diabetes research and clinical practice 103 (2014) 57–62
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Screening for gestational diabetes mellitus and its prevalence in Bangladesh Subrina Jesmin a,b,*, Shamima Akter a,c, Hidechika Akashi c, Abdullah Al-Mamun a,d, Md. Arifur Rahman a,d, Md. Majedul Islam a,b, Farzana Sohael a,b, Osamu Okazaki c, Masao Moroi c, Satoru Kawano b, Taro Mizutani b a
Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, Bangladesh b Graduate School of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan c National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan d Shahid Ziaur Rahman Medical College, Bogra, Bangladesh
article info
abstract
Article history:
Background: The prevalence of gestational diabetes mellitus (GDM) has important health
Received 18 July 2013
complications for both mother and child and is increasing all over the world. Although
Accepted 29 November 2013
prevalence estimates for GDM are not new in developed and many developing countries,
Available online 7 December 2013
data are lacking for many low-income countries like Bangladesh. Objective: To evaluate the prevalence of GDM in Bangladesh.
Keywords:
Research design and methods: This cross-sectional study included 3447 women who consec-
Gestational diabetes mellitus
utively visited the antenatal clinics with an average gestation age of 26 weeks. GDM was
Screening
defined according to WHO criteria (fasting plasma glucose [FPG] 7.0 mmol/L or 2-h
Bangladesh
7.8 mmol/L) and the new ADA criteria (FPG 5.3 mmol/L or 2-h 8.6 mmol/L OGTT). We also calculated overt diabetes as FPG 7.0 mmol/L. Results: Prevalence of GDM was 9.7% according to the WHO criteria and 12.9% according to the ADA criteria in this study population. Prevalence of overt diabetes was 1.8%. Women with GDM were older, higher educated, had higher household income, higher parity, parental history of diabetes, and more hypertensive, compared with non-GDM women. Conclusion: This study demonstrates a high prevalence of GDM in Bangladesh. These estimates for GDM may help to formulate new policies to prevent and manage diabetes. # 2013 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy, defined as glucose intolerance with onset or first recognition during
pregnancy [1]. GDM can adversely impact perinatal outcome, increase the risk of obesity in offspring and the subsequent development of diabetes in mothers [2–4]. Overall, GDM rates have been on the rise in all ethnic groups, but most noticeable in Asian countries, where the prevalence rate is around 17% [5]. Further, among the Asians, South Asians are more prone to
* Corresponding author at: Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, Bangladesh. Tel.: +88 01721 512282; fax: +81 29 853 3092. E-mail addresses: [email protected], [email protected] (S. Jesmin). 0168-8227/$ – see front matter # 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.diabres.2013.11.024
58
diabetes research and clinical practice 103 (2014) 57–62
have diabetes at an earlier age [6] and thus more vulnerable to GDM. Among the developing countries several studies has been conducted to estimate the prevalence of GDM, including India [7–9], China [10,11], Sri Lanka [12], Iran [13,14], and Malaysia [15]. However, to date no study has been conducted in Bangladesh. Like many developing countries, Bangladesh is also experiencing a high prevalence of diabetes [16]. In order to effectively manage this condition in a cost effective manner in a low-income country like Bangladesh, it is imperative to identify mothers with GDM early on in their pregnancy. In this manner, lifestyle interventions and treatment may prevent the development of diabetes and other health complications both for mother and offspring, and to avoid high treatment costs. The aim of this study was to determine the prevalence of GDM for the first time among women in Bangladesh by using the World Health Organization (WHO) and the new American Diabetes Association (ADA) criteria.
2.
Data and methodology
2.1.
Study design
A base-line survey was done in 12 Upzillas of 6 districts under 3 divisions during 2012–2013 in Bangladesh. Twelve GDM corners were established in antenatal clinics, where antenatal care was offered to all pregnant women. A total of 4890 pregnant women, with an average gestation age of 26 weeks, participated in this study. We used the WHO STEPS approach (modified), which entails a stepwise collection of risk factor data based on standardized questionnaires covering the following parameters: demographic characteristics, somatic illnesses, somatic and mental symptoms, medications, life style, and health-related behavior (step 1), basic physical measures (step 2) and basic biochemical investigations, such as blood glucose and cholesterol (step 3). The study was approved by the Ethical Committee of the Health and Disease Research Center of Rural Peoples (HDRCRP), Dhaka, Bangladesh, and conforms to the principles outlined in the Helsinki Declaration. All subjects gave their written informed consent prior to participation.
2.2.
Study subjects
Of the 4890 subjects, we excluded 1410 subjects who were not fasting. Among the 3480 subjects, who had an oral glucose challenge test (OGCT), 624 women were found to have an abnormal OGCT (7.8 mmol/l). Of the 624 subjects who were advised to have an oral glucose tolerance test (OGTT), 591participated and 33 dropped out. Ultimately a total of 3447subjects were included in the present study.
2.3.
Anthropometric and other variables
Well-trained examiners conducted anthropometric measurements on individuals wearing light clothing and without shoes. Height was measured to the nearest 0.1 cm using the portable stadiometer. Weight was measured in an upright
position, to the nearest 0.1 kg, using a calibrated balance beam scale. Body mass index (BMI) was calculated as the body weight (kg) divided by the square of the body height (m2). Blood pressure was measured twice in the right arm in a sitting position using a standard mercury manometer and cuff, to the nearest 2 mmHg, with the initial reading taken at least 5 minutes after the subject was made comfortable, and again after an interval of 15 min. The average systolic blood pressure (SBP) and diastolic blood pressure (DBP) were then estimated. Hypertension was defined as SBP 140 or DBP 90 or taking antihypertensive medication. Number of parity, history of still birth or abortion, parental history of diabetes, parental history of hypertension, respondent’s education, and household income were self-reported.
2.4.
Assessment for GDM
All pregnant women were first screened for GDM using a 1-h 50 g OGCT, performed in the morning after an overnight fast. As we performed a fasting GCT we also measured fasting plasma glucose (FPG) using a glucometer. Subjects with abnormal 1-h blood glucose level (7.8 mmol/l) proceeded to an OGTT within one week of the abnormal screening test. Women with abnormal OGCT had a standard 2-h OGTT with a 75-g glucose load administered after a 12–14-h fast with blood collected fasting and 1-h and 2-h. GDM was defined according to the 1999 WHO criteria – FPG 7.0 mmol/L or 2-h 7.8 mmol/L [17]. It was additionally defined according to the new ADA criteria of FPG 5.3 mmol/L or 2-h 8.6 mmol/L after a 2-h OGTT [18]. We also calculated overt diabetes according to the new ADA criteria as, FPG 7.0 mmol/L [18].
2.5.
Statistical analysis
Differences in anthropometric and socio-demographic characteristics between subjects with GDM and non-GDM were assessed by t-test and Chi-square test for continuous and categorical variables, respectively. Mean S.D. and percentage were presented, where appropriate. Two-sided P values of less than 0.05 were considered statistically significant. All analyses were performed using Stata version 12.0 (StataCorp, College Station, Texas, USA).
3.
Results
The mean age of our study population was 22 4 years (mean SD), with a median schooling of 7 years. Among the pregnant women only 7.7% had a basic knowledge about GDM. Only 51.6% women were receiving antenatal care during their pregnancy. Table 1 shows the characteristics of the study population who completed the OGCT. The majority (38.4%) were in the 20– 24 year age group, education below 5 years (43.8%), and household income more than 15,000 Tk (31.1%). More than half of the pregnant women were zero parity women (51.5%) and had normal BMI (18.5–23.0) (55.3%). Table 2 shows total and age-specific prevalence of GDM and overt diabetes. The total prevalence of GDM was 9.7%
59
diabetes research and clinical practice 103 (2014) 57–62
Table 1 – Characteristics of study population completing a 1-h OGCT test. Subjects screened, n (%) Age (years)
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Screening for gestational diabetes mellitus and its prevalence in Bangladesh Subrina Jesmin a,b,*, Shamima Akter a,c, Hidechika Akashi c, Abdullah Al-Mamun a,d, Md. Arifur Rahman a,d, Md. Majedul Islam a,b, Farzana Sohael a,b, Osamu Okazaki c, Masao Moroi c, Satoru Kawano b, Taro Mizutani b a
Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, Bangladesh b Graduate School of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan c National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan d Shahid Ziaur Rahman Medical College, Bogra, Bangladesh
article info
abstract
Article history:
Background: The prevalence of gestational diabetes mellitus (GDM) has important health
Received 18 July 2013
complications for both mother and child and is increasing all over the world. Although
Accepted 29 November 2013
prevalence estimates for GDM are not new in developed and many developing countries,
Available online 7 December 2013
data are lacking for many low-income countries like Bangladesh. Objective: To evaluate the prevalence of GDM in Bangladesh.
Keywords:
Research design and methods: This cross-sectional study included 3447 women who consec-
Gestational diabetes mellitus
utively visited the antenatal clinics with an average gestation age of 26 weeks. GDM was
Screening
defined according to WHO criteria (fasting plasma glucose [FPG] 7.0 mmol/L or 2-h
Bangladesh
7.8 mmol/L) and the new ADA criteria (FPG 5.3 mmol/L or 2-h 8.6 mmol/L OGTT). We also calculated overt diabetes as FPG 7.0 mmol/L. Results: Prevalence of GDM was 9.7% according to the WHO criteria and 12.9% according to the ADA criteria in this study population. Prevalence of overt diabetes was 1.8%. Women with GDM were older, higher educated, had higher household income, higher parity, parental history of diabetes, and more hypertensive, compared with non-GDM women. Conclusion: This study demonstrates a high prevalence of GDM in Bangladesh. These estimates for GDM may help to formulate new policies to prevent and manage diabetes. # 2013 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy, defined as glucose intolerance with onset or first recognition during
pregnancy [1]. GDM can adversely impact perinatal outcome, increase the risk of obesity in offspring and the subsequent development of diabetes in mothers [2–4]. Overall, GDM rates have been on the rise in all ethnic groups, but most noticeable in Asian countries, where the prevalence rate is around 17% [5]. Further, among the Asians, South Asians are more prone to
* Corresponding author at: Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, Bangladesh. Tel.: +88 01721 512282; fax: +81 29 853 3092. E-mail addresses: [email protected], [email protected] (S. Jesmin). 0168-8227/$ – see front matter # 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.diabres.2013.11.024
58
diabetes research and clinical practice 103 (2014) 57–62
have diabetes at an earlier age [6] and thus more vulnerable to GDM. Among the developing countries several studies has been conducted to estimate the prevalence of GDM, including India [7–9], China [10,11], Sri Lanka [12], Iran [13,14], and Malaysia [15]. However, to date no study has been conducted in Bangladesh. Like many developing countries, Bangladesh is also experiencing a high prevalence of diabetes [16]. In order to effectively manage this condition in a cost effective manner in a low-income country like Bangladesh, it is imperative to identify mothers with GDM early on in their pregnancy. In this manner, lifestyle interventions and treatment may prevent the development of diabetes and other health complications both for mother and offspring, and to avoid high treatment costs. The aim of this study was to determine the prevalence of GDM for the first time among women in Bangladesh by using the World Health Organization (WHO) and the new American Diabetes Association (ADA) criteria.
2.
Data and methodology
2.1.
Study design
A base-line survey was done in 12 Upzillas of 6 districts under 3 divisions during 2012–2013 in Bangladesh. Twelve GDM corners were established in antenatal clinics, where antenatal care was offered to all pregnant women. A total of 4890 pregnant women, with an average gestation age of 26 weeks, participated in this study. We used the WHO STEPS approach (modified), which entails a stepwise collection of risk factor data based on standardized questionnaires covering the following parameters: demographic characteristics, somatic illnesses, somatic and mental symptoms, medications, life style, and health-related behavior (step 1), basic physical measures (step 2) and basic biochemical investigations, such as blood glucose and cholesterol (step 3). The study was approved by the Ethical Committee of the Health and Disease Research Center of Rural Peoples (HDRCRP), Dhaka, Bangladesh, and conforms to the principles outlined in the Helsinki Declaration. All subjects gave their written informed consent prior to participation.
2.2.
Study subjects
Of the 4890 subjects, we excluded 1410 subjects who were not fasting. Among the 3480 subjects, who had an oral glucose challenge test (OGCT), 624 women were found to have an abnormal OGCT (7.8 mmol/l). Of the 624 subjects who were advised to have an oral glucose tolerance test (OGTT), 591participated and 33 dropped out. Ultimately a total of 3447subjects were included in the present study.
2.3.
Anthropometric and other variables
Well-trained examiners conducted anthropometric measurements on individuals wearing light clothing and without shoes. Height was measured to the nearest 0.1 cm using the portable stadiometer. Weight was measured in an upright
position, to the nearest 0.1 kg, using a calibrated balance beam scale. Body mass index (BMI) was calculated as the body weight (kg) divided by the square of the body height (m2). Blood pressure was measured twice in the right arm in a sitting position using a standard mercury manometer and cuff, to the nearest 2 mmHg, with the initial reading taken at least 5 minutes after the subject was made comfortable, and again after an interval of 15 min. The average systolic blood pressure (SBP) and diastolic blood pressure (DBP) were then estimated. Hypertension was defined as SBP 140 or DBP 90 or taking antihypertensive medication. Number of parity, history of still birth or abortion, parental history of diabetes, parental history of hypertension, respondent’s education, and household income were self-reported.
2.4.
Assessment for GDM
All pregnant women were first screened for GDM using a 1-h 50 g OGCT, performed in the morning after an overnight fast. As we performed a fasting GCT we also measured fasting plasma glucose (FPG) using a glucometer. Subjects with abnormal 1-h blood glucose level (7.8 mmol/l) proceeded to an OGTT within one week of the abnormal screening test. Women with abnormal OGCT had a standard 2-h OGTT with a 75-g glucose load administered after a 12–14-h fast with blood collected fasting and 1-h and 2-h. GDM was defined according to the 1999 WHO criteria – FPG 7.0 mmol/L or 2-h 7.8 mmol/L [17]. It was additionally defined according to the new ADA criteria of FPG 5.3 mmol/L or 2-h 8.6 mmol/L after a 2-h OGTT [18]. We also calculated overt diabetes according to the new ADA criteria as, FPG 7.0 mmol/L [18].
2.5.
Statistical analysis
Differences in anthropometric and socio-demographic characteristics between subjects with GDM and non-GDM were assessed by t-test and Chi-square test for continuous and categorical variables, respectively. Mean S.D. and percentage were presented, where appropriate. Two-sided P values of less than 0.05 were considered statistically significant. All analyses were performed using Stata version 12.0 (StataCorp, College Station, Texas, USA).
3.
Results
The mean age of our study population was 22 4 years (mean SD), with a median schooling of 7 years. Among the pregnant women only 7.7% had a basic knowledge about GDM. Only 51.6% women were receiving antenatal care during their pregnancy. Table 1 shows the characteristics of the study population who completed the OGCT. The majority (38.4%) were in the 20– 24 year age group, education below 5 years (43.8%), and household income more than 15,000 Tk (31.1%). More than half of the pregnant women were zero parity women (51.5%) and had normal BMI (18.5–23.0) (55.3%). Table 2 shows total and age-specific prevalence of GDM and overt diabetes. The total prevalence of GDM was 9.7%
59
diabetes research and clinical practice 103 (2014) 57–62
Table 1 – Characteristics of study population completing a 1-h OGCT test. Subjects screened, n (%) Age (years)
