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