tag:theconversation.com,2011:/africa/topics/gestational-diabetes-4414/articlesGestational diabetes – The Conversation2023-08-14T20:00:06Ztag:theconversation.com,2011:article/2059192023-08-14T20:00:06Z2023-08-14T20:00:06Z1 in 6 women are diagnosed with gestational diabetes. But this diagnosis may not benefit them or their babies<figure><img src="https://images.theconversation.com/files/539721/original/file-20230727-18363-k1nhbm.jpg?ixlib=rb-1.1.0&rect=115%2C49%2C5390%2C3615&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/depressed-pregnant-woman-worried-about-her-2210916539">Shutterstock</a></span></figcaption></figure><p>When Sophie was pregnant with her first baby, she had an <a href="https://www.ncbi.nlm.nih.gov/books/NBK279331/#:%7E:text=Oral%20glucose%20tolerance%20tests%20(OGTT,enough%20by%20the%20body's%20cells.)">oral glucose tolerance</a> blood test. A few days later, the hospital phoned telling her she had gestational diabetes.</p>
<p>Despite having only a slightly raised glucose (blood sugar) level, Sophie describes being diagnosed as affecting her pregnancy tremendously. She tested her blood glucose levels four times a day, kept food diaries and had extra appointments with doctors and dietitians. </p>
<p>She was advised to have an induction because of the risk of having a large baby. At 39 weeks her son was born, weighing a very average 3.5kg. But he was separated from Sophie for four hours so his glucose levels could be monitored. </p>
<p>Sophie is not alone. About <a href="https://www.aihw.gov.au/reports/diabetes/diabetes/contents/how-many-australians-have-diabetes/gestational-diabetes">one in six</a> pregnant women in Australia are now diagnosed with gestational diabetes. </p>
<p>That was not always so. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827530/">New criteria</a> were developed in 2010 which dropped an initial screening test and lowered the diagnostic set-points. Gestational diabetes diagnoses have since <a href="https://www.aihw.gov.au/reports/diabetes/diabetes/contents/how-many-australians-have-diabetes/gestational-diabetes">more than doubled</a>.</p>
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<img alt="" src="https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536691/original/file-20230710-23-v8weyw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Gestational diabetes rates more than doubled after the threshold changed.</span>
<span class="attribution"><span class="source">AIHW</span>, <span class="license">Author provided</span></span>
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<p>But <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2204091">recent</a> <a href="https://pubmed.ncbi.nlm.nih.gov/33704936/">studies</a> cast doubt on the ways we diagnose and manage gestational diabetes, especially for women like Sophie with only mildly elevated glucose. Here’s what’s wrong with gestational diabetes screening.</p>
<h2>The glucose test is unreliable</h2>
<p>The test used to diagnose gestational diabetes – the oral glucose tolerance test – has poor reproducibility. This means subsequent tests may give a different result.</p>
<p>In a <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2214956">recent Australian trial</a> of earlier testing in pregnancy, one-third of the women initially classified as having gestational diabetes (but neither told nor treated) did not have gestational diabetes when retested later in pregnancy. That is a problem. </p>
<p>Usually when a test has poor reproducibility – for example, blood pressure or cholesterol – we repeat the test to confirm before making a diagnosis. </p>
<p>Much of the increase in the incidence of gestational diabetes after the introduction of new diagnostic criteria was due to the switch from using two tests to only using a single test for diagnosis.</p>
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<img alt="Pregnant woman cooks dinner with her child" src="https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540334/original/file-20230801-157556-lb9vkv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Women with only mildly elevated glucose levels are being diagnosed with gestational diabetes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/black-pregnant-woman-cooking-her-daughter-2019300152">Shutterstock</a></span>
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<h2>The thresholds are too low</h2>
<p>Despite little evidence of benefit for either women or babies, the current Australian criteria diagnose women with only mildly abnormal results as having “gestational diabetes”. </p>
<p>Recent studies have shown this doesn’t benefit women and may cause harms. A <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2204091">New Zealand trial</a> of more than 4,000 women randomly assigned women to be assessed based on the current Australian thresholds or to higher threshold levels (similar to the pre-2010 criteria). </p>
<p>The trial found no additional benefit from using the current low threshold levels, with overall no difference in the proportion of infants born large for gestational age. </p>
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Read more:
<a href="https://theconversation.com/sixteen-pound-baby-born-in-brazil-heres-what-increases-the-risk-of-giving-birth-to-a-giant-baby-198423">Sixteen-pound baby born in Brazil: here's what increases the risk of giving birth to a giant baby</a>
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<p>However, the trial found several harms, including more neonatal hypoglycaemia (low blood sugar in newborns), induction of labour, use of diabetic medications including insulin injections, and use of health services. </p>
<p>The study authors also looked at the subgroup of women who were diagnosed with glucose levels between the higher and lower thresholds. In this subgroup, there was some reduction in large babies, and in shoulder problems at delivery. </p>
<p>But there was also an increase in small babies. This is of concern because being small for gestational age can also have consequences for babies, including long-term health consequences.</p>
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<img alt="" src="https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=349&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=349&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=349&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=438&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=438&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540643/original/file-20230802-29-1dw2rw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=438&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">NEJM</span>, <span class="license">Author provided</span></span>
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<h2>Testing too early</h2>
<p>Some centres have begun testing women at higher risk of gestational diabetes earlier in the pregnancy (between 12 and 20 weeks).</p>
<p>However, a <a href="https://pubmed.ncbi.nlm.nih.gov/37144983/">recent trial</a> showed no clear benefit compared with testing at the usual 24–28 weeks: possibly fewer large babies, but again matched by more small babies.</p>
<p>There was a reduction in transient “respiratory distress” – needing extra oxygen for a few hours – but not in serious clinical events. </p>
<h2>Impact on women with gestational diabetes</h2>
<p>For women diagnosed using the higher glucose thresholds, dietary advice, glucose monitoring and, where necessary, insulin therapy has been shown to reduce complications during delivery and the post-natal period. </p>
<p>However, current models of care can also cause harm. Women with gestational diabetes are often denied their preferred model of care – for example, midwifery continuity of carer. In rural areas, they may have to transfer to a larger hospital, requiring longer travel to antenatal visits and moving to a larger centre for their birth – away from their families and support networks for several weeks. </p>
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Read more:
<a href="https://theconversation.com/are-you-at-risk-of-being-diagnosed-with-gestational-diabetes-it-depends-on-where-you-live-112515">Are you at risk of being diagnosed with gestational diabetes? It depends on where you live</a>
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<p>Women say the diagnosis often dominates their antenatal care and their whole <a href="https://pubmed.ncbi.nlm.nih.gov/32028931/">experience of pregnancy</a>, reducing time for other issues or concerns. </p>
<p>Women from culturally and linguistically diverse communities <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-021-03981-5">find it difficult</a> to reconcile the advice given about diet and exercise with their own cultural practices and beliefs about pregnancy.</p>
<p>Some women with gestational diabetes <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-2745-1">become</a> extremely anxious about their eating and undertake extensive calorie restrictions or disordered eating habits.</p>
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<img alt="Woman stands in garden looking at her pregnant belly" src="https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540324/original/file-20230801-241351-uvur05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some pregnant women become extremely anxious after being diagnosed with gestational diabetes.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/gYnEka3-tCI">Unsplash/Jordan Bauer</a></span>
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<h2>Time to reassess the advice</h2>
<p>Recent evidence from both randomised controlled trials and from qualitative studies with women diagnosed with gestational diabetes suggest we need to reassess how we currently diagnose and manage gestational diabetes, particularly for women with only slightly elevated levels.</p>
<p>It is time for a review to consider all the problems described above. This review should include the views of all those impacted by these decisions: women in childbearing years, and the GPs, dietitians, diabetes educators, midwives and obstetricians who care for them.</p>
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Read more:
<a href="https://theconversation.com/had-gestational-diabetes-here-are-5-things-to-help-lower-your-future-risk-of-type-2-diabetes-114298">Had gestational diabetes? Here are 5 things to help lower your future risk of type 2 diabetes</a>
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<p><em>This article was co-authored by maternity services consumer advocate Leah Hardiman.</em></p><img src="https://counter.theconversation.com/content/205919/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Glasziou receives funding from an NHMRC Investigator grant.</span></em></p><p class="fine-print"><em><span>Jenny Doust receives funding from NHMRC and MRFF. </span></em></p>About one in six pregnant women in Australia are now diagnosed with gestational diabetes. Rates have more than doubled since the thresholds for diagnosis were changed.Paul Glasziou, Professor of Medicine, Bond UniversityJenny Doust, Clinical Professorial Research Fellow, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1984232023-02-01T06:12:06Z2023-02-01T06:12:06ZSixteen-pound baby born in Brazil: here’s what increases the risk of giving birth to a giant baby<figure><img src="https://images.theconversation.com/files/506664/original/file-20230126-20-in3s17.jpg?ixlib=rb-1.1.0&rect=5%2C0%2C3337%2C2195&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/giant-baby-childrens-room-photo-media-1412847251">Zastolskiy Victor/Shutterstock</a></span></figcaption></figure><p>A mother in Brazil recently gave birth to a two-foot-tall baby weighing 16lb (7.3kg). Angerson Santos was born via caesarean section at Hospital Padre Colombo in Parintins, Amazonas State. </p>
<p>Angerson eclipsed the heaviest <a href="https://eu.usatoday.com/story/news/2016/05/27/15-pound-baby-might-heaviest-girl-ever-born/85030720/">baby girl</a> on record, who was 15lb (6.8kg) when she was born in 2016, but neither come close to the <a href="https://www.guinnessworldrecords.com/world-records/heaviest-birth">heaviest baby on record</a>, who tipped the scales at a whopping 22lb 8oz (10.2kg), in Italy in 1955.</p>
<p>To put this in perspective, <a href="https://www.medicalnewstoday.com/articles/325630#average-weights">newborn</a> boys typically weigh 7lb 6oz (3.3kg) and girls 7lb 2oz (3.2kg).</p>
<p>The term used to describe these giant babies is <a href="https://www.mayoclinic.org/diseases-conditions/fetal-macrosomia/symptoms-causes/syc-20372579">macrosomia</a> (Greek for large body). Any baby that weighs more than 4kg, regardless of its gestational age, is said to have macrosomia. </p>
<p>Babies with macrosomia account for about 12% of births. In mothers with gestational diabetes (high blood sugar that arises during pregnancy), this increases to between <a href="https://www.karger.com/Article/FullText/371628">15% and 45%</a> of births.</p>
<h2>Increased risk</h2>
<p>Certain factors increase the risk of a mother giving birth to a giant baby – one of them being body weight. Obese mothers are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4273542/">twice as likely</a> to have a newborn with macrosomia. And excessive <a href="https://link.springer.com/article/10.1007/s00404-015-3825-8">weight gain</a> during pregnancy likewise <a href="https://jamanetwork.com/journals/jama/fullarticle/2630599">increases</a> the risk of macrosomia.</p>
<p>Gestational diabetes is a risk factor, too. (The doctors at Hospital Padre Colombo put Angerson’s large size down to his mother’s “<a href="https://www.dailymail.co.uk/news/article-11660747/16lb-baby-measuring-2ft-long-born-C-section-Brazil.html">diabetes condition</a>”.) Some of it is linked to an increase in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4290225/">insulin resistance</a> in the mother during pregnancy (even in those without gestational diabetes), which increases the amount of glucose that travels across the placenta to the foetus, helping the foetus to grow excessively. The condition also helps <a href="https://pubmed.ncbi.nlm.nih.gov/16940551/">lipids (fats) to enter the placenta</a>, providing the baby with more fuel for growth.</p>
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<img alt="Pregnant woman having her blood sugar tested" src="https://images.theconversation.com/files/506849/original/file-20230127-7269-8lbfyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/506849/original/file-20230127-7269-8lbfyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/506849/original/file-20230127-7269-8lbfyv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/506849/original/file-20230127-7269-8lbfyv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/506849/original/file-20230127-7269-8lbfyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/506849/original/file-20230127-7269-8lbfyv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/506849/original/file-20230127-7269-8lbfyv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Gestational diabetes can increase the risk of a baby being macrosomic.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-makes-blood-test-pregnant-girl-797753236">VGstockstudio/Shutterstock</a></span>
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<p>Being older when pregnant also increases the odds of having a baby with macrosomia. A maternal age <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9239628/">greater than 35</a> makes it 20% more likely that the baby will have macrosomia. The father’s age counts, too. A paternal age <a href="https://pubmed.ncbi.nlm.nih.gov/35777059/">greater than 35</a> increases the risk of macrosomia by 10%.</p>
<p>Previous pregnancies increase the risk of macrosomia because with each successive pregnancy, <a href="https://onlinelibrary.wiley.com/doi/10.1111/apa.15598">birth weight</a> increases. Overdue pregnancies – those that run past the typical 40 weeks – also increase the risk of a baby being macrosomic, particularly at <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-021-01988-5">42 weeks or more</a>.</p>
<p>Having a boy increases the likelihood of macrosomia. Boys are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751438/">three times</a> more likely than girls to be born macrosomic.</p>
<h2>Harms during birth</h2>
<p>Babies with macrosomia are more likely to encounter difficulties moving through the birth canal because of their large size. For example, it is quite common for the baby’s shoulder to get caught behind the mother’s pubic bone. The medical term for this is “shoulder dystocia”. </p>
<p>While the baby is stuck, <a href="https://www.pregnancybirthbaby.org.au/shoulder-dystocia">it cannot breathe</a> and the umbilical cord may be squeezed. It can also cause the baby’s <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5129063/">collarbones to break</a> or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5375046/">damage</a> the brachial plexus nerves that supply the arms – in the most severe cases, this damage can be permanent. Shoulder dystocia occurs in about <a href="https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/shoulder-dystocia-patient-information-leaflet/#:%7E:text=What%20is%20shoulder%20dystocia%3F,to%20release%20the%20baby's%20shoulder.">0.7% of all births</a>, but in macrosomic babies, the incidence is <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.13268">about 25%</a>.</p>
<p>Mothers are also at <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.20278">increased</a> risk of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6106949/">vaginal tear</a> during delivery, which then <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326562/">increases the risk</a> of postpartum haemorrhage (bleeding). Postpartum haemorrhage is the leading cause of maternal death worldwide, and hence the larger the baby, the greater the risk of damage during normal vaginal delivery.</p>
<p>Macrosomia of newborns also leads to an <a href="https://pubmed.ncbi.nlm.nih.gov/14557004/">increased risk</a> of a prolonged second phase of labour, which is when the cervix is fully dilated and the baby’s head moves into the vagina. Due to <a href="https://pubmed.ncbi.nlm.nih.gov/12908019/">the size</a> of macrosomic babies, this movement can be slower than usual which can increase the risk of the mother suffering from <a href="https://journals.lww.com/obstetricanesthesia/Abstract/2016/12000/Prolonged_Second_Stage_of_Labor,_Maternal.29.aspx">infection, urinary retention and haematoma</a> (internal bleeding).</p>
<p>One thing we don’t know about macrosomic babies is whether they stay bigger throughout life. The limited data there is does exist suggest that they are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596738/">more likely</a> to be overweight or obese by the age of seven and are also more likely to develop <a href="https://pubmed.ncbi.nlm.nih.gov/12861409/">type 2 diabetes</a> in later life.</p>
<p>We may see more “giant” babies being born as those born after 1970 appear to be about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3310964/">450g heavier</a> than their pre-1970s counterparts. Similarly, with increasing rates of obesity, which is a major factor in the development of macrosomia, we will probably see more “giant” babies.</p><img src="https://counter.theconversation.com/content/198423/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Taylor is affiliated with The Anatomical Society. </span></em></p>Around 12% of babies are born weighing more than 4kg.Adam Taylor, Professor and Director of the Clinical Anatomy Learning Centre, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1938072022-11-30T13:39:31Z2022-11-30T13:39:31ZPregnancy is a genetic battlefield – how conflicts of interest pit mom’s and dad’s genes against each other<figure><img src="https://images.theconversation.com/files/497774/original/file-20221128-20372-q68nv3.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2059%2C1454&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paternal and maternal genes drive fetal development in different directions.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/hacking-baby-embryo-decoding-the-dna-of-royalty-free-illustration/1125420175">Valentina Kruchinina/iStock via Getty Images</a></span></figcaption></figure><p>Baby showers. Babymoons. Baby-arrival parties. There are many opportunities to celebrate the 40-week transition to parenthood. Often, these celebrations implicitly assume that pregnancy is cooperative and mutually beneficial to both the parent and the fetus. But this belief obscures a more interesting truth about pregnancy – the mother and the fetus may not be peacefully coexisting in the same body at all.</p>
<p>At the most fundamental level, there is a conflict between the interests of the parent and fetus. While this may sound like the beginning of a thriller, this <a href="https://doi.org/10.1086/418300">genetic conflict</a> is a normal part of pregnancy, leading to typical growth and development both during pregnancy and across an individual’s lifetime – something <a href="https://scholar.google.com/citations?user=YBPxHqkAAAAJ&hl=en&oi=ao">my research</a> focuses on. </p>
<p>However, even though genetic conflict is normal during pregnancy, it can play a role in pregnancy complications and developmental disorders when left unchecked.</p>
<h2>What is genetic conflict?</h2>
<p>Pregnancy is generally thought of as a period when a new individual is created from a unified blend of genes from their parents. But this is not quite right. </p>
<p>The genes a fetus gets from each parent carry slightly different instructions for development. This means there are contrasting and sometimes conflicting blueprints for how to build the new individual. Conflict over <a href="https://doi.org/10.1016/0168-9525(91)90230-N">which blueprint to follow</a> for fetal growth and development is the essence of the genetic conflict that occurs during pregnancy.</p>
<p>Moms have to use their bodies to help the fetus grow during pregnancy while dads don’t. This means that the genes the fetus inherits from mom have to not only provide for the current fetus, but also try to keep mom alive and healthy and make sure there are resources left over for a potential future pregnancy. These reserves include both biological resources like glucose, protein, iron and calcium, as well as the time and energy needed to help her children after birth as they grow and develop.</p>
<p>Dad’s genes don’t have this same pressure because they don’t use their bodies to help the fetus grow during pregnancy. A dad’s genes, then, don’t need to ensure that anyone other than the current fetus thrives.</p>
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<figcaption><span class="caption">Pregnancy transforms every organ in the body.</span></figcaption>
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<p>To better understand this situation, pretend that all of the resources a mom can give her children come in the form of a <a href="https://cir.nii.ac.jp/crid/1570854174915527168">milkshake</a>. Once the milkshake runs out, mom has nothing left to give her children. Maternal genes, therefore, want each child to drink only as much as they need to grow and develop. This ensures that the milkshake can be “shared” across all current and future children. </p>
<p>Paternal genes, on the other hand, have no such guarantee of representation in this mother’s other children – the father of the current child may not be the father of the mother’s potential future children. This lack of guaranteed genetic representation means there is no pressure on the father to “share” the milkshake. The best strategy when it comes to paternal genes, then, is for the fetus to drink as much of the milkshake as they can.</p>
<p>These two strategies play a figurative game of tug of war throughout pregnancy. Both sides are trying to pull fetal development slightly more toward their side. Paternal genes encourage the fetus to grow and develop quickly and take more resources, while maternal genes encourage the fetus to grow and use only what’s necessary for proper development. Conflict over how deeply the <a href="https://doi.org/10.1016/0168-9525(91)90230-N">embryo implants</a> in the uterus and how quickly the <a href="https://doi.org/10.1016/j.placenta.2012.05.002">placenta</a> and <a href="https://doi.org/10.1016/j.placenta.2005.07.004">fetus</a> grow are just a few areas where researchers have documented this tug of war during pregnancy.</p>
<p>The milkshake problem helps researchers determine where to look for genetic conflict by simplifying where trade-offs may take place during pregnancy. Because fetal growth is at the heart of genetic conflict, researchers have focused on processes where conflict over resource transfers from mother to fetus can be observed. These investigations have found that the placenta, a fetal organ responsible for all resource transfers during pregnancy, is <a href="https://www.hup.harvard.edu/catalog.php?isbn=9780674027220">dominated by paternally-expressed genes</a>. It releases paternally-derived <a href="https://doi.org/10.1038/ng0593-98">insulin-like growth factors</a> that make mom less sensitive to her own insulin and hormones that <a href="https://doi.org/10.1093/humrep/16.1.13">increase maternal blood pressure</a>, both of which ultimately increase the amount of resources the fetus can use to grow during pregnancy but have the potential to harm the mother’s health.</p>
<h2>Genetic conflict and pregnancy complications</h2>
<p>If genetic conflict goes uncontrolled, it can cause <a href="https://doi.org/10.1086/418300">pregnancy complications</a> for the mother and <a href="https://doi.org/10.1002/ajhb.10150">developmental disorders</a> for the child. In fact, there is a growing consensus among researchers that some of the most well-known pregnancy complications like <a href="https://doi.org/10.1126/science.1111726">preeclampsia</a>, <a href="https://doi.org/10.1007/978-3-319-19650-3_3044">gestational diabetes</a>, <a href="https://doi.org/10.1016/j.semcdb.2022.01.007">miscarriages</a> and <a href="https://doi.org/10.1093/aje/kwp325">preterm births</a> may best be explained by unchecked genetic conflict.</p>
<p>Despite the potential role that genetic conflict plays in pregnancy complications, current medical treatments are reactive rather than proactive. A pregnant person must <a href="https://www.mayoclinic.org/diseases-conditions/preeclampsia/diagnosis-treatment/drc-20355751">show signs of experiencing complications</a> before medical interventions and treatments can take place. </p>
<p>Knowing how unchecked genetic conflict contributes to pregnancy complications could provide researchers another way to develop treatments that are proactive and, ideally, preventive. However, there are currently no treatments for pregnancy complications that consider genetic conflict. Though <a href="https://doi.org/10.2337%2Fdb19-0798">gestational diabetes</a> can be attributed to underlying genetic conflict, a pregnant person must present with elevated blood sugar levels before doctors can treat underlying conflict over insulin production and blood sugar.</p>
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<figcaption><span class="caption">Pregnancy during the COVID-19 pandemic has been challenging for many.</span></figcaption>
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<p>The experiences of pregnant people during the COVID-19 pandemic provide an example of why more research on genetic conflict is needed. During the pandemic, doctors saw both a dramatic decrease in the number of <a href="http://dx.doi.org/10.1136/archdischild-2020-319990">preterm births</a> as well as an increase in the number of <a href="https://doi.org/10.1001/jama.2020.12746">stillbirths and miscarriages</a>. Both types of complications are influenced by genetic conflict, but the reasons behind these opposing trends are unclear.</p>
<p>As a woman who was pregnant early in the pandemic, my pregnancy was scary and stressful, spent at home away from the pressures of “normal” life. More research on the complex process of pregnancy and genetic conflict’s role in complications could help researchers better understand how the changes brought by the pandemic produced such wildly different pregnancy outcomes.</p><img src="https://counter.theconversation.com/content/193807/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jessica D. Ayers does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Genetic conflict may play a role in pregnancy complications, such as preeclampsia and gestational diabetes, as well as developmental disorders.Jessica D. Ayers, Assistant Professor of Psychological Science, Boise State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1945022022-11-14T10:44:38Z2022-11-14T10:44:38ZOver 12% of South African adults have diabetes - education is critical to achieve good outcomes<figure><img src="https://images.theconversation.com/files/494927/original/file-20221112-29604-1ypgsq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Type 2 diabetes mostly affects adults of a certain age.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>Over <a href="https://www.up.ac.za/tshwane-insulin-project-tip/news/post_2937261-world-diabetes-day-up-insulin-project-acknowledges-crucial-role-of-nurses-in-managing-the-disease">12%</a> of adults in South Africa have diabetes. Since 2019, researchers at the University of Pretoria have been working on the <a href="https://www.up.ac.za/diabetes-research-centre/article/3107624/tshwane-insulin-programme-tip">Tshwane Insulin Project</a>. The project consists of delivering training workshops on comprehensive diabetes and hypertension management in primary care. The researchers also provide technical assistance to healthcare professionals to improve diabetes care. The Conversation Africa spoke to project manager Dr Patrick Ngassa Piotie about what diabetes is and why it’s so difficult to manage.</em></p>
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<h2>What is diabetes?</h2>
<p>Diabetes mellitus, or <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">diabetes</a>, refers to a group of conditions that affect how the body uses blood glucose (sugar). Diabetes occurs when the pancreas is no longer <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes.html">able to make insulin</a>, or when the body cannot make good use of the insulin it produces. This leads to elevated glucose levels in the blood. Over time, high blood glucose levels cause damage to the body and the failure of various organs.</p>
<p>There are different types of diabetes. Type 2 is the most common. It accounts for 90% of all cases. With type 2, the body is still able to produce insulin but can’t use it correctly. Type 2 diabetes mostly affects adults of a certain age, who are overweight, don’t exercise, and have a family history of diabetes.</p>
<p>Type 1 diabetes can develop at any age, but it occurs most frequently in children and adolescents. With type 1 diabetes, the pancreas produces very little to no insulin. This means people who have type 1 diabetes need insulin daily to maintain blood glucose levels. </p>
<p>Lastly, there’s diabetes that occurs during pregnancy – gestational diabetes. It affects both mother and child, but usually disappears after pregnancy.</p>
<p>Pre-diabetes is a reversible condition. It happens when blood glucose levels are higher than normal, but <a href="https://www.mayoclinic.org/diseases-conditions/diabetes/symptoms-causes/syc-20371444">not high enough to be called diabetes</a>. It can lead to diabetes unless measures such as lifestyle modifications are taken to prevent it.</p>
<p>The symptoms of diabetes are linked to the high levels of sugar in the blood. They include feeling tired and weak, feeling more thirsty than usual, urinating often, or losing weight without trying. Other symptoms such as blurry vision, recurring infections or slow-healing sores are signs of an advanced stage of the disease.</p>
<h2>How is it managed?</h2>
<p>This depends on the type of diabetes. For example, people with type 1 diabetes need daily insulin injections. The management of type 2 diabetes consists of adopting a healthy lifestyle including increased physical activity and healthy diet. However, type 2 diabetes is a progressive disease. This means that, as the condition progresses, people with type 2 diabetes will need oral drugs and/or insulin to keep their blood glucose levels under control.</p>
<p>Managing diabetes is not just about keeping the blood glucose levels within normal ranges. Often, people with diabetes and healthcare professionals must control the blood pressure and cholesterol levels as well. In addition, a key aspect of managing diabetes is to prevent complications by protecting target organs such as the kidneys and the heart, or the feet.</p>
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Read more:
<a href="https://theconversation.com/technology-and-home-visits-can-help-south-africans-with-diabetes-cope-with-insulin-186000">Technology and home visits can help South Africans with diabetes cope with insulin</a>
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<p>At the <a href="http://www.diabetes.up.ac.za">University of Pretoria Diabetes Research Centre</a>, we have developed an acronym that summarises our approach to good diabetes care: the <a href="https://www.up.ac.za/media/shared/856/ZP_Resources/living-with-diabetes_starting-insulin.zp225902.pdf">four “Bs” and four “Cs”</a> or 4Bs 4Cs.</p>
<p>The 4Bs are critical elements to control diabetes:</p>
<ul>
<li><p>Blood pressure control</p></li>
<li><p>Blood glucose control</p></li>
<li><p>Blood cholesterol control</p></li>
<li><p>Breathe air, don’t smoke</p></li>
</ul>
<p>The 4Cs are important tests that people with diabetes should receive every year:</p>
<ul>
<li><p>Check eyes, with a diabetic eye screening – a specific test to check for eye problems caused by diabetes</p></li>
<li><p>Check mouth, by going to the dentist</p></li>
<li><p>Check kidneys, with a laboratory test</p></li>
<li><p>Check feet, with a simple easy-to-do foot exam.</p></li>
</ul>
<p>To manage diabetes, healthcare professionals need the full participation of people with diabetes and their families. That is why it’s important that people with diabetes and their families receive <a href="https://www.semdsa.org.za/">diabetes education</a>. People with diabetes must be <a href="https://worlddiabetesday.org/about/theme/">equipped</a> with the skills to navigate self-management decisions and activities. </p>
<h2>What are the main challenges in managing the condition?</h2>
<p>In South Africa, most people with diabetes rely on the public health system for care. This system is overburdened, overstretched and under-resourced. These systemic challenges have an impact on the delivery of diabetes care, despite the availability of diabetes medication – including insulin – free of charge at primary care clinics.</p>
<p>Healthcare professionals often don’t have time for diabetes education because of long queues and congested health facilities. As a result, people with diabetes <a href="https://pubmed.ncbi.nlm.nih.gov/28156143/">don’t receive the education they need</a>. This, in turn, means people don’t have a good understanding of their condition, which affects their ability to adopt appropriate self-management behaviours, and to adhere to their medication.</p>
<p>Research conducted in South Africa has consistently shown that healthcare workers <a href="https://pubmed.ncbi.nlm.nih.gov/32242428/">don’t comply with diabetes management guidelines</a>. They also fail to implement the recommended processes of care such as measurements of body mass index, waist circumference or weight.</p>
<p>Having paper-based medical records instead of electronic medical records is an additional barrier. The medical records are often lost or misplaced. In a context where healthcare professionals rotate often between departments, it becomes difficult to preserve patient history and to ensure continuity of care. A paper-based system makes it difficult to implement structured diabetes care.</p>
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Read more:
<a href="https://theconversation.com/our-research-shows-gaps-in-south-africas-diabetes-management-programme-160275">Our research shows gaps in South Africa's diabetes management programme</a>
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<p>South African <a href="https://pubmed.ncbi.nlm.nih.gov/35532128/">studies</a> have found that screening for diabetes-related complications is lacking. For example, healthcare professionals are <a href="https://www.diabetessa.org.za/challenges-facing-sa-in-the-fight-against-diabetic-retinopathy/">not able to screen patients for eye problems</a> caused by diabetes. Diabetic eye screening requires a specific camera that is not available in most clinics and community health centres. </p>
<h2>How can these be addressed?</h2>
<p><a href="https://guidelines.diabetes.ca/cpg">Diabetes care</a> should be structured, evidence-based and facilitated by a multidisciplinary team trained in diabetes management.</p>
<p>South Africa’s health system should be strengthened. Investments are needed to improve the delivery of diabetes care. There is a pressing need for the continuous training of healthcare professionals in diabetes management.</p>
<p>Because of the heavy workload on primary care nurses and doctors, allied healthcare workers, community health workers and health promoters should be trained to carry out non-clinical duties like diabetes education and support.</p>
<p>The recognition and integration of diabetes educators within the public healthcare system should be a priority. This will ensure that diabetes education becomes systematic and consistent. It should be repeated at regular intervals. Families of people living with diabetes should also be involved and receive diabetes education because their support is crucial.</p>
<p>Technology, digital health solutions and telehealth can improve the delivery of quality diabetes care. Clinical information systems such as electronic medical records and electronic patient registries can have a positive impact on evidence-based diabetes care. Those systems should be introduced as a matter of urgency.</p>
<h2>What are some of the key lessons from the Tshwane Insulin Project so far?</h2>
<p>The use of digital health, enhancing the role played by community health workers and following patients proactively are some of the <a href="https://pubmed.ncbi.nlm.nih.gov/34733467/">innovations that were introduced</a>.</p>
<p>Most healthcare professionals are eager to embrace change and new knowledge. And people with diabetes and their families were appreciative of the education they were receiving. They qualified it as life changing.</p>
<p>Improving diabetes care and outcomes in South Africa will require a strong will and unwavering support from the health authorities, the introduction of clinical information systems, the use of technology and digital solutions, advocacy and accountability.</p><img src="https://counter.theconversation.com/content/194502/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick Ngassa Piotie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Improving diabetes care in South Africa requires strong will and support from health authorities, introduction of clinical information systems, the use of technology and digital solutions.Patrick Ngassa Piotie, Project Manager, University of Pretoria Diabetes Research Centre, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1497662020-11-12T15:14:24Z2020-11-12T15:14:24ZDiabetes is a ticking time bomb in sub-Saharan Africa<figure><img src="https://images.theconversation.com/files/368529/original/file-20201110-21-1bo5kk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Diabetes is a serious, chronic condition that affects the lives and well-being of individuals, families, and <a href="https://www.diabetesatlas.org/en/">societies globally</a>. It is characterised by excess levels of sugar in the blood. </p>
<p>There are three main types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.</p>
<p>Type 1 diabetes often begins from childhood. It occurs when the body attacks the pancreas with antibodies. The pancreas is damaged and is unable to produce the hormone, insulin, responsible for regulating the blood sugar level. As a consequence, people with type 1 diabetes rely on daily injections of insulin to survive. Type 1 diabetes constitutes about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146037/">5%–10%</a> of all cases of diabetes</p>
<p>Type 2 diabetes occurs mostly in adults from the ages of <a href="https://www.ncbi.nlm.nih.gov/books/NBK513253/">20 to 79</a>. It accounts for about <a href="https://www.idf.org/aboutdiabetes/type-2-diabetes.html#:%7E:text=Type%202%20diabetes%20is%20the,keep%20rising%2C%20releasing%20more%20insulin.">90%</a> of all diabetes cases. In type 2, the pancreas produces insulin, but it is either not enough or the body cells fail to use it – what’s known as insulin resistance. People who are obese have a high risk of developing type 2 diabetes.</p>
<p>Gestational diabetes refers to high blood sugar that appears only in pregnancy, and usually goes away after delivery. But women with gestational diabetes have high chances of developing type 2 diabetes later in their life.</p>
<p>In 2019 about <a href="https://www.diabetesatlas.org/en/">1 in 11 adults</a> in the world – 436 million people – had diabetes. Of these, 19 million lived in sub-Saharan Africa. Around 60% of them were not aware of their condition.</p>
<p>These numbers are expected to grow exponentially over the next 25 years. The number of people with diabetes in sub-Saharan Africa is expected to more than double to <a href="https://www.dovepress.com/mitigating-the-burden-of-diabetes-in-sub-saharan-africa-through-an-int-peer-reviewed-fulltext-article-DMSO">45 million by 2045</a>. This is because many people are at high future risk of diabetes, otherwise known as people with prediabetes. In 2019, about 45 million Africans aged 20 to 79 years had impaired glucose tolerance, which is a form of prediabetes.</p>
<p>The <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30925-9/fulltext">Global Burden of Disease Study</a> estimates that diabetes is the fifth leading cause of deaths due to noncommunicable diseases in the region. Others ahead of it are stroke, ischaemic heart disease, congenital birth defects, and chronic liver diseases.</p>
<p>The expected rapid rise in diabetes must not be overlooked as it could have devastating <a href="https://theconversation.com/lifestyle-diseases-could-scupper-africas-rising-life-expectancy-107220">health and economic consequences</a> for the region. Most national health systems are unprepared to deal with the growing burden as they struggle to cope with infectious diseases. The COVID-19 pandemic has added to these pressures.</p>
<p>Given that this is a lifestyle disease, governments need to act urgently to encourage changes in behaviour in a bid to manage it.</p>
<h2>Implications of high rates of diabetes</h2>
<p>Diabetes and other noncommunicable diseases result in people living many years in poor health in sub-Saharan Africa. The <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30977-6/fulltext">average life expectancy</a> in the region is currently estimated to be 64.5 years, with 11% of those years spent in poor health.</p>
<p>One-third of all health loss (measured using disability-adjusted life-years) in 2019 in sub-Saharan Africa was due to noncommunicable diseases such as diabetes. This figure rose from 18% in 1990. Disability-adjusted life-years is a measure of disease burden that captures both <a href="https://theconversation.com/people-in-africa-live-longer-but-their-health-is-poor-in-those-extra-years-108691">early death and ill health</a>. </p>
<p>According to the Global Burden of Disease Study, the proportion of all years of life lost to early death due to diabetes and other noncommunicable diseases increased by more than 68% in sub-Saharan Africa <a href="https://doi.org/10.1016/S0140-6736(20)30925-9">between 1990 and 2019</a>.</p>
<p>Diabetes can lead to death and <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">life-threatening complications</a>, such as severe damage to the heart, blood vessels, eyes, kidneys, and nerves. These complications can lead to heart attacks, strokes, blindness, kidney failure, and lower limb amputation. For example, adults with diabetes are three times more likely to suffer from heart attacks and strokes than adults without diabetes.</p>
<p>Diabetes can also increase the <a href="https://www.dovepress.com/mitigating-the-burden-of-diabetes-in-sub-saharan-africa-through-an-int-peer-reviewed-article-DMSO">risk of infectious diseases</a> such as pneumonia and tuberculosis. It has also been shown that people living with diabetes who are infected with SARS-CoV-2 are more likely to develop <a href="https://dx.doi.org/10.1111/cob.12414">severe COVID-19</a>, to require extended stay in the hospital, to have a greater need for ventilation, and to have higher chances of <a href="https://doi.org/10.1016/j.dsx.2020.04.044">dying from COVID-19</a>.</p>
<h2>Future risks</h2>
<p>Sub-Saharan Africa faces unique challenges in <a href="https://www.dovepress.com/diabetes-in-sub-saharan-africa-from-policy-to-practice-to-progress-tar-peer-reviewed-article-DMSO">combating diabetes</a>. These include the lack of funding for noncommunicable diseases, lack of studies and guidelines specific to the population, lack of medications, differences in urban and rural patients, and inequity between public and private sector health care. </p>
<p>Because of these challenges, diabetes has a more significant impact on health loss in sub-Saharan Africa than any other region in the world.</p>
<p>The <a href="https://www.diabetesatlas.org/en/">International Diabetes Federation</a> estimated the cost of diabetes in sub-Saharan Africa in 2019 to be US$ 9.5 billion, and this will increase to US$ 17.4 billion by 2045.</p>
<p>The rising prevalence of diabetes is linked to the increase in obesity and other lifestyle changes such as poor eating habits and lack of physical activity. </p>
<p>The risk factors for developing diabetes are <a href="https://www.who.int/news-room/fact-sheets/detail/diabetes">modifiable</a>, meaning they can be changed. People should be encouraged to eat healthily, be physically active, and avoid extreme weight gain. Such simple lifestyle changes are effective in preventing type 2 diabetes. </p>
<p>Studies over the past two decades have unequivocally shown that <a href="https://doi.org/10.1111/j.1464-5491.2007.02157.x">lifestyle modification</a> can prevent or delay the onset of type 2 diabetes in people who are at high future risk of the disease. Such studies have been conducted in <a href="https://www.diabetesatlas.org/en/">numerous countries</a>, including the United States of America, Finland, China, India, Japan, and Pakistan. </p>
<p>A coordinated multi-sectoral approach within and across countries is needed to stem the tide of diabetes in sub-Saharan Africa.</p><img src="https://counter.theconversation.com/content/149766/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andre Pascal Kengne received from the South African Medical Research Council (SAMRC); The European & Developing Countries Clinical Trials Partnership (EDCTP) and The Global Alliance for Chronic Diseases (GACD).</span></em></p><p class="fine-print"><em><span>Charles Shey Wiysonge receives funding from the South African Medical Research Council.</span></em></p><p class="fine-print"><em><span>Chinwe Juliana Iwu-Jaja does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The rapid rise in diabetes mustn’t be overlooked, as it could have devastating health and economic effects. Most national health systems are already struggling with infectious diseases.Chinwe Juliana Iwu-Jaja, Public Health researcher, Stellenbosch UniversityAndre Pascal Kengne, Director of the Non-Communicable Diseases Research Unit at the South African Medical Research Council, Professor in the Department of Medicine, University of Cape TownCharles Shey Wiysonge, Regional Adviser, Immunisation, WHO Regional Office for Africa, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1293492020-01-08T18:50:17Z2020-01-08T18:50:17ZPregnant women should take extra care to minimise their exposure to bushfire smoke<figure><img src="https://images.theconversation.com/files/308938/original/file-20200108-107219-kvwdju.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C2986%2C1998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregnant women should try to stay inside when the air pollution is high.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Smoke haze from Australia’s catastrophic bushfires is continuing to affect many parts of the country.</p>
<p>Although there’s no safe level of air pollution, the health hazards tend to be greatest for vulnerable groups. Alongside people with pre-existing conditions, smoke exposure presents unique risks for pregnant women. </p>
<p>Research shows prolonged exposure to bushfire smoke increases the risk of pregnancy complications including <a href="http://www.mdpi.com/resolver?pii=ijerph16193720">high blood pressure</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204222/">gestational diabetes</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Ebisu+berman+bell+weight">low birth weight</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=basu.+Pearson+delivery+california">premature birth</a> (before 37 weeks).</p>
<p>These conditions can have short-term and lifelong effects on <a href="https://ukhealthcare.uky.edu/wellness-community/health-information/short-long-term-effects-preterm-birth">a baby’s health</a>, with increased risk of conditions including cerebral palsy and visual or hearing impairment. Even babies born only a few weeks early can experience learning difficulties and behavioural problems, and have an elevated risk of heart disease in later life.</p>
<p>So it’s especially important pregnant women protect themselves from exposure to bushfire smoke.</p>
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Read more:
<a href="https://theconversation.com/how-does-poor-air-quality-from-bushfire-smoke-affect-our-health-126835">How does poor air quality from bushfire smoke affect our health?</a>
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<h2>Why are pregnant women at higher risk?</h2>
<p>Pregnant women breathe at an increased rate, and their hearts need to <a href="https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.115.06667">work harder</a> than those of non-pregnant people to transport oxygen to the fetus. This makes them particularly vulnerable to the effects of air pollution, including bushfire smoke.</p>
<p>We often measure poor air quality by the presence of ultra-fine particles called PM2.5 (small particles of less than 2.5 micrometres in size). These particles are concerning because they can penetrate into <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3248967/">our lungs</a>, and into blood and tissue to cause inflammation throughout the body.</p>
<p>Importantly in pregnant women, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6468584/">environmental pollutants</a> can cause <a href="https://academic.oup.com/humupd/article/12/6/747/624349">inflammatory damage</a> to the placenta’s blood supply. This can interfere with the placenta’s development and function, which can in turn compromise the growth of the fetus.</p>
<h2>What the evidence says</h2>
<p>Many studies have linked poor air quality, particularly high <a href="https://www.sciencedirect.com/science/article/abs/pii/S0013935118303700?via%3Dihub">PM2.5 levels</a>, to poor pregnancy outcomes. Data from 183 countries showed in 2010, an estimated <a href="https://www.sciencedirect.com/science/article/pii/S0160412016305992?via%3Dihub">2.7 million premature births</a>, 18% of the total, were associated with PM2.5 pollution.</p>
<p>A 2019 <a href="http://www.mdpi.com/resolver?pii=ijerph16193720">study</a> of more than 500,000 pregnant women from Colorado looked at the effect of bushfire smoke on pregnancy outcomes. The authors analysed data on air quality, fire incidence and pregnancy and birth records from 2007-2015, during which time Colorado was regularly affected by smoke from fires burning in California and the Pacific Northwest.</p>
<p>The study found PM2.5 due to bushfire smoke was linked to spikes in <a href="http://www.mdpi.com/resolver?pii=ijerph16193720">premature birth</a>, especially in women exposed during the second trimester. </p>
<p>In women exposed to smoke during the first trimester, <a href="http://www.mdpi.com/resolver?pii=ijerph16193720">birth weight was lower than average</a>. Further, exposure during any trimester increased the chance of <a href="http://www.mdpi.com/resolver?pii=ijerph16193720">gestational diabetes and high blood pressure</a>. </p>
<p>The effects were detectable even with low exposure to smoke and small increases in PM2.5. For every 1 microgram/m³ increase in average daily exposure to PM2.5 during the second trimester of pregnancy, the risk of premature birth <a href="http://www.mdpi.com/resolver?pii=ijerph16193720">increased by 13%</a>. </p>
<p>To put this into context, in Canberra in the first week of January, <a href="https://www.health.act.gov.au/about-our-health-system/population-health/environmental-monitoring/monitoring-and-regulating-air">PM2.5 levels</a> averaged more than 200 micrograms/m³, compared with the typical background concentration of 5 micrograms/m³. EPA Victoria classifies PM2.5 levels above 25 micrograms/m³ as <a href="https://www.epa.vic.gov.au/for-community/environmental-information/air-quality/pm25-particles-in-the-air">unsafe</a> for vulnerable people.</p>
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Read more:
<a href="https://theconversation.com/evacuating-with-a-baby-heres-what-to-put-in-your-emergency-kit-127026">Evacuating with a baby? Here's what to put in your emergency kit</a>
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<p>In another large study, <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=klepac+kukec+pollution">a 24% increase in premature birth</a> was seen after 10 micrograms/m³ increase in PM2.5.</p>
<p>As well as PM2.5, bushfire smoke contains larger PM10 particles, nitric oxides, carbon monoxide and other gases and toxic chemicals. These all have potential to impair lung and heart function in the mother, activate inflammation, and directly affect fetal and placental development.</p>
<h2>Smoke threatens fertility, too</h2>
<p>Air quality is also a factor for couples <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6311303/">attempting to conceive</a> or <a href="https://www.ncbi.nlm.nih.gov/pubmed/28754128">dealing with infertility</a>. </p>
<p>Population studies suggest air pollution compromises human fertility by reducing <a href="https://www.endocrine-abstracts.org/ea/0063/ea0063p311">ovarian reserve</a> (the number of eggs in the ovary) and affecting <a href="https://dx.doi.org/10.1021/acs.est.8b06942">sperm number</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/19217100">movement</a>.</p>
<p>Direct exposure to <a href="https://www.ncbi.nlm.nih.gov/pubmed/21991169">fire, burns</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/29241080">fire retardant chemicals</a> can also negatively impact fertility.</p>
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Read more:
<a href="https://theconversation.com/how-to-monitor-the-bushfires-raging-across-australia-129298">How to monitor the bushfires raging across Australia</a>
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<h2>Precautions to take if you’re pregnant</h2>
<p>The best strategy is to reduce smoke exposure as much as possible. Recommendations from <a href="https://www.health.nsw.gov.au/environment/air/pages/bushfire-smoke.aspx">NSW Health</a> include staying inside on high-risk days, sealing the house to prevent smoke infiltration and using air conditioning to keep cool.</p>
<p>Avoid creating smoke by cigarette smoking, burning candles, or frying and grilling. Use PM2 (N95) masks and air-filtering devices if possible, and avoid exposure to ash, which contains particulate material you can inhale.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/308941/original/file-20200108-107255-pvj5e7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/308941/original/file-20200108-107255-pvj5e7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=378&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308941/original/file-20200108-107255-pvj5e7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=378&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308941/original/file-20200108-107255-pvj5e7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=378&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308941/original/file-20200108-107255-pvj5e7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=475&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308941/original/file-20200108-107255-pvj5e7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=475&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308941/original/file-20200108-107255-pvj5e7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=475&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Studies have shown when women are exposed to bushfire smoke during pregnancy, the rates of premature birth increase.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>Pregnant women in a fire region should carefully follow emergency services’ direction. It’s better to evacuate early, with an <a href="https://www.qld.gov.au/emergency/dealing-disasters/prepare-for-disasters/emergency-kit">emergency supply kit</a> containing clothes, medications, water and food you don’t need to cook. </p>
<p>Make sure your medication and prenatal vitamins are accessible, continue to take them, and stay well hydrated. Inform authorities and shelters you are pregnant and need to maintain your antenatal care. </p>
<p>Be aware of the <a href="https://www.betterhealth.vic.gov.au/health/healthyliving/pregnancy-premature-labour">signs of premature labour</a> including abdominal cramps or contractions, a heavy vaginal discharge, loss of fluid or vaginal bleeding, pelvic pressure and low backache. Seek help if you think you may be going into labour. </p>
<p>Given what we know about the consequences of poor air quality on pregnancy outcomes, it’s critical pregnant women are given top priority when it comes to bushfire relief and health care support.</p>
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<strong>
Read more:
<a href="https://theconversation.com/from-face-masks-to-air-purifiers-what-actually-works-to-protect-us-from-bushfire-smoke-128633">From face masks to air purifiers: what actually works to protect us from bushfire smoke?</a>
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<img src="https://counter.theconversation.com/content/129349/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Robertson receives funding from the National Health and Medical Research Council of Australia, and the Australian Research Council. </span></em></p><p class="fine-print"><em><span>Louise Hull receives funding from the National Health and Medical Research Council of Australia and the Medical Research Futures Fund, a grant from the Australasian Gynaecologic and Endoscopic Society and the Adelaide Women's and Children's Research Foundation. Associate Professor Louise Hull has ownership in Embrace Fertility an independent fertility and IVF practice which is affiliated with REPROMED.</span></em></p>Pregnant women exposed to bushfire smoke face a higher risk of complications including gestational diabetes, high blood pressure and giving birth prematurely.Sarah Robertson, Professor and Director, Robinson Research Institute, University of AdelaideLouise Hull, Associate Professor and Fertility and Conception Theme Leader, The Robinson Research Institute, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1142982019-07-02T02:03:45Z2019-07-02T02:03:45ZHad gestational diabetes? Here are 5 things to help lower your future risk of type 2 diabetes<figure><img src="https://images.theconversation.com/files/281943/original/file-20190701-105176-1wsuqpp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For women who have had gestational diabetes, maintaining a healthy diet can help lower the risk of developing type 2 diabetes later on.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Gestational diabetes is a specific type of diabetes that <a href="https://www.diabetesaustralia.com.au/gestational-diabetes">occurs in pregnancy</a>. </p>
<p>Once you’ve had gestational diabetes, your risk of having it again in your next pregnancy is higher. So too is your lifetime chance of <a href="https://www.ncbi.nlm.nih.gov/pubmed/19465232">developing type 2 diabetes</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2494649/">heart disease</a>. </p>
<p>The good news is taking steps such as adopting a healthier diet and being more active will lower those risks, while improving health and well-being for you and your family. </p>
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Read more:
<a href="https://theconversation.com/gestational-diabetes-in-the-mother-increases-type-1-and-type-2-diabetes-risks-for-the-whole-family-115978">Gestational diabetes in the mother increases Type 1 and Type 2 diabetes risks for the whole family</a>
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<h2>What is gestational diabetes?</h2>
<p>Gestational diabetes affects <a href="https://www.diabetesaustralia.com.au/gestational-diabetes">about one in seven to eight pregnant women</a> in Australia.
Women are screened for gestational diabetes at around 24 to 28 weeks gestation using a <a href="https://www.healthdirect.gov.au/diabetes-diagnosis">glucose tolerance test</a>. Gestational diabetes is <a href="https://www.diabetesaustralia.com.au/gestational-diabetes">diagnosed when blood glucose levels</a>, also called blood sugar levels, are higher than the normal range.</p>
<p>Screening is designed to ensure women with gestational diabetes receive treatment as early as possible to <a href="https://www.ncbi.nlm.nih.gov/pubmed/27703397">minimise health risks</a> for both the mother and the baby. Risks include having a baby born weighing more than four kilograms, and the need to have a caesarean section. <a href="https://www.diabetesaustralia.com.au/managing-gestational-diabetes">Management of gestational diabetes</a> includes close monitoring of blood glucose levels, a healthy diet, and being physically active.</p>
<p>The risk of developing type 2 diabetes increases markedly <a href="https://www.ncbi.nlm.nih.gov/pubmed/12351492">in the first five years following gestational diabetes</a>, with risk plateauing after ten years. Women who have had gestational diabetes have <a href="https://www.ncbi.nlm.nih.gov/pubmed/19465232">more than seven times the risk</a> of developing type 2 diabetes in the future than women who haven’t had the condition. </p>
<h2>Type 2 diabetes</h2>
<p>If type 2 diabetes goes undiagnosed, the impact on your health can be high – especially if it’s not detected until complications arise. </p>
<p>Early <a href="https://www.diabetesaustralia.com.au/what-is-diabetes">signs and symptoms of type 2 diabetes</a> include extreme thirst, frequent urination, blurred vision, frequent infections and feeling tired and lethargic. </p>
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<img alt="" src="https://images.theconversation.com/files/281944/original/file-20190701-105172-1chklgc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281944/original/file-20190701-105172-1chklgc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281944/original/file-20190701-105172-1chklgc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281944/original/file-20190701-105172-1chklgc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281944/original/file-20190701-105172-1chklgc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281944/original/file-20190701-105172-1chklgc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281944/original/file-20190701-105172-1chklgc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Doing regular exercise can lessen the risk of developing type 2 diabetes.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p><a href="https://www.healthdirect.gov.au/complications-of-diabetes">Long-term complications include</a> an increased risk of heart disease and stroke, damage to nerves (especially those in the fingers and toes), damage to the small blood vessels in the kidneys, leading to kidney disease, and damage to blood vessels in the eyes, leading to diabetes-related eye disease (called diabetic retinopathy).</p>
<p>If you’ve ever been diagnosed with gestational diabetes, here are five things you can do to lower your risk of developing type 2 diabetes.</p>
<h2>1. Monitor your diabetes risk</h2>
<p>Although gestational diabetes is a well-known risk factor for type 2 diabetes, some women have <a href="https://www.ncbi.nlm.nih.gov/pubmed/20653745">not been informed of the increased risk</a>. This means they may not be aware of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/11874954">recommendations to help prevent type 2 diabetes</a>. </p>
<p>All women diagnosed with gestational diabetes should have a 75g oral glucose tolerance test <a href="https://www.racgp.org.au/afp/2013/august/gestational-diabetes-mellitus/">at 6–12 weeks after giving birth</a>. This is to check how their body responds to a spike in blood sugar after they’ve had the baby, and to develop a better picture of their likelihood of developing type 2 diabetes. </p>
<p>From that point, women who have had gestational diabetes should continue to have regular testing to see whether type 2 diabetes has developed.</p>
<p>Talk to your GP about how to best monitor diabetes risk factors. Diabetes Australia recommends a blood glucose test <a href="https://www.diabetesaustralia.com.au/gestational-diabetes">every one to three years</a>.</p>
<h2>2. Aim to eat healthily</h2>
<p>Dietary patterns that include vegetables and fruit, whole grains, fish and foods rich in fibre and monounsaturated fats are associated with a <a href="https://www.ncbi.nlm.nih.gov/pubmed/19531025">lower risk of developing type 2 diabetes</a>. </p>
<p>In more than 4,400 <a href="https://www.ncbi.nlm.nih.gov/pubmed/22987062">women with prior gestational diabetes</a>, those who had healthier eating patterns, assessed using diet quality scoring tools, had a 40-57% lower risk of developing type 2 diabetes compared with women with the lowest diet quality scores. </p>
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Read more:
<a href="https://theconversation.com/are-you-at-risk-of-being-diagnosed-with-gestational-diabetes-it-depends-on-where-you-live-112515">Are you at risk of being diagnosed with gestational diabetes? It depends on where you live</a>
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<p><a href="https://www.diabetesaustralia.com.au/glycemic-index">Glycaemic index</a> (GI) ranks carbohydrate-containing foods according to their effect on blood glucose levels. The lower the GI, the slower the rise in blood sugar levels after eating. Research suggests that a higher GI diet, and consuming lots of high GI foods (glycaemic load), is associated with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4144100/">a higher risk of developing type 2 diabetes</a>, while a lower GI diet <a href="https://care.diabetesjournals.org/content/36/12/4166">may lower the risk of type 2 diabetes</a>. </p>
<p>Take our <a href="https://heq-new.newcastle.edu.au/">Healthy Eating Quiz</a> to check how healthy your diet is and receive personal feedback and suggestions on how to boost your score.</p>
<h2>3. Be as active as possible</h2>
<p>Increasing your physical activity level <a href="https://www.ncbi.nlm.nih.gov/pubmed/24841449">can help lower your risk</a> of developing type 2 diabetes. </p>
<p>Engaging in 150 minutes of moderate-intensity exercise per week, such as walking for 30 minutes on five days a week; or accumulating 75 minutes of vigorous-intensity physical activity a week by swimming, running, tennis, cycling, or aerobics, is associated with <a href="https://www.ncbi.nlm.nih.gov/pubmed/24841449">a 45% lower risk of developing type 2 diabetes</a> after having had gestational diabetes. Importantly, both walking and jogging produced a similar lower risk of type 2 diabetes.</p>
<p>In contrast, prolonged time spent watching TV was associated with a <a href="https://www.ncbi.nlm.nih.gov/pubmed/24841449">higher risk of type 2 diabetes</a> in women with a history of gestational diabetes.</p>
<p>Strength training is also important. A large study of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5161704/">35,754 healthy women found those who engaged in any type strength training</a>, such as pilates, resistance exercise or weights, had a 30% lower rate of developing type 2 diabetes compared to women who did not do any type of strength training. </p>
<p>Women who did both strength training and aerobic activity had an even lower risk of developing either type 2 diabetes or heart disease.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/281945/original/file-20190701-105182-1popdwv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281945/original/file-20190701-105182-1popdwv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281945/original/file-20190701-105182-1popdwv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281945/original/file-20190701-105182-1popdwv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281945/original/file-20190701-105182-1popdwv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281945/original/file-20190701-105182-1popdwv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281945/original/file-20190701-105182-1popdwv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Breastfeeding has been shown to reduce the risk of type 2 diabetes, even in mums who haven’t had gestational diabetes.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<h2>4. Breastfeed for as long as you can</h2>
<p>Research shows <a href="https://www.ncbi.nlm.nih.gov/pubmed/23069624">breastfeeding for longer than three months</a> reduces the risk of developing type 2 diabetes by about 46% in women who have had gestational diabetes. It is thought that breastfeeding leads to improved glucose and fat metabolism.</p>
<p>The Nurses Health Study followed more than 150,000 women over 16 years. It found that for every additional year of breastfeeding, the <a href="https://www.ncbi.nlm.nih.gov/pubmed/16304074">risk of developing type 2 diabetes was reduced by 14-15%</a> – even in mothers who had not been diagnosed with gestational diabetes. </p>
<p>Organisations such as the <a href="https://www.breastfeeding.asn.au/">Australian Breastfeeding Association</a> and lactation consultants offer support to help all women, including those who have had gestational diabetes, to breastfeed their infants for as long as they choose. </p>
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Read more:
<a href="https://theconversation.com/want-to-breastfeed-these-five-things-will-make-it-easier-109507">Want to breastfeed? These five things will make it easier</a>
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</em>
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<h2>5. Keep an eye on your weight</h2>
<p>Weight gain is a known <a href="https://www.ncbi.nlm.nih.gov/pubmed/7872581">risk factor for developing type 2 diabetes</a>. In a study of 666 Hispanic women with previous gestational diabetes, a weight gain of 4.5kg during 2.2 years follow-up increased their risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/8551882">developing type 2 diabetes by 1.54 times</a>. </p>
<p>Another study saw 1,695 women with previous gestational diabetes followed up between eight to 18 years after their diagnosis. This research found that for each 5kg of weight gained, <a href="https://www.ncbi.nlm.nih.gov/pubmed/25796371">the risk of developing type 2 diabetes increased by 27%</a>. </p>
<p>Aiming to modify your eating habits and being as active as you can will help with weight management and <a href="https://www.ncbi.nlm.nih.gov/pubmed/28958344">lower the risk of developing type 2 diabetes</a>. Within interventions that support people to adopt a healthy lifestyle, one review found every extra kilogram lost by participants was <a href="https://www.ncbi.nlm.nih.gov/pubmed/29934481">associated with 43% lower odds of developing type 2 diabetes</a>. </p>
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Read more:
<a href="https://theconversation.com/health-check-whats-the-best-diet-for-weight-loss-21557">Health Check: what's the best diet for weight loss?</a>
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<img src="https://counter.theconversation.com/content/114298/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Clare Collins is affiliated with the Priority Research Centre for Physical Activity and Nutrition, the University of Newcastle, NSW. She is an NHMRC Senior Research and Gladys M Brawn Research Fellow. She has received research grants from NHMRC, ARC, Hunter Medical Research Institute, Meat and Livestock Australia, Diabetes Australia, Heart Foundation, Bill and Melinda Gates Foundation, nib foundation, Rijk Zwaan Australia and Greater Charitable Foundation. She has consulted to SHINE Australia, Novo Nordisk, Quality Bakers, the Sax Institute and the ABC. She was a team member conducting systematic reviews to inform the Australian Dietary Guidelines update and 2017 evidence review on dietary patterns for the Heart Foundation.</span></em></p><p class="fine-print"><em><span>Hannah May Brown is affiliated with the Priority Research Centre for Physical Activity and Nutrition at the University of Newcastle as a PhD Candidate. Hannah’s PhD is supported by an Australian Government Research Training Program (RTP) Scholarship and The Neville Eric Sansom Scholarship.</span></em></p><p class="fine-print"><em><span>Megan Rollo has received research funding from a number of bodies including the Bill & Melinda Gates Foundation, NIB Foundation, Australian Research Council, Diabetes Australia, Hunter Medical Research Institute, New South Wales Government (TechVoucher) and Novo Nordisk, and consulted to the Sax Institute and Quality Bakers Australia Pty Limited. She is affiliated with the Priority Research Centre in Physical Activity and Nutrition at the University of Newcastle and a member of professional organisations including the Dietitians Association of Australia.</span></em></p>Women who have had gestational diabetes during pregnancy are at higher risk of developing type 2 diabetes. But regular checks, a healthy diet and exercise are can help to manage this risk.Clare Collins, Professor in Nutrition and Dietetics, University of NewcastleHannah Brown, PhD Candidate Nutrition and Dietetics, University of NewcastleMegan Rollo, Postdoctoral Research Fellow, Nutrition & Dietetics, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1159782019-05-30T22:44:20Z2019-05-30T22:44:20ZGestational diabetes in the mother increases Type 1 and Type 2 diabetes risks for the whole family<figure><img src="https://images.theconversation.com/files/276152/original/file-20190523-187172-92y0cv.jpg?ixlib=rb-1.1.0&rect=0%2C120%2C6689%2C4094&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New research shows that diabetes is a family affair. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>You probably know someone with diabetes, as it is an increasingly common disease. In 2017, <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html">more than 425 million adults were living with diabetes, and more than 1,106,500 children were living with Type 1 diabetes</a>, globally. </p>
<p>There are <a href="https://www.diabetes.ca/diabetes-basics/what-is-diabetes">three common types of diabetes</a>. In Type 1, the body’s immune system attacks the cells that make insulin, the hormone that gets blood sugar (our body’s fuel) where it needs to go. In Type 2, the body makes insulin but the insulin cannot do its job. In both cases, blood sugar levels go up. </p>
<p>A third kind of diabetes, gestational diabetes, is temporary during pregnancy. However, our recent studies show that diabetes in one family member is related to diabetes in other family members. </p>
<p>Gestational diabetes in mothers is linked to future diabetes not only in the mothers themselves, but <a href="https://doi.org/10.1093/aje/kwx263">also in their partners</a> and <a href="https://doi.org/10.1503/cmaj.181001">children</a>.</p>
<h2>Couples share diabetes risk</h2>
<p>In most cases, Type 2 and gestational diabetes are related not only to genetics, but also to <a href="https://doi.org/10.1007/s10654-016-0176-0">lower physical activity</a> and <a href="https://doi.org/10.1093/aje/kwx095">less healthy ways of eating</a>. Improving eating and activity can <a href="https://doi.org/10.1007/s11892-003-0034-9">cut Type 2 diabetes risk by half</a>. A lot of studies have shown that many women with gestational diabetes go on to develop Type 2 diabetes in the <a href="https://doi.org/10.1016/S0140-6736(09)60731-5">decade after pregnancy</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276153/original/file-20190523-187172-1uczbux.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Couples often follow the same lifestyle patterns.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>We looked at data from about 70,000 couples who were parents in Quebec. We found that if the mother had gestational diabetes, the father was 20 per cent more likely to develop Type 2 diabetes in the <a href="https://academic.oup.com/aje/article/186/10/1115/3896096">10 years after pregnancy</a>. </p>
<p>If the mother had both gestational diabetes and gestational hypertension — temporary high blood pressure during pregnancy — the father was 80 per cent more likely to develop Type 2 diabetes in the future. </p>
<p>Couples share <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2091401">physical activity, eating</a> and <a href="https://www.nejm.org/doi/full/10.1056/NEJMsa066082">weight patterns</a>. We think that is why they share diabetes risk. </p>
<p>It’s time to share action: to improve health behaviours together and try to prevent diabetes development in the future.</p>
<h2>What about the kids?</h2>
<p>We had information on the children of the couples we studied, from birth to 22 years old. More than <a href="https://www.childhealthbc.ca/sites/default/files/10%2010%2018%20Status%20Report%20on%20the%20BC%20Pediatric%20Diabetes%20Program%20(Final).pdf">90 per cent of diabetes</a> that starts before the age of 22 in most Canadian provinces is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933641/">Type 1, not Type 2</a>. </p>
<p>The exception is Manitoba where there are many <a href="https://www.aadnc-aandc.gc.ca/eng/1100100020400/1100100020404">Indigenous Canadians</a>, an established <a href="https://guidelines.diabetes.ca/docs/cpg/Ch38-Type-2-Diabetes-and-Indigenous-Peoples.pdf">link with diabetes</a> and a <a href="https://doi.org/10.1016/j.jcjd.2012.04.013">high occurrence of Type 2 in young people</a>. </p>
<p><a href="http://care.diabetesjournals.org/content/39/12/2240.long">Studies from Manitoba</a> show a link between <a href="https://jamanetwork.com/journals/jamapediatrics/article-abstract/2684232">gestational diabetes in mothers and Type 2 in kids</a>. One study in Sweden showed a link between having either Type 2 or gestational diabetes in the mother and the <a href="https://link.springer.com/article/10.1007/s00125-015-3580-1">development of Type 1 in the kids</a>.</p>
<p>We found that between birth and 22 years, the kids of mothers with gestational diabetes were <a href="https://doi.org/10.1503/cmaj.181001">twice as likely to develop Type 1 diabetes</a>. If you had 5,000 young people whom you watched for two years, our results indicate that two of them would develop Type 1 if their mom did not have gestational diabetes. Four or five would develop Type 1 if their mom did have gestational diabetes. So it is rare, but it is important. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=426&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=426&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=426&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=535&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=535&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276150/original/file-20190523-187165-9vfp7m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=535&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A small percentage of children whose mother had gestational diabetes will go on to develop Type 1 or Type 2 diabetes.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>A study also from Quebec shows that one quarter of young people who develop Type 1 <a href="https://doi.org/10.1503/cmaj.170676">come to the hospital in a medical crisis</a> the first time they are diagnosed. The early signs of Type 1 may be missed: being really thirsty, having to urinate more often, a bit of blurry vision, some fatigue you can’t explain. </p>
<p>Understanding the link with gestational diabetes might be another useful piece of the puzzle — to push young people, their families and their healthcare providers to consider the possibility of diabetes, just as they do when their parents are known to have Type 1 or Type 2. </p>
<h2>Gestational diabetes is a family affair</h2>
<p>We don’t yet know why there is a link between gestational diabetes in mothers and Type 1 in young people. The important thing to remember though is that gestational diabetes is a family affair. </p>
<p>Future Type 2 diabetes can be prevented in many family members within the home environment — by eating more home-cooked healthy meals and lots of fruits and vegetables, by reducing fried foods and eating out and with a whole family emphasis on being active. </p>
<p>Type 1 diabetes, though rare, might also be diagnosed earlier in kids and teens, with an awareness of the link to mom’s gestational diabetes.</p>
<p>Finally, we need greater effort at the public health and policy levels to build awareness of diabetes risk and to support community-based diabetes prevention programs.</p><img src="https://counter.theconversation.com/content/115978/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaberi Dasgupta does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many couples share exercise, eating and weight patterns. Families of women with gestational diabetes and gestational hypertension more likely to develop Type 2 diabetes in the future.Kaberi Dasgupta, Professor of Medicine, McGill University; Physician-Scientist and Director of the Centre for Outcomes Research and Evaluation at the McGill University Health Centre, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1125152019-03-05T19:07:40Z2019-03-05T19:07:40ZAre you at risk of being diagnosed with gestational diabetes? It depends on where you live<figure><img src="https://images.theconversation.com/files/262051/original/file-20190305-92307-2xmyql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Gestational diabetes is diagnosed when women have elevated levels of sugar in their blood during pregnancy. But there's no international threshold.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/xTedodxYTuQ"> freestocks.org</a></span></figcaption></figure><p>Sarah lives in London. She is pregnant with her first child. Her mother had gestational diabetes and Sarah is told this puts her into a higher risk category for the condition, thus she should have a test. </p>
<p>At 26 weeks, she has a 75g fasting glucose test to see if she has gestational diabetes. The test requires fasting, drinking the equivalent of two cans of soft drink, and takes several hours. </p>
<p>The next week her doctor tells her the initial fasting blood test showed a blood glucose level of 5.5 millimoles per litre (mmol/l), and that the two-hour level was 7.5mmol/l. This means she is under the cut-off and so not diagnosed with gestational diabetes. She is delighted.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-rein-in-the-widening-disease-definitions-that-label-more-healthy-people-as-sick-76804">How to rein in the widening disease definitions that label more healthy people as sick</a>
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<p>Donna lives in Brisbane and is pregnant with her first child too. In Australia all women are tested for gestational diabetes and Donna is told to have a routine test for diabetes at 26 weeks. </p>
<p>She takes the same test which shows she has the same blood glucose level as Sarah. But because Donna lives in Australia she is diagnosed with gestational diabetes. Donna is devastated. </p>
<p>Donna was allocated a dedicated care provider when she was 15 weeks pregnant. But now she is considered “high risk” and is transferred to “standard care” where she has a different health provider every visit. She also has more medical appointments than before and sees a dietitian. </p>
<p>Since 2014, more Australian women have been diagnosed with gestational diabetes than in previous years and compared to women in other countries. But it’s not because they’re less healthy – it’s because the threshold for diagnosis has changed.</p>
<h2>What is gestational diabetes?</h2>
<p>Gestational diabetes mellitus (GDM) is a diagnosis some pregnant women receive when they have elevated blood sugar (glucose) in pregnancy. A diagnosis can occur in several ways. </p>
<p>Some are diagnosed with diabetes while pregnant but have blood glucose levels high enough to be similar to diabetes diagnosed outside of pregnancy. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/262055/original/file-20190305-92310-1mbgaqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/262055/original/file-20190305-92310-1mbgaqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/262055/original/file-20190305-92310-1mbgaqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/262055/original/file-20190305-92310-1mbgaqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/262055/original/file-20190305-92310-1mbgaqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/262055/original/file-20190305-92310-1mbgaqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/262055/original/file-20190305-92310-1mbgaqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some women diagnosed with gesational diabetes may still have lower blood sugar levels than those with diabetes who aren’t pregnant.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/RcgiSN482VI">Echo Grid</a></span>
</figcaption>
</figure>
<p>Others have glucose levels higher than normal and so are diagnosed with developing diabetes while pregnant but wouldn’t fulfil the usual criteria for diabetes if they weren’t pregnant. These two different women would be diagnosed with gestational diabetes.</p>
<p>Some women may have been diagnosed with diabetes before they were pregnant. These women would be diagnosed with pregestational diabetes. </p>
<p>These diagnostic pathways differ and the health risks to the mothers and babies diagnosed in these different pathways also differs, but all women are <a href="https://www.diabetesaustralia.com.au/managing-gestational-diabetes">treated the same</a>: their blood glucose levels are monitored and their diet restricted. </p>
<h2>Why does gestational diabetes worry clinicians?</h2>
<p>Several health problems can occur for mothers diagnosed with high glucose levels in pregnancy and their babies, including a higher risk of having a “big” baby. The average baby weighs just over 3kg but “big” babies are over the 90th percentile and weigh around 4kg. </p>
<p>Other risks include having a pre-term delivery, having a cesarean section and babies having low glucose levels at birth. Rarely, babies can have a stuck shoulder during birth.</p>
<p><strong>Chance of having a big baby</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/262062/original/file-20190305-92304-9cnke3.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/262062/original/file-20190305-92304-9cnke3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/262062/original/file-20190305-92304-9cnke3.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=234&fit=crop&dpr=1 600w, https://images.theconversation.com/files/262062/original/file-20190305-92304-9cnke3.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=234&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/262062/original/file-20190305-92304-9cnke3.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=234&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/262062/original/file-20190305-92304-9cnke3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=294&fit=crop&dpr=1 754w, https://images.theconversation.com/files/262062/original/file-20190305-92304-9cnke3.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=294&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/262062/original/file-20190305-92304-9cnke3.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=294&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Hyperglycemia and Adverse Pregnancy Outcome study cohort.</span>, <span class="license">Author provided</span></span>
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</figure>
<p><strong>Chance of having a cesarean section</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/262065/original/file-20190305-92289-12bcn7y.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/262065/original/file-20190305-92289-12bcn7y.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/262065/original/file-20190305-92289-12bcn7y.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=256&fit=crop&dpr=1 600w, https://images.theconversation.com/files/262065/original/file-20190305-92289-12bcn7y.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=256&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/262065/original/file-20190305-92289-12bcn7y.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=256&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/262065/original/file-20190305-92289-12bcn7y.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=322&fit=crop&dpr=1 754w, https://images.theconversation.com/files/262065/original/file-20190305-92289-12bcn7y.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=322&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/262065/original/file-20190305-92289-12bcn7y.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=322&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Hyperglycemia and Adverse Pregnancy Outcome study cohort</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p><strong>Chance of the baby sustaining a shoulder or other birth injury</strong> </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/262064/original/file-20190305-92289-1lagqhx.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/262064/original/file-20190305-92289-1lagqhx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/262064/original/file-20190305-92289-1lagqhx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=240&fit=crop&dpr=1 600w, https://images.theconversation.com/files/262064/original/file-20190305-92289-1lagqhx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=240&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/262064/original/file-20190305-92289-1lagqhx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=240&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/262064/original/file-20190305-92289-1lagqhx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=301&fit=crop&dpr=1 754w, https://images.theconversation.com/files/262064/original/file-20190305-92289-1lagqhx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=301&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/262064/original/file-20190305-92289-1lagqhx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=301&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Shoulder dystocia is where one of the baby’s shoulders becomes stuck behind the mother’s pelvic bone during childbirth.</span>
<span class="attribution"><span class="source">Hyperglycemia and Adverse Pregnancy Outcome study cohort</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Women diagnosed with gestational diabetes also often report feelings of self-blame, anxiety, confusion and stress of managing a new dietary regime. </p>
<h2>Why is Donna diagnosed and not Sarah?</h2>
<p>There is currently no internationally uniform definition of gestational diabetes. Experts disagree about the degree of glucose intolerance that poses a sufficiently increased risk to mother or baby. </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/19011170">multinational study published in 2009</a> was supposed to clarify the uncertainty but the results showed that increased glucose levels were a continuous risk for poor outcomes in pregnancy. There was no clear cut-off; the more glucose intolerant, the more risk to mother and baby. </p>
<p>An international group recommended a cut-off but different countries have adopted different testing regimes and cut-offs. </p>
<p>In Australia, the diagnostic criteria for gestational diabetes changed in 2014 with the aim to improve diagnostic accuracy and prevent harmful health outcomes for women and their babies. </p>
<p>This figure shows you how complicated it is. The glucose results of <a href="https://www.ncbi.nlm.nih.gov/pubmed/19011170">1,248 Brisbane women from the HAPO study</a> were matched to four different international criteria for gestational diabetes. Although 191 women would have met one or more criteria, only 30 (15%) met criteria for all four.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/261189/original/file-20190227-150715-szw8pi.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/261189/original/file-20190227-150715-szw8pi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/261189/original/file-20190227-150715-szw8pi.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=471&fit=crop&dpr=1 600w, https://images.theconversation.com/files/261189/original/file-20190227-150715-szw8pi.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=471&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/261189/original/file-20190227-150715-szw8pi.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=471&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/261189/original/file-20190227-150715-szw8pi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=592&fit=crop&dpr=1 754w, https://images.theconversation.com/files/261189/original/file-20190227-150715-szw8pi.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=592&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/261189/original/file-20190227-150715-szw8pi.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=592&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Abbreviations: ADIPS Australasian Diabetes in Pregnancy Society; IADPSG International Association of the Diabetes and Pregnancy Study Groups; NICE National Institute for Clinical Excellence; ACOG American College of Obstetricians and Gynecologists.</span>
<span class="attribution"><a class="source" href="https://www.ncbi.nlm.nih.gov/pubmed/29550360">Adapted from McIntyre HD, Gibbons KS, Lowe J, Oats JJN. Colour and pictures added.</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Testing processes can also differ. Australia has universal screening, with a one-step process where all women have a test for diabetes, and those who test positive are diagnosed. </p>
<p>New Zealand has a two-step confirmatory process where women who test positive on an initial test (around 25% of women) go onto have a second confirmatory test. Only women with a positive result in the second test are diagnosed with gestational diabetes. </p>
<p>In some countries, such as the United Kingdom and the Netherlands, only women with at least one risk factor for gestational diabetes will be offered testing. </p>
<h2>Rising rates in Australia</h2>
<p>Rates of gestational diabetes diagnoses in Australia <a href="http://adips-2018.p.asnevents.com.au/days/2018-08-24/abstract/53233">have increased</a> from 2% in 1990 to nearly 14% in 2017. </p>
<p>Some of this is due to the increasing age of women becoming pregnant, more women being overweight, more testing, and better recording. But much of the rise has occurred since 2014 when the Australian definition changed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weight-gain-during-pregnancy-how-much-is-too-much-89016">Weight gain during pregnancy: how much is too much?</a>
</strong>
</em>
</p>
<hr>
<p>The percentage of women diagnosed with gestational diabetes in Mackay in Far North Queensland <a href="https://www.ncbi.nlm.nih.gov/pubmed/29323444">increased from 9.8% to 19.6%</a> in the first year of the change. </p>
<p>In a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326329/">Melbourne hospital</a>, researchers found the percentage of women diagnosed with gestational diabetes increased from 5.9% in 2014 under the old criteria, to 10.3% in 2016 under the new criteria. </p>
<p>In both studies, there was little to no change in health outcomes for mothers or babies.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/262060/original/file-20190305-92280-1bix8ui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/262060/original/file-20190305-92280-1bix8ui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/262060/original/file-20190305-92280-1bix8ui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/262060/original/file-20190305-92280-1bix8ui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/262060/original/file-20190305-92280-1bix8ui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/262060/original/file-20190305-92280-1bix8ui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/262060/original/file-20190305-92280-1bix8ui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A diagnosis depends, at least in part, on where you live.</span>
<span class="attribution"><span class="source">Adi Saputra</span></span>
</figcaption>
</figure>
<p>So although there were significant increases in the number of women diagnosed with gestational diabetes, there are seemingly negligible health benefits.</p>
<p>However there were substantial health care costs. The Melbourne hospital above spent A$560,000 more caring for the additional women diagnosed with gestational diabetes under the criteria change. </p>
<p>Applying the same formula to the Australian population data, we estimate the net increase in Australian health costs due to the change in gestational diabetes criteria to be around A$28 million per year. </p>
<p>Guidelines and clinical practices are often revisited every two to five years, especially when there is emerging evidence of benefits or harms. It’s time to review how we define gestational diabetes and the impact on women, their babies and the Australian health system. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-risks-associated-with-gestational-diabetes-dont-end-after-pregnancy-96856">The risks associated with gestational diabetes don't end after pregnancy</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/112515/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rae Thomas works for the Centre for Research in Evidence-Based Practice and is supported by a NHMRC Program Grant. </span></em></p><p class="fine-print"><em><span>Julia Lowe was one of the researchers involved in the multi-national Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study which was published in 2008. Julia is a volunteer for the Australian Greens.</span></em></p><p class="fine-print"><em><span>Clare Heal does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sarah and Donna are 26 weeks pregnant and have the same blood sugar levels. But while Donna is diagnosed with gestational diabetes, Sarah is spared from the label. It comes down to where she lives.Rae Thomas, Associate professor, Bond UniversityClare Heal, Professor, Promotional Chair, James Cook UniversityJulia Lowe, Conjoint Associate Professor, School of Medicine and Public Health Faculty of Health and Medicine, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/968562018-06-25T19:56:24Z2018-06-25T19:56:24ZThe risks associated with gestational diabetes don’t end after pregnancy<figure><img src="https://images.theconversation.com/files/221317/original/file-20180601-88495-14z7dyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women who've had gestational diabetes are at an increased risk of health problems down the track. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>In Australia <a href="https://www.diabetesaustralia.com.au/gestational-diabetes">12-14% of pregnancies</a> are affected by gestational diabetes. Despite its prevalence, most people aren’t aware the risks don’t end when the pregnancy does.</p>
<p>Diabetes occurs when the level of glucose (sugar) in the blood is higher than normal. Cells in the pancreas control blood glucose levels by producing insulin. When these cells are destroyed, type 1 diabetes results. When the body becomes resistant to the action of insulin and not enough insulin can be made, this is known as type 2 diabetes. </p>
<p>Resistance to insulin action occurs for many reasons, including increasing age and body fat, low physical activity, hormone changes, and genetic makeup. </p>
<p>Gestational diabetes occurs when high blood glucose levels are detected for the first time during pregnancy. Infrequently, this is due to previously undiagnosed diabetes. More commonly, the diabetes is only related to pregnancy. Pregnancy hormones reduce insulin action and increase insulin demand, in a similar way to type 2 diabetes, but usually after the baby is born, hormones and blood glucose levels go back to normal.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weight-gain-during-pregnancy-how-much-is-too-much-89016">Weight gain during pregnancy: how much is too much?</a>
</strong>
</em>
</p>
<hr>
<h2>Who gets gestational diabetes?</h2>
<p>Factors that increase the risk of gestational diabetes include: </p>
<ul>
<li><p>a strong family history of diabetes</p></li>
<li><p>weight above the healthy range</p></li>
<li><p>non Anglo-European ethnicity</p></li>
<li><p>being an older mum. </p></li>
</ul>
<p>Weight is the major risk factor that can be changed. But in some cases, gestational diabetes may develop without any of these risk factors. </p>
<p>Rates of gestational diabetes in Australia have approximately doubled in the last decade. Increased testing for gestational diabetes, changing population characteristics, and higher rates of overweight and obesity may have contributed to this. There are likely to be other factors we do not fully understand.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/girls-with-early-first-periods-become-women-with-greater-risk-of-gestational-diabetes-73913">Girls with early first periods become women with greater risk of gestational diabetes</a>
</strong>
</em>
</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/222725/original/file-20180612-52445-1nhkgf4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/222725/original/file-20180612-52445-1nhkgf4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/222725/original/file-20180612-52445-1nhkgf4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/222725/original/file-20180612-52445-1nhkgf4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/222725/original/file-20180612-52445-1nhkgf4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/222725/original/file-20180612-52445-1nhkgf4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/222725/original/file-20180612-52445-1nhkgf4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/222725/original/file-20180612-52445-1nhkgf4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">All women with a history of gestational diabetes should have a yearly medical check-up.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Ongoing effects</h2>
<p>If gestational diabetes is not well managed, there’s greater risk of complications during pregnancy and childbirth for both mother and baby, including high blood pressure, premature birth, having a large baby, or needing a caesarean section. With good pregnancy care, healthy eating, physical activity and the use of medications such as insulin or metformin (which lowers blood glucose levels) where needed, many of these problems can be avoided. </p>
<p>A blood test six to twelve weeks after childbirth can confirm if the diabetes has gone away. After this it can be tempting to forget about the gestational diabetes altogether. Unfortunately, however, we know this is not necessarily the end of the diabetes journey.</p>
<p>In recent years, we’ve realised women with gestational diabetes have a higher risk of developing health problems later in life. Pregnancy is a special kind of “metabolic test”. It unmasks potential problems of resistance to insulin action, or inadequate insulin production which were hidden before pregnancy.</p>
<p>The risk of type 2 diabetes in women who have had gestational diabetes is up to <a href="https://www.ncbi.nlm.nih.gov/pubmed/19465232">seven times that</a> of women who haven’t.</p>
<p>Compared to women without gestational diabetes, the risk of developing <a href="https://www.ncbi.nlm.nih.gov/pubmed/24576544">high blood pressure</a> and <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002488">heart disease</a> is nearly tripled.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/27174368">Research also suggests</a> children of gestational diabetes pregnancies have higher risk of being overweight and having diabetes as they grow up. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28583472">In some studies</a>, diabetes was increased up to four times. As more women are having gestational diabetes, this could be one contributor to escalating rates of diabetes and obesity, especially in young people.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/better-health-and-diet-well-before-conception-results-in-healthier-pregnancies-94400">Better health and diet well before conception results in healthier pregnancies</a>
</strong>
</em>
</p>
<hr>
<h2>Changing the future</h2>
<p>Gestational diabetes should be seen as an opportunity to identify families at higher risk of metabolic problems and take action. All women with a history of gestational diabetes should have a yearly medical check-up and management of weight, blood pressure, cholesterol, and other risk factors for heart disease.</p>
<p><a href="http://care.diabetesjournals.org/content/41/Supplement_1/S137">Guidelines suggest</a> testing for diabetes every one to three years, depending on risk. Knowing a woman’s diabetes status before her next pregnancy is important. </p>
<p>We need to better understand who is at highest risk and research which interventions will reduce that risk. In the meantime, those in health care should recommend lifestyle changes that reduce body fat, such as healthy eating and physical activity. These changes can be adopted by the whole family. </p>
<p>Women should aim to lose the excess weight gained during pregnancy and be within or closer to their healthy weight range. <a href="https://www.ncbi.nlm.nih.gov/pubmed/26595611">Breastfeeding is beneficial</a> for preventing weight gain and potentially even diabetes. </p>
<p>Gestational diabetes is a window into the future health of women and their children. With appropriate education, support, monitoring and preventative action, this glimpse into the future allows us to change our destiny.</p><img src="https://counter.theconversation.com/content/96856/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Gestational diabetes should be seen as an opportunity to identify families at higher risk of metabolic problems and take action.Allison Sigmund, Dietitian/Clinical Trial Manager, Western Sydney UniversitySue Lynn Lau, Endocrinologist, Western Sydney UniversitySusan Hendon, Reseach Trial Manager/Midwife, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/907562018-04-04T21:27:44Z2018-04-04T21:27:44ZHow compassion can triumph over toxic childhood trauma<figure><img src="https://images.theconversation.com/files/212866/original/file-20180402-189795-keekl0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New research shows that when mothers who have experienced childhood trauma feel supported by the people around them -- such as therapists, physicians, friends and neighbours -- their risk of pregnancy complications is substantially reduced.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>In a recent piece on the television show <em>60 Minutes</em>, Oprah Winfrey discussed <a href="https://www.cbsnews.com/news/oprah-winfrey-treating-childhood-trauma/">childhood trauma</a> — shining a public spotlight on the lasting effects of abuse and adversity in childhood. Oprah herself is a survivor of childhood abuse. </p>
<p>Adverse childhood experiences, commonly called ACEs, include witnessing verbal or physical conflict between parents and having a parent with a mental illness or substance-abuse issue. They also include parent separation, divorce and incarceration and the experience of neglect or abuse (sexual, physical or emotional) as a child. </p>
<p>ACEs are common. Approximately <a href="http://europepmc.org/abstract/med/21160456">60 per cent of the general population</a> report experiencing at least one before the age of 18. More than eight per cent of the population report experiencing four or more ACEs. </p>
<p>Research has consistently found that the more adverse childhood experiences a person has, the greater their risk for later health problems. </p>
<p>Our <a href="https://www.sciencedirect.com/science/article/pii/S0749379717306517">research group</a> investigates how ACEs affect women’s physical and psychological health in pregnancy. We study how adversities are “inherited” or <a href="http://pediatrics.aappublications.org/content/early/2018/03/16/peds.2017-2495">passed from parent to child</a>, as well as how the risks of ACEs in pregnant women can be reduced. </p>
<p>Our latest finding suggests that <a href="https://link.springer.com/article/10.1007/s00737-018-0826-1">when mothers who have experienced ACEs feel supported by the people around them, their risk of having pregnancy complications is substantially reduced</a>. In essence, feeling supported by friends and family can counteract the negative effects of having ACEs. </p>
<h2>From liver disease to early death</h2>
<p>Adverse childhood experiences increase the risks of many health challenges later in life. These include mental health problems like <a href="http://www.jad-journal.com/article/S0165-0327(04)00028-X/abstract">depression</a>, <a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.456.757&rep=rep1&type=pdf">alcohol and drug abuse and suicide attempts</a>.</p>
<p>They also include health risk behaviours, such as <a href="https://doi.org/10.1016/S2468-2667(17)30118-4">smoking, sexually transmitted diseases</a> and <a href="https://dx.doi.org/10.1038/sj.ijo.0802038">obesity</a>, as well as diseases like <a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.456.757&rep=rep1&type=pdf">heart, lung and liver disease</a>. </p>
<p>For example, an individual who has experienced four or more ACEs is <a href="https://doi.org/10.1016/S2468-2667(17)30118-4">four times more likely to experience a mental health problem</a> than someone who has not. </p>
<p>People with <a href="http://dx.doi.org/10.1016/j.amepre.2009.06.021">a high number of ACEs may even be at risk for early death</a>.</p>
<h2>Toxic stress and the body</h2>
<p>When children are exposed to abuse and adversity, they experience heightened levels of stress without a strong support system to help them through these difficult experiences. This is <a href="http://www.albertafamilywellness.org/resources/video/toxic-stress">often referred to as “toxic stress.”</a> </p>
<p>This stress is different from the tolerable types of stress that can help with development — such as learning to make new friends, going to a new school or taking a test. </p>
<p>Experiencing high levels of toxic stress during abusive or traumatic experiences can alter how our brain and body process future experiences and stressful events. Toxic stress impacts how we think and learn. </p>
<p>How does this happen? Toxic stress can cause excessive “wear and tear” on the body. It primes our system to be hyper-sensitive to stressors. This wear and tear builds up over time and can lead to both physical and mental health problems throughout our life. </p>
<p>When adults become parents, the effects that ACEs have had on their own body, mind and behaviour can influence how they experience their pregnancy and their pregnancy health. It can affect how they are able to interact with, and care for, their children. </p>
<h2>Babies with developmental delays</h2>
<p>In our work, we’ve shown that <a href="https://doi.org/10.1016/j.jpeds.2017.04.052">mothers who experience a higher number of ACEs are more likely to have gestational diabetes and hypertension</a>. </p>
<p>They are also more likely to deliver a baby who is born too small or too soon or needs intensive care. </p>
<p>Even if the baby is born full term, children born to mothers with ACEs are at risk of developmental delay. For each additional maternal ACE, there is an <a href="http://pediatrics.aappublications.org/content/141/4/e20172826">18 per cent increase in the risk</a> that their child will be identified as delayed.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/212868/original/file-20180403-189801-q1w4yt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/212868/original/file-20180403-189801-q1w4yt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/212868/original/file-20180403-189801-q1w4yt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/212868/original/file-20180403-189801-q1w4yt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/212868/original/file-20180403-189801-q1w4yt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/212868/original/file-20180403-189801-q1w4yt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/212868/original/file-20180403-189801-q1w4yt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Health professionals can help new parents burdened by childhood adversity simply by supporting and listening to them.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Ultimately, we have found that the effects of adversity can be passed down from one generation to the next. </p>
<p>However, with the right supports in place, our work also reveals that mothers can show remarkable resilience to adversity. </p>
<h2>Compassion is protective</h2>
<p>What helps promote resilience in the face of stress and adversity? How do we help families triumph over past experiences?</p>
<p>For some, even just being aware of how past adversities and traumas can impact their current functioning, including physical and mental health, is an important first step. This can start the road to recovery. Some people may benefit from additional counselling and professional support to launch them into a brighter future. </p>
<p>For others, it’s the compassionate response they receive when they talk to someone about their early experiences. </p>
<p>Oprah Winfrey and others have wisely encouraged people to replace saying “what’s wrong with you?” with “what happened to you?” — to allow for a more compassionate and understanding approach to individual experiences, including trauma and adversity. </p>
<p>Oprah describes her main protective factor from adversity as school, and pinpoints certain teachers who encouraged her intellectually and creatively. School and caring teachers helped her to feel valued and gave her a sense of belonging, helping heal the emotional wounds of abuse. </p>
<h2>How to foster resilience</h2>
<p>Supportive relationships are indeed a key ingredient for change. Support from friends, family, spouses or neighbours can boost the quality and security of life for people. </p>
<p>Community supports also matter. For example, our work suggests that when women participate in low-cost community programs and recreation, such as story time at the library, and <a href="http://dx.doi.org/10.1136/bmjopen-2016-012096">when they can be encouraged to develop or engage in social support networks, their children do better</a>.</p>
<p>Investing in families with young children makes financial sense too. Strategies that <a href="https://heckmanequation.org/resource/invest-in-early-childhood-development-reduce-deficits-strengthen-the-economy/">help new parents develop supports and parenting skills have a particularly high return on investment</a> — improving outcomes for parents, children and their families and avoiding later, higher-cost interventions.</p>
<p>Whether we have been affected by ACEs or not, we can all play a role in fostering resilience by being the buffering support to our friends, family members and neighbours. </p>
<p>Using <a href="https://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf">a trauma-informed approach to patient care</a>, health professionals can also play a central role simply by supporting and listening to patients burdened by childhood adversity. </p>
<p>The silver lining is that ACEs don’t define who we are or who we can become. </p>
<p>With supports, people who have endured ACEs can achieve emotional and physical well-being. It is compelling to realize that many people struggling with past adversity can identify support from teachers, neighbours, spouses and friends as instrumental in overcoming their adversities. </p>
<p>Each and every one of us can help make a difference in someone’s life. </p>
<p><em>Individuals are encouraged to speak to a physician or health care professional if they have concerns about how their adverse experiences might be impacting their functioning. For helpful resources and information on the science of early adversity visit The <a href="http://www.albertafamilywellness.org/">Alberta Family Wellness Initiative</a> or Harvard University’s <a href="https://developingchild.harvard.edu/">Center on the Developing Child</a>.</em></p><img src="https://counter.theconversation.com/content/90756/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sheri Madigan receives funding from Social Sciences and Humanities Research Council, the Canada Research Chairs program, and the Alberta Children's Hospital Foundation.</span></em></p><p class="fine-print"><em><span>Nicole Racine receives funding from the Social Sciences and Humanities Research Council, the Alberta Children's Hospital Research Institute, and the University of Calgary Cumming School of Medicine. </span></em></p><p class="fine-print"><em><span>Suzanne Tough receives funding from the Alberta Childrens Hospitial Foundation, the Social Sciences and Humanities Research Council, the Canadian Institutes of Health Research, the Owerko Centre and the Max Bell Foundation </span></em></p>Childhood trauma impacts women’s health and can be passed from parent to child. New research shows that when new mothers feel supported, the risk of pregnancy complications is reduced.Sheri Madigan, Assistant Professor, Canada Research Chair in Determinants of Child Development, Alberta Children’s Hospital Research Institute, University of CalgaryNicole Racine, Postdoctoral Research Fellow, University of CalgarySuzanne Tough, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/768042017-05-15T20:10:17Z2017-05-15T20:10:17ZHow to rein in the widening disease definitions that label more healthy people as sick<figure><img src="https://images.theconversation.com/files/169258/original/file-20170515-3659-3iadt0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical panels are constantly lowering thresholds across many diseases, which results in more and more healthy people being diagnosed as sick.</span> <span class="attribution"><a class="source" href="https://unsplash.com/search/crowd?photo=45sjAjSjArQ">José Martín/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>In the early 1990s a small meeting of experts, part-funded by drug companies, <a href="http://www.bmj.com/content/350/bmj.h2088">decided on a new definition</a> of the bone condition osteoporosis. Historically, the label was limited to people who had fractures, but with the coming of new technology that could see someone’s bone density, doctors started broadening the definition to include healthy people considered at risk of a fracture.</p>
<p>The experts arbitrarily and controversially created a new cut-off for diagnosis that classified more than a quarter of all post-menopausal women as having the “disease”. The following year (1995) pharmaceutical company <a href="http://www.health.harvard.edu/diseases-and-conditions/whats_the_story_with_fosamax">Merck launched Fosamax</a>, a drug for osteoporosis that would soon become a multi-billion-dollar blockbuster.</p>
<p>In 2008 a guideline from the United States National Osteoporosis Foundation <a href="https://www.ncbi.nlm.nih.gov/pubmed/19049330">further increased the numbers</a>, with a recommendation that more than 70% of white women over 65 should take osteoporosis drugs. With medication, of course people benefit by avoiding a fracture. But many of those at low risk will suffer more harm than good, unnecessarily taking potentially harmful drugs. </p>
<p>Osteoporosis is just one condition that has had its definitions widen over time and, with that, the pool of people diagnosed as having it. An article published today in the journal <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2626860">JAMA Internal Medicine</a> outlines the first serious attempt to set some global rules for those experts who move diagnostic goalposts that label more people as sick.</p>
<p>Medical panels are constantly changing diagnostic cut-offs and lowering thresholds to classify many conditions and diseases. Those changes determine whether we or our loved ones receive a diagnosis that might help us – by, for example, giving us access to a life-saving treatment – or harm us – by bringing the anxiety, cost and danger of an unneeded medical label. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/169263/original/file-20170515-3675-b1t2w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/169263/original/file-20170515-3675-b1t2w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/169263/original/file-20170515-3675-b1t2w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=326&fit=crop&dpr=1 600w, https://images.theconversation.com/files/169263/original/file-20170515-3675-b1t2w0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=326&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/169263/original/file-20170515-3675-b1t2w0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=326&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/169263/original/file-20170515-3675-b1t2w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=409&fit=crop&dpr=1 754w, https://images.theconversation.com/files/169263/original/file-20170515-3675-b1t2w0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=409&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/169263/original/file-20170515-3675-b1t2w0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=409&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Osteoporosis has had its definitions widen over time and, with that, the pool of people diagnosed as having it.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>New ‘pre’-diseases</h2>
<p>Widening disease definitions have been central to <a href="https://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">the problem of overdiagnosis</a>, where classifying previously healthy people as sick can lead to more harm than good. </p>
<p>For instance, minor memory or cognitive changes are increasingly being seen as symptoms of a condition called “<a href="https://theconversation.com/the-perils-of-pre-diseases-forgetfulness-mild-cognitive-impairment-and-pre-dementia-8702">pre-dementia</a>”. This label can potentially be applied to a third of people over the age of 65. Some of them may never have dementia, yet are faced with the anxiety and stigma of a possible, eventual diagnosis.</p>
<p>Another example is the emergence of “pre-diabetes”, which labels 30% to 50% of all adults, depending on the diagnostic criteria used. “Pre-diabetes” is a controversial term used to describe a blood sugar level above normal, but below that of someone with diabetes. </p>
<p>While some argue the label may bring benefits – for example, by encouraging healthier lifestyles – such a dramatic widening could do much harm. As one <a href="http://www.bmj.com/content/349/bmj.g4485">article in the BMJ journal</a> states: </p>
<blockquote>
<p>A label of pre-diabetes brings problems with self-image, insurance and employment as well as the burdens and costs of health care and drug side effects.</p>
</blockquote>
<p>Then there’s <a href="http://www.bmj.com/content/348/bmj.g1567">gestational diabetes</a> – the type diagnosed in pregnant women. In 2010 a global panel – which influences how the condition is diagnosed in many places, including Australia – recommended changes to the diagnosis that would double or even triple the numbers of pregnant women labelled. The decision was taken on the basis of new evidence suggesting benefits for mother and baby diagnosed at the new lower thresholds.</p>
<p>Yet when an independent group convened at the <a href="https://consensus.nih.gov/2013/docs/Gestational_Diabetes_Mellitus508.pdf">United States National Institutes of Health</a> in 2013 took a close look at the 2010 decision, they rejected it. The reviewers cited a lack of convincing evidence newly diagnosed women would benefit from treatment. They also raised concerns about additional costs to the health system, and unintended consequences of labelling, such as an increased rate of caesarean births and related patient costs.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/169272/original/file-20170515-3672-1bjbrin.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/169272/original/file-20170515-3672-1bjbrin.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/169272/original/file-20170515-3672-1bjbrin.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=762&fit=crop&dpr=1 600w, https://images.theconversation.com/files/169272/original/file-20170515-3672-1bjbrin.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=762&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/169272/original/file-20170515-3672-1bjbrin.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=762&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/169272/original/file-20170515-3672-1bjbrin.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=957&fit=crop&dpr=1 754w, https://images.theconversation.com/files/169272/original/file-20170515-3672-1bjbrin.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=957&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/169272/original/file-20170515-3672-1bjbrin.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=957&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Pre-diabetes is used to describe a blood sugar level above normal, but below that of someone with diabetes.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Reforming new diagnoses</h2>
<p>A <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">recent study</a> of changes to the definitions of more than a dozen common conditions, including high blood pressure, depression and asthma, found three things. </p>
<p>First, the expert panels of doctors who made these changes often decided to widen definitions classifying more people as patients. Generally, the motivation was that treating milder problems, or finding diseases earlier, would benefit the newly diagnosed.</p>
<p>Second, these panels did not rigorously investigate the downsides of that expansion; none examined how many people would be overdiagnosed. </p>
<p>And, third, most panel members had financial relationships with drug companies that stood to benefit from panel decisions. </p>
<p>Following that study, a global body that sets guiding rules for these panels – the <a href="http://www.g-i-n.net/home">Guidelines International Network</a> – set up a working group in 2014 to consider the problem of widening disease definitions. It included members with a range of experience, from genetics to guideline development, as well as from the World Health Organisation.</p>
<p>Following a review of the literature and consultation, the group created a short common-sense checklist of questions being published today in <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2626860">JAMA Internal Medicine</a>. These questions are intended for expert panels to think about, before they decide to widen definitions and move the medical goalposts. Some of them include:</p>
<ul>
<li>What are the differences between the old and new disease definition?</li>
<li>How will the new definition change the numbers of people diagnosed?</li>
<li>What are the potential benefits for those classified under the new definition?</li>
<li>What are the potential harms for those diagnosed and society?</li>
</ul>
<p>This new guidance might seem somewhat abstract. But it directly affects all of us. The next step is to test how the new guidance works in practice, where panels of experts are actually considering a change to a disease definition.</p><img src="https://counter.theconversation.com/content/76804/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Ray Moynihan receives funding from the National Health and Medical Research Council, via an Early Career Fellowship. He is also co-chair of the scientific steering committee for the Preventing Overdiagnosis international scientific conference. </span></em></p><p class="fine-print"><em><span>Rita Horvath is an advisory member on the board of the National Prescribing Service, a not-for-profit government organisation that advises GPs on rational test utilisation to avoid inappropriate diagnosis. She is also a member of the Pathology Clinical Committee.</span></em></p>More of us are labelled as sick with the constantly changing diagnostic cut-offs for diseases. Now an international expert panel has drafted a list of things to consider before setting new thresholds.Ray Moynihan, Senior Research Fellow, Bond UniversityRita Horvath, Honorary Professor at Sydney University & Conjoint Professor at UNSW, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/739132017-03-07T19:24:30Z2017-03-07T19:24:30ZGirls with early first periods become women with greater risk of gestational diabetes<figure><img src="https://images.theconversation.com/files/159701/original/image-20170307-20756-1i9knd9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In Western societies, average age of first period has dropped from 17 to 13 years over the past century. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/justanotherhuman/27448588632/in/photolist-HPxc79-4pN4PD-foCbk5-55ucKn-qVJgbB-4Kyj2S-fnXLsA-4kq3Lh-55yGqb-p177e3-4CnSjg-nwez1e-foBtCh-avGoyL-9qk8P4-foAzxb-fnJtpB-fondQ8-fo5oXG-nPmnCe-r1iASv-dxTNMh-foBnxC-4kq345-4Uufqh-a3b1gZ-pJfqWe-9F4dKY-foAzL7-ddVKBU-fnXTvw-nyYn36-gP7CjH-d4sSE5-foCaMj-4kq3Ys-bpFkbt-4UpZxP-gN7gLp-cdKSvN-biHqSa-fo4LA5-55uuUH-fomgWa-7ANPHM-5u3bw8-4km1ep-vsKHF-foBrp7-Qh156i">justanotherhuman/flickr </a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>As a young girl, getting your period for the first time is a big deal. It comes with mental and social expectations around “becoming a woman” and a host of cultural practices that act to celebrate or stigmatise menstruation. </p>
<p>But <a href="https://academic.oup.com/aje/article-lookup/doi/10.1093/aje/kww201">evidence</a> now suggests the timing of this event could also have health implications for girls who get their first period earlier than their peers. </p>
<p>During puberty our bodies change and sexually mature, and a girl’s first period is an important point in this process. The age when girls get their first period varies, however younger than 12 years is generally considered to be “early”. The possibility that a first period before the age of 12 is linked with pregnancy health was explored in our <a href="https://academic.oup.com/aje/article-lookup/doi/10.1093/aje/kww201">recent study</a>. We found that girls who had early first periods were more likely to develop diabetes when they later became pregnant as an adult. </p>
<p>Gestational diabetes is a <a href="https://www.diabetesaustralia.com.au/gestational-diabetes">serious pregnancy complication</a>, as it increases the risk of pre-term labour and giving birth to a large baby. It is also considered a “stress test” for the later development of type 2 diabetes; both the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990903/">mother</a> and <a href="http://diabetes.diabetesjournals.org/content/60/7/1849">child</a> in affected pregnancies face a six to seven fold increased risk of developing type 2 diabetes. </p>
<h2>Age of first period and diabetes during pregnancy</h2>
<p>We studied a group of more than 4,700 women from the <a href="http://www.alswh.org.au">Australian Longitudinal Study on Women’s Health</a> (also known as Women’s Health Australia). This longitudinal study has collected detailed health and well-being information from the same women at multiple points in time over the past 20 years. The women were 18-23 years old in 1996 when the study started. The women reported on the age of their first period and were followed throughout their pregnancies. </p>
<p>Most women experienced their first period between age 12 and 13, but 12% had early first periods. We found girls who had their first periods before age 12 were more likely to be from a disadvantaged background in childhood. They were also more likely to report being overweight in childhood and in adult life, compared with women who had their first period at a later age. While taking these early life and adulthood characteristics into account, women with earlier first periods were still <a href="https://academic.oup.com/aje/article-lookup/doi/10.1093/aje/kww201">50% more likely to develop diabetes during pregnancy</a>. </p>
<h2>Is the age at first period changing?</h2>
<p>The age of first menstruation has decreased in most Western countries, from an <a href="https://www.ncbi.nlm.nih.gov/pubmed/16757103">average of 17 more than a century ago, to around 13 today</a>. This decline seems to have <a href="http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-10-175">stabilised</a>, however discussion persists about whether the trend is continuing at a slower rate. The initial decline is likely explained by improved health and nutrition. The more recent declines may also be largely attributable to environmental and lifestyle factors. </p>
<p>We know circumstances in early life – including <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287288/">psychosocial stressors</a>, such as parental divorce and abuse, as well as <a href="http://www.sciencedirect.com/science/article/pii/S1043276009000587">childhood obesity</a> – can trigger early reproductive development. Other <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065309/">recent environmental changes</a> – such as the use of hair products, plastic water bottles, and food packaging – have also been examined as a possible cause of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958977/">early age at first period</a>.</p>
<h2>What does this mean for women’s health?</h2>
<p>An early transition to adulthood can be characterised by increased stresses and challenges as girls have to adapt to their new social roles. Girls with an early first period are at greater risk of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2927128/">depression and anxiety</a>, and display higher rates of risky-behaviours such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892192/">smoking, drinking, illicit drug use</a>, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/19958543">unprotected sex</a>. </p>
<p>The falling age of first menstruation is concerning as it also increases the risk of health conditions. In addition to the higher risk of <a href="https://academic.oup.com/aje/article-lookup/doi/10.1093/aje/kww201">diabetes during pregnancy</a> found in our study, early menstruation has also been shown to increase the risk of developing chronic conditions in later life, such as <a href="http://link.springer.com/article/10.1007%2Fs00592-014-0579-x">type 2 diabetes</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488186/">breast cancer</a>. </p>
<h2>What can we do?</h2>
<p>Ideally we would one day be able to prevent girls from having their first period too early, but there is no one single cause that determines when this happens. However, supporting healthy environments and behaviours from early in life are important strategies. Childhood obesity is a well-known factor increasing the likelihood of early age at first period. Given that <a href="http://www.aihw.gov.au/overweight-and-obesity/">one in four children in Australia are overweight or obese</a>, promoting healthy eating and physical activity should be a priority for young mothers, schools, and health policy. </p>
<p>Clinicians including GPs and specialists, who provide advice and treatment for women, should be aware of the importance of early age at first menstruation as a potential marker of future health issues. Early monitoring and advice on a healthy diet and weight and physical activity may help women to lower these risks.</p><img src="https://counter.theconversation.com/content/73913/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Girls who have their first period at a young age are more likely to experience poorer health as a adult, including an elevated risk of diabetes during pregnancy.Danielle Schoenaker, PhD Candidate and Research Officer, The University of QueenslandGita Mishra, Professor of Life Course Epidemiology, Faculty of Medicine, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/569242016-03-31T19:20:35Z2016-03-31T19:20:35ZResisting expanding disease empires: why we shouldn’t label healthy people as sick<figure><img src="https://images.theconversation.com/files/116871/original/image-20160331-28472-11ghdvy.jpg?ixlib=rb-1.1.0&rect=0%2C95%2C1600%2C970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Expanding the definitions of disease can cause a cascade of overtesting and overtreatment.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/ftmeade/7349088852/">Fort George G. Meade Public Affairs Office/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>You might have heard the frightening news last year suggesting half of all Americans had some form of diabetes. A <a href="http://jama.jamanetwork.com/article.aspx?articleid=2434682">survey in the journal JAMA</a> was covered extensively, including by <a href="http://www.nbcnews.com/health/diabetes/half-americans-have-diabetes-or-high-blood-sugar-survey-finds-n423491">NBC</a>, <a href="http://www.webmd.com/diabetes/news/20150908/diabetes-prediabetes-americans">WebMD</a> and the <a href="http://www.latimes.com/science/la-sci-sn-diabetes-study-20150908-story.html">Los Angeles Times</a>. </p>
<p>But as the <a href="http://www.healthnewsreview.org/2015/09/half-of-americans-have-diabetes-or-pre-diabetes-really-what-does-that-mean/">HealthNewsReview blog</a> later pointed out, almost none of the media coverage raised questions about the expanding definition of diabetes or the controversial new “pre-diabetes”, <a href="https://content.govdelivery.com/accounts/USCDC/bulletins/13b4f85">claimed to afflict</a> close to 90 million Americans. </p>
<p>Part of the expanding empires of disease, the creation of new “pre-conditions” is turning millions of people into patients across the globe. We now have pre-osteoporosis, pre-hypertension and pre-dementia – and, like pre-diabetes, all of them are controversial. </p>
<p>An <a href="http://www.bmj.com/content/349/bmj.g4485">article in The BMJ</a> (British Medical Journal) in 2014 asked bluntly “whether it is worth having the category of pre-diabetes at all”. It suggested the term go into cold storage until it was clear that the millions of people being labelled with it would actually benefit. </p>
<p>“Rather than turning healthy people into patients with pre-diabetes,” argued two distinguished professors in The BMJ, “we should use available resources to change the food, education, health and economic policies that have driven this epidemic.” </p>
<h2>Diagnosis creep</h2>
<p>As I explain in an editorial on this problem of “diagnosis creep” in <a href="http://www.australianprescriber.com/">the journal Australian Prescriber</a> today, there is an urgent need for much greater scepticism about the expanding empires of disease – and we’re not just talking about pre-diseases. </p>
<p>A dramatically expanded definition of “chronic kidney disease” gives a label to around one in ten adults, and almost half of the elderly, many of whom will never suffer any kidney disease, chronic or otherwise. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116873/original/image-20160331-6126-1afmtu8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The creation of new</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/dfid/15834977505/">DFID - UK Department for International Development/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>New diagnostic criteria will almost triple the numbers of pregnant women who are labelled as having gestational diabetes – without good evidence that the newly labelled women or their babies will benefit. </p>
<p>And thresholds that define attention-deficit hyperactivity disorder (ADHD) continue to fall, which means even more children and now adults will be diagnosed.</p>
<h2>Early diagnosis is a double-edged sword</h2>
<p>Medicine is transforming more and more formerly healthy people into patients and building ever bigger potential markets for the industries that sell treatments. </p>
<p>Some of the newly labelled patients will benefit – early detection can mean deadly disease is stopped in its tracks. </p>
<p>But early diagnosis is a double-edged sword. For other people with mild problems or at very low risk of future illness, a diagnosis can bring more harm than good. It can cause a cascade of overtesting and overtreatment and waste precious resources better spent on those in greatest need. </p>
<p>A few years ago, colleagues and I analysed changes made by expert panels of doctors to the definitions of 14 common conditions, including high-blood pressure, depression, arthritis and Alzheimer’s disease. Our study was published in the international journal <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">PLOS Medicine</a> and was covered on <a href="https://theconversation.com/how-diseases-get-defined-and-what-that-means-for-you-16965">The Conversation</a>. </p>
<p>In summary, most conditions were expanded – including high blood pressure, Alzheimer’s disease, high cholesterol, depression, rheumatoid arthritis, multiple sclerosis and myocardial infarction or heart attack. Pre-diseases were created, thresholds for diagnosis were lowered, or the processes used to diagnose were changed so that people would be diagnosed and labelled earlier. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116874/original/image-20160331-28443-q29qmn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There’s no evidence to suggest patients benefit from expanded definitions.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-133606469/stock-photo-man-reading-prescription-bottle.html?src=EEiSdHN_5TmJiOIks_-e0g-3-11">Burlingham/Shutterstock</a></span>
</figcaption>
</figure>
<p>No panel rigorously investigated and reported on the potential downside of their decision to expand – the danger that some people might be caught unnecessarily by the newly widened definitions. </p>
<p>No panels reported on the possibility that the new patients created by the new definitions might be “<a href="https://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">overdiagnosed</a>” – they might be labelled with a disease that would never harm them, or be given a diagnosis and treatment that would do them more harm than good. </p>
<h2>An epidemic of conflicts of interest</h2>
<p>Perhaps most disturbingly, among the panels of experts who included disclosure sections in their publications, 75% revealed multiple financial ties to around seven drug companies each. </p>
<p>These influential doctors – who were deciding whether millions of people around the world would be defined as healthy or sick – were being paid directly by pharmaceutical companies for activities like speaking, consulting, advising or researching. </p>
<p>This epidemic of conflicts of interest is in direct contrast to recommendations from organisations like the prestigious <a href="http://www.nationalacademies.org/hmd/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx">US Institute of Medicine</a>, which is calling for much greater independence among those who write influential medical guidelines. </p>
<p>Some of the conflicts are unbelievable. Among the expert guideline panel that in 2003 created a diagnostic category called “pre-hypertension” or pre-high blood pressure, <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">80% of members disclosed ties</a> to an average of around 12 companies each, including companies selling drugs for high blood pressure. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116877/original/image-20160331-28476-14ttq53.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Exercise a healthy scepticism about how new diseases are defined.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-328829339/stock-photo-blurred-image-people-sitting-in-hospital-room.html?src=7cShDS-DUX7sE_FJiZOZLQ-1-58">NanD_PhanuwatTH/Flickr</a></span>
</figcaption>
</figure>
<p>More than half of the members of the 2011 panel that described “pre-dementia” and defined “pre-clinical” Alzheimer’s disease <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">had financial ties</a> to around five companies each. </p>
<p>It was a similar situation for the <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">2012 psychiatric panels</a> that widened the definitions of depression and attention-deficit hyperactivity disorder. More than half of the experts disclosed links to drug companies, including those that could directly benefit by selling drugs to expanded patient populations.</p>
<h2>Reforming unhealthy disease definitions</h2>
<p>There is a growing unease about these expanding empires of disease and the epidemics of conflicts of interest among those driving the expansion. </p>
<p>A series in The BMJ is <a href="http://www.bmj.com/content/347/bmj.f4247">examining expanding disease definitions</a> and the risk of overdiagnosis. It has already included articles on the controversy over gestational diabetes, attention-deficit hyperactivity disorder, chronic kidney disease, pre-dementia, mild hypertension, osteoporosis and pulmonary embolism. </p>
<p>A group of GPs in the UK have successfully lobbied the Royal College of General Practitioners to set up a standing committee to address overdiagnosis. <a href="http://bjgp.org/content/66/644/116.long">Some of them last month called for</a> a “grassroots revolution” to tackle this problem. </p>
<p>Across Europe, the new “quaternary prevention” movement is also gathering strength. This doctor-led movement is aimed at preventing people receiving diagnoses that may do them more harm than good. </p>
<p>Globally, the Guidelines International Network – an umbrella group for all medical guidelines – has <a href="http://www.g-i-n.net/working-groups/overdiagnosis">just created an overdiagnosis working group</a> to push the process of reform. </p>
<p>At the same time, many global initiatives are addressing the problem of too much medicine, including <a href="http://www.choosingwisely.org.au/home">Choosing Wisely</a>, <a href="http://lowninstitute.org/">The Right Care campaign</a> and the international <a href="http://www.preventingoverdiagnosis.net">Preventing Overdiagnosis conferences</a>, the fourth being held in Barcelona this September. </p>
<p>But until we see genuine reform of the conflicted panels that define diseases – greater independence, more broadly representative and much more interested in both the benefits and harms of their decisions – a healthy scepticism about expanding definitions is highly recommended. </p>
<p><em>This ideas in this article are based on a piece published today in the peer-reviewed journal <a href="http://www.australianprescriber.com/">Australian Prescriber</a>.</em></p><img src="https://counter.theconversation.com/content/56924/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Ray Moynihan and colleagues have recently received funding from the NHMRC to investigate the problems of overdiagnosis and overtreatment. Ray is a Senior Research Fellow at Bond University, and an honorary Senior Research Fellow at the Sydney Medical School - Public Health. He is also co-chair of the scientific committee for the Preventing Overdiagnosis international conference, taking place in September 2016. </span></em></p>The creation of new “pre-conditions” is turning millions of people into patients across the globe.Ray Moynihan, Senior Research Fellow, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/503272015-11-12T04:48:57Z2015-11-12T04:48:57ZPregnancy diabetes is a red flashing light that we can’t ignore<figure><img src="https://images.theconversation.com/files/101068/original/image-20151106-16273-174q1zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The diabetes self-test: up to 16% of pregnant women are positive</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=gestational%20diabetes&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=174171077">Image Point Fr</a></span></figcaption></figure><p>Most people are well aware of two of the <a href="http://www.diabetes.co.uk/diabetes-types.html">main forms of diabetes</a> – type 1, which usually first appears in young people; and the more common type 2, which often emerges in the over 40s and is associated with obesity and sedentary lifestyles. We hear far less about the third form, gestational diabetes, which <a href="http://www.news-medical.net/news/20100226/Over-1625-of-pregnant-women-diagnosed-with-gestational-diabetes.aspx">temporarily affects</a> as many as 16% of pregnant women. </p>
<p>Gestational diabetes is defined as glucose intolerance that is first diagnosed during pregnancy. Women with gestational diabetes are unable to produce enough insulin to meet the extra demands of carrying a child, the risk of which increases with each successive pregnancy. For the majority of them, the condition is diagnosed during the second or third trimester. Many of the risk factors, such as age, obesity and family history, <a href="http://www.mayoclinic.org/diseases-conditions/gestational-diabetes/basics/risk-factors/con-20014854">are the same as</a> those for type 2 diabetes. And, <a href="https://www.diabetes.org.uk/About_us/News/Number-of-people-diagnosed-with-diabetes-reaches-32-million/">just like</a> type 2 diabetes, many countries have seen prevalence rates rise over the past few decades. </p>
<h2>Risky business</h2>
<p>Most women with gestational diabetes return to normal glucose tolerance after delivery, but there are immediate risks for both mother and baby. These include spontaneous pre-term labour, delivering a large baby, <a href="http://www.nhs.uk/Conditions/respiratory-distress-syndrome/Pages/introduction.aspx">infant respiratory distress syndrome</a> and <a href="http://www.nhs.uk/conditions/cardiomyopathy/Pages/Introduction.aspx">heart muscle diseases</a>. </p>
<p>But gestational diabetes is also associated with an increased risk of developing type 2 diabetes in later life: seven times that of the general population. This equates to a staggering 50% chance of developing type 2 diabetes within ten years. The children of women who have had gestational diabetes <a href="https://www.diabetes.org.uk/About_us/News/Gestational-diabetes-and-children/">are also</a> six times more at risk of developing type 2 diabetes as the general population. </p>
<p>Women with gestational diabetes are not unaware of these risks. Claire Eades, a University of Stirling researcher, <a href="http://www.biomedcentral.com/1471-2393/15/11">recently interviewed</a> some Scottish women who had had the condition. At the time of diagnosis, most had worried about the possible side effects to the baby, and talked graphically about their fears of delivering a big baby. Some changed their lifestyles during pregnancy as a result. </p>
<p>The women usually also knew their increased risk of type 2 diabetes, having been told by their healthcare professionals. But once they had delivered a healthy baby and returned to normal glucose tolerance, many quickly forgot. One compared gestational diabetes to maternity clothes – put away and forgotten until the next pregnancy. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/101070/original/image-20151106-24388-18yhnni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/101070/original/image-20151106-24388-18yhnni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/101070/original/image-20151106-24388-18yhnni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/101070/original/image-20151106-24388-18yhnni.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/101070/original/image-20151106-24388-18yhnni.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/101070/original/image-20151106-24388-18yhnni.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/101070/original/image-20151106-24388-18yhnni.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/101070/original/image-20151106-24388-18yhnni.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Healthy baby, why worry?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=6KUT8Z4whIsvuBX2HZbP8w&searchterm=mother%20and%20baby&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=159151331">LiAndStudio</a></span>
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</figure>
<h2>The case for action</h2>
<p>Since the risks of type 2 diabetes can be reduced by taking more exercise, a healthy diet and maintaining a healthy weight, we need to find ways to encourage this where it is needed. The later stages of pregnancy and early stages of motherhood are hardly the best time when women are dealing with big life changes and pressing demands on time and energy. </p>
<p>To date, there have been few attempts to measure which kinds of interventions are best to encourage women to take the best steps – which possibly reflects the scale of the challenge. There is <a href="http://www.ncbi.nlm.nih.gov/pubmed/23861824">some evidence</a> that women are more likely to respond positively if the interventions include face-to-face interaction either with peers or professionals, if their partners are involved, and if the women are offered childcare support. We’ve been asking women who have had gestational diabetes about what they think would be the best kinds of interventions to try out. </p>
<p>We probably also need to remind women of the increased risk of type 2 diabetes more regularly once the early-motherhood period has passed. It is therefore time to think about raising the profile of gestational diabetes across the whole population. It offers a big opportunity to gain ground in the fight against diabetes. World diabetes rates <a href="http://www.diabetes.co.uk/diabetes-prevalence.html">are set to rise 50%</a> to nearly 600m by 2035 – and the disease has <a href="http://blogs.novonordisk.com/easd2013/files/2013/09/060213-Diabetes_Flashcard_Types.pdf">been described</a> as a global pandemic. So long as gestational diabetes is out of sight and out of mind except during pregnancy, we won’t be able to use it to make people aware of the importance of a healthy lifestyle and to prevent more cases of type 2. Instead, it offers a big opportunity to gain ground in the fight against diabetes.</p><img src="https://counter.theconversation.com/content/50327/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Josie receives funding from the Medical Research Council and the Chief Scientist Office</span></em></p>It affects nearly one in five women, and half go on to develop type 2 diabetes. It’s one of the great intervention opportunities that public health overseers keep ignoring.Josie Evans, Reader in Public Health, University of StirlingLicensed as Creative Commons – attribution, no derivatives.