Letters to the Editor
disease. Among people aged 40 years and older in urban areas, this number climbed to 19%. Nepal is also facing the consequences of urban lifestyle leading to obesity and metabolic syndrome. Studies have shown prevalence of overweight and obesity in certain sections of the population to be as high as 32.9% and 7.2%, respectively.[3] In a hospital based cross sectional study, the prevalence of metabolic syndrome in diabetes patients as per NCEP/ATP III and IDF criteria were 71% and 82%, respectively.[4] Iodine deficiency is endemic in Nepal and thyroid dysfunction is a major public health problem. A recent hospital based study done in the western region of the country has shown the prevalence of thyroid dysfunction to be 17.42%.[5] Disorders of pituitary, adrenal, and other endocrine disorders are also encountered, but data are lacking. Nepal is still lacking sufficient health care providers. Appropriate referrals and consultations are not a common practice. Osteoporosis is treated mostly by orthopedicians. Members of the endocrine society have established an osteoporosis society jointly with gynecologists, radiologists, and orthopedicians to help resolve some of these issues. Diagnostics have only improved in the last few years in Nepal but only marginally. Laboratories are centered in the capital and lack quality control, and there are only a handful of reliable laboratories. Hormone assays are still sent to the laboratories in India, except few. Nuclear medicine and advanced radiology are still lacking. Challenges lie in funding, central database system, support from trained personnel, referral system, and patient education. However to be hopeful, Endocrinology is a growing field in Nepal. National Academy of Medical Sciences (NAMS) has started specialization course (DM in Endocrinology), and there are few trained endocrinologists currently providing specialty care in the capital. Organizations like Nepal Diabetes Association, Astha Nepal regularly conduct public awareness programs, and free health camps to help reduce diabetes problems. Although there has been no major high quality scientific research in the field of endocrinology, research works and publication trend among Nepalese scholars in national and international endocrinology journals is gradually rising. Most of them are hospital-based cross sectional studies, communitybased screenings, case control studies or perspective reviews. Resham Raj Poudel Department of Medicine, Institute of Medicine, Kathmandu, Nepal Corresponding Author: Dr. Resham Raj Poudel, Institute of Medicine, Kathmandu, Nepal. E-mail: [email protected]
REFERENCES 1.
Ono K, Limbu YR, Rai SK, Kurokawa M, Yanagida J, Rai G, et al. The
2.
3.
4.
5.
prevalence of type 2 diabetes mellitus and impaired fasting glucose in semi-urban population of Nepal. Nepal Med Coll J 2007;9:154-6. WHO’S certified [Internet]. Country and regional data on diabetes. WHO South-East Asia Region. Prevalence of diabetes in the WHO South-East Asia Region. Available from: http://www.who.int/diabetes/ facts/world_figures/en/index 5.html[Last accessed on Mar 30, 2013]. Vaidya AK, Pokharel PK, Nagesh S, Karki P, Kumar S, Majhi S, et al. Association of obesity and physical activity in adult males of Dharan, Nepal. Kathmandu Univ Med J 2006;4:192-7. Bhattarai S, Kohli SC, Sapkota S. Prevalence of metabolic syndrome in type 2 diabetes mellitus patients using NCEP/ATP III and IDF criteria in Nepal. Nepal J Med Sci 2012;1:79-83. Yadav RK, Magar NT, Poudel B, Yadav NK, Yadav B. A prevalence of thyroid disorder in Western part of Nepal. J Clin Diagn Res 2013;7:193-6. Access this article online Quick Response Code: Website: www.ijem.in DOI: 10.4103/2230-8210.126593
Hyperglycemia and adverse pregnancy outcome (HAPO) study: Should it show the other side of the coin? Sir, Carrington et al. first coined the term “Gestational diabetes” in 1957.[1] Since then, the subject of gestational diabetes mellitus (GDM) has remained of considerable controversies. In 1964, O’Sullivan and Mahan proposed criteria for diagnosis of GDM to indicate a higher chance of developing type 2 diabetes mellitus for the mother.[2] They did not at that time, imply a higher risk for perinatal complications. Subsequently hyperglycemia and adverse pregnancy outcomes (HAPO) study showed that there is an increase in adverse pregnancy outcomes even with hyperglycemia less severe than that diagnostic of overt diabetes mellitus.[3] Based on HAPO data, International Association of Diabetes Pregnancy Study Group (IADPSG) used the oral glucose tolerance test (OGTT) cut-offs that identified odds ratios of 1.75 (compared to median values) for the risk of fetal macrosomia, neonatal adiposity and fetal hyperinsulinemia (all defined as >90th percentile).[3,4] With
Indian Journal of Endocrinology and Metabolism / Jan-Feb 2014 / Vol 18 | Issue 1
119
Letters to the Editor
new criteria the prevalence of GDM increased dramatically. The increase occurred more in women with a lesser degree of glucose intolerance. In the absence of clarity of treatment benefit in additional women diagnosed of IADPSG criteria, it generated new controversy. Furthermore, it took away attention completely from long-term maternal outcomes to short-term perinatal outcomes. O’Sullivan and Mahan criteria and its subsequent modifications (the last being Carpenter and Coustan criteria) were validated for the outcome of future maternal diabetes, whereas IADPSG criteria is validated for perinatal outcomes.[2,4] The two criteria shows the different side of the same coin, which may be the reason of un-satisfaction with either of the diagnostic criteria. Both short-term as well as long-term outcomes of GDM have its own importance and none can take a stepmother treatment. The validation of newer criteria as well as original 7 categories of glycemic levels in HAPO study in terms of future risk of maternal diabetes may solve the controversy.[3] Since, it is nearly 5 years since HAPO study has been published, follow-up of strong cohort of over 23,000 women across different countries to determine the conversion rates to diabetes or pre-diabetes will be valuable.[3] The cut-offs of OGTT during pregnancy, which determines a significant risk for these outcomes could be determined. The composite scenario taking perinatal outcomes as well as long-term future risk of diabetes for mother, may better determines the cut-off at which the interventions may be cost-effective. Yashdeep Gupta, Bharti Kalra1 Department of Medicine, Government Medical College and Hospital, Chandigarh, 1Department of Obstetrics and Gynaecology, Bharti Hospital, Karnal, Haryana, India Corresponding Author: Dr. Bharti Kalra, Department of Obstetrics and Gynaecology, Bharti Hospital, Kunjpura Road, Karnal, Haryana - 132 001, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
4.
120
Carrington ER, Shuman CR, Reardon HS. Evaluation of the prediabetic state during pregnancy. Obstet Gynecol 1957;9:664-9. O’Sullivan JB, Mahan CM. Criteria for the oral glucose tolerance test in pregnancy. Diabetes 1964;13:278-85. HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008;358:1991-2002. International Association of Diabetes and Pregnancy Study Groups Consensus Panel, Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676-82.
Access this article online Quick Response Code: Website: www.ijem.in DOI: 10.4103/2230-8210.126594
Converting disability to opportunity: GDM women as new role models of diabetes care Sir, Four million women are diagnosed with gestational diabetes mellitus (GDM) annually in India and 50% develop type 2 diabetes within 5 years of the index pregnancy.[1] This adds to the already existing huge burden of ‘diabetics’ (61.3 million in 2011), pressurizing the healthcare system in terms of both direct and indirect costs. With less stringent criteria recommended by American Diabetes Association (ADA) in 2011, prevalence of GDM is expected to rise further. Even the developed economies have concerns, in terms of dramatic increase in requirement of finances and healthcare resources to cater the additional burden of ‘gestational diabetics’. The calculations have not been made for India, but the concerns can be well foreseen. Can India benefit by investing at present for better future? Yes! Asians have an early onset of diabetes with more than one-third developing diabetes before the age of 44 years.[2] Thus, the opportunity for action for primary prevention is narrow for Asians. Glucose intolerance detected during pregnancy easily provides the population which is at risk for future diabetes and cardiovascular disease. Women with ‘gestational diabetes’ are very much receptive for diabetic education and a recent study in GDM found diabetes prevention interventions to be highly cost effective in India.[3] The cost effectiveness would increase further if the risk of subsequent diabetic complications in mother and adverse long - term outcomes in offspring are accounted for. Unfortunately, none of the cost effective analysis has
Indian Journal of Endocrinology and Metabolism / Jan-Feb 2014 / Vol 18 | Issue 1
Copyright of Indian Journal of Endocrinology & Metabolism is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
disease. Among people aged 40 years and older in urban areas, this number climbed to 19%. Nepal is also facing the consequences of urban lifestyle leading to obesity and metabolic syndrome. Studies have shown prevalence of overweight and obesity in certain sections of the population to be as high as 32.9% and 7.2%, respectively.[3] In a hospital based cross sectional study, the prevalence of metabolic syndrome in diabetes patients as per NCEP/ATP III and IDF criteria were 71% and 82%, respectively.[4] Iodine deficiency is endemic in Nepal and thyroid dysfunction is a major public health problem. A recent hospital based study done in the western region of the country has shown the prevalence of thyroid dysfunction to be 17.42%.[5] Disorders of pituitary, adrenal, and other endocrine disorders are also encountered, but data are lacking. Nepal is still lacking sufficient health care providers. Appropriate referrals and consultations are not a common practice. Osteoporosis is treated mostly by orthopedicians. Members of the endocrine society have established an osteoporosis society jointly with gynecologists, radiologists, and orthopedicians to help resolve some of these issues. Diagnostics have only improved in the last few years in Nepal but only marginally. Laboratories are centered in the capital and lack quality control, and there are only a handful of reliable laboratories. Hormone assays are still sent to the laboratories in India, except few. Nuclear medicine and advanced radiology are still lacking. Challenges lie in funding, central database system, support from trained personnel, referral system, and patient education. However to be hopeful, Endocrinology is a growing field in Nepal. National Academy of Medical Sciences (NAMS) has started specialization course (DM in Endocrinology), and there are few trained endocrinologists currently providing specialty care in the capital. Organizations like Nepal Diabetes Association, Astha Nepal regularly conduct public awareness programs, and free health camps to help reduce diabetes problems. Although there has been no major high quality scientific research in the field of endocrinology, research works and publication trend among Nepalese scholars in national and international endocrinology journals is gradually rising. Most of them are hospital-based cross sectional studies, communitybased screenings, case control studies or perspective reviews. Resham Raj Poudel Department of Medicine, Institute of Medicine, Kathmandu, Nepal Corresponding Author: Dr. Resham Raj Poudel, Institute of Medicine, Kathmandu, Nepal. E-mail: [email protected]
REFERENCES 1.
Ono K, Limbu YR, Rai SK, Kurokawa M, Yanagida J, Rai G, et al. The
2.
3.
4.
5.
prevalence of type 2 diabetes mellitus and impaired fasting glucose in semi-urban population of Nepal. Nepal Med Coll J 2007;9:154-6. WHO’S certified [Internet]. Country and regional data on diabetes. WHO South-East Asia Region. Prevalence of diabetes in the WHO South-East Asia Region. Available from: http://www.who.int/diabetes/ facts/world_figures/en/index 5.html[Last accessed on Mar 30, 2013]. Vaidya AK, Pokharel PK, Nagesh S, Karki P, Kumar S, Majhi S, et al. Association of obesity and physical activity in adult males of Dharan, Nepal. Kathmandu Univ Med J 2006;4:192-7. Bhattarai S, Kohli SC, Sapkota S. Prevalence of metabolic syndrome in type 2 diabetes mellitus patients using NCEP/ATP III and IDF criteria in Nepal. Nepal J Med Sci 2012;1:79-83. Yadav RK, Magar NT, Poudel B, Yadav NK, Yadav B. A prevalence of thyroid disorder in Western part of Nepal. J Clin Diagn Res 2013;7:193-6. Access this article online Quick Response Code: Website: www.ijem.in DOI: 10.4103/2230-8210.126593
Hyperglycemia and adverse pregnancy outcome (HAPO) study: Should it show the other side of the coin? Sir, Carrington et al. first coined the term “Gestational diabetes” in 1957.[1] Since then, the subject of gestational diabetes mellitus (GDM) has remained of considerable controversies. In 1964, O’Sullivan and Mahan proposed criteria for diagnosis of GDM to indicate a higher chance of developing type 2 diabetes mellitus for the mother.[2] They did not at that time, imply a higher risk for perinatal complications. Subsequently hyperglycemia and adverse pregnancy outcomes (HAPO) study showed that there is an increase in adverse pregnancy outcomes even with hyperglycemia less severe than that diagnostic of overt diabetes mellitus.[3] Based on HAPO data, International Association of Diabetes Pregnancy Study Group (IADPSG) used the oral glucose tolerance test (OGTT) cut-offs that identified odds ratios of 1.75 (compared to median values) for the risk of fetal macrosomia, neonatal adiposity and fetal hyperinsulinemia (all defined as >90th percentile).[3,4] With
Indian Journal of Endocrinology and Metabolism / Jan-Feb 2014 / Vol 18 | Issue 1
119
Letters to the Editor
new criteria the prevalence of GDM increased dramatically. The increase occurred more in women with a lesser degree of glucose intolerance. In the absence of clarity of treatment benefit in additional women diagnosed of IADPSG criteria, it generated new controversy. Furthermore, it took away attention completely from long-term maternal outcomes to short-term perinatal outcomes. O’Sullivan and Mahan criteria and its subsequent modifications (the last being Carpenter and Coustan criteria) were validated for the outcome of future maternal diabetes, whereas IADPSG criteria is validated for perinatal outcomes.[2,4] The two criteria shows the different side of the same coin, which may be the reason of un-satisfaction with either of the diagnostic criteria. Both short-term as well as long-term outcomes of GDM have its own importance and none can take a stepmother treatment. The validation of newer criteria as well as original 7 categories of glycemic levels in HAPO study in terms of future risk of maternal diabetes may solve the controversy.[3] Since, it is nearly 5 years since HAPO study has been published, follow-up of strong cohort of over 23,000 women across different countries to determine the conversion rates to diabetes or pre-diabetes will be valuable.[3] The cut-offs of OGTT during pregnancy, which determines a significant risk for these outcomes could be determined. The composite scenario taking perinatal outcomes as well as long-term future risk of diabetes for mother, may better determines the cut-off at which the interventions may be cost-effective. Yashdeep Gupta, Bharti Kalra1 Department of Medicine, Government Medical College and Hospital, Chandigarh, 1Department of Obstetrics and Gynaecology, Bharti Hospital, Karnal, Haryana, India Corresponding Author: Dr. Bharti Kalra, Department of Obstetrics and Gynaecology, Bharti Hospital, Kunjpura Road, Karnal, Haryana - 132 001, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
4.
120
Carrington ER, Shuman CR, Reardon HS. Evaluation of the prediabetic state during pregnancy. Obstet Gynecol 1957;9:664-9. O’Sullivan JB, Mahan CM. Criteria for the oral glucose tolerance test in pregnancy. Diabetes 1964;13:278-85. HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008;358:1991-2002. International Association of Diabetes and Pregnancy Study Groups Consensus Panel, Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676-82.
Access this article online Quick Response Code: Website: www.ijem.in DOI: 10.4103/2230-8210.126594
Converting disability to opportunity: GDM women as new role models of diabetes care Sir, Four million women are diagnosed with gestational diabetes mellitus (GDM) annually in India and 50% develop type 2 diabetes within 5 years of the index pregnancy.[1] This adds to the already existing huge burden of ‘diabetics’ (61.3 million in 2011), pressurizing the healthcare system in terms of both direct and indirect costs. With less stringent criteria recommended by American Diabetes Association (ADA) in 2011, prevalence of GDM is expected to rise further. Even the developed economies have concerns, in terms of dramatic increase in requirement of finances and healthcare resources to cater the additional burden of ‘gestational diabetics’. The calculations have not been made for India, but the concerns can be well foreseen. Can India benefit by investing at present for better future? Yes! Asians have an early onset of diabetes with more than one-third developing diabetes before the age of 44 years.[2] Thus, the opportunity for action for primary prevention is narrow for Asians. Glucose intolerance detected during pregnancy easily provides the population which is at risk for future diabetes and cardiovascular disease. Women with ‘gestational diabetes’ are very much receptive for diabetic education and a recent study in GDM found diabetes prevention interventions to be highly cost effective in India.[3] The cost effectiveness would increase further if the risk of subsequent diabetic complications in mother and adverse long - term outcomes in offspring are accounted for. Unfortunately, none of the cost effective analysis has
Indian Journal of Endocrinology and Metabolism / Jan-Feb 2014 / Vol 18 | Issue 1
Copyright of Indian Journal of Endocrinology & Metabolism is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
