Date Published: September 9, 2019
Publisher: Public Library of Science
Author(s): Tawanda Chivese, Shane A. Norris, Naomi S. Levitt, Huixia Yang
Abstract: BackgroundGlobal data indicate that women with a history of hyperglycemia first detected in pregnancy (HFDP) are at up to 7 times risk of progressing to type 2 diabetes mellitus (T2DM) compared with their counterparts who have pregnancies that are not complicated by hyperglycemia. However, there are no data from the sub-Saharan African region, which has the highest projected rise in diabetes prevalence globally. The aim of this study was to determine the proportion of women who progress to T2DM and associated risk factors 5 to 6 years after HFDP in Cape Town, South Africa.Methods and findingsAll women with HFDP, at a major referral hospital in Cape Town, were followed up 5 to 6 years later using a cross-sectional study. Each participant had a 75 g oral glucose tolerance test; anthropometric measurements and a survey were administered. A total of 220 participants were followed up. At this time, their mean age was 37.2 years (SD 6.0). Forty-eight percent (95% CI 41.2–54.4) progressed to T2DM, 5.5% (95% CI 3.1–9.4) had impaired fasting glucose, and 10.5% (95% CI 7.0–15.3) had impaired glucose tolerance. Of the participants who progressed to T2DM, 47% were unaware of their diabetes status. When HFDP was categorized post hoc according to WHO 2013 guidelines, progression in the diabetes in pregnancy (DIP) group was 81% (95% CI 70.2–89.0) and 31.3% (95% CI 24.4–39.3) in the gestational diabetes mellitus (GDM) category. Factors associated with risk of progression to T2DM were; at follow-up: waist circumference (odds ratios [OR] 1.1, 95% CI 1.0–1.1, p = 0.007), hip circumference (OR 0.9, 95% CI 0.8–1.0, p = 0.001), and BMI (OR 1.1, 95% CI 1.0–1.3, p = 0.001), and at baseline: insulin (OR 25.8, 95% CI 3.9–171.4, p = 0.001) and oral hypoglycaemic treatment during HFDP (OR 4.1, 95% CI 1.3–12.9, p = 0.018), fasting (OR 2.7, 95% CI 1.5–4.8, p = 0.001), and oral glucose tolerance test 2-hour glucose concentration at HFDP diagnosis (OR 4.3, 95% CI 2.4–7.7, p < 0.001). Our findings have limitations in that we did not include a control group of women without a history of HFDP.ConclusionsThe progression to T2DM in women with previous HFDP found in this study highlights the need for interventions to delay or prevent progression to T2DM after HFDP. In addition, interventions to prevent HFDP may also contribute to reducing the risk of T2DM.
Partial Text: Sub-Saharan Africa, compared with other regions, is expected to have the greatest increase in the number of people living with diabetes by the year 2040, with more than half the people affected unaware of their diabetes status . Since 2015, diabetes has already risen to be the second leading cause of death, after tuberculosis, in South Africa . The prevalence of obesity, the strongest known risk factor for type 2 diabetes, has increased across the world, and more so in African women, with a recent meta-analysis showing that in this group, mean body mass index (BMI) increased from 22 kg/m2 in 1980 to 25 kg/m2 in 2014 . In South Africa, the combined obesity and overweight prevalence increased from 29% to 40% in men and 57% to 70% in women during the period of 2002 to 2016 [4,5]. Other drivers of the diabetes epidemic, such as poor nutrition and decreased physical activity, have also increased during the last 2 decades . Further, HIV antiretroviral therapy–induced lipodystrophy may also increase risk of diabetes, especially in women of childbearing age, who are disproportionally affected by HIV, compared with their male counterparts . In view of the current high burden of diabetes and the expected rise in diabetes prevalence, it is imperative to identify populations at elevated risk and introduce risk-lowering interventions.
Of the 498 eligible women, 220 (44.2%) participated in the follow-up study, 234 (47.0%) could not be contacted, and 44 (8.8%) could not participate (Fig 1). There were no major differences between participants who were followed up and those lost to follow-up, except that participants who followed up had a higher mean BMI at booking and a lower mean OGTT 2-hour glucose concentration at the time of HFDP diagnosis (S1 Table).
Our major findings are that in women 5 to 6 years post HFDP, only 36.4% had normal glucose tolerance; 47.7% had progressed to T2DM, of whom 47% were previously undiagnosed, 5.5% had IFG, and 10.9% IGT. When we further categorized the HFDP post hoc using modified WHO 2013 GDM criteria, progression to T2DM was 83% and 31% in the DIP and GDM categories, respectively. Factors associated with risk of T2DM were fasting and OGTT 2-hour glucose concentration at HFDP diagnosis, oral hypoglycaemic and insulin treatment during HFDP, primary school education, BMI, and waist and hip circumferences at follow-up.
Almost half of the women with a history of HFDP progress to T2DM within 5 to 6 years, with almost half of them undiagnosed, in Cape Town, South Africa. There is a need for postpartum screening and interventions to reduce the risk of progression.