Southern California Kaiser-Permanente data base (175,249 deliveries)
0.81% 1.82% (p < 0.001)
Increases noted in all age-groups and all racial/ethnic groups (but greatest increases in youngest women)
7.5% 7.4% (N.S.)
The epidemic increase in diabetes in early 21 st century Western societies is almost exclusively an increase in Type 2 diabetes.
Type 2 diabetes is a disease of lifestyle (and therefore largely preventable).
Gestational Diabetes “Any degree of glucose intolerance with onset or first recognition during pregnancy” 7% of all pregnancies More than 200,000 cases annually Range of prevalence 1-14% (higher in non-Caucasians)
Humans evolved as hunter-gathers
‘ Thrifty Genotype / Phenotype’
Competition between fetus and mother for finite resources
What would you do if you were the fetus?
‘Endocrinology of Pregnancy’
The placenta produces larger quantities of more hormones than any other human organ:
Human placental lactogen
Estrogen / progesterone
The majority of its products are released into the maternal circulation to induce changes on the fetuses’ behalf.
Glucose Metabolism in Pregnancy
Fetal growth is dependent upon maternal glucose
Carbohydrates from maternal diet
Stored glycogen converted to glucose
High levels of glucose transported by diffusion to the fetus
Randomized 1000 women with 2-hr 75 gram glucose values 140-200 to treatment – no treatment (‘normal < 155).
Treatment group: Fewer serious perinatal complications and lower birth weights but more NICU admissions.
Number needed to treat to prevent a ‘serious complication’ (death, shoulder dystocia, bone fracture, nerve palsy) was 34.
No change in cesarean rate.
HAPO vs ACHOIS
If it takes 43 ACHOIS interventions (in women with GDM) to prevent one ‘serious complication’, how many women with borderline abnormal carbohydrate tolerance will we have to diagnose and treat in order to prevent one such problem?
(I don’t know for sure, but it will be a lot)
MFMU GDM Trial
‘ Mild’ GDM (Normal FBS, elevation of 2 or 3 post-prandial values) randomized to unblinded treatment or blinded observation.
Composite outcome of death, birth trauma, neonatal hypoglycemia or jaundice, or elevated cord C-peptide.
Recruitment ended October 2007 (enrollment = 1889) – last deliveries occurred in March 2008. (Utah was #2 in recruiting)
Results anticipated for January 2009 SMFM meeting.
GDM requiring medical treatment identifies a group of pregnant women at risk for multiple pregnancy complications and at increased long-term risk of type 2 diabetes.
Lesser degrees of abnormal carbohydrate metabolism are also associated with an increased rate of pregnancy complications, but the threshold for treatment / non-treatment is not yet clear.
Risks and complications of type 2 diabetes (and probably GDM) can be decreased by changes in lifestyle, particularly diet and exercise.