Diabetes is an increasingly common pregnancy complication


My clinical experiences suggest that more pregnant patients have been developing diabetes over the past several years, and it turns out this is a national phenomenon. A recent report from the Centers for Disease Control and Prevention documented a precipitous rise in the rate of gestational diabetes in the U.S. from 2016 to 2020, based on data collected from birth certificates. In 2020, gestational diabetes affected 7.8% of all pregnancies, reflecting a 13% increase since 2019 and a 30% increase since 2016. Prevalence increased with increasing age (2.5% in patients younger than 20 years and 15.3% in those aged 40 or older) and increasing pre-pregnancy body mass index (BMI). Both factors are likely driving the overall rise in gestational diabetes; the median age at which U.S. women gave birth reached an all-time high of 30 years in 2019 and only 2 in 5 women with a live birth in 2020 had a normal BMI prior to pregnancy.

The U.S. Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes in asymptomatic pregnant patients at or after 24 weeks of gestation. Although the USPSTF did not identify a preferred test, a previously discussed study suggested that the two-step approach (a non-fasting 50 gram oral glucose challenge test followed by a fasting 100 gram glucose tolerance test if the first test is positive) “produces equivalent benefits, and fewer harms, than the one-step approach.”

Adverse outcomes associated with gestational diabetes include gestational hypertension, preeclampsia, shoulder dystocia, macrosomia, and Cesarean delivery. Gestational diabetes also confers a 7-fold greater maternal risk of developing type 2 diabetes later in life and 1.5 times greater risk of the child being overweight in childhood or adolescence. Management of gestational diabetes begins with glucose self-monitoring and lifestyle modifications, followed by oral medication or insulin if target blood glucose levels are not achieved.

Prevention of gestational diabetes includes counseling on appropriate weight gain goals based on pre-pregnancy BMI, which can generally be achieved by averaging “350 to 450 calories per day above the previous intake (e.g., two slices of bread with half an avocado, ¾ cup of Greek yogurt or 1 cup of blueberries with two hard-boiled eggs).” Additionally, “patients should be encouraged to engage in moderate aerobic activity most days of the week for at least 20 to 30 minutes at a time, for a total of at least 150 minutes per week.” The USPSTF recommends offering behavioral counseling interventions for healthy weight and weight gain in pregnancy; effective interventions generally started at the end of the first trimester and varied in duration and intensity (from 15 to 120 minutes and from 1 to more than 12 total contacts).

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Preventive services mandate can be improved, but eliminating it isn’t the answer


Over the past 12 years since the Affordable Care Act became law, individuals, business groups, and state officials who object to one or more of its provisions have filed a lengthy list of mostly unsuccessful lawsuits seeking to have part or all of it declared unconstitutional by the courts. The latest legal challenge involves the requirement that private health insurers cover without patient cost-sharing all evidence-based preventive services, defined as more than 100 services recommended by the Advisory Committee on Immunization Practices, the U.S. Preventive Services Task Force, Bright Futures, or the Women’s Preventive Service Initiative. When I went to my family doctor last month and received screening tests for colorectal cancer, high blood pressure, and cholesterol, these tests were all covered under the ACA’s preventive services mandate. When I take my kids to receive their school-required vaccinations, those shots are fully covered too. The same goes for the costs of clinicians counseling pregnant patients about healthy weight and weight gain to prevent complications such as gestational diabetes, and similar counseling for to midlife women (aged 40 to 60 years) to maintain weight or limit weight gain to prevent obesity.

Why would anyone have a problem with requiring insurers to cover preventive services? Some employers have religious or ideological objections to paying for birth control and sterilization, preexposure prophylaxis for HIV prevention, or testing for sexually transmitted diseases. Others might oppose the increased employer or government contribution to insurance premiums that may result from mandating that these services be covered, though in reality the types of health care that drive up premiums tend to be pricey procedures and medications such as the Alzheimer’s drug Aduhelm, whose initial projected price of $56,000 per year drove the highest-ever increase in Medicare premiums from 2021 to 2022.

Ensuring that patients can afford preventive services is only the first step toward getting them done. Only about two-thirds of eligible adults are up-to-date on colorectal cancer screening, for example, and a much lower percentage of current or past heavy smokers over age 50 have been offered or received lung cancer screening. Behavioral health preventive services such as screening for depression, intimate partner violence, and unhealthy alcohol use can be difficult to fit into clinical practice workflows that rely on dysfunctional electronic health records (systems that are optimized for billing rather than patient care).

The narrow focus of the ACA’s preventive services mandate on health care services also leaves out other private and public programs that can have large benefits on disease prevention and care. For example, the final report of the National Clinical Care Commission included population-level diabetes prevention recommendations involving the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, and the Department of Housing and Urban Development. A related analysis article in Health Affairs bemoaned the fragmented state of US health care and policy that has stalled progress in preventing and controlling type 2 diabetes:

At the population level, fragmentation and lack of shared population health goals across stakeholders mean that there is no ownership for large segments of the population who are at risk for or have diabetes. Payers carry the liability for the health service costs of their beneficiaries and can track utilization. Enrollee churn reduces payers’ incentives to take on long-term responsibility or investments in higher-quality preventive services for which returns are only realized in the long term. … Similarly, the movement of people between health systems undermines incentives for long-term, high-value care.

So you’ll get no pushback from me if you observe that there are lots of flaws and loopholes in the preventive services mandate (beginning with the fact that it doesn’t even apply to half of Americans who are either publicly insured or uninsured). But getting rid of it is throwing the baby out with the bathwater: an exceedingly dumb and harmful proposition that would result in more preventable illness and poorer quality of life for millions of Americans.



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Mismeasuring quality in primary care


After several years of doing family medicine commentaries for Medscape as part of a collaboration with Georgetown University Medical Center, I recently wrote my first commentary as a clinician and faculty member at the Lancaster General Hospital Family Medicine Residency Program about my mostly unsuccessful pursuit of elusive “quality” bonuses and the problems with current metrics used to judge care provided by primary care physicians. Here’s an excerpt that discusses another notable perspective that inspired me to write about this topic: 

In a recent commentary, Drs. Christine Sinsky and Jeffrey Panzer distinguished “solution shop” from “production line” work in primary care and argued that though the medical training physicians receive makes us uniquely qualified to do the former, we end up spending most of our time and energy on the latter. Similarly, they observed that “most quality-improvement efforts have focused on improving production line–type measures and not on improving the conditions for sound medical decision-making and relationship building.” Being able to correctly diagnose and treat patients who come in for chest or abdominal pain, for example, counts less (or not at all) toward my quality score compared with the percentage of patients who receive lead screening or diabetic eye exams.



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Common Sense Family Doctor: Peanut allergy: prevention and treatment advances


People with severe peanut allergy are at risk of life-threatening anaphylaxis from unintentional ingestion of small amounts of peanuts. A new drug review in American Family Physician discussed oral immunotherapy with peanut allergen powder, which increases tolerance for ingesting the amount of peanut protein in a single peanut by 63% but has important downsides: 1 in 10 patients need to use epinephrine after administration (compared to 1 in 20 in a placebo group); common short-term adverse effects include abdominal pain, throat irritation, and oral pruritus; and a price of approximately $3000 annually.

Although it was once believed that children should not consume peanuts early in life, a United Kingdom randomized trial in infants 4 to 11 months of age at high risk of developing peanut allergies found that early consumption of peanuts reduced the risk of developing peanut allergy by age 5 years by 80% (absolute risk reduction=14%, NNT=7). This finding led the National Institute of Allergy and Infectious Diseases to recommend in 2017 that peanut-containing foods be introduced into the diet of infants with severe eczema, egg allergy, or both at 4 to 6 months of age. In 2021, a consensus document on the primary prevention of food allergy from three North American professional allergy societies recommended introducing peanut-containing products to all infants around 6 months of age, regardless of their risk of developing peanut allergy.

A similar change to infant feeding guidelines in Australia occurred in 2016, recommending that all infants be introduced to peanuts before age 12 months. A recent study in JAMA evaluated changes in feeding practices and the prevalence of peanut allergy across two population-based cross-sectional samples recruited in 2007-2011 and 2018-2019. Although infants in the later sample were much more likely to have consumed peanuts before 12 months than infants in the earlier sample (86% vs. 22%), overall there was no statistical difference in peanut allergy prevalence. Noting that East Asian ancestry is considered a risk factor for peanut allergy, the authors hypothesized that the increased representation of infants with parents from East Asia in the later sample may have contributed to finding no effect. Another possible explanation is that early introduction of peanut-containing foods does not significantly modify peanut allergy development in infants not at high risk.

In a previous paper on identifying and using clinical practice guidelines, Dr. David Slawson and I observed: “The ultimate test of a good guideline is whether or not it has been prospectively validated; that is, has its adoption been shown to improve patient-oriented outcomes in real-world settings?” Based on the JAMA study, infant feeding recommendations to prevent peanut allergies have not yet passed this test. On the other hand, an accompanying editorial argued that “given the potential for benefit and the low risk of harm, the [study results] should not dissuade clinicians from following current consensus guidance that recommends early peanut introduction for infants.” The challenge of identifying children at increased risk for peanut allergy (as noted in the consensus document, definitions have varied across studies and guidelines) and the inherently artificial nature of previous guidance restricting what an infant would otherwise naturally eat make this a reasonable course of action in the face of imperfect evidence.

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This post first appeared on the AFP Community Blog.



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Tim Spector: The Latest Science on Gut Health (and How To Find The Right Diet For You)

Tim Spector: The Latest Science on Gut Health (and How To Find The Right Diet For You)


For the last in the current series of Feel Better Live More, I’m welcoming back someone I know you’ll love. Professor Tim Spector was my first-ever guest, and he returns for the third time today, with the very latest on gut health and personalised nutrition.

Tim is a professor of genetic epidemiology and Head of the Department of Twin Research at King’s College London. He’s a world-leader when it comes to the gut microbiome – and Director of the British Gut Project – whose research has transformed what we know about food and health. Tim is author of two excellent books, The Diet Myth and Spoonfed: Why Everything You Know About Food Is Wrong.

If you’re familiar with his work, this conversation will bring you up to date with all Tim’s most recent findings and practical advice. But don’t worry if you’re new to the subject of gut health, as we also provide a need-to-know guide to get you up to speed.

We start by discussing why gut health is such a hot topic. Tim explains that, unlike our genes, it’s something we can influence, thereby improving not just digestion but almost all aspects of our wellbeing. He reveals the gut-friendly properties of plant fibre, polyphenols and fermented foods. And because diversity is key, Tim shares some of his own food hacks for getting to 30 different plant foods a week.

Tim believes the obesity crisis is more of a food crisis, fuelled by ultra-processed foods. We discuss a move towards counting quality instead of calories, and why the new mandatory calorie labels are unhelpful for most people. We also talk about personalised nutrition and the revolutionary PREDICT studies, carried out for Tim’s ZOE nutritional science company, which found people can have dramatically different biological responses to the same foods. The results have led him to develop a personalised nutrition testing kit and app that you can try too.

Our conversation covers much more, including the benefits of time restricted eating for gut health, why skipping breakfast isn’t bad for you, and the pros and cons of health trackers. Tim also reveals the gut parasite that 1 in 4 of us have, which rather than making us ill, can actually have huge benefits for our health.

This is a fascinating conversation; full of practical and actionable information. I hope you enjoy listening.

Disclaimer: The content in the podcast and on this webpage is not intended to constitute or be a substitute for professional medical advice, diagnosis, or treatment.*

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Find out more about Tim:

Website     Instagram     Twitter      PREDICT study   

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Tim’s books:

Spoon Fed: why almost everything we’ve been told about food is wrong

The Diet Myth: The Real Science Behind What We Eat

Identically Different: Why you can change your genes

Related Feel Better Live More episodes:

#1 Gut Health and why we need to throw out the rule-book with Professor Tim Spector

#131 Tim Spector: Why Everything You’ve Been Told About Food Is Wrong

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*DISCLAIMER: Always seek the advice of your doctor or other qualified health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have heard on the podcast or on my website.

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BITESIZE | How to Design Your Perfect Life | Peter Crone

BITESIZE | How to Design Your Perfect Life | Peter Crone


What if the only thing separating you from living your perfect life is the dialogue that exists within your subconscious mind?

Feel Better Live More Bitesize is my weekly podcast for your mind, body, and heart.  Each week I’ll be featuring inspirational stories and practical tips from some of my former guests.

Today’s clip is from episode 199 of the podcast with Peter Crone, also known as ‘The Mind Architect’

In this clip, he explains why we all have the power to choose how we respond to any situation and the impact this can have on how we live our lives.

Disclaimer: The content in the podcast and on this webpage is not intended to constitute or be a substitute for professional medical advice, diagnosis, or treatment.*

Click here for more information on our sponsor athleticgreens.com/livemore

Listen to the full conversation with Peter Crone here:

#199 How To Design Your Perfect Life with Peter Crone

Subscribe to Feel Better Live More:

Support the podcast and enjoy Ad-Free episodes. Try FREE for 7 days on Apple Podcasts. For other podcast platforms click here.

Dr Chatterjee’s books and resources:

*DISCLAIMER: Always seek the advice of your doctor or other qualified health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have heard on the podcast or on my website.

†Disclosure: All books marked with a † are hyperlinked to an affiliate program. We take part in Amazon’s affiliate advertising program designed to provide a way for us to earn fees by linking to Amazon’s website. You are not charged any extra by using these links to purchase books.





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Race-based clinical prediction tools are ripe for reassessment


In June, Dr. Bonzo Reddick’s editorial “Fallacies and Dangers of Practicing Race-Based Medicine” reviewed the limitations of several commonly used clinical prediction tools that employ race as a biologic variable rather than recognizing it as a social construct. For example, he pointed out that the American College of Cardiology / American Heart Association Pooled Cohort Equations (PCE) predict that “a 40-year-old White male smoker has a lower cardiovascular risk than a 40-year-old Black male nonsmoker,” or put more bluntly, “being a Black man is more dangerous than smoking.” Since then, researchers and policy makers have made considerable progress in addressing the inappropriate use of race in medical decision making.

A Curbside Consultation in the September issue of American Family Physician introduced a multiracial patient who is confused by the need to identify as African American, White, or Other so that his clinician can evaluate the appropriateness of statin therapy. If White, his estimated 10-year cardiovascular disease (CVD) risk would be 5.8%; if African American, it would be 17.7%. Similarly, a preprint study using thousands of hypothetical and actual patients concluded that large differences in PCE estimates in Black versus White persons with identical risk factor profiles would have the practical effect of “introduc[ing] race-related variations in clinical recommendations for CVD prevention.” Until new cardiovascular risk prediction models are developed that omit race, Drs. Mara Gordon and Isha Marina Di Bartolo suggested that physicians exercise caution when using race as a marker of genetic ancestry; consider alternative approaches to risk stratification; and use social determinants of health as an alternative to demographics.

Turning from the heart to the kidneys, including race in the estimation of glomerular filtration rate (eGFR) has the effect of increasing a Black person’s eGFR relative to a White person’s with the same serum creatinine level. Consequently, Black patients with chronic kidney disease become eligible for kidney transplants nearly two years later than their White counterparts. Underlying this point, Glenda Roberts, a patient representative to a National Kidney Foundation and American Society of Nephrology Task Force that recommended implementing a refitted eGFR calculation that does not include race, observed in a recent opinion piece that though she self-identifies as Black, learning from a DNA analysis that her ancestry was only 48% African (making her, technically, White) would have gotten her on the transplant list sooner! The Chronic Kidney Disease Epidemiology Collaboration has published new eGFR equations that omit race and incorporate serum creatinine and cystatin C.

A 2007 calculator for predicting the likelihood of a successful vaginal birth after cesarean (VBAC) delivery that includes race-based correction factors for African American and Hispanic women was later challenged for promoting disparities in cesarean rates. Earlier this year, researchers from the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network unveiled a new VBAC calculator without race variables that has excellent calibration and a similar area under the receiver operating characteristic curve as the previous calculator.

Further work remains to be done. The Agency for Healthcare Research and Quality (AHRQ) posted draft Key Questions for a future systematic evidence report on the impact of clinical algorithms on racial disparities in health and health care. Another AHRQ-funded methods report on racism and health inequities in clinical preventive services and guideline development supported the U.S. Preventive Services Task Force’s proposed changes to its recommendation processes to mitigate the effects of systemic racism.

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This post first appeared on the AFP Community Blog.



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Common Sense Family Doctor: #ThisIsOurShot at Starbucks


As the Delta variant continues to cause severe COVID-19 infections in the 40% of the U.S. population that is not fully vaccinated (71% have received at least one dose), and the more contagious Omicron variant establishes a foothold heading into winter, physicians across America are volunteering their time to reach outside of their patient panels and have community conversations about the effectiveness and safety of the vaccines. I am pleased to partner with Starbucks for a listening and informational session next week at one of their stores in southeast DC. Come have a cup with me!



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Breaking the chain of transmission through vaccination


Like any other human vaccine, coronavirus vaccines aren’t only meant to protect individuals from developing symptomatic COVID-19, but to break chains of transmission throughout the population, insulating vulnerable people through multiple layers of protection. Let me explain how this works. Say that the older of two unvaccinated child siblings, E.L., is exposed to a classmate with COVID-19 in the school cafeteria. What’s the chance that she brings the infection home to her younger sibling, G.L., and what’s the chance that younger sibling inadvertently gives the infection to Grandpa when he visits? Grandpa is vaccinated and boosted, of course, but since he has cancer and is immune compromised, he is only 60 percent less likely to catch the virus than an unvaccinated person. Let’s say that due to the vagaries of distance and air circulation, the unvaccinated older sibling has a 50 percent chance of developing COVID-19 from her school exposure. Since she shares a bed with her younger sibling and doesn’t go into quarantine until she has been infectious for two days, let’s say that there is an 80 percent chance that if infected, she infects her sister also. This then becomes a straightforward math problem.

Probability E.L. catches COVID-19 from classmate: 0.50

Probability G.L. catches COVID-19 from E.L: 0.50 X 0.80 = 0.40

Probability Grandpa catches COVID-19 from G.L.: 0.40 X (1 – 0.60) = 0.16

So, there is about a 1 in 6 chance of an intact chain of transmission from E.L.’s classmate to E.L.’s Grandpa, via G.L. Not tremendously high, but outcomes with 1 in 6 odds happen all the time, as any sports fan can attest, and given the high risk of severe illness in immune compromised adults over age 65, most people would probably call this an unacceptable risk for Grandpa.

What if E.L. and G.L. were both fully vaccinated, though? The Pfizer-BioNTech vaccine had a reported efficacy of 90.7 percent against symptomatic disease in a randomized clinical trial of 5 to 11 year-old children; efficacy against asymptomatic transmission is uncertain, but for the sake of this scenario I will assume it’s 80 percent. Let’s run these calculations again, with the vaccine actions in bold.

Probability E.L. catches COVID-19 from classmate: 0.50 X (1 – 0.80)

Probability G.L. catches COVID-19 from E.L: 0.10 X 0.80 X (1 – 0.80) = 0.016

Probability Grandpa catches COVID-19 from G.L.: 0.016 X (1 – 0.60) = 0.0064

In this scenario, there is about a 1 in 156 chance of an intact chain of transmission from E.L.’s classmate to E.L.’s Grandpa, via G.L. 1 in 156 is better odds than winning the big prize in the lottery, but most people would feel pretty comfortable that an event this unlikely would not happen on any given day.

In summary, people who suggest that once Grandpa (or Grandma, or Great-Aunt Amy or other older people who are important to you or somebody else) is vaccinated and boosted, it’s a “personal choice” for them and their children to get vaccinated too, are demonstrating ignorance of math and public health. We will only get through this pandemic by breaking the transmission chain together, not with 1 in 5 American adults declining vaccinations for themselves and their children because they don’t think they will get very sick or that their inaction could quite possibly lead to someone else’s disability or death – maybe even someone they love. I wish that every person with access to vaccination would just do the right thing and mandates wouldn’t be necessary, but the declaration “I’m pro-vaccine but anti-mandate” is a non sequitur. If you’re really pro-vaccine, you want everyone to get vaccinated whether they like it or not, for the good of your community and country and the whole human race.



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Dietary and nutrition guidance for the holidays and beyond


As the days get shorter and people look forward to holiday celebrations, three recent dietary and nutrition guidelines provide practical advice for patients, physicians, and food vendors.

The 2020-2025 Dietary Guidelines for Americans are the latest iteration of a scientific collaboration between the U.S. Departments of Agriculture (USDA) and Health and Human Services dating back to 1980. The current report provides guidance for healthy eating across a person’s lifespan, emphasizing dietary patterns with nutrient-dense foods and beverages:

At least one-half of food eaten should be fruits and vegetables, especially whole fruits and vegetables of a variety of colors. The core elements of the other half of food that should be eaten include grains, dairy, protein, and oils with lower saturated fat. At least one-half of grain servings should be whole grains. Minimize alcohol use and consumption of foods with added sugar, saturated fat, and sodium.

In an American Family Physician editorial, Drs. Amy Locke and Rachel Goossen from the University of Utah observed that “although many of the recommendations are widely accepted, … criticisms revolve around the authors’ reported financial ties to the food industry and the discrepancies between the published guidelines and the recommendations submitted to the authors by the scientific advisory committee.” Examples of such discrepancies include the Dietary Guidelines’ overemphasis on consuming dairy and animal-based proteins and insufficient limits on alcohol use. Drs. Locke and Goossen suggested that “the most accessible way to use the information included in the report is through the USDA’s MyPlate website and app” that organize advice by food groups and subgroups.
Recognizing that nearly 9 in 10 adults consume more sodium than the National Academy of Medicine’s Chronic Disease Risk Reduction (CDRR) intake of 2,300 mg/day, the U.S. Food and Drug Administration finalized voluntary guidance for industry that aims to reduce the average American’s daily sodium intake by 12% (from 3,400 to 3,000 mg/day) over the next two and a half years. Industry cooperation is critical because more than 70% of sodium intake comes from packaged food and food prepared away from home. Whether these goals will be achieved in the absence of an enforcement mechanism is unclear, as the sodium content of popular commercially processed and restaurant foods has changed little over the past decade.
Finally, the U.S. Preventive Services Task Force reiterated its 2014 recommendation that found insufficient evidence to assess the benefits and harms of screening for vitamin D deficiency in asymptomatic adults. In a Putting Prevention into Practice case study in AFP, Drs. Howard Tracer and Robert West noted that due to individual variability, “no one serum vitamin D level cutoff point defines deficiency, and no consensus exists regarding the precise serum levels of vitamin D that represent optimal health or sufficiency.” In a previous editorial, I observed that frequent measurement of vitamin D levels in clinical practice is inconsistent with the evidence. As for supplementation, “family physicians should also counsel patients on the recommended dietary allowance for vitamin D (600 IU per day in adults 70 years and younger, and 800 IU per day in adults older than 70 years), and discourage most patients from using supplements, especially in dosages near or above the tolerable upper limit of 4,000 IU per day.”

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