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The Impact of Insulin Resistance on Proinsulin Secretion in Pregnancy

Hyperproinsulinemia is not a feature of gestational diabetes

¹ Division of Endocrinology, University of Toronto, Toronto, Ontario, Canada
² Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada
³ Division of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada

Address correspondence and reprint requests to Dr. Bernard Zinman, Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Lebovic Building, Room L5-024, 600 University Ave., Toronto, Ontario, Canada, M5G1X5. E-mail: zinman{at}mshri.on.ca

OBJECTIVE—Excessive secretion of the insulin precursor proinsulin, as manifested by an increased serum proinsulin-to-insulin ratio, has been associated with ß-cell dysfunction. In women with gestational diabetes mellitus (GDM), previous studies of the proinsulin-to-insulin ratio have yielded conflicting results, despite the presence of ß-cell dysfunction. The interpretation of the proinsulin-to-insulin ratio, however, may be confounded by the variable effects of hepatic insulin extraction. Thus, we sought to determine whether GDM is characterized by relative hyperproinsulinemia as measured by the proinsulin–to–C-peptide ratio, an alternate measure of proinsulin secretion that is not affected by hepatic insulin extraction.

RESEARCH DESIGN AND METHODS—Serum proinsulin, C-peptide, and insulin were measured in a cross-sectional study of 180 women undergoing oral glucose tolerance tests (OGTTs) in the late second or early third trimester. Based on the OGTT, participants were stratified into three groups: 1) normal glucose tolerance (NGT; n = 93), 2) impaired glucose tolerance (IGT; n = 39), and 3) GDM (n = 48). Insulin sensitivity (IS) was measured using the IS_OGTT index of Matsuda and DeFronzo, which has been previously validated in pregnant women.

RESULTS—There were no significant differences in mean fasting proinsulin–to–C-peptide ratio between the three glucose tolerance groups (NGT, 0.024; IGT, 0.022; GDM, 0.019; P = 0.4). Furthermore, adjustment for age, weeks’ gestation, prepregnancy BMI, ethnicity, previous GDM, and family history of diabetes did not reveal any association between the proinsulin–to–C-peptide ratio and glucose tolerance status. Using Spearman univariate correlation analysis, fasting proinsulin–to–C-peptide ratio was significantly correlated with IS_OGTT (r = 0.29, P < 0.0001) and inversely related to the homeostasis model assessment of insulin resistance (r = –0.36, P < 0.0001) and prepregnancy BMI (r = –0.23, P < 0.005). On multiple linear regression analysis, IS_OGTT emerged as the strongest independent correlate of the dependent variable proinsulin–to–C-peptide ratio. Furthermore, after adjustment for potential covariates, a stepwise decrease in proinsulin–to–C-peptide ratio was observed per decreasing tertile of IS_OGTT (trend P = 0.0019), consistent with enhanced efficiency of proinsulin processing (i.e., reduced proinsulin–to–C-peptide ratio) as insulin resistance increases.

CONCLUSIONS—GDM is not independently associated with hyperproinsulinemia as measured by the proinsulin–to–C-peptide ratio. Instead, in pregnant women, increased insulin resistance is associated with decreased proinsulin–to–C-peptide ratio, independently of glucose tolerance status. These data suggest that relative proinsulin secretion in late pregnancy is primarily related to insulin resistance and does not necessarily reflect ß-cell function.

Abbreviations: AUC, area under the curve • GDM, gestational diabetes mellitus • HOMA-B, homeostasis model assessment for ß-cell function • HOMA-IR, HOMA of insulin resistance • IGT, impaired glucose tolerance • NGT, normal glucose tolerance • OGTT, oral glucose tolerance test

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