- Email: [email protected]
Pregnancy: A window of opportunity for improving current and future health
International Journal of Gynecology and Obstetrics 115 Suppl. 1 (2011) S50–S51
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
COMMENTARY
Pregnancy: A window of opportunity for improving current and future health Anil Kapur * Managing Director, World Diabetes Foundation, Gentofte, Denmark
1. Early-life origins of noncommunicable diseases
2. NCDs impact pregnancy outcomes
Cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases are the most common noncommunicable diseases (NCDs), accounting for 63% of global deaths (36 million) in 2008 and projected to claim 52 million lives by 2030. Almost 80% of these deaths occur prematurely in low- or low/middle-income countries [1]. NCDs become burdensome, costly, and debilitating over time, negatively impacting productivity and family income. They are, however, largely preventable with focus on lifestyle interventions in adult life, targeting adults at high risk—a strategy fraught with implementation difficulties [2]. Mounting evidence shows that prenatal and early-life development influence the risks of NCD in later life [3–5] and might be especially relevant to low-resource countries [5–8]. A mother’s diet, body composition, and health determine fetal environment and are shown to affect risk factors. Improvements in access to care in many low- and middle-income countries have led to improved survival for even the “at risk” small for gestational age (SGA) babies born to undernourished mothers in rural settings. These babies continue to be malnourished and stunted during childhood, but remain at relatively low risk for NCDs in adult life as long as they have a subsistence lifestyle. With even minor changes towards improved living conditions as a consequence of economic development or migration to towns or cities, these individuals manifest the risk of diabetes and other NCDs at much lower body mass index (BMI) and central adiposity threshold [9]. Transition in lifestyle in this population seems to produce rapid adverse changes favoring development of diabetes and cardiometabolic disorders [10]. In young women, adverse changes may present early in pregnancy, resulting in gestational diabetes and/or pregnancyinduced hypertension. Seshiah et al. [11] reported prevalence rates of 8–10% for gestational diabetes mellitus (GDM) among women of low socioeconomic status who had a prepregnancy BMI of less than 19, and significantly higher prevalence rates at higher BMIs and in urban environments [11]. Estimates based on data from the International Diabetes Federation’s Diabetes Atlas [12] show that approximately 76 million women in the 20–39 years’ reproductive age group have diabetes or impaired glucose tolerance/pre-diabetes, and thus are potentially at risk of diabetes during pregnancy; this link creates a vicious cycle of diabetes begetting diabetes. While maternal undernutrition and its links to future NCDs in offspring have been more widely studied, similar mechanisms may apply to other conditions, such as maternal malaria and HIV/AIDS that also result in low birth weight and SGA babies.
Hemorrhage, hypertensive disorders, obstructed labor, and infection/sepsis are among the leading global causes of maternal mortality [13]. High blood pressure and GDM are linked directly or indirectly to all of them. The rising prevalence of high blood pressure and GDM is increasing the adverse outcomes of pregnancy and maternal health [1]. Undiagnosed or poorly managed diabetes or hyperglycemia during pregnancy is associated with a significantly higher risk of maternal and perinatal morbidity and mortality, as well as poor pregnancy outcomes including spontaneous abortion, still birth, congenital anomalies, macrosomia, need for cesarean delivery, and assisted deliveries [14]. The occurrence of hypertensive disorder or hyperglycemia during pregnancy is a strong marker of a high future risk for hypertension and diabetes, and thus offers opportunities for instituting preventive strategies early on.
* E-mail address: [email protected] (A. Kapur).
3. Pregnancy: a window of opportunity The concept of fetal programming and its consequences are paradigm changing. It highlights that pregnancy offers a window of opportunity to provide maternal care services, not only to reduce the traditionally known maternal and perinatal morbidity and mortality indicators, but also great potential for intergenerational prevention of several chronic diseases, such as diabetes, arterial hypertension, cardiovascular disease, and stroke. Thus, with one high-quality intervention related to maternal and child health services, it is now possible to achieve several objectives with farreaching health and economic benefits [14]. The international health community, including donors and national governments, cannot afford to continue with their “silo” short-term approach of fixing certain health and development indicators while continuing to ignore the long-term overall health and economic benefits that would accrue from an integrated health system approach. While this approach saves many vulnerable lives, it does not address the root cause of the vulnerability and, in fact, may increase the vulnerability of future generations. Having saved a mother with GDM and eclampsia and her large-for-gestationalage baby, or a mother with anemia and her low birth weight baby, what can we do to ensure their future good health and prevent or significantly delay the onset of hypertension or type 2 diabetes? To get it right will require strengthening of health systems to further reinforce maternal and child care services at primary care level and integrating elements of NCD prevention and health promotion. It will also require investments in information technology to identify and track high-risk individuals to enlighten, empower, and encourage them to adopt healthy living throughout life. Monitoring
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
A. Kapur / International Journal of Gynecology and Obstetrics 115S1 (2011) S50–S51
women during pregnancy and their offspring may be the most appropriate place to begin this health system transformation. We have the evidence, we also have the technology, and we know it is feasible, but do we have the willingness to work together to get it done? Conflict of interest statement The author declares that he has no conflict of interest. References 1. United Nations. Prevention and control of non-communicable diseases. Report of the Secretary General. UN General Assembly, 19 May 2011. Available at: http://www.un.org/ga/search/view_doc.asp?symbol=A/66/83&referer=/ english/&Lang=E 2. Hanson MA, Gluckman PD. Developmental origins of noncommunicable disease: population and public health implications. Am J Clin Nutr 2011. doi:10.3945/ ajcn.110.001206. 3. Godfrey KM. Maternal regulation of fetal development and health in adult life. Eur J Obstet Gynecol Reprod Biol 1998;78(2):141–50. 4. McCance DR, Pettitt DJ, Hanson RL, Jacobsson LT, Knowler WC, Bennett PH. Birth weight and non-insulin dependent diabetes: thrifty genotype, thrifty phenotype, or surviving small baby genotype? Br Med J 1994;308(6934):942–5. 5. Gluckman PD, Hanson MA, Cooper C, Thornburg KL. Effect of in utero and earlylife conditions on adult health and disease. N Engl J Med 2008;359(1):61–73.
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6. Yajnik CS, Deshmukh US. Maternal nutrition, intrauterine programming and consequential risks in the off spring. Rev Endocr Metab Disord 2008;9(3): 203–11. 7. Ma RC, Chan JCN. Pregnancy and diabetes scenario around the world: China. Int J Gynecol Obstet 2009;104(Suppl 1):S42–5. 8. Tam WH, Ma RC, Yang X, Ko GT, Tong PC, Cockram CS. Glucose intolerance and cardiometabolic risk in children exposed to maternal gestational diabetes mellitus in utero. Pediatrics 2008;122(6):1229–34. 9. Ramachandran A, Snehalatha C, Baskar AS, Mary S, Kumar CK, Selvam S, et al. Temporal changes in prevalence of diabetes and impaired glucose tolerance associated with lifestyle transition occurring in the rural population in India. Diabetologia 2004;47(5):860–5. 10. Snehalatha C, Ramachandran A. Cardiovascular risk factors in the normoglycaemic Asian-Indian population—influence of urbanisation. Diabetologia 2009;52(4):596–9. 11. Seshiah V, Balaji V, Balaji MS, Paneerselvam A, Kapur A. Pregnancy and diabetes scenario around the world: India. Int J Gynecol Obstet 2009;104(Suppl 1): S35–8. 12. International Diabetes Federation. http://www.diabetesatlas.org/. Accessed 10 June, 2011. 13. Khan KS, Wojdlya D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367(9516):1066–74. 14. World Diabetes Foundation, Global Alliance for Women’s Health. Diabetes, Women, and Development. Meeting summary, expert recommendations for policy action, conclusion, and follow-up actions. Int J Gynecol Obstet 2009;104(Suppl 1):S46–50.
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
COMMENTARY
Pregnancy: A window of opportunity for improving current and future health Anil Kapur * Managing Director, World Diabetes Foundation, Gentofte, Denmark
1. Early-life origins of noncommunicable diseases
2. NCDs impact pregnancy outcomes
Cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases are the most common noncommunicable diseases (NCDs), accounting for 63% of global deaths (36 million) in 2008 and projected to claim 52 million lives by 2030. Almost 80% of these deaths occur prematurely in low- or low/middle-income countries [1]. NCDs become burdensome, costly, and debilitating over time, negatively impacting productivity and family income. They are, however, largely preventable with focus on lifestyle interventions in adult life, targeting adults at high risk—a strategy fraught with implementation difficulties [2]. Mounting evidence shows that prenatal and early-life development influence the risks of NCD in later life [3–5] and might be especially relevant to low-resource countries [5–8]. A mother’s diet, body composition, and health determine fetal environment and are shown to affect risk factors. Improvements in access to care in many low- and middle-income countries have led to improved survival for even the “at risk” small for gestational age (SGA) babies born to undernourished mothers in rural settings. These babies continue to be malnourished and stunted during childhood, but remain at relatively low risk for NCDs in adult life as long as they have a subsistence lifestyle. With even minor changes towards improved living conditions as a consequence of economic development or migration to towns or cities, these individuals manifest the risk of diabetes and other NCDs at much lower body mass index (BMI) and central adiposity threshold [9]. Transition in lifestyle in this population seems to produce rapid adverse changes favoring development of diabetes and cardiometabolic disorders [10]. In young women, adverse changes may present early in pregnancy, resulting in gestational diabetes and/or pregnancyinduced hypertension. Seshiah et al. [11] reported prevalence rates of 8–10% for gestational diabetes mellitus (GDM) among women of low socioeconomic status who had a prepregnancy BMI of less than 19, and significantly higher prevalence rates at higher BMIs and in urban environments [11]. Estimates based on data from the International Diabetes Federation’s Diabetes Atlas [12] show that approximately 76 million women in the 20–39 years’ reproductive age group have diabetes or impaired glucose tolerance/pre-diabetes, and thus are potentially at risk of diabetes during pregnancy; this link creates a vicious cycle of diabetes begetting diabetes. While maternal undernutrition and its links to future NCDs in offspring have been more widely studied, similar mechanisms may apply to other conditions, such as maternal malaria and HIV/AIDS that also result in low birth weight and SGA babies.
Hemorrhage, hypertensive disorders, obstructed labor, and infection/sepsis are among the leading global causes of maternal mortality [13]. High blood pressure and GDM are linked directly or indirectly to all of them. The rising prevalence of high blood pressure and GDM is increasing the adverse outcomes of pregnancy and maternal health [1]. Undiagnosed or poorly managed diabetes or hyperglycemia during pregnancy is associated with a significantly higher risk of maternal and perinatal morbidity and mortality, as well as poor pregnancy outcomes including spontaneous abortion, still birth, congenital anomalies, macrosomia, need for cesarean delivery, and assisted deliveries [14]. The occurrence of hypertensive disorder or hyperglycemia during pregnancy is a strong marker of a high future risk for hypertension and diabetes, and thus offers opportunities for instituting preventive strategies early on.
* E-mail address: [email protected] (A. Kapur).
3. Pregnancy: a window of opportunity The concept of fetal programming and its consequences are paradigm changing. It highlights that pregnancy offers a window of opportunity to provide maternal care services, not only to reduce the traditionally known maternal and perinatal morbidity and mortality indicators, but also great potential for intergenerational prevention of several chronic diseases, such as diabetes, arterial hypertension, cardiovascular disease, and stroke. Thus, with one high-quality intervention related to maternal and child health services, it is now possible to achieve several objectives with farreaching health and economic benefits [14]. The international health community, including donors and national governments, cannot afford to continue with their “silo” short-term approach of fixing certain health and development indicators while continuing to ignore the long-term overall health and economic benefits that would accrue from an integrated health system approach. While this approach saves many vulnerable lives, it does not address the root cause of the vulnerability and, in fact, may increase the vulnerability of future generations. Having saved a mother with GDM and eclampsia and her large-for-gestationalage baby, or a mother with anemia and her low birth weight baby, what can we do to ensure their future good health and prevent or significantly delay the onset of hypertension or type 2 diabetes? To get it right will require strengthening of health systems to further reinforce maternal and child care services at primary care level and integrating elements of NCD prevention and health promotion. It will also require investments in information technology to identify and track high-risk individuals to enlighten, empower, and encourage them to adopt healthy living throughout life. Monitoring
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
A. Kapur / International Journal of Gynecology and Obstetrics 115S1 (2011) S50–S51
women during pregnancy and their offspring may be the most appropriate place to begin this health system transformation. We have the evidence, we also have the technology, and we know it is feasible, but do we have the willingness to work together to get it done? Conflict of interest statement The author declares that he has no conflict of interest. References 1. United Nations. Prevention and control of non-communicable diseases. Report of the Secretary General. UN General Assembly, 19 May 2011. Available at: http://www.un.org/ga/search/view_doc.asp?symbol=A/66/83&referer=/ english/&Lang=E 2. Hanson MA, Gluckman PD. Developmental origins of noncommunicable disease: population and public health implications. Am J Clin Nutr 2011. doi:10.3945/ ajcn.110.001206. 3. Godfrey KM. Maternal regulation of fetal development and health in adult life. Eur J Obstet Gynecol Reprod Biol 1998;78(2):141–50. 4. McCance DR, Pettitt DJ, Hanson RL, Jacobsson LT, Knowler WC, Bennett PH. Birth weight and non-insulin dependent diabetes: thrifty genotype, thrifty phenotype, or surviving small baby genotype? Br Med J 1994;308(6934):942–5. 5. Gluckman PD, Hanson MA, Cooper C, Thornburg KL. Effect of in utero and earlylife conditions on adult health and disease. N Engl J Med 2008;359(1):61–73.
S51
6. Yajnik CS, Deshmukh US. Maternal nutrition, intrauterine programming and consequential risks in the off spring. Rev Endocr Metab Disord 2008;9(3): 203–11. 7. Ma RC, Chan JCN. Pregnancy and diabetes scenario around the world: China. Int J Gynecol Obstet 2009;104(Suppl 1):S42–5. 8. Tam WH, Ma RC, Yang X, Ko GT, Tong PC, Cockram CS. Glucose intolerance and cardiometabolic risk in children exposed to maternal gestational diabetes mellitus in utero. Pediatrics 2008;122(6):1229–34. 9. Ramachandran A, Snehalatha C, Baskar AS, Mary S, Kumar CK, Selvam S, et al. Temporal changes in prevalence of diabetes and impaired glucose tolerance associated with lifestyle transition occurring in the rural population in India. Diabetologia 2004;47(5):860–5. 10. Snehalatha C, Ramachandran A. Cardiovascular risk factors in the normoglycaemic Asian-Indian population—influence of urbanisation. Diabetologia 2009;52(4):596–9. 11. Seshiah V, Balaji V, Balaji MS, Paneerselvam A, Kapur A. Pregnancy and diabetes scenario around the world: India. Int J Gynecol Obstet 2009;104(Suppl 1): S35–8. 12. International Diabetes Federation. http://www.diabetesatlas.org/. Accessed 10 June, 2011. 13. Khan KS, Wojdlya D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367(9516):1066–74. 14. World Diabetes Foundation, Global Alliance for Women’s Health. Diabetes, Women, and Development. Meeting summary, expert recommendations for policy action, conclusion, and follow-up actions. Int J Gynecol Obstet 2009;104(Suppl 1):S46–50.