- Email: [email protected]
From biology to policy: The link between maternal health and current and future burden of chronic noncommunicable disease
International Journal of Gynecology and Obstetrics 115 Suppl. 1 (2011) S1–S2
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
EDITORIAL
From biology to policy: The link between maternal health and current and future burden of chronic noncommunicable diseases On the back of the United Nations High-level Meeting on NonCommunicable Diseases (NCDs) held in New York (September 19–20, 2011), this Supplement to the International Journal of Gynecology and Obstetrics takes a comprehensive view on an important aspect of the burgeoning NCD epidemic that is currently sweeping across the world. This global health challenge has left no country untouched and bridges the divide between rich and poor countries. We are all affected by the rising prevalence of chronic NCDs, wherever one takes a closer look. The concept that the foundation for lifelong risk and susceptibility to numerous diseases begins in the womb and in early life— now referred to by the term Developmental Origins of Health and Disease (DOHaD)—is not entirely new, but has only recently gained acceptance from the broader scientific community because of a swathe of good research producing hard evidence of the link. The biological evidence is there, but its knowledge has remained confined to the academic environment and needs wider dissemination. To move from evidence to policy change requires a broad evidence base of proven solutions, including assessments of how much it costs, over how long a period of time, and what health benefits are expected. But policy is never dictated by hard evidence alone. It requires advocacy, persistence, and resourceful arguments. This is particularly important in the current global economic setting where there is fierce competition for limited resources and the focus on maximizing health impact for the money spent is even stronger. Economic arguments make focusing on the link between maternal health and future health burden even more relevant and attractive. We know that provision of good services for maternal and child health (MCH) is needed to stimulate development and reduce high rates of maternal and child morbidity and mortality; addressing the DOHaD link presents another compelling reason to do so with more vigor. The marginal cost of linking MCH services with health promotion efforts directed at prevention of NCDs is low, but the future savings may be manifold. Who would not want to prioritize such a low-risk strategy that has high potential gain? The link has for many years only been discussed and debated in small circles, so to make this a high priority we need to create more awareness. People working in maternal health are not the only ones who should be aware—we also urge anyone working in NCD control to address the link in their prevention strategies. This Supplement is an attempt to bring more awareness to the issue. It contains articles from global experts, covering the broad range of topics mentioned above. Hanson and Gluckman [1] take us through the biological basis, including how undernutrition in the pregnant mother makes her child vulnerable to a range of chronic NCDs over its lifespan. Aviram et al. [2] list the extensive evidence for maternal obesity as a risk factor for complications in the mother and her offspring. Gangopadhyay et al. [3] and Christensen et al. [4] cover two aspects of anemia in pregnancy. The former closes the
circle and describes how anemia in pregnant women with chronic disease leads to small babies, which in return is associated with chronic disease occurrence when the child grows up. The latter spotlights an as yet remarkably overlooked potential link between one of the major infectious diseases in the southern hemisphere, malaria, and the NCD epidemic. This link has yet to be proven, but according to the authors more data will shortly be forthcoming. We are waiting with excitement! One of the few interventions with an effect on short-term complications, built on solid evidence from randomized trials, is detection and management of diabetes in pregnancy—so-called gestational diabetes mellitus (GDM). Proper GDM management leads to fewer birth complications [5,6], and intensive lifestyle interventions after birth seem to reduce the risk of chronic disease for many years [7]. But for these interventions to be taken up by a health system, the balance between cost and effect needs to be right. Lohse et al. [8] have developed and tested a mathematical model on data from India and Israel, and have produced encouraging estimates of the cost-effectiveness of GDM screening on lifetime risk of chronic diseases. If one trusts their results, introducing GDM screening at population level seems to be a no-brainer. However encouraging, results from models should be interpreted with caution, and preferably undergo repeated testing under different conditions. One way to increase real-life cost-effectiveness even further could be to tailor the screening and treatment strategies to local GDM prevalence and economic capacity of the healthcare system. While McIntyre et al. [9] suggest a tiered approach to GDM testing, treatment, and postpregnancy follow-up in different income level settings, Agarwal et al. [10] reanalyze the solid data from the HAPO study in a middle-eastern cohort of pregnant women and come up with a “lighter” screening algorithm in this high GDM prevalence group. They also give us a glimpse of new candidate technologies for GDM screening, reminding us how an easy-to-use, portable, noninvasive technology that does not require the woman to be fasting could revolutionize access to GDM screening among the millions of women who live in areas where the distance from home to health centers that have up-to-date equipment available is a major barrier to accessing good quality health care. While part of the answer to increased access may lie in new technologies, another solution may be to leverage existing systems and services. This is the focus of the article by Maina [11] who rightly and wisely recommends that GDM screening be integrated into MCH programs. The effect of such integrated programs will need to be tested, and Norris [12] shares with us his experiences as he carefully guides us through the steps that should be considered when designing such intervention studies. But no dramatic changes happen in any health system without the acceptance from policy makers. Not only do we need solid evidence and economic evaluations, we need to package the
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
S2
EDITORIAL / International Journal of Gynecology and Obstetrics 115S1 (2011) S1–S2
information in the right way and deliver it to policy makers at the right time in an understandable manner. This is exactly what both Madhab et al. [13] and Lieberman et al. [14] are doing, but in two very different countries and with the use of quite different methods. The former has stimulated policy change through a media campaign targeted at both the general public and at policy makers, while the latter has used local data on cost and health impact to create health economic arguments presented to a national committee of scientific specialists and policy makers. Getting attention to the subject of DOHaD on the global scene requires buy-in from a global voice. The International Federation of Gynecology and Obstetrics (FIGO) is such a voice. Without losing the focus on major causes of maternal morbidity and mortality, FIGO President, Gamal Serour [15], stresses the life-course link between NCDs and maternal health, and the unique opportunity we have now for change—an opportunity we should not miss. World Diabetes Foundation President, Anil Kapur [16], makes a call to the whole international community for more attention and funding. Finally, Lohse et al. [17] explain the emerging willingness expressed by the for-profit sector to play an active role in global health governance; and specifically the role of businesses to undertake part of the daunting task of stemming the tide of NCDs. Thus, the message of the intergenerational effects of NCDs and the unique prevention opportunity represented by a healthy pregnancy has yet to reach broadly to individuals, organizations, and governments. Transforming the biological evidence into reallife change—so-called knowledge translation—is far from complete. But the seed has been planted and it is growing. We are hopeful and confident that this Supplement, with its views on the topic spanning from biology and epidemiology to policy and service delivery, will serve as a source of inspiration and provide valuable information. This Supplement is for anyone who is interested in understanding the developmental roots of the NCD epidemic, and who would like to bring about new knowledge and induce changes at any level. Conflict of interest statement Nicolai Lohse is a full-time employee of Novo Nordisk A/S, a research-based pharmaceutical company with a strong focus on diabetes. The other authors have no conflict of interest to report. References 1. Hanson MA, Gluckman PD. Developmental origins of health and disease: Moving from biological concepts to interventions and policy. Int J Gynecol Obstet 2011; 115(Suppl 1):S3–5. 2. Aviram A, Hod M, Yogev Y. Maternal obesity: Implications for pregnancy outcome and long-term risks—a link to maternal nutrition. Int J Gynecol Obstet 2011;115(Suppl 1):S6–10.
3. Gangopadhyay R, Karoshi M, Keith L. Anemia and pregnancy: A link to maternal chronic diseases. Int J Gynecol Obstet 2011;115(Suppl 1):S11–5. 4. Christensen DL, Kapur A, Bygbjerg IC. Physiological adaption to maternal malaria and other adverse exposure: Low birth weight, functional capacity, and possible metabolic disease in adult life. Int J Gynecol Obstet 2011;115(Suppl 1):S16–9. 5. Landon MB, Spong CY, Thom E, Carpenter MW, Ramin SM, Casey B, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med 2009;361(14):1339–48. 6. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352(24):2477–86. 7. Ratner RE, Christophi CA, Metzger BE, Dabelea D, Bennett PH, Pi-Sunyer X, et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab 2008;93(12): 4774–9. 8. Lohse N, Marseille E, Kahn JG. Development of a model to assess the cost-effectiveness of gestational diabetes mellitus screening and lifestyle change for the prevention of type 2 diabetes mellitus. Int J Gynecol Obstet 2011;115(Suppl 1):S20–5. 9. McIntyre HD, Oats JJN, Zeck W, Seshiah V, Hod M. Matching diagnosis and management of diabetes in pregnancy to local priorities and resources: An international approach. Int J Gynecol Obstet 2011;115(Suppl 1):S26–9. 10. Agarwal MM, Weigl B, Hod M. Gestational diabetes screening: The low-cost algorithm. Int J Gynecol Obstet 2011;115(Suppl 1):S30–3. 11. Maina WK. Integrating noncommunicable disease prevention into maternal and child health programs: Can it be done and what will it take? Int J Gynecol Obstet 2011;115(Suppl 1):S34–6. 12. Norris SA. Designing feasible interventions for healthy pregnancies in low-resource settings. Int J Gynecol Obstet 2011;115(Suppl 1):S37–40. 13. Madhab A, Prasad VM, Kapur A. Gestational diabetes mellitus: Advocating for policy change in India. Int J Gynecol Obstet 2011;115(Suppl 1):S41–4. 14. Lieberman N, Kalter-Leibovici O, Hod M. Global adaptation of IADPSG recommendations: A national approach. Int J Gynecol Obstet 2011;115(Suppl 1): S45–7. 15. Serour GI, Cabero Roura L. FIGO—A professional nonprofit organization: Reproductive, maternal, and child health policy and programs to address noncommunicable childhood disease. Int J Gynecol Obstet 2011;115(Suppl 1): S48–9. 16. Kapur A. Pregnancy: A window of opportunity for improving current and future health. Int J Gynecol Obstet 2011;115(Suppl 1):S50–1. 17. Lohse N, Ersbøll C, Kingo L. Taking on the challenge of noncommunicable diseases: We all hold a piece of the puzzle. Int J Gynecol Obstet 2011; 115(Suppl 1):S52–4.
Luis Cabero Roura Autonomous University of Barcelona, Spain Moshe Hod Rabin Medical Center, Tel Aviv University, Israel Anil Kapur World Diabetes Foundation, Denmark Nicolai Lohse * Novo Nordisk A/S, Denmark *E-mail address: [email protected].
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
EDITORIAL
From biology to policy: The link between maternal health and current and future burden of chronic noncommunicable diseases On the back of the United Nations High-level Meeting on NonCommunicable Diseases (NCDs) held in New York (September 19–20, 2011), this Supplement to the International Journal of Gynecology and Obstetrics takes a comprehensive view on an important aspect of the burgeoning NCD epidemic that is currently sweeping across the world. This global health challenge has left no country untouched and bridges the divide between rich and poor countries. We are all affected by the rising prevalence of chronic NCDs, wherever one takes a closer look. The concept that the foundation for lifelong risk and susceptibility to numerous diseases begins in the womb and in early life— now referred to by the term Developmental Origins of Health and Disease (DOHaD)—is not entirely new, but has only recently gained acceptance from the broader scientific community because of a swathe of good research producing hard evidence of the link. The biological evidence is there, but its knowledge has remained confined to the academic environment and needs wider dissemination. To move from evidence to policy change requires a broad evidence base of proven solutions, including assessments of how much it costs, over how long a period of time, and what health benefits are expected. But policy is never dictated by hard evidence alone. It requires advocacy, persistence, and resourceful arguments. This is particularly important in the current global economic setting where there is fierce competition for limited resources and the focus on maximizing health impact for the money spent is even stronger. Economic arguments make focusing on the link between maternal health and future health burden even more relevant and attractive. We know that provision of good services for maternal and child health (MCH) is needed to stimulate development and reduce high rates of maternal and child morbidity and mortality; addressing the DOHaD link presents another compelling reason to do so with more vigor. The marginal cost of linking MCH services with health promotion efforts directed at prevention of NCDs is low, but the future savings may be manifold. Who would not want to prioritize such a low-risk strategy that has high potential gain? The link has for many years only been discussed and debated in small circles, so to make this a high priority we need to create more awareness. People working in maternal health are not the only ones who should be aware—we also urge anyone working in NCD control to address the link in their prevention strategies. This Supplement is an attempt to bring more awareness to the issue. It contains articles from global experts, covering the broad range of topics mentioned above. Hanson and Gluckman [1] take us through the biological basis, including how undernutrition in the pregnant mother makes her child vulnerable to a range of chronic NCDs over its lifespan. Aviram et al. [2] list the extensive evidence for maternal obesity as a risk factor for complications in the mother and her offspring. Gangopadhyay et al. [3] and Christensen et al. [4] cover two aspects of anemia in pregnancy. The former closes the
circle and describes how anemia in pregnant women with chronic disease leads to small babies, which in return is associated with chronic disease occurrence when the child grows up. The latter spotlights an as yet remarkably overlooked potential link between one of the major infectious diseases in the southern hemisphere, malaria, and the NCD epidemic. This link has yet to be proven, but according to the authors more data will shortly be forthcoming. We are waiting with excitement! One of the few interventions with an effect on short-term complications, built on solid evidence from randomized trials, is detection and management of diabetes in pregnancy—so-called gestational diabetes mellitus (GDM). Proper GDM management leads to fewer birth complications [5,6], and intensive lifestyle interventions after birth seem to reduce the risk of chronic disease for many years [7]. But for these interventions to be taken up by a health system, the balance between cost and effect needs to be right. Lohse et al. [8] have developed and tested a mathematical model on data from India and Israel, and have produced encouraging estimates of the cost-effectiveness of GDM screening on lifetime risk of chronic diseases. If one trusts their results, introducing GDM screening at population level seems to be a no-brainer. However encouraging, results from models should be interpreted with caution, and preferably undergo repeated testing under different conditions. One way to increase real-life cost-effectiveness even further could be to tailor the screening and treatment strategies to local GDM prevalence and economic capacity of the healthcare system. While McIntyre et al. [9] suggest a tiered approach to GDM testing, treatment, and postpregnancy follow-up in different income level settings, Agarwal et al. [10] reanalyze the solid data from the HAPO study in a middle-eastern cohort of pregnant women and come up with a “lighter” screening algorithm in this high GDM prevalence group. They also give us a glimpse of new candidate technologies for GDM screening, reminding us how an easy-to-use, portable, noninvasive technology that does not require the woman to be fasting could revolutionize access to GDM screening among the millions of women who live in areas where the distance from home to health centers that have up-to-date equipment available is a major barrier to accessing good quality health care. While part of the answer to increased access may lie in new technologies, another solution may be to leverage existing systems and services. This is the focus of the article by Maina [11] who rightly and wisely recommends that GDM screening be integrated into MCH programs. The effect of such integrated programs will need to be tested, and Norris [12] shares with us his experiences as he carefully guides us through the steps that should be considered when designing such intervention studies. But no dramatic changes happen in any health system without the acceptance from policy makers. Not only do we need solid evidence and economic evaluations, we need to package the
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
S2
EDITORIAL / International Journal of Gynecology and Obstetrics 115S1 (2011) S1–S2
information in the right way and deliver it to policy makers at the right time in an understandable manner. This is exactly what both Madhab et al. [13] and Lieberman et al. [14] are doing, but in two very different countries and with the use of quite different methods. The former has stimulated policy change through a media campaign targeted at both the general public and at policy makers, while the latter has used local data on cost and health impact to create health economic arguments presented to a national committee of scientific specialists and policy makers. Getting attention to the subject of DOHaD on the global scene requires buy-in from a global voice. The International Federation of Gynecology and Obstetrics (FIGO) is such a voice. Without losing the focus on major causes of maternal morbidity and mortality, FIGO President, Gamal Serour [15], stresses the life-course link between NCDs and maternal health, and the unique opportunity we have now for change—an opportunity we should not miss. World Diabetes Foundation President, Anil Kapur [16], makes a call to the whole international community for more attention and funding. Finally, Lohse et al. [17] explain the emerging willingness expressed by the for-profit sector to play an active role in global health governance; and specifically the role of businesses to undertake part of the daunting task of stemming the tide of NCDs. Thus, the message of the intergenerational effects of NCDs and the unique prevention opportunity represented by a healthy pregnancy has yet to reach broadly to individuals, organizations, and governments. Transforming the biological evidence into reallife change—so-called knowledge translation—is far from complete. But the seed has been planted and it is growing. We are hopeful and confident that this Supplement, with its views on the topic spanning from biology and epidemiology to policy and service delivery, will serve as a source of inspiration and provide valuable information. This Supplement is for anyone who is interested in understanding the developmental roots of the NCD epidemic, and who would like to bring about new knowledge and induce changes at any level. Conflict of interest statement Nicolai Lohse is a full-time employee of Novo Nordisk A/S, a research-based pharmaceutical company with a strong focus on diabetes. The other authors have no conflict of interest to report. References 1. Hanson MA, Gluckman PD. Developmental origins of health and disease: Moving from biological concepts to interventions and policy. Int J Gynecol Obstet 2011; 115(Suppl 1):S3–5. 2. Aviram A, Hod M, Yogev Y. Maternal obesity: Implications for pregnancy outcome and long-term risks—a link to maternal nutrition. Int J Gynecol Obstet 2011;115(Suppl 1):S6–10.
3. Gangopadhyay R, Karoshi M, Keith L. Anemia and pregnancy: A link to maternal chronic diseases. Int J Gynecol Obstet 2011;115(Suppl 1):S11–5. 4. Christensen DL, Kapur A, Bygbjerg IC. Physiological adaption to maternal malaria and other adverse exposure: Low birth weight, functional capacity, and possible metabolic disease in adult life. Int J Gynecol Obstet 2011;115(Suppl 1):S16–9. 5. Landon MB, Spong CY, Thom E, Carpenter MW, Ramin SM, Casey B, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med 2009;361(14):1339–48. 6. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352(24):2477–86. 7. Ratner RE, Christophi CA, Metzger BE, Dabelea D, Bennett PH, Pi-Sunyer X, et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab 2008;93(12): 4774–9. 8. Lohse N, Marseille E, Kahn JG. Development of a model to assess the cost-effectiveness of gestational diabetes mellitus screening and lifestyle change for the prevention of type 2 diabetes mellitus. Int J Gynecol Obstet 2011;115(Suppl 1):S20–5. 9. McIntyre HD, Oats JJN, Zeck W, Seshiah V, Hod M. Matching diagnosis and management of diabetes in pregnancy to local priorities and resources: An international approach. Int J Gynecol Obstet 2011;115(Suppl 1):S26–9. 10. Agarwal MM, Weigl B, Hod M. Gestational diabetes screening: The low-cost algorithm. Int J Gynecol Obstet 2011;115(Suppl 1):S30–3. 11. Maina WK. Integrating noncommunicable disease prevention into maternal and child health programs: Can it be done and what will it take? Int J Gynecol Obstet 2011;115(Suppl 1):S34–6. 12. Norris SA. Designing feasible interventions for healthy pregnancies in low-resource settings. Int J Gynecol Obstet 2011;115(Suppl 1):S37–40. 13. Madhab A, Prasad VM, Kapur A. Gestational diabetes mellitus: Advocating for policy change in India. Int J Gynecol Obstet 2011;115(Suppl 1):S41–4. 14. Lieberman N, Kalter-Leibovici O, Hod M. Global adaptation of IADPSG recommendations: A national approach. Int J Gynecol Obstet 2011;115(Suppl 1): S45–7. 15. Serour GI, Cabero Roura L. FIGO—A professional nonprofit organization: Reproductive, maternal, and child health policy and programs to address noncommunicable childhood disease. Int J Gynecol Obstet 2011;115(Suppl 1): S48–9. 16. Kapur A. Pregnancy: A window of opportunity for improving current and future health. Int J Gynecol Obstet 2011;115(Suppl 1):S50–1. 17. Lohse N, Ersbøll C, Kingo L. Taking on the challenge of noncommunicable diseases: We all hold a piece of the puzzle. Int J Gynecol Obstet 2011; 115(Suppl 1):S52–4.
Luis Cabero Roura Autonomous University of Barcelona, Spain Moshe Hod Rabin Medical Center, Tel Aviv University, Israel Anil Kapur World Diabetes Foundation, Denmark Nicolai Lohse * Novo Nordisk A/S, Denmark *E-mail address: [email protected].