gestational diabetes mellitus in a multi-ethnic asian...

Turning Discovery into Healthier Communities

Gestational diabetes mellitus in a multi-ethnic Asian cohort

MARY CHONG

Assistant Professor, Saw Swee Hock School of Public

Health, NUS

Principal Investigator, CNRC, SICS, A*STAR

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Gestational Diabetes Mellitus (GDM)

Definition of

“ Any degree of glucose intolerance

that is first detected during pregnancy”

Rani & Begum, 2016; Magon, 2011; Mumtaz, 2000; Schmidt et al., 2001;Avi & Arnon, 2010

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Pathophysiology of GDM

Pancreatic β-cells effect:

normal glucose tolerance

Pancreatic β-cells

deficit: GDM

4

Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

Commonly used guidelines for GDM diagnosis

Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy, WHO, 2013

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Country-specific prevalence of GDM

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GDM in Singapore

• > 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

1 in 4 pregnant women gets

affected by GDM every year.

Up to…

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Risk Factors for GDM

8


9

Risk Factors for GDM

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Findings from the

GUSTO Study

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IN UTERO BIRTH INFANCY & CHILDHOOD

• 1200 mothers

• 3 major ethnic groups

• Deep phenotyping

3 yr 4 yr 5 yr 6 yr 7 yr 8 yr 9 yr

26th – 28th gestation

Birth 3 mth 6 mth 9 mth 12 mth 24 mth

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Smoking Alcohol

Physical

Activities SES

Nutrient

Biomarkers Diet Myopia

MRI - Brain/Body

Composition

Neurocognitive

Test Sleep Quality

Diet Development

Anthropometrics Allergy

Environmental

Oral Health Gut Microbiota

MRI Brain/Body

INFANT and CHILD HEALTH OUTCOMES

PREGNANCY OUTCOMES

GDM Pre-Eclampsia

IUGR Pre-Term

BIRTH OUTCOMES

Anthropometrics BIA/PEAPOD

MRI - Brain/Body

Composition Cord Blood

Neurocognitive

Test

MATERNAL HEALTH &

PRACTICES

Mental Health Breastfeeding

Practices

Diet & Feeding Practices and Behaviour

Genes Family Medical

History

Existing Health

Conditions Mental Health

Anthropometrics OGTT

Vascular

Function Retinal Health

Acknowledgements to Toh Jia Ying for help with slides Epigenes/genes

Smoking Alcohol

Maternal

Nutrition

INFANT and CHILD HEALTH OU

Infant

Nutrition

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Ethnic Differences

0%

5%

10%

15%

20%

25%

Whole Cohort Chinese Malay Indian

Lifestyle Factors

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Maternal dietary patterns

Vegetables

Fruits

Wholegrain bread

Nuts and seeds

White rice

Fried potatoes

Burger

Carbonated Drinks

Flavoured rice

Sweetened Drinks

Fried Meat / Meat in

curry

VEGETABLE, FRUIT

AND RICE-BASED (VFR)

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

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Imbalance Folate and B12

B12-insufficient (<221pmol/L) B12-sufficient (≥221pmol/L)

Ref.

1.94 1.97

0

0.5

1

1.5

2

2.5

3

3.5

4

OR

an

d 9

5% C

I fo

r G

DM

T1 18.2(11.6,24.4)

T2 34.5(32.3,37.1)

T3 49.7(44.5,58.5)

Median (IQR) of plasma folate (nmol/L)

Ref.

0.82

1.42

0

0.5

1

1.5

2

2.5

3

3.5

OR

an

d 9

5% C

I fo

r G

DM

Median (IQR) of plasma folate (nmol/L)

T1 18.2(11.6,24.4)

T2 34.5(32.3,37.1)

T3 49.7(44.5,58.5)

P= 0.036 (T2 vs T1)

P= 0.034 (T3vs T1)

P= 0.669 (T2 vs T1)

P= 0.413 (T3 vs T1) * *

Sleep

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Implications of

GDM on child

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A continuous relationship

between maternal glycemia

and excessive neonatal

adiposity extends across the

range of maternal glycemia.

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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

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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

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Long term implications of GDM on child

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Transition to Type 2

Diabetes

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Incidence of T2DM amongst GDM

women in different countries

45.40%

48.30%

26%

40.80%

61.30%

0%

10%

20%

30%

40%

50%

60%

70%

Singapore Germany Australia Taiwan Sri Lanka

Incid

ence R

ate

s

Risk Factors for Transition to Type 2 Diabetes

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Protective Factors -

Lifestyle changes

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Physical Activity

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Intensive lifestyle vs pharmacological

treatments to prevent transition to T2DM

Protective Factors-

Breastfeeding

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Lactation Intensity and Postpartum Maternal

Glucose tolerance in Women with GDM

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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

“

Unless screening offered at work, no regular check-ups or proactively seeking

help/treatment.

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Social, behavioral factors and perception of

developing T2DM in mothers with GDM – a

Qualitative study

SPoster 3

S. S. Hewage et al

Channel News Asia

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Objectives

1. Establish an effective system for early diagnosis of GDM, optimal care and follow-up during pregnancy.

2. Pilot a structured follow-up after delivery to diagnose T2DM yearly and allow good care for disease.

Temasek Foundation Cares has committed $1.09 million to the GDM Care programme to be piloted over a 3 year period.1

New Model of Care for women with GDM

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

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Thank you for your kind attention!

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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

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