encyclopedia covering every aspect of medicine (licensed from A.D.A.M., Inc.). The ADAM Medical Encyclopedia Web site address is http://www.nlm.nih.gov/medlineplus/encyclopedia.html. ADAM is also available on commercial Web sites such as drkoop.com (http://www.drkoop.com/) and Web MD (http://my.webmd.com/adam/asset/adam_disease_articles/a_to_z/a). Topics of interest can be researched by using keywords before continuing elsewhere, as these basic definitions and concepts will be useful in more advanced areas of research. You may choose to print various pages specifically relating to gestational diabetes and keep them on file. The NIH, in particular, suggests that patients with gestational diabetes visit the following Web sites in the ADAM Medical Encyclopedia: ·

Basic Guidelines for Gestational Diabetes

204 Gestational Diabetes

Gestational diabetes Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000896.htm ·

Signs & Symptoms for Gestational Diabetes Blurred vision Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003029.htm Fatigue Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003088.htm Increased appetite Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003134.htm Increased thirst Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003085.htm Increased urination Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003146.htm Nausea Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003117.htm Obesity Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003101.htm Vomiting Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003117.htm Weight loss Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003107.htm

Online Glossaries 205

·

Diagnostics and Tests for Gestational Diabetes Blood glucose level Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm Blood glucose levels Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm Glucose tolerance test Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003466.htm Oral glucose tolerance test Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003466.htm Ultrasound Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003336.htm

·

Nutrition for Gestational Diabetes Carbohydrate Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002469.htm Diet for diabetics Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002440.htm

·

Background Topics for Gestational Diabetes Incidence Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002387.htm

206 Gestational Diabetes

Online Dictionary Directories The following are additional online directories compiled by the National Library of Medicine, including a number of specialized medical dictionaries and glossaries: ·

Medical Dictionaries: Medical & Biological (World Health Organization): http://www.who.int/hlt/virtuallibrary/English/diction.htm#Medical

·

MEL-Michigan Electronic Library List of Online Health and Medical Dictionaries (Michigan Electronic Library): http://mel.lib.mi.us/health/health-dictionaries.html

·

Patient Education: Glossaries (DMOZ Open Directory Project): http://dmoz.org/Health/Education/Patient_Education/Glossaries/

·

Web of Online Dictionaries (Bucknell University): http://www.yourdictionary.com/diction5.html#medicine

Glossary 207

GESTATIONAL DIABETES GLOSSARY The following is a complete glossary of terms used in this sourcebook. The definitions are derived from official public sources including the National Institutes of Health [NIH] and the European Union [EU]. After this glossary, we list a number of additional hardbound and electronic glossaries and dictionaries that you may wish to consult. Abdomen: That portion of the body that lies between the thorax and the pelvis. [NIH] Aberrant: Wandering or deviating from the usual or normal course. [EU] Abortion: 1. the premature expulsion from the uterus of the products of conception - of the embryo, or of a nonviable fetus. The four classic symptoms, usually present in each type of abortion, are uterine contractions, uterine haemorrhage, softening and dilatation of the cervix, and presentation or expulsion of all or part of the products of conception. 2. premature stoppage of a natural or a pathological process. [EU] Acidosis: A pathologic condition resulting from accumulation of acid or depletion of the alkaline reserve (bicarbonate content) in the blood and body tissues, and characterized by an increase in hydrogen ion concentration. [EU] Adolescence: The period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth. The years usually referred to as adolescence lie between 13 and 18 years of age. [NIH]

Adrenergic: Activated by, characteristic of, or secreting epinephrine or substances with similar activity; the term is applied to those nerve fibres that liberate norepinephrine at a synapse when a nerve impulse passes, i.e., the sympathetic fibres. [EU] Adverse: Harmful. [EU] Aerobic: 1. having molecular oxygen present. 2. growing, living, or occurring in the presence of molecular oxygen. 3. requiring oxygen for respiration. [EU] Aggressiveness: The quality of being aggressive (= characterized by aggression; militant; enterprising; spreading with vigour; chemically active; variable and adaptable). [EU] Alleles: Mutually exclusive forms of the same gene, occupying the same locus on homologous chromosomes, and governing the same biochemical and developmental process. [NIH] Amniocentesis:

Percutaneous transabdominal puncture of the uterus

208 Gestational Diabetes

during pregnancy to obtain amniotic fluid. It is commonly used for fetal karyotype determination in order to diagnose abnormal fetal conditions. [NIH] Anemia: A reduction in the number of circulating erythrocytes or in the quantity of hemoglobin. [NIH] Antibody: An immunoglobulin molecule that has a specific amino acid sequence by virtue of which it interacts only with the antigen that induced its synthesis in cells of the lymphoid series (especially plasma cells), or with antigen closely related to it. Antibodies are classified according to their ode of action as agglutinins, bacteriolysins, haemolysins, opsonins, precipitins, etc. [EU] Antidiabetic: An agent that prevents or alleviates diabetes. [EU] Antigen: Any substance which is capable, under appropriate conditions, of inducing a specific immune response and of reacting with the products of that response, that is, with specific antibody or specifically sensitized Tlymphocytes, or both. Antigens may be soluble substances, such as toxins and foreign proteins, or particulate, such as bacteria and tissue cells; however, only the portion of the protein or polysaccharide molecule known as the antigenic determinant (q.v.) combines with antibody or a specific receptor on a lymphocyte. Abbreviated Ag. [EU] Aspartame: Flavoring agent sweeter than sugar, metabolized as phenylalanine and aspartic acid. [NIH] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Asymptomatic: Showing or causing no symptoms. [EU] Autoantigens: Endogenous tissue constituents that have the ability to interact with autoantibodies and cause an immune response. [NIH] Autoimmunity: Process whereby the immune system reacts against the body's own tissues. Autoimmunity may produce or be caused by autoimmune diseases. [NIH] Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Bilirubin: A bile pigment that is a degradation product of heme. [NIH] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Blindness: The inability to see or the loss or absence of perception of visual stimuli. This condition may be the result of eye diseases; optic nerve diseases; optic chiasm diseases; or brain diseases affecting the visual pathways or occipital lobe. [NIH]

Glossary 209

Calcium: A mineral that the body needs for strong bones and teeth. Calcium may form stones in the kidney. [NIH] Capillary: Any one of the minute vessels that connect the arterioles and venules, forming a network in nearly all parts of the body. Their walls act as semipermeable membranes for the interchange of various substances, including fluids, between the blood and tissue fluid; called also vas capillare. [EU]

Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cardiac: Pertaining to the heart. [EU] Cardiomyopathy: A general diagnostic term designating primary myocardial disease, often of obscure or unknown etiology. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Chronic: Lasting a long time. Chronic diseases develop slowly. Chronic renal failure may develop over many years and lead to end-stage renal disease. [NIH] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Confusion: Disturbed orientation in regard to time, place, or person, sometimes accompanied by disordered consciousness. [EU] Constipation: Infrequent or difficult evacuation of the faeces. [EU] Contraception: The prevention of conception or impregnation. [EU] Coronary: Encircling in the manner of a crown; a term applied to vessels; nerves, ligaments, etc. The term usually denotes the arteries that supply the heart muscle and, by extension, a pathologic involvement of them. [EU] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU]

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Dehydration: The condition that results from excessive loss of body water. Called also anhydration, deaquation and hypohydration. [EU] Demography: Statistical interpretation and description of a population with reference to distribution, composition, or structure. [NIH] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Digestion: The process of breakdown of food for metabolism and use by the body. [NIH] Dizziness: An imprecise term which may refer to a sense of spatial disorientation, motion of the environment, or lightheadedness. [NIH] Dystocia: Difficult childbirth or labor. [NIH] Edema: Excessive amount of watery fluid accumulated in the intercellular spaces, most commonly present in subcutaneous tissue. [NIH] Elastic: Susceptible of resisting and recovering from stretching, compression or distortion applied by a force. [EU] Embryo: In animals, those derivatives of the fertilized ovum that eventually become the offspring, during their period of most rapid development, i.e., after the long axis appears until all major structures are represented. In man, the developing organism is an embryo from about two weeks after fertilization to the end of seventh or eighth week. [EU] Endocrinology: A subspecialty of internal medicine concerned with the metabolism, physiology, and disorders of the endocrine system. [NIH] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any disease, injury, or other health-related event occurring in such outbreaks. [EU] Epidemiological: Relating to, or involving epidemiology. [EU] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the

Glossary 211

urine in diabetes mellitus. [EU] Glyburide: An antidiabetic sulfonylurea derivative with actions similar to those of chlorpropamide. [NIH] Gynecology: A medical-surgical specialty concerned with the physiology and disorders primarily of the female genital tract, as well as female endocrinology and reproductive physiology. [NIH] Heartburn: Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. [NIH] Hepatic: Pertaining to the liver. [EU] Homeostasis: A tendency to stability in the normal body states (internal environment) of the organism. It is achieved by a system of control mechanisms activated by negative feedback; e.g. a high level of carbon dioxide in extracellular fluid triggers increased pulmonary ventilation, which in turn causes a decrease in carbon dioxide concentration. [EU] Hormone: A natural chemical produced in one part of the body and released into the blood to trigger or regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down urine production. [NIH] Hunger: The desire for food generated by a sensation arising from the lack of food in the stomach. [NIH] Hyperglycaemia: Abnormally increased content of sugar in the blood. [EU] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Idiopathic: Of the nature of an idiopathy; self-originated; of unknown causation. [EU] Immunotherapy: Manipulation of the host's immune system in treatment of disease. It includes both active and passive immunization as well as immunosuppressive therapy to prevent graft rejection. [NIH] Indicative: That indicates; that points out more or less exactly; that reveals fairly clearly. [EU] Induction: The act or process of inducing or causing to occur, especially the production of a specific morphogenetic effect in the developing embryo through the influence of evocators or organizers, or the production of anaesthesia or unconsciousness by use of appropriate agents. [EU] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator

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of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Ischemia: Deficiency of blood in a part, due to functional constriction or actual obstruction of a blood vessel. [EU] Jaundice: A clinical manifestation of hyperbilirubinemia, consisting of deposition of bile pigments in the skin, resulting in a yellowish staining of the skin and mucous membranes. [NIH] Ketoacidosis: Acidosis accompanied by the accumulation of ketone bodies (ketosis) in the body tissues and fluids, as in diabetic acidosis. [EU] Leucine: An essential branched-chain amino acid important for hemoglobin formation. [NIH] Lipid: Any of a heterogeneous group of flats and fatlike substances characterized by being water-insoluble and being extractable by nonpolar (or fat) solvents such as alcohol, ether, chloroform, benzene, etc. All contain as a major constituent aliphatic hydrocarbons. The lipids, which are easily stored in the body, serve as a source of fuel, are an important constituent of cell structure, and serve other biological functions. Lipids may be considered to include fatty acids, neutral fats, waxes, and steroids. Compound lipids comprise the glycolipids, lipoproteins, and phospholipids. [EU] Lipoprotein: Any of the lipid-protein complexes in which lipids are transported in the blood; lipoprotein particles consist of a spherical hydrophobic core of triglycerides or cholesterol esters surrounded by an amphipathic monolayer of phospholipids, cholesterol, and apolipoproteins; the four principal classes are high-density, low-density, and very-lowdensity lipoproteins and chylomicrons. [EU] Malformation: A morphologic defect resulting from an intrinsically abnormal developmental process. [EU] Mannitol: A diuretic and renal diagnostic aid related to sorbitol. It has little significant energy value as it is largely eliminated from the body before any metabolism can take place. It can be used to treat oliguria associated with kidney failure or other manifestations of inadequate renal function and has been used for determination of glomerular filtration rate. Mannitol is also commonly used as a research tool in cell biological studies, usually to control osmolarity. [NIH] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU]

Glossary 213

Midwifery: The practice of assisting women in childbirth. [NIH] Molasses: The syrup remaining after sugar is crystallized out of sugar cane or sugar beet juice. It is also used in animal feed, and in a fermented form, is used to make industrial ethyl alcohol and alcoholic beverages. [NIH] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Monocytes: Large, phagocytic mononuclear leukocytes produced in the vertebrate bone marrow and released into the blood; contain a large, oval or somewhat indented nucleus surrounded by voluminous cytoplasm and numerous organelles. [NIH] Morale: The prevailing temper or spirit of an individual or group in relation to the tasks or functions which are expected. [NIH] Myocardium: The muscle tissue of the HEART composed of striated, involuntary muscle known as cardiac muscle. [NIH] Nadir: The lowest point; point of greatest adversity or despair. [EU] Necrosis: The sum of the morphological changes indicative of cell death and caused by the progressive degradative action of enzymes; it may affect groups of cells or part of a structure or an organ. [EU] Neonatal: Pertaining to the first four weeks after birth. [EU] Nephrogenic: Constant thirst and frequent urination because the kidney tubules cannot respond to antidiuretic hormone and therefore pass too much water. [NIH] Nephropathy: Disease of the kidneys. [EU] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neurogenic: Loss of bladder control caused by damage to the nerves controlling the bladder. [NIH] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Nitrogen: An element with the atomic symbol N, atomic number 7, and atomic weight 14. Nitrogen exists as a diatomic gas and makes up about 78% of the earth's atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. [NIH] Obstetrics: A medical-surgical specialty concerned with management and care of women during pregnancy, parturition, and the puerperium. [NIH] Ophthalmology: A surgical specialty concerned with the structure and function of the eye and the medical and surgical treatment of its defects and

214 Gestational Diabetes

diseases. [NIH] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Osteodystrophy: Defective bone formation. [EU] Otolaryngology: A surgical specialty concerned with the study and treatment of disorders of the ear, nose, and throat. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Oxytocin: A nonapeptide posterior pituitary hormone that causes uterine contractions and stimulates lactation. [NIH] Palpitation: A subjective sensation of an unduly rapid or irregular heart beat. [EU] Pancreas: A mixed exocrine and endocrine gland situated transversely across the posterior abdominal wall in the epigastric and hypochondriac regions. The endocrine portion is comprised of the islets of langerhans, while the exocrine portion is a compound acinar gland that secretes digestive enzymes. [NIH] Pancreatitis: Acute or chronic inflammation of the pancreas, which may be asymptomatic or symptomatic, and which is due to autodigestion of a pancreatic tissue by its own enzymes. It is caused most often by alcoholism or biliary tract disease; less commonly it may be associated with hyperlipaemia, hyperparathyroidism, abdominal trauma (accidental or operative injury), vasculitis, or uraemia. [EU] Parenteral: Not through the alimentary canal but rather by injection through some other route, as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intrasternal, intravenous, etc. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Pelvic: Muscles that support the bladder. [NIH] Perinatal: Pertaining to or occurring in the period shortly before and after birth; variously defined as beginning with completion of the twentieth to twenty-eighth week of gestation and ending 7 to 28 days after birth. [EU] Perineal: Pertaining to the perineum. [EU] Phallic: Pertaining to the phallus, or penis. [EU] Pharmacologic: Pertaining to pharmacology or to the properties and reactions of drugs. [EU] Phenotype: The outward appearance of the individual. It is the product of interactions between genes and between the genotype and the environment. This includes the killer phenotype, characteristic of yeasts. [NIH]

Glossary 215

Phenylalanine: An aromatic amino acid that is essential in the animal diet. It is a precursor of melanin, dopamine, noradrenalin, and thyroxine. [NIH] Placenta: A highly vascular fetal organ through which the fetus absorbs oxygen and other nutrients and excretes carbon dioxide and other wastes. It begins to form about the eighth day of gestation when the blastocyst adheres to the decidua. [NIH] Polyhydramnios: Excess of amniotic fluid greater than 2,000 ml. It is a common obstetrical complication whose major causes include maternal diabetes, chromosomal disorders, isoimmunological disease, congenital abnormalities, and multiple gestations. [NIH] Postnatal: Occurring after birth, with reference to the newborn. [EU] Postprandial: Occurring after dinner, or after a meal; postcibal. [EU] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Precursor: Something that precedes. In biological processes, a substance from which another, usually more active or mature substance is formed. In clinical medicine, a sign or symptom that heralds another. [EU] Predisposition: A latent susceptibility to disease which may be activated under certain conditions, as by stress. [EU] Preeclampsia: A toxaemia of late pregnancy characterized by hypertension, edema, and proteinuria, when convulsions and coma are associated, it is called eclampsia. [EU] Prenatal: Existing or occurring before birth, with reference to the fetus. [EU] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. [NIH] Proportional: Being in proportion : corresponding in size, degree, or intensity, having the same or a constant ratio; of, relating to, or used in determining proportions. [EU] Puberty: The period during which the secondary sex characteristics begin to develop and the capability of sexual reproduction is attained. [EU] Pulse: The rhythmical expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle of the heart as it contracts. [NIH] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a

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specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Recurrence: The return of a sign, symptom, or disease after a remission. [NIH] Reperfusion: Restoration of blood supply to tissue which is ischemic due to decrease in normal blood supply. The decrease may result from any source including atherosclerotic obstruction, narrowing of the artery, or surgical clamping. It is primarily a procedure for treating infarction or other ischemia, by enabling viable ischemic tissue to recover, thus limiting further necrosis. However, it is thought that reperfusion can itself further damage the ischemic tissue, causing reperfusion injury. [NIH] Retinopathy: 1. retinitis (= inflammation of the retina). 2. retinosis (= degenerative, noninflammatory condition of the retina). [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Saccharin: Flavoring agent and non-nutritive sweetener. [NIH] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Sedentary: 1. sitting habitually; of inactive habits. 2. pertaining to a sitting posture. [EU] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Sequela: Any lesion or affection following or caused by an attack of disease. [EU]

Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Sorbitol: A polyhydric alcohol with about half the sweetness of sucrose. Sorbitol occurs naturally and is also produced synthetically from glucose. It was formerly used as a diuretic and may still be used as a laxative and in

Glossary 217

irrigating solutions for some surgical procedures. It is also used in many manufacturing processes, as a pharmaceutical aid, and in several research applications. [NIH] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Spices: The dried seeds, bark, root, stems, buds, leaves, or fruit of aromatic plants used to season food. [NIH] Stomach: An organ of digestion situated in the left upper quadrant of the abdomen between the termination of the esophagus and the beginning of the duodenum. [NIH] Substrate: A substance upon which an enzyme acts. [EU] Systemic: Pertaining to or affecting the body as a whole. [EU] Thermoregulation: Heat regulation. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Tolazamide: A sulphonylurea hypoglycemic agent with actions and uses similar to those of chlorpropamide. [NIH] Tolerance: 1. the ability to endure unusually large doses of a drug or toxin. 2. acquired drug tolerance; a decreasing response to repeated constant doses of a drug or the need for increasing doses to maintain a constant response. [EU]

Toxemia: A generalized intoxication produced by toxins and other substances elaborated by an infectious agent. [NIH] Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU] Transfusion: The introduction of whole blood or blood component directly into the blood stream. [EU] Transplantation: The grafting of tissues taken from the patient's own body or from another. [EU] Triage: The sorting out and classification of patients or casualties to determine priority of need and proper place of treatment. [NIH] Tumour: 1. swelling, one of the cardinal signs of inflammations; morbid enlargement. 2. a new growth of tissue in which the multiplication of cells is uncontrolled and progressive; called also neoplasm. [EU] Urinary: Urination eight or more times a day. [NIH] Urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder, and expelled from the body through the urethra by the act of

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voiding or urinating. [NIH] Uterus: The hollow muscular organ in female mammals in which the fertilized ovum normally becomes embedded and in which the developing embryo and fetus is nourished. In the nongravid human, it is a pear-shaped structure; about 3 inches in length, consisting of a body, fundus, isthmus, and cervix. Its cavity opens into the vagina below, and into the uterine tube on either side at the cornu. It is supported by direct attachment to the vagina and by indirect attachment to various other nearby pelvic structures. Called also metra. [EU] Vagina: The tube in a woman's body that runs beside the urethra and connects the womb (uterus) to the outside of the body. Sometimes called the birth canal. [NIH]

General Dictionaries and Glossaries While the above glossary is essentially complete, the dictionaries listed here cover virtually all aspects of medicine, from basic words and phrases to more advanced terms (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Dictionary of Medical Acronymns & Abbreviations by Stanley Jablonski (Editor), Paperback, 4th edition (2001), Lippincott Williams & Wilkins Publishers, ISBN: 1560534605, http://www.amazon.com/exec/obidos/ASIN/1560534605/icongroupinterna

·

Dictionary of Medical Terms : For the Nonmedical Person (Dictionary of Medical Terms for the Nonmedical Person, Ed 4) by Mikel A. Rothenberg, M.D, et al, Paperback - 544 pages, 4th edition (2000), Barrons Educational Series, ISBN: 0764112015, http://www.amazon.com/exec/obidos/ASIN/0764112015/icongroupinterna

·

A Dictionary of the History of Medicine by A. Sebastian, CD-Rom edition (2001), CRC Press-Parthenon Publishers, ISBN: 185070368X, http://www.amazon.com/exec/obidos/ASIN/185070368X/icongroupinterna

·

Dorland's Illustrated Medical Dictionary (Standard Version) by Dorland, et al, Hardcover - 2088 pages, 29th edition (2000), W B Saunders Co, ISBN: 0721662544, http://www.amazon.com/exec/obidos/ASIN/0721662544/icongroupinterna

·

Dorland's Electronic Medical Dictionary by Dorland, et al, Software, 29th Book & CD-Rom edition (2000), Harcourt Health Sciences, ISBN: 0721694934, http://www.amazon.com/exec/obidos/ASIN/0721694934/icongroupinterna

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·

Dorland's Pocket Medical Dictionary (Dorland's Pocket Medical Dictionary, 26th Ed) Hardcover - 912 pages, 26th edition (2001), W B Saunders Co, ISBN: 0721682812, http://www.amazon.com/exec/obidos/ASIN/0721682812/icongroupinterna /103-4193558-7304618

·

Melloni's Illustrated Medical Dictionary (Melloni's Illustrated Medical Dictionary, 4th Ed) by Melloni, Hardcover, 4th edition (2001), CRC PressParthenon Publishers, ISBN: 85070094X, http://www.amazon.com/exec/obidos/ASIN/85070094X/icongroupinterna

·

Stedman's Electronic Medical Dictionary Version 5.0 (CD-ROM for Windows and Macintosh, Individual) by Stedmans, CD-ROM edition (2000), Lippincott Williams & Wilkins Publishers, ISBN: 0781726328, http://www.amazon.com/exec/obidos/ASIN/0781726328/icongroupinterna

·

Stedman's Medical Dictionary by Thomas Lathrop Stedman, Hardcover 2098 pages, 27th edition (2000), Lippincott, Williams & Wilkins, ISBN: 068340007X, http://www.amazon.com/exec/obidos/ASIN/068340007X/icongroupinterna

·

Tabers Cyclopedic Medical Dictionary (Thumb Index) by Donald Venes (Editor), et al, Hardcover - 2439 pages, 19th edition (2001), F A Davis Co, ISBN: 0803606540, http://www.amazon.com/exec/obidos/ASIN/0803606540/icongroupinterna

220 Gestational Diabetes

INDEX A Abdomen .......................................20, 217 Abortion ...............................................207 Acidosis .................................18, 174, 212 Adolescence ........................175, 207, 214 Adrenergic ...........................................128 Adverse .................................................70 Aerobic ................................................106 Alleles ....................................................68 Amniocentesis ...........................20, 21, 22 Anemia ........................................111, 130 Antibody...........................76, 94, 168, 208 Antidiabetic ..............................70, 94, 211 Antigen ..........................................93, 208 Aspartame .............................................31 Assay.....................................................99 Asymptomatic ......................118, 134, 214 Autoimmunity.........................................68 B Bacteria .................94, 113, 162, 208, 217 Bilirubin ..................................................23 Biochemical ...........................93, 120, 207 Blindness ...............................................57 C Calcium......................16, 27, 35, 163, 164 Capillary...........................................70, 77 Capsules..............................................165 Carbohydrate......45, 51, 72, 73, 122, 123, 164, 210 Cardiac ..........................................95, 213 Cardiovascular.......................................48 Cholesterol ..............32, 95, 162, 164, 212 Chronic ....57, 77, 119, 129, 134, 186, 214 Confusion ..............................................38 Constipation...........................................32 D Degenerative .........................96, 163, 216 Dehydration ...........................................38 Diarrhea...............................................162 Digestion........................................32, 217 Dizziness .........................................38, 39 Dystocia...............................................120 E Edema .....................................48, 53, 215 Elastic ....................................................20 Embryo ....54, 95, 113, 207, 210, 211, 218 Endocrinology................................63, 211 Epidemiological ...........................120, 124 F Fatigue...................................................12 G Gastrointestinal............................113, 210 Genotype .......................................96, 214

Glyburide......................................... 71, 72 Gynecology ........................................... 60 H Heartburn .............................................. 33 Homeostasis ....................................... 107 Hormone ...... 11, 21, 52, 57, 63, 164, 174, 200, 211, 212, 213, 214 Hunger .......................................... 38, 121 Hypertension......................... 53, 106, 215 I Idiopathic............................... 94, 118, 211 Indicative............................. 120, 175, 213 Induction ....................................... 93, 156 Ischemia........................................ 96, 216 J Jaundice.......................................... 23, 74 L Leucine ............................................... 169 Lipid .................................. 52, 72, 95, 212 Lipoprotein .................................... 95, 212 M Mannitol ................................................ 31 Molasses......................................... 11, 31 Molecular ... 108, 116, 126, 128, 134, 207, 215 N Necrosis ................................ 96, 172, 216 Neonatal............................ 71, 72, 78, 168 Nephrogenic ......................................... 56 Neural ................................................. 163 Neurogenic............................................ 56 Niacin .................................................. 163 Nitrogen .............................................. 169 O Obstetrics.................................. 20, 60, 99 Oral ...... 13, 48, 52, 68, 69, 70, 71, 76, 98, 107, 120, 121, 209, 214 Overdose ............................................ 163 Oxytocin .......................................... 20, 21 P Pancreas...... 11, 12, 15, 52, 57, 118, 134, 211, 214 Pancreatitis ......................................... 124 Pelvic ...................................... 38, 54, 218 Perinatal.................. 69, 76, 107, 120, 169 Pharmacologic ...................................... 69 Phenotype..................................... 96, 214 Phenylalanine ....................... 51, 169, 208 Placenta .... 12, 14, 17, 20, 21, 22, 24, 39, 71, 110 Polyhydramnios .............................. 13, 48 Postnatal ............................................... 43 Postprandial ........................................ 107

Index 221

Potassium............................................164 Precursor .....................................175, 215 Predisposition ........................................72 Preeclampsia...........................25, 69, 123 Prenatal .............................26, 30, 69, 123 Prevalence...............................56, 70, 111 R Receptor ........................................94, 208 Recurrence ............................................73 Reperfusion ...................................96, 216 Riboflavin.............................................162 S Secretion .........................71, 96, 118, 216 Selenium..............................................164 Sequela ...............................................168 Serum ................................16, 53, 71, 216 Sorbitol ....................................31, 52, 212

Spices ................................................... 36 Stomach.... 11, 27, 52, 113, 200, 210, 211 T Thermoregulation................................ 162 Tolerance .... 4, 13, 14, 41, 68, 69, 72, 76, 98, 107, 119, 120, 121, 124, 170, 205, 217 Toxemia .......................................... 22, 48 Transplantation ............................... 48, 57 Tumour................................................ 172 U Urinary .......................................... 56, 123 Urine .... 11, 13, 14, 18, 19, 22, 25, 42, 44, 45, 48, 52, 102, 110, 175, 211, 216 Uterus ........... 20, 21, 38, 51, 54, 207, 218 V Vagina............................. 15, 54, 201, 218

222 Gestational Diabetes