Controlling gestational diabetes critical to mother, baby’s future
GDM is glucose intolerance that develops or is first diagnosed during pregnancy. It has shortterm and longterm implications for maternal and foetal health. It increases the risk of type 2 diabetes in women later in life. Children face consequences such as obesity, insulin resistance, and diabetes
The ultimate idea is to address the problem headon and create a generation free of diabetes through primordial prevention
The 18th Annual Conference of the Diabetes in Pregnancy Study Group India 2024 (DIPSI), which was held in March in New Delhi, marked a significant milestone in the fight against noncommunicable diseases (NCDs) with the unveiling of the Delhi Declaration. This pioneering document provides a futuristic perspective on the primordial prevention strategy for diabetes, especially gestational diabetes (GDM), which has amplified the global threat of NCDs.
GDM was originally described as any form of glucose intolerance that develops or is first diagnosed during pregnancy. This condition is an antepartum complication that has shortterm and longterm implications for maternal and foetal health. GDM increases the risk of type 2 diabetes in women later in life. At the same time, their children face consequences such as obesity, insulin resistance, and type 2 diabetes due to likely epigenetic modifications caused by exposure to high glucose concentrations in utero. Hence, identifying GDM at the right time and proper management are pivotal in reducing these risks.
Due to the increased attention paid to GDM, the Delhi Declaration encourages using the single test procedure formulated by DIPSI and approved by the Ministry of Health and Family Welfare, Government of India. This lowcost and effective strategy is crucial to identifying glucose intolerance in pregnancy to prevent the progression of NCDs.
Foetal programming
One of the key issues emphasised in the Delhi Declaration is foetal programming. This refers to alterations in the structure, anatomy, and biochemical activities due to injurious influences or stress during specific developmental phases of fetal growth. One such adverse stimulus is hyperglycemia during pregnancy, which increases the risk of the fetus developing NCDs when it grows up, a concept known as the “Foetal Origin of Adult Diseases.”
The studies show that women should be screened for glucose intolerance at eight weeks of pregnancy. Foetal beta cells begin to secrete insulin at the gestational age of 11 weeks of pregnancy. Maternal 2hour postprandial blood glucose (PPBG) level of 110 mg/dL by the 10th week of pregnancy predicts GDM. This early glucose intolerance, called Early Gestational Glucose Intolerance (EGGI), requires treatment in order to keep blood glucose levels below 110 mg/dl at 10 weeks to avoid foetal hyperinsulinemia (higher than normal levels of insulin in the blood) and, subsequently, GDM.
A National Institutes of Health, US, and WHO analysis states that a 2 hour post prandial blood sugar of 110 mg/dl at the 10th week predicts early GDM. This will enable the launch of appropriate lifestyle changes and medical interventions even before GDM is actually established. The 2013 WHO guideline does not include A1c as a means of diagnosing diabetes in a pregnant woman and for monitoring. Screening between the 8th and 10th weeks enables healthcare providers to keep maternal glucose levels below 110 mg/dl. Taking early action can greatly change the course of NCD development.
The Delhi Declaration states that all pregnant women with PPBG ≥₹110 mg/dl should be put on medical nutrition therapy and begin taking metformin 250 mg twice a day until delivery. These interventions aim to ensure that glycemic levels remain between 99 ± 10 mg/dl during the pregnancy. Metformin is still relatively safe at this stage because the advantages of better glycemic control outweigh the potential hazards.
A pilot study carried out in this regard has revealed some promising findings. Group A included 82 antenatal women with PPBG < 110 mg/dl at eight weeks and no intervention; only one woman developed GDM in the third trimester because she was bearing multiple foetuses. On the other hand, in Group B, which had 70 antenatal women with PPBG of 110mg/dl at eight weeks on MNT plus metformin, only one woman had GDM resulting from discontinuation of the intervention. These outcomes provide proof that the primordial prevention of diabetes is possible and feasible.
The Delhi Declaration has urged clinicians, researchers, diabetologists, obstetricians, and public health specialists to achieve set metabolic targets at the beginning of pregnancy for improved maternal and fetal health. The pledge involves the following principles:
• using advocacy to raise awareness of screening for PPBS at eight weeks of gestation,
• working with healthcare professionals and families to ensure euglycemia and
• ensure sound policies and programmes for the education, screening, and management of pregnant women.
Freedom from diabetes
The Diabetes in Pregnancy Study Group India 2024 conference has also set a clear agenda for the future: to launch social media advocacy campaigns, improve postpartum compliance, and reduce discrimination against pregnant women with diabetes. The ultimate idea is to address the problem headon and create a generation free of diabetes through primordial prevention.
By adhering to these guidelines, the Delhi Declaration seeks to pave the way for healthier futures for the mom and her child.
The ideology of early detection and intervention is not only medically sound but also a public health call that holds out the prospect of dousing the epidemic of diabetes and other NCDs.
To sum up, we need to bear the following points as a mantra in the treatment of pregnant women: Prediction of GDM should be done on the basis of a 2hr PPBS reading of >110 mg/dl at the
10th week. Preventive action has to be taken so that maternal PPBS remains under the 110 mg/dl blood sugar mark throughout the pregnancy. The mother should be on Maternal Nutrition Therapy and oral Metformin for the entire pregnancy. Followup for women who have recorded GDM is essential after delivery.
With these simple, practical guidelines and an understanding of what the Delhi Declaration offers, we now have the means and the knowhow to create a real and lasting improvement in the health of future generations.
The focus on early identification and treatment is not only a requirement of modern medicine but also a social mandate. Together, we can pave the way for a healthier, diabetesfree generation in the future. The womb is more important than the home, in some senses. It all starts in utero. Hence, for a diabetes free generation we should concentrate on the development of offspring.
(Dr. V. Seshiah is an eminent Diabetologist practicing in Chennai and is the founder and patron of the Diabetes in Pregnancy Study Group India. vseshiah@gmail.com)