Epidemiology of Stress and GDM among Latina Women

描述(申请人提供)：糖尿病和肥胖症在美国已经达到流行的程度，拉丁裔的发病率一直高于非拉丁裔白人。将这些疾病的预防期限向上游转移到怀孕，可能是一种创新的战略。这项提案的主要目的是评估关于拉丁裔妇女妊娠期糖尿病可改变决定因素的新的和及时的假设。我们建议评估外部应激源(体力活动)、内部应激源(心理社会应激)以及这些变量与妊娠期糖尿病风险之间的关系。 采用前瞻性队列设计，2300名拉丁裔(主要是波多黎各人)产前护理患者将在第一次产前护理访问(怀孕8-12周)时从贝斯托医学中心招募。双语面试者将通过制定并验证在这一人群中使用的妊娠体力活动问卷(NIH/NICHDR03-39341)获得有关体力活动模式的详细信息。心理社会压力将通过1)自我报告(生活事件、感知的压力、焦虑、抑郁和自尊)使用在拉丁裔人群中有效的量表进行评估，以及2)唾液皮质醇，一种对压力做出反应的生理标记。关于孕前体重指数、饮食、吸烟、药物滥用、医疗和产科病史、文化适应和社会人口因素的信息也将受到质疑。将测量体重和腰围。随后在常规超声检查(妊娠18-20周)和妊娠期糖尿病筛查(妊娠24-28周)时进行的两次访谈，将更新有关感兴趣变量的信息，并重复唾液皮质醇收集。将从队列中选择100名孕妇的胎龄分层样本，以评估皮质醇测量的日变化。实验室报告将被提取用于GDM筛查结果，并将在妊娠32-34周时对筛查血糖升高的人进行第四次访谈。分娩后，医疗记录将被提取以确认妊娠期糖尿病事件和出生结局。Logistic回归将用于评估体力活动、心理社会压力和妊娠期糖尿病风险之间的关系。边际结构模型将评估饮食、体脂分布、体重增加和吸烟作为压力和GDM之间关系的中介变量的作用。皮质醇将在116例妊娠期糖尿病病例和匹配的4：1对照样本中以嵌套病例对照方式进行分析。二次分析将前瞻性地评估在筛查血糖升高的妇女中应激与不良分娩结局之间的关系。 这项拟议的研究基于我们在拉丁美洲GDM研究(美国糖尿病协会职业奖)中的经验，并通过对怀孕多个时间点的前瞻性评估、压力测量的多维方法以及对大量高危人群中潜在混杂和中介因素的详细评估，扩展了先前调查的工作。该提案中使用的多学科研究合作是美国国立卫生研究院医学研究路线图的一个关键组成部分，旨在建立“未来的研究团队”。

DESCRIPTION (provided by applicant): Diabetes and obesity have reached epidemic proportions in the U.S. with rates consistently higher in Latinas than non-Latina whites. Shifting the prevention period for these conditions upstream, to pregnancy, may be an innovative strategy. The major aims of this proposal are to evaluate new and timely hypotheses regarding modifiable determinants of GDM among Latina women. We propose to evaluate the association between external stressors (physical activity), internal stressors (psychosocial stress), and mediators between these variables and risk of GDM. Using a prospective cohort design, 2,300 Latina (predominantly Puerto Rican) prenatal care patients will be recruited from Baystate Medical Center at their first prenatal care visit (8-12 weeks gestation). Bilingual interviewers will obtain detailed information on physical activity patterns via the Pregnancy Physical Activity Questionnaire (PPAQ) (NIH/NICHD R03-39341) developed and validated for use in this population. Psychosocial stress will be assessed through 1) self-report (life events, perceived stress, anxiety, depression, and self-esteem) using scales validated in Latina populations, and 2) salivary cortisol, a physiologic marker of response to stress. Information on pregravid BMI, diet, cigarette smoking, substance abuse, medical and obstetric history, acculturation, and sociodemographic factors will also be queried. Weight and waist circumference will be measured. Two subsequent interviews, conducted at the time of routine ultrasound (18-20 weeks gestation) and GDM screen (24-28 weeks gestation), will update information on the variables of interest and repeat the salivary cortisol collection. A gestational-age stratified sample of 100 women from the cohort will be selected to assess diurnal variation in the cortisol measure. Lab reports will be abstracted for GDM screen results and a 4th interview will be conducted at 32-34 weeks gestation among those with elevated screening glucose. After delivery, medical records will be abstracted to confirm incident GDM and birth outcomes. Logistic regression will be used to assess the relationship between physical activity, psychosocial stress and GDM risk. Marginal structural models will assess the role of diet, body fat distribution, weight gain, and smoking as mediating variables in the relationship between stress and GDM. Cortisol will be analyzed in a nested case-control fashion on 116 GDM cases and a matched 4:1 sample of controls. A secondary analysis will prospectively assess the relationship between stress and adverse birth outcomes in among women with elevated screening glucose. The proposed study builds upon our experience in the Latina GDM Study (American Diabetes Association Career Award) and extends the work of prior investigations through prospective assessment at multiple points in gestation, a multidimensional approach to stress measurement, and detailed evaluation of potential confounding and mediating factors in a large, high-risk population. The multidisciplinary research collaboration utilized in this proposal is a key component of the NIH Roadmap for Medical Research in building "Research Teams of the Future".