This World Health Day (April 7) the World Health Organization (WHO) in its wisdom, has chosen an apt theme: Healthy Beginnings, Hopeful Futures. As diabetologists, we have, for decades, been propounding the theory of primordial prevention, or preventing diabetes in the womb itself, in order to ensure a happy and healthy future for both the mother and the baby. We see the WHO’s choice of theme for this World Health Day as a vindication of the work and advocacy campaigns we have undertaken towards this goal.
Diabetes has long been a silent epidemic, affecting millions worldwide, but its roots often lie much earlier than commonly recognised. Gestational diabetes mellitus (GDM) is a high risk for type 2 diabetes in mothers and metabolic disorders in children. GDM is usually diagnosed between 24 to 28 weeks of pregnancy. However, current evidence also points to the ability to prevent its onset during the first trimester or even earlier, and its impacts on both the mother and the child are profound and lasting.
Research in the growing body underlines that maternal glucose levels should be carefully regulated as early as the eighth week of pregnancy. An early intervention that would help prevent foetal hyperinsulinemia, a metabolic disturbance that occurs in the 11th week, might avoid this and reduce the risk of the child developing diabetes and other non-communicable diseases (NCDs) later in life. Given India’s recent burgeoning diabetes burden, this matter needs immediate attention from the medical community and policymakers.
The case for early glucose screening
Existing GDM management is based on screening in the second trimester and commencing treatment. Nevertheless, it may be too late. Maternal hyperglycemia in the first trimester appears to program the child’s foetal metabolism, increasing the risk that the child will be obese and insulin-resistant or develop diabetes later in life.
Leading endocrinologists concur that glucose intolerance should be screened much earlier—at about the eighth week of pregnancy. Reasonable justification exists because, by the 24-week time point in GDM, the foetus has been exposed to excessive glucose for months. This results inexcessive foetal insulin production, which can lead to lifelong metabolic disorders.
Foetal origin of adult diseases
The “Foetal Origin of Adult Diseases” (Barker’s Hypothesis) suggests that conditions during gestation will affect the child’s health over the long term. Early in development, if a foetus is exposed to high blood glucose levels, the programming will be to store more fat, resist insulin, and form metabolic disorders later in life. As a result, researchers have called for a rethink of prenatal care, with glucose control as a primary concern right from the start of pregnancy.
Our aim is not only to deal with diabetes in pregnancy but to prevent it before it starts, as stated earlier, through a policy called primordial prevention. The goal of primordial prevention is to prevent diabetes from ever developing in the first place and decrease risk factors before they occur.
The eight-week strategy
To mitigate these risks, a new model of early GDM intervention has been proposed, focusing on a key eight-point agenda. These include: Firstly, glucose testing by eight weeks of pregnancy. That way, anything potentially wrong could be picked up before it starts harming the development of the unborn.
Secondly, doing so will prevent foetal hyperinsulinemia, and no long-term hypoglycemia (low sugar levels) is observed. If the 10-week glucose control of postprandial blood sugar remains below 110 mg/dL, metabolic risks will be limited. In case the post prandial blood sugar levels are over 110 mg/dL, medical nutrition therapy and low-dose metformin (250 mg twice daily) can halt the rise of glucose to prevent the development of GDM later in pregnancy. There is clinical evidence that this strategy has been effective in preventing GDM in the third trimester with less probability. It further prevents the necessity of insulin therapy since it is at this stage that GDM is mostly diagnosed.
The Indian context
Currently, India has more than seventy-seven million people with diabetes, and the numbers are increasing. It is pretty alarming that about 20% of pregnant moms in India develop GDM, exposing both the mothers and their offspring to long-term health burdens related to metabolic disease. One reason this is so is because the maternal care checklists and prenatal care guidelines remain anchored to traditional screening times.
There are several issues which are prevalent only in India that make early intervention all the more important. Lack of early care: The majority of women of Indian origin do not go for antenatal checkups until the second trimester, thereby missing the screening period.
Indian women are more vulnerable to insulin resistance and diabetes profile than any other racial group. Therefore, colourful efforts should be made in early diagnosis and intervention.
Not only patients but also healthcare providers lack sufficient knowledge of first-trimester hyperglycemia and its possible consequences.
Therefore, the development of the early GDM screening and intervention policy across the country is now absolutely critical.
Rethinking policy and clinical guidelines
Diabetologists have lately urged early detection and intervention of blood glucose levels. While concluding the 18th Annual Conference of Diabetes in Pregnancy Study Group India (DIPSI 2024), the delegates and experts stressed on the following points: Risk modification through the pre-conception period concerns dietary control, exercise, and preventive medication before conception; Long-term monitoring of blood glucose levels in high-risk pregnant mothers to trace glucose levels throughout pregnancy.
Some measures are recommended in the national guidelines to implement them and standardise the care in India. The facts regarding the matter are evident and vivid—timely interventions are well capable of eradicating lifetime-long complications regarding the health of both the mother and the child.
Implementing change
To ensure that this new approach works, there is a need for a new conceptualisation of maternal care involving all the stakeholders, including the care providers, policymakers, and the general public. Key steps include: Developing educational programmes to encourage healthcare providers in primary and remote areas to use early glucose screening; changing the guidelines for pregnancy care across all the states and territories to provide glucose screening by the eighth week.
Making all tests and treatment accessible and affordable for the mother and the foetus is another key recommendation.
A new standard for maternal health
Diabetes prevention starts even in the womb. Consequently, the first eight weeks of pregnancy pose a critical period that we have no reason to disregard. However, by moving to early screening and testing, glycemic control, and early interventions, we can stop the cycle of diabetes development.
Since diabetes is a major emerging epidemic in India, adapting this standard of maternal care for the country is no longer a choice; it is a must. If allowed to fight diabetes, we should do it right from the roots, or in this case, from the womb.
(Dr. V. Seshiah, is a diabetologist practicing in Chennai and is the founder and patron of the Diabetes in Pregnancy Study Group India and can be reached at vseshiah@gmail.com
Dr. A Panneerselvam, senior consultant diabetologist, can be reached at drapselvam58@yahoo.com
Dr. Anjalakshi Chandrasekar is senior consultant in obstetrics and gynaecology, can be reached at dranjalakshi@gmail.com and
Dr. A. Bhavadharani is senior consultant diabetologist, can be reached at srcdiab@yahoo.com)
Published – April 11, 2025 06:00 am IST
Leave a Reply