From left: Dr. Anil Kapur, Dr. Hema Divakar, Professor Moshe Hod, Professor Chandrika Wijeyaratne, Professor V. Seshiah and Dr. P. Jayawardena
By Fathima Riznaz Hafi
Diabetes has become the fastest growing chronic disease in the world, with alarming statistics indicating increasing numbers and South Asia is no exception as the region struggles in its battle against non-communicable diseases. Diabetes in pregnancy further exacerbates this dilemma as its adversities affect the pregnant woman, her child and future generations.
The 1st DIP Asia Pacific Symposium on Diabetes, Hypertension, Metabolic Syndrome and Pregnancy (DIPAP) held in Colombo from 8-10 September addressed this issue through deliberations of an international team of experts.
World Diabetes Foundation Chairman and SAIDIP Conference President Dr. Anil Kapur from India, FIGO HIP Working Group Chair and DIPAP Conference Co-President Professor Moshe Hod from Israel, FIGO HIP Working Group Co-Chair and Federation of Obstetrics and Gynaecology Societies of India (FOGSI) Past President Dr. Hema Divakar from India, Tamil Nadu MGR Medical University Professor and Diabetes in Pregnancy Study Group India (DIPSI) Founder Chairman Professor V. Seshiah from India and SAIDIP Co President and local host of the conference Professor Chandrika Wijeyaratne, representing this team, shared their concerns on this topic at a press conference held recently in an attempt to spread the message about the serious nature of this condition to the public with suggestions for change.
Epidemic of future diabetics
“Diabetes is becoming a big issue in South Asia. We believe there are about 85 million people in South Asia that have diabetes and it is estimated that by 2040, that is, 25 years from now, this number will almost double to about 150 million people. In Sri Lanka you are very fortunate that you have a wonderful healthcare system; that you have excellent maternal and child health services and that Sri Lanka has been able to lower its maternal mortality rate considerably and it is by now 33 per 100,000 births which is almost like in many of the developed countries. But in the rest of South Asia we have a huge problem with maternal mortality, newborn mortality, under-5 mortality and under nutrition,” said Dr. Anil Kapur.
“Ill-health of the mother directly affects the health of the child in her womb. Unhealthy mothers can drive the epidemic of future diabetics. A child born to a mother that has been under nourished has been programmed to get diabetes and future cardiovascular disease. If it is a girl-child, she is likely to experience for the first time, high blood sugar level during pregnancy and when that happens, the children born to her are also programmed and the cycle is going to repeat and therefore we are in a state in South Asia where we are going to experience an increasing burden of not only diabetes but cerebrovascular diseases and all the NCDs,” he said.
Some of the root causes of this lie in the health of the mother – before pregnancy, during pregnancy and after pregnancy. It is said the 1,000 golden days are the nine months in the womb and the first two years of life – and they actually determine – when we are 50 or 60 whether we will get heart attacks, diabetes, etc.
“Paying attention to the health of the mother is a very important issue; we feel that South Asia is on the verge of a huge gamut of all this and therefore we need to address this and as a result FIGO has decided that the first regional focus on this issue, will be done in South Asia and then felt what better place to do it than in a country which is doing fabulously well in terms of improving maternal health – not so well in terms of diabetes prevention at this stage but perhaps it will help us motivate others to start acting on it and the best part was the creation of the ‘Colombo Declaration’ for hyperglycemia in pregnancy for South Asia.”
Two sides of a coin
“Everything about this is really like two sides of a coin – it’s a sweet disease – but there are many bitter truths about this sweet disease,” said Dr. Hema Divakar. “There are 85 million diabetics in South Asia, out of which 70 million are living in India – so we have a large burden of diabetes but we are not so proud that we are leading in terms of numbers in diabetes. On the other side of the coin, we are proud of ourselves that we have done the best we could do contain this in our own country by focussing on managing the women after testing them in pregnancy.”
Out of the 70 million Indians with diabetes, half of them are women so that is 35 million women; out of which half of them, that is about 15-17 million would have had diabetes in their pregnancy and then they move on in their life to become the adult type 2 diabetics.
“If we had paid enough attention, both for testing and managing diabetes in pregnancies, we would have perhaps managed to alert ourselves and them that moving forward they should take care of their diet, weight decline, lifestyle and exercise pattern; they must come for their annual sugar check and we would have controlled and contained their unfolding into diabetes in the next 5-10 years.
“That’s why this entire region of South Asia needs a focus on testing and management of diabetes in pregnancy so we worked out some of our own novel ways of how we could reach every single pregnant woman in this region – to do our best for them because if we do our best for them we would not only be doing good for those women by preventing diabetes unfolding a couple of years later but we could also have done a very brilliant job in protecting the child from the high sugar environment. So the healthy care of these women – that is the Colombo Declaration – that is the resolve and commitment that we as an organisation are making to the people of South Asia at large.
“We are also as a professional organisation trying our best to build the capacity of all the healthcare workers to take care of these women. So to take care of this demand and supply when they meet eye to eye, I’m sure that the generations to come will be much healthier than what we are today,” she said.
Referring to the Colombo Declaration, Professor Moshe Hod going back in history said that there was a similar declaration in Italy called ‘San Vincent Declaration’ 27 years ago in 1989, which was related to diabetes. “They declared that in 10 years they would equal the complications in diabetic pregnancies to that of the normal population. It has been 27 years and they have not managed to do that! They are still fighting this problem,” he said.
“But now we have the tools – the proper tools to deal with it and to reduce the complications in the mother and the offspring. Let’s hope the Colombo Declaration will bring us to a completely different outcome,” he said.
The pregnant mother should not be overweight nor should she be underweight. When the child is born with low or high birth weight he is prone to future illness with risks of developing diabetes or obesity. “If it is a boy-child he can develop diabetes in the future and if it is a girl-child she could develop hyperglycemia when pregnant. We must stop this vicious cycle – one generation passes it on to the next,” said Professor V. Seshiah.
“It is very important to check blood sugar levels at pregnancy. As soon as the mother comes for check-up in early pregnancy the first thing we do is check the blood sugar level. If we check early we can take control of the blood sugar so it won’t turn into diabetes. By our care we can break this cycle,” he said.
He elaborated on the three main steps they take in their attempt to break the cycle. The first step is to check the levels and after diagnosis is made, if problems are detected, the second step would be the provision of necessary treatment, advice and therapy to make sure the blood sugar and pressure don’t cross safe levels. The third step is after the child is born, again the mother’s blood sugar and pressure is checked and she is advised to be careful and follow the recommended diet to make sure she won’t become diabetic.
Not a good sign
“Most of the mothers get screened in the first three months of pregnancy and we found that almost a quarter, that is one in four had high blood sugar levels – that is not a good sign because pregnancy is considered a ‘stress test’ – if you have a risk to develop diabetes it can show up when you get pregnant and your hormones increase,” said Professor Chandrika Wijeyaratne.
It’s not that the baby develops diabetes then and there but in the long term we are fashioning that baby – the next generation to develop diabetes earlier in life and that is going to become an unmanageable situation. It is important to realise if you identify this problem and manage properly you can prevent all the bad things that can happen to mother and baby.
“We want to protect the mother as well as the baby in the long term because when those children are born, fashioned to get overweight or obese, they will develop it when they are 10 or 13 and very often by the age of 20 they develop diabetes.”
Complications during pregnancy
“If the mother has high blood pressure in the first three months, when the organs are formed – those babies can get abnormalities – heart defects and various terrible defects. That is preventable if the blood sugars are managed properly. Also these babies, when they are very severely damaged, can get miscarried,” she said.
Abortions can occur even in the middle or later in pregnancy – not just in the first trimester. Mothers have a risk of developing high blood pressure and that pressure can even kill the mother! Additionally if these babies get a lot of sugar from the mother they tend to become very big – it is called ‘macrosomia’ when the birth rate is more than 3.5 kg. That means the mother probably had diabetes, Professor Wijeyaratne noted.
Embark on healthy lifestyle before pregnancy
Stressing the importance of a healthy lifestyle to ensure a safe pregnancy, Dr. Hema Divakar said, “Exercise, healthy eating and keeping to the normal BMI should actually start before they embark on pregnancy. During pregnancy there is a specific instruction from us as obstetricians that the mother must walk after every meal and have a routine of exercises, which is very crucial. Diet and exercise is the major form of management for women with high sugars in pregnancy.”
She added that ‘eating for two’ and ‘exercise will harm the baby’ are two myths that need to be changed as they result in the mother over-eating and not getting the exercise she needs for a healthy pregnancy.
Socio economic impact
Urging the public not to think of this as a health issue for only the individual Dr. Anil Kapur says this is a public health issue and has economic consequences. “People who get diabetes will spend a lot of money on treatment with complications. When someone with diabetes becomes blind or has an amputation it is an economic catastrophe and drives people to poverty. It is a huge socio economic issue and investment in good care of mothers and investment in good care for diabetics actually reduces the future burden of ill-health. We need to address prevention!” he said.
Professor Wijeyaratne added that we have a good maternal and child health service and Sri Lanka is aiming to unify this with NCDs so we can tackle the issues together but there are gaps. “We need to move forward to try and prevent illness and protect the next generation,” she said, citing the Colombo Declaration as the way towards achieving that goal. “We would like the help of policy makers as well as civil society who can push for its implementation in this country. We have the political will and the commitment of our leaders but still many systems – not just health but other systems also have to come into play.”