DIABETES, LIKE any other non-communicable disease is caused by genetic and environmental factors; both of them play a vital and complementary role.
`The genetic factor loads the gun and environment triggers it off.' Thus despite genetic susceptibility to develop diabetes, the environment has to trigger the onset of the disease. The environment that triggers the disease could be intrauterine and/or extrauterine.
Ideal strategy
Primary prevention is ideal. This would mean to keep genetically or otherwise susceptible individuals `normoglycemic,' not only preventing diabetes from developing. In this aspect of primary prevention, women with gestational diabetes are an ideal group to target.
Pregnant women who develop glucose intolerance during pregnancy are at lifetime risk of developing diabetes after a varying period of life. Their children face the same fate too. Thus two generations are at risk.
The hyperglycemic intrauterine environment predisposes the offspring to develop diabetes in the future.
This fact has been proved in animal models. In Wistar rats with a low genetic risk of diabetes, exposure to hyperglycemia in utero, significantly increases the risk of diabetes in adult life. An almost similar observation was made in human beings.
The offspring of Pima Indians who were in utero when their mother had diabetes had a greater risk of diabetes than their earlier siblings born before their mother developed diabetes.
Yet another study documented that the offspring of gestational diabetic mothers have diminished early insulin secretion on oral glucose tolerance test and mean insulin secretion rate during glucose infusion. They are prone to develop diabetes in later life due to their compromised insulin secretary capacity.
An epidemiological study in Pima Indians has established the fact that intrauterine hyperglycemia milieu plays a role. The children born to gestational diabetic mothers were followed up. By 35 years of age more than 50 per cent of them had developed glucose intolerance.
The epidemic of Type 2 diabetes in Pima Indians was almost entirely accounted to the increased exposure to abnormal glucose during pregnancy.
To detect the development of abnormal glucose tolerance during pregnancy, screening had to be performed in the pregnant mother. The screening is usually recommended between 24-28th gestational weeks.
Studies have shown that detection and correction of glucose intolerance in the later half of pregnancy do not help in achieving normal birth weight of the newborns.
Good foetal outcome
The early screening for glucose intolerance during pregnancy and correction with changed meal plan or insulin results in good foetal outcome; the newborn baby has ideal body weight.
So, preventive measures starting during the intrauterine period should be given the top priority in any diabetes prevention programme.
No single period in human development provides a greater potential for long-range `pay-off' via relatively short-range period of enlightened metabolic manipulation.
Preventive medicine starts before birth. People who missed this opportunity still have scope for the prevention.
The other option still exists to prevent progress from mild glucose tolerance to diabetes. Lifestyle modifications like regular exercise and adopting healthy food habits delay the progression of disease.
Effective alternative
The drug intervention has also proved to be an effective alternative therapy for the prevention of development of diabetes. This disease modifying effort is known as `post primary prevention'.
Even after the manifestation of the disease, a person could lead a full life despite diabetes, if that person maintains the blood glucose as close to normal as possible.
Two landmark studies, Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Studies (UKPDS) have proved that good sugar control prevents and delay's the development of complications.
The benefits are much more if the blood pressure and cholesterol are kept in check. These measures are considered as secondary prevention.
Thus there are a number of windows of opportunities from "intrauterine to extrauterine life" in the prevention of diabetes.
DR. V. SESHIAH
Diabetes Care and Research Institute, Chennai
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