Presentation on theme: "Anil Kapur. Women and Diabetes 123.8 192.3 155.6 233.5."— Presentation transcript:
Women and Diabetes 123.8 192.3 155.6 233.5
Estimates of DM & IGT in women 20-39 years 19.0 (15.3%) 49.7 (32%) 68.8 (24.6%) 25.0 (13.0%) 57.0 (24.4%) 82.1 (19.3%)
GDM IGT 2% Agarwal S, Gupta AN. Gestational Diabetes. J Assoc Physicians India 1982;30:203 2% Ramachandran A, et.al., High prevalence of diabetes in an urban population in south India. BMJ 1988;3; 297(6648):587-90 1980s 7.6% Narendra J, Munichoodappa C, et al, Prevalence of glucose intolerance during pregnancy. Int J Diab Dev Countries 1991;11:2-4 8.2% Ramachandran A, Snehalatha c, Dharmaraj D, Viswanathan M. Prevalence of glucose intolerance in Asian Indians. Diabetes Care 1992; 15:1348-55 1990s 16.6% V Seshiah, V Balaji, Madhuri S Balaji, CB Sanjeevi, A. Green. Gestational Diabetes Mellitus in India. J Assoc Physicians India 2004;52:707 14.5% Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V,Das AK, Rao PV, Yajnik CS, Prasanna Kumar KM, Nair JD.For the Diabetes Epidemiology Study Group in India (DESI).Diabetologia 2001;44:1094-1101. 2000s GDM prevalence linked to background IGT rates
GDM & Pre gestational DM Awareness of diabetes and GDM is low No well defined and internationally accepted screening protocols and guidelines Wide variation in estimates of GDM (3 to 15%)Considerable under detectionIncidence of GDM is increasing
Diabetes and Pregnancy – Why it is relevant? Hyperglycaemia during pregnancy is associated with high risk of maternal and perinatal morbidity and mortality and poor pregnancy outcome Diagnosis of GDM identifies women at high risk of future diabetes, offers opportunity of primary prevention Maternal hyperglycaemia is associated with development of metabolic problems including type 2 diabetes in the offspring
Diabetes and Pregnancy Maternal hyperglycaemia is associated with high risk of maternal and perinatal morbidity and mortality and poor pregnancy outcome It has been shown beyond reasonable doubt that treatment of GDM significantly improves pregnancy outcomes Spontaneous abortion, intrauterine death and still birth Lethal or handicapping congenital malformation Shoulder dystocia and birth injuries Neonatal hypoglycemia and IRDS Foetal Risks Hydroamnios, pre- eclampsia, PIH Progression of retinopathy Obstructed labor, assisted delivery & C-section Infections Materna l Risks
Risk of maternal diabetes after GDM GDM is the best known predictor of type 2 diabetes Up to one third of women with diabetes may have had GDM previously (Cheung NW, Byth K. Population health significance of gestational diabetes. Diabetes Care 2003; 26(7):2005-2009) Up to 70% of women with GDM may go on to develop diabetes within 10 years The incidence of diabetes after GDM is increasing By identifying women with GDM and instituting proper care it is possible to prevent or significantly delay the onset of maternal diabetes
Glucose tolerance at follow-up J Lauenborg et al, Diab Care 2004
Diabetes Begets Diabetes Offspring's of women with GDM, have a 4 to 8 fold increased risk of diabetes. Clausen TD et al., Diabetes Care 2008
Foetal Programming Rapid increase in IGT, diabetes and other NCDs in the developing world cannot be explained merely on the basis of higher genetic risk factors and rising obesity. Many individuals developing diabetes and other NCDs in low income or emerging economies are not obese by BMI criteria, but are centrally obese (large waist hip ratio) and adipose (higher body fat percent) and fit the criteria of thin- fat. Foetal programming may predispose to several chronic non communicable diseases.
Foetal Programming Permanent change in structure or function in response to a defined stimulus during development Metabolic, Vascular, etc Critical periods (Windows of opportunity)Stimuli: Nutrients, metabolites, temperature…SpecificityIs it epigenetic? Yajnik et al, Diabetes Care 2007
Foetal Programming Maternal malnutrition, particularly protein and micronutrient deficiencies are associated with small babies. These apparently, small-thin babies have significantly higher abdominal fat deposits (thin- fat babies) When over nourished during infancy & early childhood, they develop anthropometric and biochemical markers of metabolic syndrome. These babies have an increased risk of diabetes, impaired glucose tolerance, arterial hypertension, CVD, lipid abnormalities and stroke in adult life, often prematurely.
Foetal Programming and Economic Transition Fetal under nutrition Undernourished (small) mother Postnatal under nutrition Insulin resistance Small baby (Thin-fat) Postnatal over nutrition (Urbanization) Under nutrition Nutrient-mediated Teratogenesis Over nutrition Altered fuels Pre gestational and gestational hyperglycemia Obesity and hyperglycemia Macrosomia Fetal adiposity & islet dysfunction Yajnik et al, Diabetes Care 2007 Fuel-mediated Teratogenesis
IUGR vis a vis Macrosomia Solution Optimal birth weight 3000 – 3500 g. Predicts development of HTN, Type 2 DM & IGT Barkers Hypothesis Low birth weight Pedersons hypothesis Macrosomia
Diabetes and Pregnancy – public health relevance Opportunity to integrate services not only to lower traditional maternal and peri natal morbidity and mortality indicators but also for inter generational prevention of NCDs such as diabetes, hypertension, CVD and stroke High risk of maternal and peri natal morbidity and mortality and poor pregnancy outcome Associated with development of metabolic problems including type 2 diabetes in the offspring Identifies women at high risk of future diabetes, offers opportunity of primary prevention