My Story Meet Tausi Suedi… AND her beautiful children!

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

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

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

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

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

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

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

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

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.

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 #

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

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

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 10-12 years out from pregnancy http://www.thenews.com.pk/article-17375-Deaths-up-from-non-communicable-diseases http://www.thehindu.com/sci-tech/health/medicine-and-research/novel-study-in-tn-to-know-gestational-diabetes-effects/article2970820.ece

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).

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

% 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. 329-323.

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. http://www.mapsofindia.com/images2/india-map.jpg

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

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”

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

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)

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

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

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