Diabetes in Pregnancy Global, Regional, and Indian Scenario
The global diabetes epidemic is on the rise; According to IDF Head Professor Andrew Boulton, diabetes has become an epidemic. The worldwide prevalence of diabetes is estimated to increase from 537 million in 2021 to 783 million in 2045, an increase of 46%. 1 Diabetes is common worldwide. This is a concern; By 2021, there will be 74.1 million diabetics in India.
This increase may be due to the aging of the population, physical inactivity, urbanization, and obesity. These conditions increase the risk of diabetes mellitus, but early life is a risk factor. As suggested in David Baker’s “Fetal origins of adult disease” hypothesis, pregnancy planning can significantly impact adult health and disease. Pregnancy can be defined as the process in which stress or stimulus during a sensitive or important period of fetal development permanently changes the structure, body, and metabolism and thus creates a predisposition to a disease in the elderly. Lifestyle changes and medical interventions have been reported to slow or delay the development of diabetes mellitus in people with impaired glucose tolerance (IGT).
This is the first line of Défense. Maintaining normoglycemia in GDM or other vulnerable individuals is the best option to prevent developing type 2 diabetes (T2DM). Diabetes can be reversed or stopped through primary prevention. For primary prevention of diabetes mellitus, women with gestational diabetes (GDM) are considered an ideal group because their children are more likely to have diabetes, and most of them acquired T2DM. Gestational diabetes may be an important factor in diabetes and obesity.
By 2021, the Global prevalence of hyperglycemia in pregnancy (HIP) will be 21.1 million people, accounting for 16.7% of births to women aged 20-49. These individuals may experience some form of hyperglycaemia during pregnancy; 80.3% of these were due to GDM [2}
Therefore, all women must be tested for GDM, even if they have no symptoms.
The global epidemic of diabetes and hyperglycemia in pregnancy (HIP) is causing many problems, some of which differ from country to country. A narrow solution is essential to solving these particular problems. In India, the Ministry of health family welfare and FOGSI have assisted medical personnel and physicians throughout the HIP management process, working with national groups such as the DIPSI Diabetes in Pregnancy Study Group India, FOGSI Federation of Obstetrics & gynecology society and International organizations such as WDF, IDF, and FIGO who have imparted capacity building of health care professional at Districts and block level with Ministry of health family welfare and states Govt for screening and management of GDM, This multifaceted approach helps solve some multifaceted problems unique to India.
Keywords: Gestational Diabetes Mellitus; Epidemiological Studies; South Asia, Prevalence, Hyperglycaemia in pregnancy, HIP, GDM
Although gestational diabetes mellitus (DIP) can cause hyperglycemia (HIP) during pregnancy, gestational diabetes mellitus (GDM) is still first detected during pregnancy . HIP, whether diagnosed before is dangerous and causes severe hyperglycemia during pregnancy that persists after delivery; Gestational diabetes usually causes mild to moderate hyperglycemia that also develops
in 50-60 % of women within 5 years of delivery. Because pregnancy occurs naturally, it can cause insulin resistance. The resulting hyperglycemia in healthy women is compensated by pancreatic β-cell hyperplasia to meet the additional metabolism needs.
However, due to various genetic and environmental factors, GDM cannot be compensated, leading to hyperglycemia . Although GDM is associated with maternal-Foetal complications, there are additional concerns. After giving birth, women with GDM are 10 times more likely to develop type 2 diabetes (T2DM) than women without GDM. Strict screening, monitoring, and preventive measures for women with postpartum GDM can help reduce T2DM in individual patients and even in the population as a whole. Due to the rise in the current global prevalence of T2DM, the postpartum period of women with GDM is important in all countries, particularly in patients with a history of Gestational diabetes mellitus (DM).
India is the largest country by Population and has the second-highest number of adults with T2DM in the world, and this number is expected to increase by more than 75% in the next 25 years .
|Figure 2: Hyperglycemia in pregnancy Per IDF region, 2021|
- Gestational Diabetes in South East Asia
Although T2DM has become a global epidemic , seven countries in Southeast Asia (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are the most severely affected by Diabetes & GDM. Disease severity accounts for approximately one-third of the global burden of diabetes and prediabetes . In 2019, there were 88 million adults with diabetes in Southeast Asia, of whom more than half (57%) were undiagnosed . If the current trend continues, 114 million Indians will be affected by 2045, and India may surpass China as the DM capital of the world.
Estimates were available per IDF Atlas 2021 for 7 IDF South East Asia (SEA) countries. All countries have relevant data except Bhutan for diabetes estimates in adults 20-79. A total of nine documents from six countries were used. Estimates for Bangladesh and Nepal are based on research over the past five years. The IDF estimates that the number of people with diabetes in Southeast Asia will increase by 68% to reach 152 million by 2045 .
At the same time, the prevalence of diabetes will increase from 30% to 11.3%. The percentage of undiagnosed diabetes is 51.2%, the third highest in the IDF region (Fig 1). The proportion of pregnancies affected by hyperglycemia is highest in the IDF region, at 25.9% (Fig 2).
A recent study involving 69 studies of 1,778,706 adults in India found that the prevalence of T2DM increased from 2.4% to 15% and from 3.3% in remote, urban, and rural areas of India between 1972 and 2019 showed an increase of 19.0% . As the prevalence of GDM is similar to T2DM, an increase in blood sugar will change women affected by GDM.
Therefore, the prevalence of GDM in Asia is higher than in Europe because Asians have more T2DM. Recent epidemiological data suggest that T2DM affects young women developing HIP during pregnancy. If immediate action and measures are not taken, morbidity & mortality from DM and GDM will continue unabated. However, as women make up half the population and GDM is a major cause of T2DM, managing GDM early in pregnancy and postpartum screening help prevent T2DM from rising.
- India: An example of global GDM trends
Globally, approaches to GDM are diverse and confusing, with little consensus. In the United States, the 1979 National Diabetes Dataset Guidelines was one of the earliest efforts to conduct an objective, systematic study of DM and GDM. After this initial guideline and four international workshops on GDM (1979-1997), the recommendations proposed significant changes in the screening and diagnosis of GDM. Over the next two years, the American Diabetes Association (ADA) and the American College of Obstetricians and Gynaecologists (ACOG) followed this trend with new guidelines for GDM and HIP, Similar to the World Health Organization (WHO) 1980, 1985, and 1999 and 2013. The Classification has also changed over time; The UK’s National Institute for Health and Care Excellence (NICE), the Canadian Diabetes Association (CDA), and the Australian Gestational Diabetes Association (ADIPS) are some of the main standard-setting bodies (others) that use local and international research for updates. Therefore, over the past decade, due to international efforts, extensive research, and international consensus meetings, GDM treatment has seen an increase in screening, diagnosis, management, and postnatal care .
Thus, for example, separating GDM from DIP under the umbrella of HIP has clarified the meaning, and its relationship to HIP is now more clearly defined. In addition, the development and validation of diagnostic methods are very important as one universal Guideline. Countrywide is the need of time.
Table 1. Current diagnostic criteria for GDM diagnosis.
The Sourced from the IDF Atlas 2019
GDM prevalence in India
The prevalence of GDM in any given population depends on several factors, including characteristics of the study group: parental age, family history of diabetes, maternal weight and BMI, race, and ethnicity. Analysis of 84 studies showed that the combined prevalence of GDM in Asia was 11.5% (95% CI 10.9-12.0) . However, there are significant differences in the majority of GDM due to differences in diagnostic criteria, screening methods, and work environments (e.g., urban and rural, home medical and community). Another study using data from 51 population studies found that the prevalence of GDM is affected by different diagnostic criteria.
In a study in the Indian population using eight specialist diagnostic criteria for the same blood glucose results to diagnose OGTT, the prevalence of GDM ranged from 9.2% to 45.3%, depending on Therefore, most GDM in India ranges from 3.8% in Kashmir to 35% in Punjab .
Another review of 90 estimates from 64 studies showed that the prevalence of GDM in India ranged from 0% to 41.9%; the authors attribute this difference to different models used in diagnosis.
This study revealed large variations in the prevalence of GDM between regions. More importantly, the same standards were used (even in disease). The authors point out an important point: a different (other than “one size fits all”) approach will be costly in different parts of India.
- Number of births with GDM in India
In India, 5-8 million women suffer from GDM each year . India’s annual birth rate is about 25 million; this means that one-third of all babies will be affected by GDM. This information is based on the 2021 International Diabetes Federation (IDF) Atlas (10th edition), which states that 1 in 4 children born with HIP in Southeast Asia and 1 in 1 child worldwide has HIP . In short, GDM is a bigger problem in India as it is more common.
Despite these challenges, it has encouraged Bangladesh, India, Pakistan, and Sri Lanka, the four largest countries responsible for more than 80 percent of the HIP burden live in Asia. With the help of policy experts, these schemes, federal and state grants, international organizations, and public health experts should conduct DIPSI tests on all pregnant women as blood sugar testing by hand using a glucometer is good today. Using a glucometer is common in Uttar Pradesh, Madya Pradesh, and other states under the National Health Mission funded program by Govt of India.
India demonstrates tremendous progress worldwide in achieving HIP pregnancy Screening by “Universal Single Test Procedure” advocated by DIPSI and adopted by Govt of India, MOHFW 2014 Guidelines.
The importance of GDM management is simple; If diagnosed, treated, and followed up after birth, it will reduce the burden of T2DM in a country now and in future generations. Therefore, GDM monitoring has the potential to change future predictions regarding T2DM.
Specifically, 90% of HIP births occur in low- and middle-income countries. There are significant challenges in universal screening for GDM, with coverage rates ranging from 10% to 90%. Missing out or not treating women with GDM leads to short-term and long-term complications associated with GDM.
India faces a challenge for all countries with limited resources: how to apply the latest research within the constraints of personnel, laboratory equipment, and bureaucratic issues. There are also large cultural differences that create logistical problems. DIPSI screenings have the largest following in India and are also approved by Govt of India MOHFW Guidelines 2014.
Because of differences in the prevalence of GDM in different states in India and given the size of the country, Experts agree that one method may not be suitable for all situations and that it is better to adapt to local solutions , a view shared by FIGO. The DIPSI test is still popular and accepted by major local organizations. So far, this is good practice.
- World Health Organization. Diagnostic criteria and classification of hyperglycemia first detected in pregnancy: A World Health Organization Guideline. Diabetes Res. Clin. Pr. 2014; 103:341–363.
- International Diabetes Federation. Diabetes Atlas, 10th ed.; International Diabetes Federation: Brussels, Belgium, 2019. Available online: http://www.diabetesatlas.org (accessed on 31 January 2021).
- International Diabetes Federation. Diabetes in South Asia. Available online: https://idf.org/our-network/regions-members/south-east-asia/diabetes-in-sea.html org (accessed on 2 February 2021).
- Ranasinghe, P.; Jayawardena, R.; Gamage, N.; Sivanandam, N.; Misra, A. Prevalence and trends of the diabetes epidemic in urban and rural India: A pooled systematic review and meta-analysis of 1.7 million adults. Ann. Epidemiol. 2021; 58: 128–148.
- Kapur A, McIntyre HD, Divakar H, Di Renzo GC, Kihara AB, McAuliffe F, Hanson M, Ma RC, Hod M; FIGO Working Group on Hyperglycemia in Pregnancy. Towards a global consensus on GDM diagnosis: Light at the end of the tunnel? Int J Gynaecol Obstet. 2020 Jun;149(3):257-261
- Lee, K.W.; Ching, S.M.; Ramachandran, V.; Yee, A.; Hoo, F.K.; Chia, Y.C.; Wan Sulaiman, W.A.; Suppiah, S.; Mohamed, M.H.; Veettil, S.K. Prevalence and risk factors of gestational diabetes mellitus in Asia: A systematic review and meta-analysis. BMC Pregnancy Childbirth. 2018; 18:494
- Mithal, A.; Bansal, B.; Kalra, S. Gestational diabetes in India: Science and society. Indian J. Endocrinol. Metab. 2015; 19: 701–704.
- Diagnosis and Management of Gestational Diabetes Mellitus. Available online: https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCH_MH_Guidelines/Gestational-Diabetes-Mellitus.pdf (accessed on 15 March 2021).