Glycemic Index, glycemic control and beyond

It is currently estimated that over 370 million individuals have diabetes, making diabetes a major public health issue contributing significantly to global morbidity and mortality. The steep rise in diabetes prevalence over the past decades is attributable, in a large part, to lifestyle changes, with dietary habits and behaviour significant contributors. Despite the relatively wide availability of anti-diabetic medicine, it is lifestyle approaches that still remain the cornerstone of diabetes prevention and treatment. Glycemic index (GI) is a nutritional tool, which represents the glycemic response to carbohydrate ingestion. In light of the major impact of nutrition on diabetes pathophysiology, with the rising need to combat the escalating diabetes epidemic, this review will focus on the role of GI in glycemic control, the primary target of diabetic treatment and beyond. The review will present the evidence relating GI and diabetes treatment and prevention, as well as weight loss, weight maintenance and CVD risk factors.

The role of monounsaturated fatty acids in the mitigation of insulin resistance

With the rising rate of obesity, there is considerable interest in dietary strategies to reduce insulin resistance, a major characteristic of the metabolic syndrome and type 2 diabetes. Diets rich in monounsaturated fatty acids (MUFA) have been suggested as an alternative to low-fat, high-carbohydrate diets to improve glycemic control. However, inconsistent effects have been observed with MUFA-rich diets in both healthy and insulin-resistant individuals. In studies that have reported favorable effects on insulin sensitivity, Mediterranean-style diets have been used that are rich not only in MUFA but also whole-grain foods, fiber, and carbohydrates with a low glycemic index. There is a need for intervention studies to examine the true impact of MUFA-rich oils on glycemic control in both Mediterranean and non-Mediterranean populations. In addition, the metabolic and genotypic status of the participants may also play a role in the inter-individual variability in insulin sensitivity in response to MUFA-rich diets.

Cardioprotective effects of insulin: how intensive insulin therapy may benefit cardiac surgery patients

Interest in the effects of insulin on the heart came with the recognition that hyperglycemia in the context of myocardial infarction is associated with increased risks of mortality, congestive heart failure, or cardiogenic shock. More recently, instigated by research findings on stress hyperglycemia in critical illness, this interest has been extended to the influence of insulin on clinical outcome after cardiac surgery. Even in nondiabetic individuals, stress hyperglycemia commonly occurs as a key metabolic response to critical illness, eg, after surgical trauma. It is recognized as a major pathophysiological feature of organ dysfunction in the critically ill. The condition stems from insulin resistance brought about by dysregulation of key homeostatic processes, which implicates immune/inflammatory, endocrine, and metabolic pathways. It has been associated with adverse clinical outcomes, including increased mortality, increased duration of mechanical ventilation, increased intensive care unit (ICU) and hospital stay, and increased risk of infection. Hyperglycemia in critical illness is managed with exogenous insulin as standard treatment; however, there is considerable disagreement among experts in the field as to what target blood glucose level is optimal for the critically ill patient. Conventionally, the aim of insulin therapy has been to maintain blood glucose levels below the renal threshold, typically 220 mg/dL (12.2 mmol/L). In recent years, some have advocated tight glycemic control (TGC) with intensive insulin therapy (IIT) to normalize blood glucose levels to within the euglycemic range, typically 80 to 110 mg/dL (4.4–6.1 mmol/L).

The impact of maternal control on children’s anxious cognitions, behaviours and affect: an experimental study

Controlling parenting is associated with child anxiety however the direction of effects remains unclear. The present study implemented a Latin-square experimental design to assess the impact of parental control on children’s anxious affect, cognitions and behaviour. A non-clinical sample of 24 mothers of children aged 4-5 years were trained to engage in (a) controlling and (b) autonomy-granting behaviours in interaction with their child during the preparation of a speech. When mothers engaged in controlling parenting behaviours, children made more negative predictions about their performance prior to delivering their speech and reported feeling less happy about the task, and this was moderated by child trait anxiety. In addition, children with higher trait anxiety displayed a significant increase in observed child anxiety in the controlling condition. The pattern of results was maintained when differences in mothers’ levels of negativity and habitual levels of control were accounted for. These findings are consistent with theories that suggest that controlling parenting is a risk factor in the development of childhood anxiety.

The effects of maternal social phobia on mother-infant interactions and infant social responsiveness

Background: Social phobia aggregates in families. The genetic contribution to intergenerational transmission is modest, and parenting is considered important. Research on the effects of social phobia on parenting has been subject to problems of small sample size, heterogeneity of samples and lack of specificity of observational frameworks. We addressed these problems in the current study.Methods: We assessed mothers with social phobia (N = 84) and control mothers (N = 89) at 10 weeks in face-to-face interactions with their infants, and during a social challenge, namely, engaging with a stranger. We also assessed mothers with generalised anxiety disorder (GAD) (N = 50). We examined the contribution to infant social responsiveness of early infant characteristics (neonatal irritability), as well as maternal behaviour. Results: Mothers with social phobia were no less sensitive to their infants during face-to-face interactions than control mothers, but when interacting with the stranger they appeared more anxious, engaged less with the stranger themselves, and were less encouraging of the infant's interaction with the stranger; infants of index mothers also showed reduced social responsiveness to the stranger. These differences did not apply to mothers with GAD and their infants. Regression analyses showed that the reduction in social responsiveness in infants of mothers with social phobia was predicted by neonatal irritability and the degree to which the mother encouraged the infant to interact with the stranger.Conclusions: Mothers with social phobia show specific parenting difficulties, and their infants show early signs of reduced social responsiveness that are related to both individual infant differences and a lack of maternal encouragement to engage in social interactions.

Disturbances in morning cortisol secretion in association with maternal postnatal depression predict subsequent depressive symptomatology in adolescents

Background: We have previously reported higher and more variable salivary morning cortisol in 13-year-old adolescents whose mothers were depressed in the postnatal period, compared with control group adolescents whose mothers did not develop postnatal depression (PND). This observation suggested a biological mechanism by which intrafamilial risk for depressive disorder may be transmitted. In the current article, we examined whether the cortisol disturbances observed at 13 years could predict depressive symptornatology in adolescents at 16 years of age. Methods: We measured self-reported depressive symptoms in 16-year-old adolescents who had (n = 48) or had not (n = 39) been exposed to postnatal maternal depression and examined their prediction by morning and evening cortisol indices obtained via 10 days of salivary collections at 13 years. Results: Elevated morning cortisol secretion at 13 years, and particularly the maximum level recorded over 10 days of collection, predicted elevated depressive symptoms at 16 years over and above 13-year depressive symptom levels and other possible confounding factors. Morning cortisol secretion mediated an association between maternal PND and symptornatology in 16-year-old offspring. Conclusions: Alterations in steroid secretion observed in association with maternal PND may provide a mechanism by which risk for depression is transmitted from mother to offspring.

Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression - 1. Impact on maternal mood!

Background: Psychological interventions for postnatal depression can be beneficial in the short term but their longer-term impact is unknown, Aims To evaluate the long-term effect on maternal mood of three psychological treatments in relation to routine primary care. Method: Women with post-partum depression (n=193)were assigned randomly to one of four conditions: routine primary care, non-directive counselling, cognitive-behavioural therapy or psychodynamic therapy. They were assessed immediately after the treatment phase (at 4.5 months) and at 18 and 60 months post-partum. Results: Compared with the control, ail three treatments had a significant impact at 4.5 months on maternal mood (Edinburgh Postnatal Depression Scale, EPDS). Only psychodynamic therapy produced a rate of reduction in depression (Structured Clinical interview for DSM III-R) significantly superior to that of the control. The benefit of treatment was no longer apparent by 9 months postpartum, treatment did not reduce subsequent episodes of post-partum depression. Conclusions: Psychological intervention for post-partum depression improves maternal mood (EPDS) in the short term. However, this benefit is not superior to spontaneous remission in the long term.

The effects of maternal postnatal depression and child sex on academic performance at age 16 years: a developmental approach

Background: Postnatal depression (PND) is associated with poor cognitive functioning in infancy and the early school years; long-term effects on academic outcome are not known. Method: Children of postnatally depressed (N = 50) and non-depressed mothers (N = 39), studied from infancy, were followed up at 16 years. We examined the effects on General Certificate of Secondary Education (GCSE) exam performance of maternal depression (postnatal and subsequent) and IQ, child sex and earlier cognitive development, and mother–child interactions, using structural equation modelling (SEM). Results: Boys, but not girls, of PND mothers had poorer GCSE results than control children. This was principally accounted for by effects on early child cognitive functioning, which showed strong continuity from infancy. PND had continuing negative effects on maternal interactions through childhood, and these also contributed to poorer GCSE performance. Neither chronic, nor recent, exposure to maternal depression had significant effects. Conclusions: The adverse effects of PND on male infants’ cognitive functioning may persist through development. Continuing difficulties in mother–child interactions are also important, suggesting that both early intervention and continuing monitoring of mothers with PND may be warranted.

Maternal adipose tissue response to nicotine administration in the pregnant rat: effects on fetal body fat and cellularity

1. Nicotine has been implicated as a causative factor in the intrauterine growth retardation associated with smoking in pregnancy. A study was set up to ascertain the effect of nicotine on fetal growth and whether this could be related to the actions of this drug on maternal adipose tissue metabolism. 2. Sprague-Dawley rats were mated and assigned to control and nicotine groups, the latter receiving nicotine in the drinking-water throughout pregnancy. Animals were weighed at regular intervals and killed on day 20 of pregnancy. Rates of maternal adipose tissue lipolysis and lipogenesis were measured. Fetal and placental weights were recorded and analysis of fetal body water, fat, protein and DNA carried out. 3. Weight gains of mothers in the nicotine group were less in the 1st and 2nd weeks of pregnancy, but similar to controls in the 3rd week. Fetal body-weights, DNA, protein and percentage water contents were similar in both groups. Mean fetal body fat (g/kg) was significantly higher in the nicotine group (96.2 (SE 5.1)) compared with controls (72.0 (SE 2.9)). Rates of maternal lipolysis were also higher in the nicotine group. 4. The cause of these differences and their effects on maternal and fetal well-being is discussed.

Maternal affective disorder and children’s representation of their families

Children’s perceptions of family relationship are related to their later emotional and social adjustment. This is of particular relevance in the context of family stressors such as maternal affective disorder. This study investigated the effects of maternal postnatal depression and anxiety on children’s family representations. In our sample of postnatally depressed mothers we also explored marital conflict as mediator between maternal psychopathology and children’s representations. Family drawings of 235 4–5 year-old children (93 control, 53 depressed and 89 anxious) were examined. When compared to controls, children of depressed, but not of anxious mothers, were more likely to draw themselves as less prominent than other family members and to represent a dysfunctional family, less likely to represent themselves with a happy face and showed a greater tendency of drawing bizarre pictures. Marital conflict mediated the association between maternal depression and dysfunctionality in drawings.

The role of negative maternal affective states and infant temperament in early interactions between infants with cleft lip and their mothers

OBJECTIVES: The study examined the early interaction between mothers and their infants with cleft lip, assessing the role of maternal affective state and expressiveness and differences in infant temperament. METHODS: Mother-infant interactions were assessed in 25 2-month-old infants with cleft lip and 25 age-matched healthy infants. Self-report and behavioral observations were used to assess maternal depressive symptoms and expressions. Mothers rated infant temperament. RESULTS: Infants with cleft lip were less engaged and their mothers showed more difficulty in interaction than control group dyads. Mothers of infants with cleft lip displayed more negative affectivity, but did not report more self-rated depressive symptoms than control group mothers. No group differences were found in infant temperament. CONCLUSIONS: In order to support the mother's experience and facilitate her ongoing parental role, findings highlight the importance of identifying maternal negative affectivity during early interactions, even when they seem have little awareness of their depressive symptoms.

The effect of salmon consumption during pregnancy on maternal and infant faecal microbiota, sIgA and calprotectin

The infant gut microbiota plays an important role in the development of the infant immune and gastrointestinal systems. We investigated whether increased salmon consumption during pregnancy, maternal weight gain during pregnancy or infant mode of feeding alter markers of gut immune defence and inflammation. Women (n = 123) who rarely ate oily fish were randomly assigned to remain on their habitual diet or to consume two 150 g portions of farmed salmon per week from 20 weeks pregnancy until delivery. At 38 weeks gestation the women (n = 75) provided a faecal sample and on days 7, 14, 28 and 84 post-partum, faecal samples were collected from the infants (n = 38). Fluorescence in situ hybridisation was used to determine the composition of the faecal microbiota and ELISA to measure faecal sIgA and calprotectin concentrations. There was no effect of salmon consumption on the faecal microbiota of the mothers or on faecal sIgA and calprotectin concentrations in either mothers or infants. Degree of weight gain influenced the maternal faecal microbiota and mode of infant feeding influenced the infant faecal microbiota. Faecal samples from infants in the salmon group tended to have lower counts of Atopobium cluster compared with those in the control group (P = 0.097). This difference was significant in formula-fed infants (P < 0.05), but not exclusively breast-fed infants. In conclusion, the impact of oily fish consumption during pregnancy on maternal and infant gut microbiota composition is limited, but significant differences were associated with maternal weight gain during pregnancy and infant mode of feeding.

Interpretation and expectations among mothers of children with anxiety disorders: associations with maternal anxiety disorder

Background Models of the development and maintenance of childhood anxiety suggest an important role for parent cognitions: that is, negative expectations of children's coping abilities lead to parenting behaviors that maintain child anxiety. The primary aims of the current study were to (1) compare expectations of child vulnerability and coping among mothers of children with anxiety disorders on the basis of whether or not mothers also had a current anxiety disorder, and (2) examine the degree to which the association between maternal anxiety disorder status and child coping expectations was mediated by how mothers interpreted ambiguous material that referred to their own experience. Methods The association between interpretations of threat, negative emotion, and control was assessed using hypothetical ambiguous scenarios in a sample of 271 anxious and nonanxious mothers of 7- to 12-year-old children with an anxiety disorder. Mothers also rated their expectations when presented with real life challenge tasks. Results There was a significant association between maternal anxiety disorder status and negative expectations of child coping behaviors. Mothers’ self-referent interpretations were found to mediate this relationship. Responses to ambiguous hypothetical scenarios correlated significantly with responses to real life challenge tasks. Conclusions Treatments for childhood anxiety disorders in the context of parental anxiety disorders may benefit from the inclusion of a component to directly address parental cognitions. Some inconsistencies were found when comparing maternal expectations in response to hypothetical scenarios with real life challenges. This should be addressed in future research.

Treatment of child anxiety in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis

Background Cognitive–behavioural therapy (CBT) for childhood anxiety disorders is associated with modest outcomes in the context of parental anxiety disorder. Objectives This study evaluated whether or not the outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders is improved by the addition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused on maternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated. Design Participants were randomised to receive (i) child cognitive–behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBT + maternal cognitive–behavioural therapy (MCBT)]; or (iii) CCBT with an intervention to target mother–child interactions (MCIs) (CCBT + MCI). Setting A NHS university clinic in Berkshire, UK. Participants Two hundred and eleven children with a primary anxiety disorder, whose mothers also had an anxiety disorder. Interventions All families received eight sessions of individual CCBT. Mothers in the CCBT + MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in the MCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact. Main outcome measures Primary clinical outcomes were the child’s primary anxiety disorder status and degree of improvement at the end of treatment. Follow-up assessments were conducted at 6 and 12 months. Outcomes in the economic analyses were identified and measured using estimated quality-adjusted life-years (QALYs). QALYS were combined with treatment, health and social care costs and presented within an incremental cost–utility analysis framework with associated uncertainty. Results MCBT was associated with significant short-term improvement in maternal anxiety; however, after children had received CCBT, group differences were no longer apparent. CCBT + MCI was associated with a reduction in maternal overinvolvement and more confident expectations of the child. However, neither CCBT + MCBT nor CCBT + MCI conferred a significant post-treatment benefit over CCBT in terms of child anxiety disorder diagnoses [adjusted risk ratio (RR) 1.18, 95% confidence interval (CI) 0.87 to 1.62, p = 0.29; adjusted RR CCBT + MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67, p = 0.20, respectively] or global improvement ratings (adjusted RR 1.25, 95% CI 1.00 to 1.59, p = 0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53, p = 0.13). CCBT + MCI outperformed CCBT on some secondary outcome measures. Furthermore, primary economic analyses suggested that, at commonly accepted thresholds of cost-effectiveness, the probability that CCBT + MCI will be cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%. Conclusions Good outcomes were achieved for children and their mothers across treatment conditions. There was no evidence of a benefit to child outcome of supplementing CCBT with either intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented a cost-effective use of resources, although the high percentage of missing data on some economic variables is a shortcoming. Future work should consider whether or not effects of the adjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the use of a broad range of services when evaluating interventions with this client group. Trial registration Current Controlled Trials ISRCTN19762288. Funding This trial was funded by the Medical Research Council (MRC) and Berkshire Healthcare Foundation Trust and managed by the National Institute for Health Research (NIHR) on behalf of the MRC–NIHR partnership (09/800/17) and will be published in full in Health Technology Assessment; Vol. 19, No. 38.

Maternal postnatal depression predicts altered offspring biological stress reactivity in adulthood

The offspring of depressed parents have been found to show elevated basal levels of the stress hormone cortisol. Whether heightened cortisol stress reactivity is also present in this group has yet to be clearly demonstrated. We tested whether postnatal maternal depression predicts subsequent increases in offspring biological sensitivity to social stress, as indexed by elevated cortisol reactivity. Participants (mean age 22.4-years) derived from a 22-year prospective longitudinal study of the offspring of mothers who had postnatal depression (PND group; n=38) and a control group (n=38). Salivary cortisol response to a social-evaluative threat (Trier Social Stress Test) was measured. Hierarchical linear modelling indicated that PND group offspring showed greater cortisol reactivity to the stress test than control group participants. Group differences were not explained by offspring depressive or anxiety symptoms, experiences of negative life events, elevated basal cortisol at age 13-years, subsequent exposure to maternal depression, or other key covariates. The findings indicate that the presence of early maternal depression can predict offspring biological sensitivity to social stress in adulthood, with potential implications for broader functioning.