Gestational diabetes mellitus in a multi-ethnic Asian cohort Turning Discovery into Healthier Communities MARY CHONG Assistant Professor, Saw Swee Hock School of Public Health, NUS Principal Investigator, CNRC, SICS, A*STAR 2 Definition of Pathophysiology of GDM Gestational Diabetes Mellitus (GDM) Any degree of glucose intolerance that is first detected during pregnancy Pancreatic β-cells effect: normal glucose tolerance Pancreatic β-cells deficit: GDM 3 Rani & Begum, 2016; Magon, 2011; Mumtaz, 2000; Schmidt et al., 2001;Avi & Arnon, 2010 4
Commonly used guidelines for GDM diagnosis Country-specific prevalence of GDM 5 Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy, WHO, 2013 6 GDM in Singapore Risk Factors for GDM Up to 1 in 4 pregnant women gets affected by GDM every year. > 1,200 women are diagnosed with GDM at KK Women s and Children Hospital (KKH) each year. About 800 women are diagnosed with GDM at National University Hospital (NUH) each year- 4 fold increase in the last decade. Figures are expected to rise further. Source: Today online (2017). Avaliable from: http://www.todayonline.com/daily-focus/taking-war-against-diabetes-pregnant-women 7 8
Risk Factors for GDM 9 10 1200 mothers 3 major ethnic groups Deep phenotyping Findings from the GUSTO Study IN UTERO BIRTH INFANCY & CHILDHOOD 26 th 28 th gestation Birth 3 mth 6 mth 9 mth 12 mth 24 mth 3 yr 4 yr 5 yr 6 yr 7 yr 8 yr 9 yr 11 12
Genes Existing Health Conditions Anthropometrics Vascular Function Family Medical History Mental Health OGTT Retinal Health PREGNANCY OUTCOMES GDM Pre-Eclampsia IUGR Pre-Term MATERNAL HEALTH & PRACTICES Breastfeeding Mental Health Practices Diet & Feeding Practices and Behaviour Ethnic Differences 25% 20% 15% 10% 5% Maternal Nutrition Infant Nutrition 0% Whole Cohort Chinese Malay Indian Smoking Physical Activities Nutrient Biomarkers Alcohol SES Diet Acknowledgements to Toh Jia Ying for help with slides Anthropometrics MRI - Brain/Body Composition Neurocognitive Test BIRTH OUTCOMES BIA/PEAPOD Cord Blood INFANT and CHILD HEALTH OUTCOMES Anthropometrics Neurocognitive Test Diet Oral Health Allergy Sleep Quality Development Gut Microbiota MRI - Brain/Body Composition Myopia Environmental 13 Epigenes/genes VEGETABLE, FRUIT AND RICE-BASED (VFR) Maternal dietary patterns Lifestyle Factors 15 Vegetables Fruits Wholegrain bread Nuts and seeds White rice Fried potatoes Burger Carbonated Drinks Flavoured rice Sweetened Drinks Fried Meat / Meat in curry SEAFOOD AND NOODLE-BASED (SfN) Soup Fish & seafood products Flavoured noodles Noodles in soup Red meat (healthy prep) Seafood Soya sauce based gravy Legumes and pulses Ethnic Bread Rice Curry gravy Other Grains 16
Imbalance Folate and B12 Sleep B12-insufficient (<221pmol/L) B12-sufficient ( 221pmol/L) 4 3.5 * * 3.5 P= 0.413 (T3 vs T1) OR and 95% CI for GDM 3 2.5 2 1.5 1 0.5 0 Ref. P= 0.036 (T2 vs T1) T1 18.2(11.6,24.4) P= 0.034 (T3vs T1) 1.94 1.97 T2 T3 34.5(32.3,37.1) 49.7(44.5,58.5) Median (IQR) of plasma folate (nmol/l) OR and 95% CI for GDM 3 2.5 2 1.5 1 0.5 0 P= 0.669 (T2 vs T1) Ref. T1 18.2(11.6,24.4) 0.82 1.42 T2 T3 34.5(32.3,37.1) 49.7(44.5,58.5) Median (IQR) of plasma folate (nmol/l) 18 Implications of GDM on child A continuous relationship between maternal glycemia and excessive neonatal adiposity extends across the range of maternal glycemia. 19 20
The Influence of Gestational Diabetes on Neurodevelopment of Children in the First Two Years of Life: Prospective Study The Influence of Gestational Diabetes on Neurodevelopment of Children in the First Two Years of Life: Prospective Study The reduced weight gain in early years of life conferred by greater breastmilk intake was observed in non-gdm children, but not GDM children. Non-GDM GDM 21 22 Long term implications of GDM on child Transition to Type 2 Diabetes 23 24
70% Incidence of T2DM amongst GDM women in different countries Risk Factors for Transition to Type 2 Diabetes 61.30% Incidence Rates 60% 50% 40% 30% 45.40% 48.30% 26% 40.80% 20% 10% 0% Singapore Germany Australia Taiwan Sri Lanka 26 Physical Activity Protective Factors - Lifestyle changes 27 28
Intensive lifestyle vs pharmacological treatments to prevent transition to T2DM Protective Factors- Breastfeeding 29 30 Lactation Intensity and Postpartum Maternal Glucose tolerance in Women with GDM 31 32
Poster 3 Social, behavioral factors and perception of developing T2DM in mothers with GDM a Qualitative study S. S. Hewage et al Most mothers perceived their risk of getting T2DM to be low. Women with abnormal OGTT results had limited understanding of their health condition AND failed to seek immediate health advice Channel News Asia Unless screening offered at work, no regular check-ups or proactively seeking help/treatment. 33 34 New Model of Care for women with GDM Temasek Foundation Cares has committed $1.09 million to the GDM Care programme to be piloted over a 3 year period. 1 Objectives 1. Establish an effective system for early diagnosis of GDM, optimal care and follow-up during pregnancy. 2. Pilot a structured followup after delivery to diagnose T2DM yearly and allow good care for disease. 1. KKH (2017) War against diabetes: Pilot programme by KKH and Temasek Foundation Cares to improve care for pregnant women with gestational diabetes mellitus 35 Key takeaways 36
Acknowledgments GUSTO team led by A/Prof Chong Yap Seng SICS team Epigen team led by Keith Godfrey NUS collaborators- A/Prof Rob van Dam, A/Prof Joanne Yoong Students and interns Hazel, Sumali, Kenneth, Darren, Yi Chieh GUSTO mothers and children Thank you for your kind attention! 37 38