Gestational diabetes (GD) is well recognised, routinely screened for and managed impeccably in joint antenatal/endocrine clinics. Labour and delivery are closely scrutinised but once the baby has been checked, the future is left to chance. A paper by Buchanan and Page (2011; summarised alongside) defines best practice in people with GD who do not immediately progress to diabetes, highlighting the importance of frequent follow-up, regular blood tests and the fundamental point of not forgetting that this group runs a very high risk of developing type 2 diabetes.
Follow-up ensures that advice and support is ongoing and means that individuals who ultimately develop diabetes receive the early intensive treatment that the UKPDS (UK Prospective Diabetes Study) defines as crucial (Holman et al, 2008).
GD is not the only factor that confers a high risk of diabetes – obesity, family history and ethnicity also do. The Quality and Outcomes Framework obesity register is pointless as it promotes no action. Why not a “diabetes risk” register that prompts annual or 6-monthly blood tests?
Having a history of GD indicates that full blown diabetes may develop; thus it should be possible to ensure screening takes place.
The authors found that GD leads to macrosomia and so the children of mothers with GD are also at risk of developing the condition. The prospect of adding this to an “at risk” register is complex, but raising parental awareness could help to improve infant and childhood nutrition.
The paper also alludes to the highly debated trial of diet and physical activity upon diagnosis of diabetes prior to drug therapy being implemented. The authors argue lucidly that diet and lifestyle can help to prevent diabetes in high-risk individuals and is a key part of treatment alongside drugs once the diagnosis is made. The strong message here, backed by the UKPDS “legacy effect” (Holman et al, 2008), is that early intensive treatment should include pharmacotherapy.
The controversy is whether drug therapy should be used in high-risk individuals prior to a formal diagnosis of diabetes. Buchanan and Page assert that there is little evidence, but XENDOS (Xenical in the Prevention of Diabetes in Obese Subjects; Torgerson et al, 2004), DREAM (Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication; DREAM Trial Investigators et al, 2006) and even NAVIGATOR (NAVIGATOR Study Group et al, 2010) suggest otherwise, although arguably most of these trials have nothing to do with preventing diabetes, merely treating it at a lower threshold. But that is another argument.
To view the summaries of each paper, please download the PDF.
