Diabetes and Pregnancy: A Public Health Issue
Ms. Joyce Kafanabo
Chair, Council on Gender-based Health for the United Nations
Minister Plenipotentiary, Permanent Mission of the United Republic of Tanzania to the United Nations in New York
Ms. Kafanabo began the meeting by making two points:
- Diabetes is a costly, debilitating disease with severe complications. Data are needed to determine exactly how much this disease costs, as the lack of data adds to the difficulty of advocating for prevention, treatment, and care for those affected by the disease.
- The panel should also discuss how to work together in partnerships in order to address the challenges ahead.
Dr. Elaine Wolfson
President, the Global Alliance for Women's Health (GAWH)
Dr. Wolfson welcomed the panel and distinguished guests and invited them to exchange ideas with the panel. She then gave a brief summary of GAWH's advocacy and goals. GAWH's main concerns center on gender-based differences in health. GAWH has facilitated the Council on Gender-based Health and the Friends of the UN Diabetes Resolution, Member States, non-governmental organizations (NGOs), and the private sector to address this, and other issues, and to promote the distinction between the needs of men and women when discussing health.
Dr. Wolfson concluded by explaining the importance of the panel. "Diabetes is a serious disease that needs to be addressed in the developing world due to its effects on men's, women's, and children's health," she said, also calling attention to the long-term implications of diabetes during pregnancy.
Dr. Anil Kapur
Managing Director, World Diabetes Foundation (WDF)
"Women and Diabetes"
Dr. Kapur's presentation led the technical portion of the panel. His presentation, "Women and Diabetes," focused on the effects of diabetes during and after pregnancy, provided key facts and information to panel attendees, and formed a strong informational foundation for further discussion during the question-and-answer segment later in the panel. Dr. Kapur shared many key facts, including the following:
- The prevalence of gestational diabetes mellitus (GDM) went from 2% in 1980 to 16 % in 2005. This highlights, with regard to GDM and pre-GDM, a lessening of awareness about diabetes, a problem in defining diabetes and considerable under-detection by medical personnel.
- A diagnosis of GDM also entails a high risk of future type 2 diabetes in the mother and a 4 to 8 times increased risk for the offspring to develop diabetes or metabolic syndrome issues.
- If the metabolic health of the mother is compromised during pregnancy, the fetus is at an increased risk for "fetal programming." For example, an undernourished woman can give birth to a low birth weight baby. The child is thus "programmed" and has a higher risk of developing metabolic syndrome several chronic NCDs.
- During an economic transition, maternal weight gain during pregnancy may lead to obesity and eventually, diabetes, as does post-natal over-nutrition. Dr. Kapur noted that there is no international protocol for diagnosing GDM, a factor strongly contributing to the under-detection, failure to treat, and overall lack of care for diabetic pregnant women.
Dr. Kapur noted that there is no international protocol for diagnosing GDM, a factor strongly contributing to the under-detection, failure to treat, and overall lack of care for diabetic pregnant women.
Dr. Mapoko Ilondo
Novo Nordisk A/S
"Changing Diabetes in Pregnancy"
Dr. Ilondo began his presentation by delivering some noteworthy statistics about diabetes around the world:
- 246 million people currently suffer from diabetes. This number will increase to 330 million by 2030.
- In 2005, 60 percent of all deaths worldwide were attributable to a non-communicable disease. This is a figure that will only continue to get worse.
- 80 percent of those suffering from diabetes are unaware they are diabetic. This includes women who do not know they have the disease and then become pregnant.
- Every five seconds, someone develops diabetes. Every 10 seconds, someone dies from it. Every 30 seconds, a loss of limb happens as a result of diabetes.
While these dramatic statistics are indicative of the global threat posed by diabetes, developing nations are particularly at risk and will see most of the increase of disease incidence in the coming decades. Main factors for the extreme changes in developing nations include transitions in national economies, obesity (especially in women of the reproductive age), rapid urbanization, and a lack of attention to chronic diseases. Further complicating the health of both men and women in these nations is the lack of knowledge about the disease.
Dr. Ilondo continued his presentation by speaking to the impact diabetes has on maternal health, especially in developing nations:
- Every year, 529,000 women die in childbirth.
- It is estimated that up to 10 percent of pregnancies worldwide are associated with diabetes.
- In developing countries, the maternal mortality risk is 1 in 48. In Sub-Saharan Africa, the risk is 1 in 16. Comparatively, the risk of maternal mortality in Denmark is 1 in 17,800 and still coming down.
Taking diabetes and the global incidence of all NCDs into account, it comes as no surprise that 93 countries (62 percent of the world population) are not on track to achieve MDG 5: improving maternal health. The solution lies in addressing the numerous barriers to care, which include lack the lack of education and awareness, the shortage of health-care providers, the lack of universal screening and the lack of proper treatment for those already diagnosed with the disease.
Dr. Manuel Carballo
International Centre for Migration, Health, and Development (ICMHD)
"Migration and pregnancy: The challenge and the opportunity"
With the prevalence of diabetes increasing around the world, migration on the rise, and decreased investment in health systems, how can the achievement of MDGs 4 and 5 be realized by the 2015 target? Dr. Manuel Carballo discussed this question during his presentation on diabetes and pregnancy within the context of migration and migrant populations.
A migrant is defined as any person leaving home and moving away in order to work or to achieve security. According to the UN, there are 300 million migrants around the world. However, UNAID estimates that this is quite conservative and there are actually closer to a billion migrants. Increases in the migrant population occur simultaneously to increases in population and the number of people with diabetes.
Migrant populations are more prone to developing diabetes than non-migrant populations. For example, in Holland, Turkish migrants are twice as likely to develop diabetes as the Dutch. The Surinamese are about nine times more likely to develop diabetes. The incidence of diabetes is higher in populations who migrate than if they remain in their home countries. For example, Jamaicans living in Jamaica have a lower prevalence rate of developing diabetes than Jamaicans living in the United Kingdom. Moreover, they tend not only to be diagnosed later, but also have greater morbidity and mortality.
Migrant populations with diabetes are also influenced by the following key factors that act as barriers to proper care:
- Lifestyle, acculturation, and stress (due to the expectation and need to change everything overnight)
- Language barriers
- Political and health systems
Echoing the opinions of the other panelists, Dr. Carballo stated that implementing a system that supports early diagnosis, proper treatment, monitoring, and bettering antenatal and postnatal care is crucial to achieving all MDGs, especially MDG 5. Working on a system that addresses the needs of migrants would also be an opportunity to test the types of care and intervention models that could also apply to non-migrant populations.
Dr. Elaine Wolfson
Dr. Wolfson expanded the conversation by discussing the findings of other diabetes experts as presented in the International Journal of Gynecology & Obstetrics (IJGO) supplement on women and diabetes. This supplement was issued as a follow-up to an Expert Meeting co-sponsored by GAWH and WDF in April 2008. Some highlights from the supplement include:
- "Asians adopting a modern lifestyle have a higher risk of diabetes than their white counterparts living in high-income countries." (J. Chan et al. Pregnancy and diabetes scenario around the world: China. S42.)
- "Africa is confronted with many problems because of the burden of disease and the lack of resources. Diabetes is only one of many challenges, but screening in pregnancy offers a window of opportunity to treat the disease at an early stage and improve maternal and perinatal outcome." (E.J. Coetzee. Pregnancy and diabetes scenario around the world: Africa. S41.)
- In reporting a community-based study in Tamil Nadu, the Dr. V. Seshiah concluded?"an important public health priority in the prevention of diabetes is to address maternal health during both the ante- and postpartum period. In this regard, the Ministry of Health, Government of Tamil Nadu, has made screening for glucose intolerance during building among field health professionals." (V Seshiah et al. Pregnancy and diabetes scenario around the world: India. S37.)
- "Type 2 diabetes in pregnancy needs to be differentiated from gestational diabetes because it is a more severe disease associated with longstanding glucose intolerance." (L. Jovanovic. Definition, size of the problem, screening and diagnostic criteria: Who should be screened, cost-effectiveness, and feasibility of screening. S17.)
Ms. Kafanabo concluded the panel discussion by reiterating the importance of dealing with diabetes in order to achieve MDGs 4 and 5 and to advance public health around the world. She then opened the floor to attendees for a lively question-and-answer session.
Question & Answer Session
- Does traditional medicine work to cure diabetes? (Adama Diop, Femme Africa Solidarite)
Dr. Ilondo: There are products in traditional medicine that reduce blood sugar, but there are no control data or facts about possible side-effects. A natural drug found by Merck in the 1960s worked as well as insulin, but was found to induce cancer in test animals. People treated with Western medicine are still here 50-60 years later, so Western medicine is definitely recommended in this case.
- Obesity is also a major risk, in adolescents especially. Promoting health programs in eating and exercising, with special emphasis on pregnant teenagers, is key. An improvement on how health centers work is also needed. (Sheila Kam Farst, Jamaica)
Dr. Kapur: With regard to obesity, it is a precursor of diabetes, but the disease also affects underweight people or women suffering from malnutrition and having low birth weight babies.
Dr. Wolfson: There needs to be more research on groups that are not obese but are at high risk for diabetes.
- Early diagnosis is key. In Tanzania, there are two key programs: for every village to have health facilities and the president's decision to include controlling NCDs, including diabetes, in his agenda. What is to be done with regard to home based care? (Dr. Donan Mbando, Health and Social Affairs, Tanzania)
Dr. Kapur: Congratulations to the Tanzanian government for their initiatives in establishing diabetes clinics with WDF. There is a need for an integrated system, not with one disease fighting another—they are all important.
Dr. Wolfson: The CARICOM community should be congratulated for their initiatives concerning diabetes.
- Has anyone looked at the economic impact of not addressing pre-natal diabetes? What is the cost of prioritizing and will it have a great economic impact later on? (Joe Connelly, United Methodist Church, United States)
Dr. Wolfson: Cost benefit studies should be employed when addressing diabetes.
Dr. Ilondo: The cost of diabetes is driven by the cost of treatment and complications. An amputation, for example, entails surgery and a hospital stay, etc. By not addressing diabetes, a country loses billions of dollars, a fact that has been well documented in the US, China, and India. For Sub-Saharan Africa, basic information is lacking. IDF has task forces collecting data to establish basic parameters.
- What is the prevalence of diabetes in Palestinian women at Israeli check-points and in undocumented migrants? (Abdel Wahabtkani, Arab Mission for Human Rights)
Dr. Carballo: In Europe, the number of people moving illegally exceeds the number of people moving legally. The situation is worst for clandestine migrants: they have high rates of complicated deliveries and low birth weight babies. By the time they are diagnosed, it is usually too late to move them into the system. Identifying and providing care to these migrants must be on the agenda.
Dr. Kapur: WDF funds a program in Palestine, on the West Bank. WDF is focused on diabetes care for the population, in co-operation with the Palestinian government. Only parts of this program focus on diabetes for women, though, with attention also paid to nutrition, exercise, and access to care.