lilrerirltioll,rl
lDUl n.ll ot LYrlcioio:Iy Jrld
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Contents lists available at Scierrr:e {Jir*ct:
International Jaurnal of Gyneeology arud Obstetrics journal homepage: www,elsevier'com/locate/ijgo
PREGI\AI{CYANDDIAt]E.li],SSCL]NAI{I0AROUND'ILIi]Wo{lI-l]
ttr-le
woriel: India
Balaji '', l\laclhr.rri S. Balaji
', Anrn.lclt.llam
Ilregnancy anet cliabetes scenario around veerasarly SeshiaS i'
ll..)i Iri
,,,'k,
vijayarl
illJS'II{,4{-I
tNFO
o1'clevelopir:g diabetes irl thi' w,ith gestational di;l.reres nrel]itus (CtlN{) aLr: at art increaseci lisk is also in irnporianf public health but televance, of clinical not onlv is GtJlvl their offspri.ng. as are tltrrre. l3'9)t'' We alscr prevalence of 6DM issue. A community-bnsed prospective -studV showed lhat the "vas and rurol aleas' Blsed on lnultiple obseryed that the irequency ol CDM valied acr'rss urban' setni-utban, histol'y ofdiabetes' aBe gredtel L:gisric rr-.gression an.rlvsis and taking tlte iJ areos into consitleration. fanrity r'vere lbttncl to have a significant to 25 et;rtal grcater or th.1lr than m'equal t0 15 Ve.lrs, Atrcl btrdv nuss ir:tlcx lDrltpeticJcnt associarioti \^',ritll llL)Vl i| 0.001 l'
W..en
i(elr&0)r/sl o.ie ct Ce5ttrtion.rl diaberes rlleliittl5
DIPAP Irr
lrdia
ri!dtc
l)Jrt nershi il
IlnrtLr s.ll sct eunilrg WorlC i)irb{:tPS Fotrtrd.rtiorr
I.
h
iji0,ei(i /ittlLiar'futt. ( oltt:iiltttlltit lli'lllll(rfli
ARTICLE
irul)lic -f
Paneerselvam "', Anil ld.lpLlr
'[ire ptevalence of rli.ibeles is incl-tl'rsitrg gloll'rllv and tlre tot'tl ruumbet ol peopie lvith l-his colclitictl is Pl'ojected to rise fl om
million in 2.000 tc 366 million in 2030. lncli.r is no excetrriion. wil-ir projected rntes o[ 7$-4 millir:rt in 20]0-a l5ti increa';e iiont ll.i milliorr in 2000 lll. The iuc'easecl plevalettce is attriSuted t. the aging popul,lrion stt'uctLlre, urhaniz.rtiort, the obesity t'pidentic, anu p'ttysicrt inactivity l2l. White.rll these lactors cotltlibtrte to the 171
potential epic'lerric of diabetes, iutrauterine exposures are emergirtg as ,.tetal origin ofadult tlisease" Sypothesis proposes risl factors []1. The ttrat gest.rtion.ll Programmirrg m.1y clitic'llly intluetrce adult health .rncl iisease [31. Gestational programnring
is a
process whereby
stimuli or suesses occuffing at critic.ll or sensitive periods of feral and nretadevel opment. pernlanently ch.rnge strttct l-u'e, phys iotogy' lit'e atlult in 1.1 l. lf tht' bolisnr. which pretlisposes indivitlu.rls t0 disease predisit pregnancy' irr glucose intolt'tattce strmulus happens to lr poses the olfspring lo an incleasecl lisk oI clevelo;ring' glncose intr.,lerancelnl.he[uture..l'hisvtciouscy[leiSlitiel.vtolllflucl.lt-enl1d
pcrpl.trtrlte rhe rnciclence and prev*lt fl,'e rll'glttcose intoler.rtrce in attv poprrlarion | 3 l.'l'herefore. prevontive l1rL..L!ufes .rg.rinst tvpc 2 cliabetes ftom early str,Luttt st,rri ciuring thr.' intr.luterine periocl and continue gestational of detection ln this rcspect, life thr.oughout childlroo<l [61. oF tliabetes nrellittr.s (CDM). cletinerl as carbohydrate intolerauce
varyingserreritywithonsetorfirstrecogt-titior:dtrr'itrgpl'cg.nattcv' becorles an illrport.lllt ptrblic health issue' We utlrlettool< a lllannt'd
(drP I(ese'l1[h llr\lllute ]lA Cttrres;1t'nd11g 'rrrthor' I)l v sEshrnll i'latlrt(': 'llt{l ()rmes [Q;d. (ilpiLtlr. Clronnai - boo 01o' I'rmitnatlu' lndt':' Tel'; +91 44 2ti4l221l6t ltriil:.157; l,lx: -:,1 ; l 2r:olUIl(l C moil dddres.s:',';i'ritl;:llirj'tlllaii,cirDl
d0i ; i0.lil16ij.iJgo
lt)(lij
tlle lf Iabeles in Pregrianty Avvlteness aucl an Plcverrtion (Dl1)AP) plojt'cl, tD.lscertaiI the pt'ev'rlence olGI]lU ii'' lndi.rn setting. cor-r'rnunlty'l).'lsr'<i sllrrly,
lfltrc]cluctiorr
11.0.-ls
(V' Se;hirl))'
2. Mt'thods adolltcrl for scrcc"nittl; o l gesration.rl .lge, who given a 75-g glucose load in were attende(l rlre ptrLhc health centers, Venous blood consent' gave infornred par-ticipallts Alt rhe fasting st.rte. samplt's il,ere collectecl at 2 hours and ttre plastlr'r glucose was estimatr'cl bv the glucose oxtdase peroxidase (GOD'POD) metilo(l b'rsed on the r-rsirlg a Hita;hi .ruto-an.rtyzer. The diagnosis of CDM was by WHO > recommended 140 m.g/dl 2-hour 75-g pos! glucose value (Nfit at glucose tolerance have norrttal to founcl was womrn l7l. lta the initial visrt, she was.rdviserl to rt-l)ent the test arotrncl the 24th lvcel<' Details lvecl< and, if krtlrtri ttornlai, to test ag.rin arorrtlcl l'he -l2nC wel e plegnartcies previotrs ol historit ;tllcl tiiahetes illstoly ol ol il'rllriy oLrtnined. l)lo0d lrrr.'ssut"e was recot-clr:tl trsilllS a melcLlfy sphlrguronrnrrirlelei. which was calibrated pericdirally llodv mass indr"x iBMl'
c0 nSr.cU t t\,e pten nt.ll wol'uL-t1, i rrespective
calcula(cri ,rs,,vcight in kilogr.I.lrs divided l:y height in tnefet-s squ;tt'cl) rvas c.rlrt.tia[ecl froln t]'re plepregnancy weight' We also was cotlsidered erliciterl the activjiy st"rtLrs o[ these rrromen' A worrl'lu a sL'deutal] if she was testt'ictr.'cl [o routine householcl r'rror]<' where'rs Wonlallwitharroccr.rllatitrn,wlriclrrequiredplrysicatexertiot.ttore.rcl.t her place of lvtlt'l< anrl perfottll thc cltltltls 'rssigrred to l-iet' r'vas colts id ert'ct .rr:l"ive.
(urb'rn' To cottrparc the n-reJn values tlf the 3 groups ol'wnmett scnri-url-t.tn. .t ntl t'ttr.rl), one-wav analysis of vat t'rnce w'rs used' The xr tlre a$ie lest \!r'i:i erlploved t{:} conlp.lre tll!' proPortion of CDIr4 across physical groups. Bfr,4l, graviclity. lanrilv lri-story of cliabetes mellittls' and Ictiuiry. Univariate ancl multiple logistrc regresston analyses were perfontred to determine the .rssociation bettqreen the risk l'actors and
v
5t6
Table 1 ChJr.rcterislics o[ the rvotllett scttlened [:y.:rea
Urban )
iI=4151
2t.l !3.55 (',i'stnli0nil I weel(s 'icdjr tl.rs: index I'
'
t'
Seshioh
et tl,
l.!,r8
lnternotialnllolmal ol
Cynecologv orld oDstctrics 104 Qa09) 535 538
o
Serli urban
Rural
ln-l]lliluj
'.F'rr.{-,
11.413.30 lli.ilt 20.913.92
2i,41 2 1.9 1
f
?1.513.09 4216.'19
2::1
20,8r1,37
P valrte'
0.000 0.00i] 0.000
Vallrc\ dte Siven ns nrennlSD ulrless o[l]erwise irldjrat('d. Body nrass index calcuLated as weight in kilogurns djvided by heiglll in meters
squn red,
o (, o
o
o @ co o
o q
cq G
o
I
the pre valr:nce of GDI\'I. 'fhe arl.rlyses were 2-tailecl alrd Ir- 0.05 was consi(lerecl significanl" St.rtistical arlalysis w.1s performed bY ttsing SPSS version l0 (SPSS, Chicago, lL, USA).
t]RBAN
SE[II URBAN ABEA
sI5.19 yoars E20-24 ysars 025-29 years 130-34 yEafs
3. Results
l.{!_I93rs
Fig. 2. Prev;ilerlce of gestnlion.rl diabetes mellitlLs by age grouP'
'Ihe stucly w.rs cotl(ltlcted in'lanliln.-rdu state, tncli.l, and a total of 4151, 3960, .1nd 3945 pregrlant woilren fiom Chennai citv (trrban), Saidapet (senti-urb.rn), and l'hiruvallur (rural), respectivelV, weie "fhe dernographic details of the wollre!-l screened during 2005-2007. glverl drc ill I .lrlc l. atcas lhc 3 in screened Of the pregnant women screened, 1679 were lotrnd to have CDI\lan over.1ll ntean prevalellce of 13.9%- The prevalence in the urhan, semi-r.rrbarl, antl rural aleas was 739 (17.8%) 54il (13.flia)' and 392 [9.9%), respt'ctivelv (i:ig- lJ. Ihe occur.rence of CDM was sigllif]carltly lower-in the rLu'al rrea (Ir<0,0001 )con-rpared with the othel areas. GDN'I was diagnoserl in 1204 (72?l) r,r'omen.lt tlle first vjsit and the rerraining 475 l.'28%).lt stlbseqLl{:'llt vlsits. Amoilg the wolllen with CDM, 12.4% !\rele detected within 16 weeks of pregrlancy, 23% between 17 and 23 weel(s, .lnd the renrainitrg 64'[i% at more than 24 weeks of pt'egnancy. 'Ilte mean .rge of thl' pregllant women screenecl in the urban, semt-urban, ancl rural areas was 23'7 t 3.55 ye.rrs, 23.413.30 Vears, ilnd 22'513.09 Vears, respectivelV' lhe clistribufion of wotrretr in the 2A-24 Vears .1ge group was relatively higher (66.473) itr rur.rl .rreas (P':0.05) cotrlpared tt'ith semi-ulban (60.3%) and Ltrbatt are.rs (.55.5'l). Significant itrcrease (P'<0.0001) in prevalence olCDM as age increased was observed in all 3 .rreas.'Ihe prev.rlence of CDM by age group is given in lrig. 2. There was .r consistent increase in the prevalence of GDM in all 3 areas as BMI increased, and the trend was statistically significant
2B.4i4|tt the Lrrl:an area, 23.8i{ itl the senli-urbclll dl'ed, arrd 1612'i in tlle rural area.l'he prevatence of GD[,{ was 771 higher-inwomenwith a BMI great-el t]ratr 25 contp.rred with womLrll with a BMI between 23.0 ancl 24.9 in urban ancl senti-urban are,rs; this rliffeleuce w.rs 57" in the rttral
area, J'he prevalence of GDM in the physically inactive group was 19.1%, 16.ti%, and 12.1%, whereas it was 17'67;' 12.87", and !l'7% in the physically active groLrp in the rtrban. semi-urban, and rut'al 'rte'rs, respectively. A trc'nd for increased prevalence of CDM among women with lower physical activity in all 3 areas was oirserved, although it was not st.ttistically significant. A positive falrily history of diabetes nrellitus was present in 25% of the wotrlen with CDN4 in thc' urb'ru,
it
14.1% in the rural area.'fhere was a (,P'-0.001) between fimilv histoLy of diabetes rssociatiorl signific.rnt nlellitus and tlte occurtence of CDM alnong pregnallt women. The prevalence of GDM increased with increasing gravidity (Fig.4)' Basecl on univariate analysis, we obsefved in al.l 3 areas that age greater than 25 years, BMI greater than 25, and family history ol di.rbetes werc significantly associ.lted with the prevalence of CDM. Based on multiple logistic reglessiotl analysis t.rking all 3 areas into colrsicleration, family history of di.rbetes, .1ge greater than 25 Vears, 19.2%
the semi-rrrban, and
(P<0.0001 ) tfig. 3). Atrong the worren witli CDM' the highest prevalence w.ls obsewed in wotrten rvith a BMI greater than 2.5, with
2
o (!
24 22
o 6
1B
C !J
a
l6 q C
o 6 I
10
o a o o E a d
8
o-
14
1?
o
6
4 2
UFAAN
0
Urban Semiurbarl
SEX,4I
UBBAN
BUFAL
AREA Rural
Io Urban E Sâ&#x201A;Źmit rban...:.F"lgj] Fig. 1. Prr:valence of gestationai di.rbetes mcllitus by area.
Fig. 3. Prt'valence oI gestJtional cliab.:tes mellitus by body tlass inrlex (calculated .ts rveight in kilogranls tlivided bv hejght in rrcters squared)'
V
Sr-slriclr
(t
I ltltL,tr(tio,al lou,lul.fCrr,cr-.lo.t,r,
el,
0,al a)rtt.fi1(J
tt)"1
l,l00g: ii5-\.aR
s37
pre!{rrl,.y. wonre, identilierl with cDIvl in the early weelts ol preg,rncv rra-y )r,lve true cDM or urdiagnosed pre-existirrg criabete-s delectcd drrri.g screening lr!)j. An Arc test is lir<ery ro crisringuistr Ihese t\,vo conditions l,l0l, bLrt because this studv was cornnrririty_
s.00
0,00
10.00
'r
5.00
20.00
Prevalence percentage of GDM
isqi,Lsit:rl Fig.4" l)rcvalr'itct oIgL:r-l,lrion,lI tiI;rirlir.s
ntrii;iis
ityq;.11,f,i1,,
anrl IIMI g-reatprthan 25 we|e ltrund to have a sigrilicant inclependent association (P<0.00-l) with CDM ('1;rblc .?).
4. Diseussion
in lhis comnrunity-based stLtr[V we ltrcterred to pet tbrm unit,ers.rl screening bec.rtrse seit,ctivc scr-cerrirrg ttasetl orr rislt i.rctors scorecl poorly i, pri:dicri,g- GDM iB,:t I, L.lniver-sal scre ening for CDful cle tect-s rnore cases .tnrl iltproves nrateltal and ollspring prognosis comparecl wjth selective screening []01. l-he universal screening appe.rrs to be the nrost reliable and desired merlrod tor the rletection of CDM IS], p.rrticLrl.rrly i, rhose popurarions ar high risk llr.r2l. For universal sc.eening, flte test should be sir-nple arrd cost_ellective. WH0 critc,ria of 2 hour PG> 140 mglcll ide,tifying.r l.r.ge nurrrrrer'olc.rses nray r.iave a grectter
ltotentiai
for- prever-rtion I 13.l4i.
The currertt recorlrnenrlation
is to perfornr
scr.eerrit.rg t-ests
hetween 24 .rnd 2B l'e'el<s of jrr-eg,arc-y, altl-rouglr so.le stLrriies repor.l
that
40.t-(;6."1i
of wonren with CDM can ire detected car-l.y cluring
llrcg'lrdncV il:i,ltiJ. l'he iclr.rl periocl to si]r.r,)t ior CiDivj is around lfi w*eeks .Itcl even earlrer irl high-risl< groups with .t hislor\r of t'et.rl wdstnge Ii7j. A diagnosis of'CI]M nlav not be l:rissr.d by screenin;1 .rrounrl 2zl-28 weel<s of llregnaltc-y, but a substantial number of pregr iant \riomen r,vho develop CDiVT in (he eat-liei wct"ks ol';}t-egna ncy .lre likeJ-y to have delayecl cliagnosis rnd r.u.ry not recejve applopriat.e nredic.rl care, Furthemrort' early scleerring for glucosc rntolerr.ance .rncl c.rre could avoid somc cliabctes-rel.rteri cr:mpJicatiofls in rvomen wrtlr GDil4 .lnd theil newborris iiB]. Ba_serl on Iltese observatious, we initiaterl the scrc.eniug, procedrrre ior-CDi\4 in plL.natal wonlen
iirr:spcctive ,l' gestatio.al weeks. A,rorrg L.lte wr:nlen wirh L,llN,l, l5.4li1 were "rt less tlrarr 24 r,vecirs of'pregrra.cy, ancl this inclutrccl 12,4)J af lvonleu v,ritlr 6DM who were it lL,ss th.llt 16 r,^reel<s ot
b.rsed it \,v(rs nor econo'rica.ily l'easibre to perrorm tiris test. Another obse'vation was trrat wornen who rrad normar glucose tolerance at lhe firsr visir hacl developed CDI\4 at subsec;uelt vislts. Hence. repear screening beconres ess{lnrial, our of 1679 with GDM. r204 (72s) wer.r" detecte(l at rhc' lirst visit and the rernaining Zgx .rt surrseque,t vrsits. ln this srurlv. cDI\4 was tbLr.d to be nr.re Lrrev.rrenr in women rivrng in tlre urb.)n irea tllan in the rur.rl area lJi l- The low prevalence in lhe nrral .rrea nr"ry be due ro the less nrecharrizecJ, agriculture_based lilestyle adopred by l-hese people whereas the thctors conrributing tr) high prevalence in the urba' area could be attribured to increa.secr maternal rge, obesily, and seclent"rry lifest-yle. Est.-rltlished risk Iar:toi.s lor CDM ar.e adv.rncerl m.rternal age, obesil-y,.rnd faniily history of cli.rlretes I.l2l. The increase in the prev.rlcrrcc of GDM *"ry lrossibly be cl,e to incre.rserj BMr rrecause high nr.'rterral weight is associateri vvith a substantiaily higher r-isk of c,lll\4 i,l ll. lu oLr. sr.dy, rhe datr lrorn alr -J.rreas shornrerr rh"lt r6,"1, orw0nlell irad a BMI gro.rter than 2.r, whiclr cr:n[rrrns that ir-rcre.rsed BfuTl js a lisl< liicror'fol GDM. Sinrilar to the fiudings of Den:ltsey et al. l.l4l. wc .llso observed inctea_sed prev.rlerrce of CDM in women who were less active, J.r.g r"t at. i.?:il loLurcl th*rl w.,ren with CDM were olcler, had higlrer lrrepregn.incy wcight, higher BMl. higher par.ities. ancl higlrer lrequencjes ot"known rliaireres in the tarnily. ln our sturly population, all ti)ese'isl< Lrctors,,ve.e observecl. ol'all the indepenrlerit risli Iactors l'or CtlJN4, RMI erler.gerl as.r nroclifi.rble r.isk trctoi.. ln cirnrltrsi(rrr, rhe prese nt sturly docu:r-rc'nts the vnrieri prevalerce of clllrrl rn thc urban, senri-urban, anrl rural are.rs oI the courmunitl(,DfuI \^/.1s detected il .rll trimester-s of pr-egn.rnc.y, \A/e .tiso r:bser-vecl BNll as a rish factol lbr CDM, r,rzhich rs moeliflable. Worlerr with CDM have a high risk ofdeveloping diabetes in the future. As such. rhey are the ideal group to b!, rargered ror lifestyle moclificatiorr or phar.ma_ cologic intervenrion in ordc"r to clelay or postpone the onset of over.t cli.rbetes" I'leuce, .ln irrportant public health pliorit-y in the prevention o1'cliabetes is to .'lriclress nr.ltern.ri he.rlth during both the .rnte- anr{ l)0s tp.tf IL,llr lreriocl. ln t his rega rtl, tlre M in ist r y ol l{ea lth, Govern]nclrt of Tamil l'larlLr, has r.ri.rde screening {or gltrcose intolerance rlur-ing pl'egnaltcy r-r't;rncl.rtttry arrci has tal(en st.eps tn trltlltl)ve c.rltacity huilding ar,ong fielcl healtlr pt-oi.essionals, N4osf inrpor.t.rntly, sentiau[o a0Jl-vzcfs arc providerl to.]ll the prinrary health care certers to inrplove tlre rliagnostic facilitv. Financi.rl support oIRs ti000 IUS $1501 is providcd. rruhich is suflicient to supplemenr a pregnant womr.ul,s rcgrrla'dict \,vtrh 50(l rnl ol ruilk, 2 e.ggs, ancl 1 piece ol'lruit dail_v to take carc. ol the nutritional requit.en.lents dur.ing the antr:_ .rnc[ postFa.rlrur pericds. worren v,,ho fail to responcl to nredical nLrtriti.n Lirer'.rpy ale .trivisecl insulrn, The NovoRapirl Flexpel (Novo Nordisl<, Denrnarlr) is give, iree olcharge to pregnant vvomerr requir.ing irsulin lrcc.rrrs,.- h,trtrllrng ol ,;he;re'r rs r,,rs1 .
The DiPAP 1)ro.jccl-, ilvrrlving the pLrblic (govenrnrelt), .r non_ p;over-llilL,nt.1l nrganiz;trorr (WDF), and.r privale institr-rte (Dr V. seshiab uiahetes care.rnrl Research I,stiiute) has sLrccesslullv estabiished tltL. corlcept oi'a "'public--privatc lt.rrtncrship" in pu[rJic
he.rJth pro.qrams. 'kble
2 AdlLrsted odds r-atio for .gest.rtlonal diatretes nlellitus wifh.rsso.iatl'd risk [acLors Risl( I.rctors
Nurnber witlr cr)llditior lio'
Age:25 y Bot v rir.rss indi:x ' i:nlrilv histLI Y oi aliabeLrs
79.+ (47,3 ) ls9 (2 i.4)
i
54i
the Ddds;.ttio re;l
(32.3')
Bodv nl.rss i,di.x cJlrul.rted.r.\ weight
srltrateci.
2.10 1.88
959.i
t.l
k^"., 1.87 163 l.l9
P v,rluc
of ifttere-st
All aUthors state lhey
lra,o,e
no conflict of interest to report..
Ac[<mowledgments
trrri*,
2.37 2,16 i79
5. Conflict
i0.(l0l .0,0r,11
<00c1
iil l{rloglat)ts (livide.l lry ir.ight in Inet.rs
We gr-c;rly .rckrrowJedge the financral .sulrltort Jtr.oviried lty the Woricl [Jiabcti:s Founcl.rticin for this stLrdy. \{e.rlso th.rnk the Cove;nrneni o1 "lantil iti.:du ibr. gr.tnting per-mission to peifornr this corrr
rl
Lr
rr
ity-bascd
st
r-rcl1z.
s:t8
y
Seshiqh ?t ol,
f
ltlternotional loLullol of Cynecology dild Obsterriri 104 (2009) 535-538
References [1] WildS,RoglicG,CreenA,SjcreeR,l(ini4tl,Clobrlprevalenceofdi.tbetEs:estimates
for the year 2000 and ptojecriors for 2030. Dirbetes C.rre 2004;27(5):1047-53, Schuller l(L The intrersing 1:rt'valence of dirbetes in pregnancy, Obstet Cynecol Clir North 4m 2007i34(2):171-99. [3] Barker Dl, Fetal origins of coronaly he.rrt dise.rse. BtuU ]995;311(6998):l7l-4, l4l Lrrcas A, Programrning by early nutrition iil nln, hr: Bocl< CR, Whelart-1, edilors. 'fhe chilcllrood environrrrcut and irdult disease. Chichester, LJl(: John Wiley ;roil Sons; 1991. p- ll8..55, l5l Seshiah V, Bal;Ui V. Ualaji Sladhuri 5, Sarrjeevi CU, Creen A 6estatjonal rliabetes mellitus in lndia, J Assoc Physicians India 2004;52:707, [6] Tuonrilehto J. A paradigrn shilt is needed in the prinrary preveDtion of type 2 diabetes. lnr 6anz [vl. ediroI PfevEr]rion ol type 2 dialletes, England:John Wiltey & Sons Ltdi 2005, p. 153-65. (71 \^rorld l-lealth Org.rnization, Prever]tior of dirberes nreltirus. WtlO Technicdt Report Series 844. Ceneva: U/tloi 1994, [8] Shanrsuddiri K, Mahdy ZA, Siti Rrnairh I..lamil MA, Rahinratr MD. Risl( faclor screering for abnorrlal glucose toletaflce in pregn.rncy, Int J Cynecol Obstel
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