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Corresponding author at: Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, Bangladesh. Tel.: +88 01721 512282; fax: +81 29 853 3092.
Affiliations
Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, BangladeshGraduate School of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, BangladeshNational Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, BangladeshShahid Ziaur Rahman Medical College, Bogra, Bangladesh
Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, BangladeshShahid Ziaur Rahman Medical College, Bogra, Bangladesh
Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, BangladeshGraduate School of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
Health & Disease Research Center for Rural Peoples (HDRCRP), Ena Arista, Flat # B-3, House # 802, Road # 3, Baitul Aman Housing Society, Adabor, Shamoli, Dhaka 1207, BangladeshGraduate School of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
The prevalence of gestational diabetes mellitus (GDM) has important health complications for both mother and child and is increasing all over the world. Although prevalence estimates for GDM are not new in developed and many developing countries, data are lacking for many low-income countries like Bangladesh.
Objective
To evaluate the prevalence of GDM in Bangladesh.
Research design and methods
This cross-sectional study included 3447 women who consecutively visited the antenatal clinics with an average gestation age of 26 weeks. GDM was defined according to WHO criteria (fasting plasma glucose [FPG] ≥7.0 mmol/L or 2-h ≥7.8 mmol/L) and the new ADA criteria (FPG ≥5.3 mmol/L or 2-h ≥8.6 mmol/L OGTT). We also calculated overt diabetes as FPG ≥7.0 mmol/L.
Results
Prevalence of GDM was 9.7% according to the WHO criteria and 12.9% according to the ADA criteria in this study population. Prevalence of overt diabetes was 1.8%. Women with GDM were older, higher educated, had higher household income, higher parity, parental history of diabetes, and more hypertensive, compared with non-GDM women.
Conclusion
This study demonstrates a high prevalence of GDM in Bangladesh. These estimates for GDM may help to formulate new policies to prevent and manage diabetes.
Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy, defined as glucose intolerance with onset or first recognition during pregnancy [
Intrauterine exposure to maternal diabetes is associated with higher adiposity and insulin resistance and clustering of cardiovascular risk markers in Indian children.
Screening for gestational diabetes at antenatal booking in a Malaysian university hospital: the role of risk factors and threshold value for the 50-g glucose challenge test.
]. However, to date no study has been conducted in Bangladesh. Like many developing countries, Bangladesh is also experiencing a high prevalence of diabetes [
]. In order to effectively manage this condition in a cost effective manner in a low-income country like Bangladesh, it is imperative to identify mothers with GDM early on in their pregnancy. In this manner, lifestyle interventions and treatment may prevent the development of diabetes and other health complications both for mother and offspring, and to avoid high treatment costs. The aim of this study was to determine the prevalence of GDM for the first time among women in Bangladesh by using the World Health Organization (WHO) and the new American Diabetes Association (ADA) criteria.
2. Data and methodology
2.1 Study design
A base-line survey was done in 12 Upzillas of 6 districts under 3 divisions during 2012–2013 in Bangladesh. Twelve GDM corners were established in antenatal clinics, where antenatal care was offered to all pregnant women. A total of 4890 pregnant women, with an average gestation age of 26 weeks, participated in this study. We used the WHO STEPS approach (modified), which entails a stepwise collection of risk factor data based on standardized questionnaires covering the following parameters: demographic characteristics, somatic illnesses, somatic and mental symptoms, medications, life style, and health-related behavior (step 1), basic physical measures (step 2) and basic biochemical investigations, such as blood glucose and cholesterol (step 3). The study was approved by the Ethical Committee of the Health and Disease Research Center of Rural Peoples (HDRCRP), Dhaka, Bangladesh, and conforms to the principles outlined in the Helsinki Declaration. All subjects gave their written informed consent prior to participation.
2.2 Study subjects
Of the 4890 subjects, we excluded 1410 subjects who were not fasting. Among the 3480 subjects, who had an oral glucose challenge test (OGCT), 624 women were found to have an abnormal OGCT (≥7.8 mmol/l). Of the 624 subjects who were advised to have an oral glucose tolerance test (OGTT), 591participated and 33 dropped out. Ultimately a total of 3447subjects were included in the present study.
2.3 Anthropometric and other variables
Well-trained examiners conducted anthropometric measurements on individuals wearing light clothing and without shoes. Height was measured to the nearest 0.1 cm using the portable stadiometer. Weight was measured in an upright position, to the nearest 0.1 kg, using a calibrated balance beam scale. Body mass index (BMI) was calculated as the body weight (kg) divided by the square of the body height (m2). Blood pressure was measured twice in the right arm in a sitting position using a standard mercury manometer and cuff, to the nearest 2 mmHg, with the initial reading taken at least 5 minutes after the subject was made comfortable, and again after an interval of 15 min. The average systolic blood pressure (SBP) and diastolic blood pressure (DBP) were then estimated. Hypertension was defined as SBP ≥140 or DBP ≥90 or taking antihypertensive medication. Number of parity, history of still birth or abortion, parental history of diabetes, parental history of hypertension, respondent's education, and household income were self-reported.
2.4 Assessment for GDM
All pregnant women were first screened for GDM using a 1-h 50 g OGCT, performed in the morning after an overnight fast. As we performed a fasting GCT we also measured fasting plasma glucose (FPG) using a glucometer. Subjects with abnormal 1-h blood glucose level (≥7.8 mmol/l) proceeded to an OGTT within one week of the abnormal screening test. Women with abnormal OGCT had a standard 2-h OGTT with a 75-g glucose load administered after a 12–14-h fast with blood collected fasting and 1-h and 2-h.
GDM was defined according to the 1999 WHO criteria – FPG ≥7.0 mmol/L or 2-h ≥7.8 mmol/L [
WHO Consultation: definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO Consultation. Part 1: diagnosis and classification of diabetes mellitus.
World Health Organization,
Geneva, WHO/NCD/NCS/99.21999
International Association of Diabetes and Pregnancy Study Groups Consensus Panel International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy.
International Association of Diabetes and Pregnancy Study Groups Consensus Panel International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy.
Differences in anthropometric and socio-demographic characteristics between subjects with GDM and non-GDM were assessed by t-test and Chi-square test for continuous and categorical variables, respectively. Mean ± S.D. and percentage were presented, where appropriate. Two-sided P values of less than 0.05 were considered statistically significant. All analyses were performed using Stata version 12.0 (StataCorp, College Station, Texas, USA).
3. Results
The mean age of our study population was 22 ± 4 years (mean ±SD), with a median schooling of 7 years. Among the pregnant women only 7.7% had a basic knowledge about GDM. Only 51.6% women were receiving antenatal care during their pregnancy.
Table 1 shows the characteristics of the study population who completed the OGCT. The majority (38.4%) were in the 20–24 year age group, education below 5 years (43.8%), and household income more than 15,000 Tk (31.1%). More than half of the pregnant women were zero parity women (51.5%) and had normal BMI (18.5–23.0) (55.3%).
Table 1Characteristics of study population completing a 1-h OGCT test.
Table 2 shows total and age-specific prevalence of GDM and overt diabetes. The total prevalence of GDM was 9.7% according to WHO criteria and 12.9% according to the ADA criteria. The prevalence of overt diabetes was 1.8% using the ADA criterion. The prevalence of GDM increased significantly with increased age for both ADA and WHO criteria. Fig. 1 shows the overlap of GDM cases diagnosed by the ADA and WHO criteria.
Table 2Age-specific prevalence of gestational diabetes mellitus (GDM) and overt diabetes.
Table 3 shows age-adjusted prevalence of GDM for WHO criteria according to the characteristics of the study population. GDM was higher among women with higher education, higher monthly household income, and those who had higher parity. Prevalence was also higher among women with hypertension, currently seeking antenatal care, no previous history of still birth/abortion, and parental history of hypertension and diabetes.
Table 3Age-adjusted prevalence of GDM according to WHO criteria.
Table 4 shows differences in anthropometric and socio-demographic characteristics of the study population according to GDM. There were significant differences in age, education, monthly household income, parity, presence of hypertension, parental history of diabetes, and those who were seeking antenatal care during pregnancy (P < 0.05 for all).
Table 4Differences in anthropometric and socio-demographic characteristics according to gestational diabetes mellitus (GDM) status (WHO criteria).
This is the first study to estimate the prevalence of GDM in Bangladesh. We also compared prevalence according to WHO and ADA criteria. We found that the prevalence of GDM was 9.7% according to WHO criteria and 12.9% according to the ADA criteria and the prevalence of overt diabetes was 1.8% according to ADA criterion.
The prevalence of GDM observed and reported here (9.6% and/or 12.9%) is comparable with other studies published from South Asian and South East Asian countries, including India, Sri Lanka, and Malaysia [
Screening for gestational diabetes at antenatal booking in a Malaysian university hospital: the role of risk factors and threshold value for the 50-g glucose challenge test.
]. Thus, prevalence of GDM seems greater in developing countries from Asians. However, it is important to note that the prevalence of GDM varies widely according to the specific cut-off points used in the various studies. The variation may be also due to time lag, specific study subject, environmental diversity, dietary habits, and other national or sub-national socio-behavioral factors. It is also difficult to compare disease prevalence, particularly for diabetes, with results from older literature because of the rapid epidemiologic and demographic transitions occurring in most developing countries.
In this study, presence of GDM was significantly higher among older, higher educated, higher household income, higher parity and hypertensive women. Consistent with our study, previous studies had been shown higher age was associated with GDM [
] indicating that older age is an independent risk factor for GDM irrespective of race and ethnicity. In a previous study, Bener et al. did not find a significant difference between education, household income, and GDM status of women [
]. In our study higher education and higher income groups were more likely to engage in sedentary work that may relate to obesity and GDM. Obesity and associated type 2 diabetes or cardiovascular disease are a growing challenge in developing world [
], wherein higher parity and gestational hypertension were significantly associated with GDM. Also prevalence of GDM was higher among women with parental history of hypertension and as with other studies, parental history of diabetes was associated with GDM [
]. Thus, women with higher parity, presence of hypertension, and parental history diabetes should be considered a high-risk group and compulsory screening should be considered in these specific groups of pregnant women.
There are some limitations to our study. We only performed OGTT in women who had abnormal OGCT and there will be some women with a normal OGCT who would have GDM if they had an OGTT. On the other hand, a greater proportion of women with an abnormal OGCT is likely to have an abnormal OGTT which would tend to exaggerate the prevalence of GDM. The combined effect of these on the overall prevalence of GDM is not known. Another limitation relates to cross-sectional design of our study which could have resulted in selection bias during case recruitment because we only examined pregnant women who had an antenatal check-up during a limited time interval and in selected clinics, and thus the results may not be generalizable to all Bangladeshi women.
In conclusion, this study shows a relatively high prevalence of GDM in Bangladeshi women and suggests screening for glucose intolerance in pregnancy should be considered as part of routine antenatal care. This information is also important in order to develop effective and targeted preventive approaches to complications associated with GDM in both the mothers and their offspring and to formulate new policies or strategies to increase awareness, prevention, and management of diabetes among pregnant women in Bangladesh.
Conflict of interest
The authors declare that they had no conflict of interest.
Author contributions
SJ wrote the report and overall conducted this research. SA analyzed the data and contributed to potential scientific discussion. MMI contributed to the epidemiological survey. HA, OO, MM, SK and TM contributed to scientific supervision of this work and contributed to discussion. All authors read and approve the final version.
Acknowledgments
This work was supported by Grant-in-Aid for Scientific Research (overseas academic) from the Ministry of Education, Culture, Sports, Science and Technology of Japan ( 23406037 , 23406016 , 23406029 , 24406026 , 25305034 ), and Japan Society for the promotion of Science . Current project (WDF11-610) on gestational diabetes from World Diabetes Foundation (WDF), Denmark to HDRCRP has also supported a part of this work.
References
American Diabetes Association
Diagnosis and classification of diabetes mellitus.
Intrauterine exposure to maternal diabetes is associated with higher adiposity and insulin resistance and clustering of cardiovascular risk markers in Indian children.
Screening for gestational diabetes at antenatal booking in a Malaysian university hospital: the role of risk factors and threshold value for the 50-g glucose challenge test.
WHO Consultation: definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO Consultation. Part 1: diagnosis and classification of diabetes mellitus.
World Health Organization,
Geneva, WHO/NCD/NCS/99.21999
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