1. My Story
Meet Tausi Suedi… AND her beautiful children!

2. Not So Good to be So Sweet: Pregnancy & Diabetes
Tausi Suedi, MPH
Mychelle Farmer, MD
Chandrakant Ruparelia, MD,MPH
Leah Hart, MSN, MPH
March 7, 2014

3. Objectives Describe the global burden of NCDs
Define gestational diabetes
List adverse maternal and newborn outcomes associated with GDM
Describe GDM screening and diagnosis approaches
Evaluate community based innovative model for screening, diagnosis and management of GDM

4. Global Burden of Disease
CAUSE %
Cardiovascular
33.2
Infections
13.9
Cancer
13.0
Chronic Respiratory Dis.
7.3
Respiratory Infxn, TB
6.6
Injuries
5.1
OB, Perinatal
5.0 GI
3.1
Diabetes
2.6
Neuro-psychiatric
2.3
65% of all deaths each year due to NCDs
NCDs leading cause of death globally for women
World Health Organization, 2008

5. Global Burden of Diabetes
I am not sure what this map shows; NCD burden?
Zimmet PZ, Medicographia, 2011

6. 50% of diabetics are undiagnosed
Nearly 70% of diabetics in Africa
57% diabetics in Western Pacific
Zimmet PZ, Medicographia, 2011

7. Diabetes Mellitus
It is a disease in which human body either does not produce or properly use insulin that regulates blood sugar resulting in increased blood glucose.
There are two type of diabetes mellitus:
Type 1 and
Type 2

8. Types of Diabetes Mellitus
Low or absent endogenous insulin due to beta cell damage
Onset before 30 years
Exogenous insulin required for life
Causes: Genetic, infection
Type 2
Insulin level is normal, elevated or absent
insulin resistance, tissue sensitivity, & impaired beta cell function
Exogenous insulin may be required for management
Causes: family history, lifestyle, obesity and aging

9. Understanding the Mechanism
: Insulin, Closed Glucose Transporter, Open Glucose Transporter,
Glucose, Insulin Receptor

10. Gestational Diabetes Mellitus (GDM)
Gestational Diabetes Mellitus (GDM) is defined as carbohydrate intolerance with recognition or onset during pregnancy’ irrespective of the treatment with diet or insulin.

11. Gestational DM Normal Pregnancy Blood glucose Insulin secretion
Slide: Courtesy of Professor Peter Damm
Normal Pregnancy
Insulin
secretion
resistance
Gestational DM
Insulin
secretion
resistance
This is the situation for GDM-women
Outside pregnancy, the insulin resistance is balanced by an adequate insulin secretion, ensuring a normal glucose tolerance.
SKIFT
However, when insulin resistance is increased during pregnancy, the insulinproduction can not be adequately raised. In this case glucose intolerance will be the consequence.
It is generally believed, that the main mechanism in GDM is a beta-cell defect.
Blood glucose #

12. GDM short-term outcomes
Babies
Macrosomia
Birth trauma such as shoulder dystocia
Stillbirth
Neonatal hypoglycemia
Mothers
Birth trauma
Increased rate of C-section
Increased risk for post-partum hemorrhage and other causes of maternal deaths

13. GDM out long-term outcomes
Babies
Type 2 diabetes
(33% increased risk)
Mothers
Type 2 diabetes
(35-60% increased risk)

14. GDM and Type 2 Diabetes
Four top NCDs worldwide: cardiovascular disease, cancer, chronic lung disease and type II diabetes
Those with GDM are 35% more likely to get type II diabetes, an average of years out from pregnancy

15. Recommended Practices
IADPSG Diagnostic Guidelines
Based on Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study
Fasting glucose ≥ 5.1 mmol/L (92 mg/dl),
2 h 75 g OGTT in pregnancy
One hour result of ≥ 10.0 mmol/L (180 mg/dl),
Two hour result of ≥ 8.5 mmol/L (153 mg/dl).

16. Country Case Study: India
Prevalence of GDM in India
Purpose of Jhpiego’s assessment in two Indian states
Results
Proposed community-based approach to screening

17. % Prevalence Urban n = 4,151 17.8 13.9 13.8 9.9 Rural n = 3,945
Total population screened N = 12,056
Urban n = 4,151
Semi Urban n = 3,960
Rural n = 3,945
V.Seshiah , V. Balaji , Madhuri S Balaji.A Paneerselvam, T Arthi, M Thamizharasi, Manjula Datta , (2008). Prevalence of GDM in Asian Indians- A community-based study. JAPI , Vol 56 , pp

18. Purpose of India assessment
To describe the current situation related to screening, diagnosis and management of diabetes in pregnancy at various health facility levels in the peri-urban regions of Mumbai, Maharashtra and Chennai, Tamil Nadu.

19. Results of situational analysis
Inconsistent use of GDM guidelines
Urine dipstick testing at sub-center levels with referral
Resource intensive follow up to positive urine screen
Inconsistent documentation of referral results and birth complications related to GDM

20. Challenges of Clinic-based GDM Screening
High volume of referral based on urine dipstick screen
Fasting required
High clinic volume due to 2-hour wait
Up to 30% “no show”

21. Community-based GDM Screening Approach
Begins at the doorstep of the pregnant woman
Cost-effective and integrated in existing services
Reduces healthcare facility burden while increasing detection

22. Beyond diagnosis… a public health approach
Pregnant Woman in the Community
12-16 weeks first ANC visit:
1st GDM Screening
24-28 weeks:
2nd
GDM Screening
Screening using Glucose Challenge Test (GCT)*
--- +
- Referred for diagnostic test and medical management
- Meal plan and medication management
- Community-based glucose monitoring
- Birth preparedness and complication readiness
98%!
Glucose Challenge Test (GCT) – 75 gm sugar dissolved in 300 ml water, ingested over 5 minutes as tolerated to avoid nausea/vomiting; test blood via glucometer and/or using venous blood draw per available resources 2 hours after solution is ingested.
GOI requested that Jhpiego draft gestational diabetes guidelines. Draft is ready; has been reviewed by India stakeholders (FOGSI,DIPSI, India office experts- Somesh Kumar knows a lot about gestational diabetes … working with the India team and NPD to get funds for a demonstration project)

23. Summary It is time to address GDM globally
Community-based single test approach to screening for GDM is the way to go
No linkages for referral? Program will fail.
Improved health outcomes is the goal, with 98% of cases managed through healthy meals and lifestyle

24. Thank You! Mychelle Farmer, MD Mychelle.farmer@jhpiego.org Tausi Suedi
Chandrakant Ruparelia, MD MPH
Leah Hart, MSN MPH

25. Thank you! The Closing Session will begin at
Please fill out an evaluation by going to this session’s page on your mobile app OR by filling out a paper evaluation in the back of the room.
The Closing Session will begin at
4pm in the Grand Ballroom.
Closing remarks will be followed by
a 30-minute social gathering (refreshments will be served). Come
meet new people and discuss the highlights of the day!
Last slide for Session 4 PPTs