My Story
Meet Tausi Suedi…
AND her beautiful
children!
1
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
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Global Burden of Disease
 65% of all deaths
each year due to
NCDs
 NCDs leading cause
of death globally for
women
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
World Health Organization, 2008
Global Burden of Diabetes
Zimmet PZ, Medicographia, 2011
5
50% of diabetics are undiagnosed
 Nearly 70% of
diabetics in
Africa
 57% diabetics in
Western Pacific
Zimmet PZ, Medicographia, 2011
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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
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Types of Diabetes Mellitus
Type 1

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
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Understanding the Mechanism
: Insulin,
Closed Glucose Transporter,
Glucose,
Insulin Receptor
Open Glucose Transporter,
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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.
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Slide: Courtesy of Professor Peter Damm
Normal Pregnancy
Insulin
secretion
Blood
glucose
Insulin
resistance
Gestational DM
Insulin
secretion
Insulin
resistance
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
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GDM out long-term outcomes
Babies
 Type 2 diabetes
(33% increased risk)
Mothers
 Type 2 diabetes
 (35-60% increased
risk)
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GDM and Type 2 Diabetes
http://www.thenews.com.pk/article-17375-Deaths-up-from-non-communicable-diseases
http://www.thehindu.com/sci-tech/health/medicine-andresearch/novel-study-in-tn-to-know-gestational-diabeteseffects/article2970820.ece
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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
1. Prevalence of GDM in India
2. Purpose of Jhpiego’s assessment in two
Indian states
3. Results
4. Proposed community-based approach to
screening
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GDM Prevalence in India
20
18
16
17.8
% Prevalence
14
12
13.9
10
13.8
8
9.9
6
4
2
0
Urban
Semi-urban
Rural
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.
Average
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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
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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
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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”
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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
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Beyond diagnosis… a public health approach
Pregnant Woman
in the
Community
---
+
12-16 weeks first
ANC visit:
1st GDM Screening
Screening using
Glucose Challenge
Test (GCT)*
- Referred for
diagnostic test and
medical management
- Meal plan and
98%!
medication
management
- Community-based
glucose monitoring
- Birth preparedness
and complication
readiness
24-28 weeks:
2nd
GDM Screening
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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
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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
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Thank you!
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!