It has long been something of a quirk in the grim universe of diabetes: a small number of pregnant women would become temporarily diabetic. With proper care, the consequences were often thought to be mild. The babies were usually healthy. And the condition would vanish after the delivery, like a cough or a headache.
But, not unlike the wider expansion of diabetes, this disorder is now growing, and indications are that it is growing fast. In New York, so-called gestational diabetes has risen by nearly 50 percent in about 10 years.
There is also broader recognition that in the lives of many pregnant women, the arrival of the condition is significant and its impact can be grave: not only does it identify those women at particularly high risk to develop permanent diabetes, but it may contribute to their babies' eventually getting diabetes as well.
Health care officials worry that insufficient attention is being paid to the rising number of cases, apparently being propelled by genetically susceptible women entering pregnancy too fat. The inattention, the officials say, is allowing young mothers to be saddled with a harrowing lifelong disease and increasing the risk to their children of ultimately sharing that troubling destiny. It is hard to say just how alarming this will become. But those who study the diabetes epidemic are concerned that it's one more time bomb.Continue reading the main story
"It's really disturbing to us that women come into their pregnancies obese and then leave them even more obese," said Barbara Hackley, a certified nurse-midwife at the health center of the Children's Health Fund and Montefiore Medical Center in the South Bronx. "I've seen weight gains during pregnancies of 50 to 60 pounds. We've had 11- and 12-pound babies that are very dangerous to deliver."
Gestational diabetes, like other forms of diabetes, is characterized by dangerously high levels of sugar in the blood. Many women who develop it have never even heard of the disorder. Afterward, they never think much about it, unless visited by its potential legacy, Type 2 diabetes, a progressive, potentially fatal illness that can produce a barrage of complications, from strokes to decaying limbs.
In 2001, the latest year researchers have studied, there were 4,200 cases of gestational diabetes in New York among women who gave birth to a single baby. Experts believe wider education about the condition might allow some heavy women, through better diet and exercise, to avert it before they become pregnant.
Furthermore, experts say, many mothers are inadequately counseled after delivery by busy clinicians -- or are unable to absorb the message -- about the need to monitor their weight and blood sugar, as well as their child's, because of the danger of chronic diabetes. A surprising number, doctors say, never even bother to confirm that the gestational diabetes went away.
Take the weight narrative of Andrea Reyes. At 21, pregnant with her first child, she weighed 153 pounds. She tacked on just seven pounds during the pregnancy, because the baby came early. But instead of shedding her baby fat, she said, "I ate the same food; but I ate more."
Four years later, pregnant with her second child, she weighed 190. During her pregnancy, doctors found that she had gestational diabetes, which usually shows up 24 to 28 weeks into pregnancy. She had no idea what it was. The baby was fine, and the diabetes disappeared, but it was resurrected during her third pregnancy, in 2001. She weighed 193. Her son was large -- 9 pounds, 9 ounces -- and had low blood sugar, complications of the condition.
Again, the diabetes subsided. But her doctor cautioned her that if she did not diet and exercise, she might acquire permanent Type 2 diabetes. In May 2004, after fitful progress, that's what happened.
She is now 32, a sprightly woman with dark hair knotted in a ponytail who lives in the South Bronx and peddles fruit salads in the summers. She takes pills and insulin, and sometimes finds herself dizzy.
Though she winnowed her weight down to 180, she has put on five pounds in the past month.
"I know," Ms. Reyes said sheepishly, "too much."
Her doctors have advised her that she needs to keep an eye on her son, whose weight is now normal. "I know," she said. "I worry."
The dimensions of gestational diabetes are imprecise, and there is considerable disagreement about how vigorously to treat it, especially milder cases, and how much difference treatment makes.
The disorder is not tracked regularly in the city or nation. Estimates are rooted in scattered studies. In its first attempt to measure the problem, the New York City Department of Health and Mental Hygiene, in a paper last September in the American Journal of Public Health, said that a review of births between 1990 and 2001 found that the prevalence had leapt to 3.8 percent, or about 4,200 pregnant women in 2001, from 2.6 percent.
There was a pronounced increase among younger women and Asians, who tend to get diabetes at lower weights. With South and Central Asian mothers, prevalence hit 11.1 percent, one of the highest documented levels in the country. An increase of more than 75 percent occurred among women delivering before age 35. Although the study did not track the weights of mothers, it concluded that obesity was probably the principal force because it has been driving increases in Type 2 diabetes.
Other regional studies suggest prevalences of 4 percent to 8 percent. Dr. Michael Engelgau, head of the diabetes division of the United States Centers for Disease Control and Prevention, said that rates are rising significantly throughout the nation, and even touching teenagers. The American Diabetes Association uses a 4 percent level for the country, or 135,000 cases a year.
Estimates are that as many as 20 to 50 percent of the women who develop gestational diabetes will get Type 2 within 5 to 10 years. Scientists do not think that the disorder causes Type 2 diabetes, but it alerts a woman that she could be headed down that road and might be able to delay or avert Type 2 with lifestyle adjustments.
Researchers have not established the subsequent impact on the child. Hereditary factors are hard to untangle and studies difficult to accomplish. But there is concern that the condition significantly contributes to the child's eventually becoming obese or diabetic.
While many mothers are conscientious about the issue, others are not and should be, said Sharon Blasi, a diabetes nurse educator in Queens. "It's almost like a looking glass," she said. "This could possibly be your future. Here's a taste of it."
Due to nonchalance or the consuming whirl of a new baby, many mothers never return after childbirth for the tests that confirm that the disorder is gone -- it could actually be undiagnosed chronic diabetes -- or to seek guidance to avoid permanent diabetes.
Dr. Carol Levy, an assistant professor of medicine and specialist in gestational diabetes at NewYork-Presbyterian/Weill Cornell Medical Center, estimated that while as much as 70 percent of mothers who have access to specialists may receive follow-up tests, the proportion is far smaller at clinics serving poor populations.
"The mothers get busy," she said. "The doctors don't remind them. I hear from patients that no one told me to do this. Is it that the doctor didn't remind them or did the patients forget?"
Ms. Hackley, the nurse-midwife, said as few as 30 to 50 percent of the mothers who use the South Bronx center return for the needed follow-up care.
From birth certificates, city health officials know which mothers had gestational diabetes -- most pregnant women are routinely screened for it. Yet officials have not checked on what postdelivery care those mothers get. Confronted with the surge in cases, the city plans to begin an initiative soon to tackle this issue.
There is a strong genetic underpinning to gestational diabetes, as with all diabetes, but doctors mention two trends in New York and elsewhere that seem to be colliding to push up prevalence: many women are entering pregnancy fatter, and more women are having children later.
Overweight women or those older than 25 are considered at higher risk, and there are steeper rates among African-American, Hispanic, Asian and Native American populations. Women carrying multiple babies face more risk as well. But some women with none of those factors also get it.
"The problem is huge," said Dr. Robin Goland, the co-director of the Naomi Berrie Diabetes Center in New York. "We had four or five referrals of gestational diabetes yesterday. We're seeing probably a third more than we did seven years ago, when we started."
Dr. Goland had treated one patient with gestational diabetes who gave birth at 57; her youngest case was 19.
Specialists suspect the caseload is greater than the city study implies, because the cases of some poor and uninsured women, who often get little or no prenatal care, go uncounted.
Last October, pregnant with her first child, Ulrica Rutkove learned that she had the condition. She had never heard of it. She weighed all of 95 pounds. "I never thought I'd get diabetes," said Ms. Rutkove, a portrait artist. "I thought people who get diabetes are overweight."
But she is 40, from the Philippines, and both her mother and grandmother had diabetes.
Most women with gestational diabetes give birth to healthy babies, though complications do arise. Evidence from studies of Pima Indians and experiments with rats, however, suggest that, genetics aside, a child, simply by being exposed to the intrauterine environment of a gestational mother, could be more likely to become obese and develop diabetes later in life. If the child is a girl, the same pattern might then repeat itself when she becomes pregnant.
"So it's a vicious cycle," said Dr. Boyd Metzger, professor of medicine and endocrinology at Northwestern University's Feinberg School of Medicine.
In studies of the Pimas, an unusual group because of their shockingly high rates of diabetes, 80 percent of the offspring of diabetic mothers -- both chronic and gestational -- had diabetes by the time they were 25 to 29. Of the children of mothers without diabetes, 5 percent had diabetes at that juncture. It's difficult, though, to draw analogies with the general population.
Doctors have long disagreed over how ambitiously to regulate the conditions of mothers-to-be with gestational diabetes. Care typically involves diet change -- including cutting down on carbohydrates, juices and sugared soda -- and exercise. Often, the women take insulin injections and are advised to monitor their blood sugar four times a day. Some doctors substitute an oral drug, glyburide, for insulin.
Jane Martinez Dowling, 37, a part-time consultant, has had gestational diabetes twice, once when she was proper weight and again now, 20 weeks into her latest pregnancy, when she feels she may be 30 pounds too heavy. After the birth, she vows on losing the weight because she said she understands the risks, and fears the prospects, of developing chronic diabetes.
She has already cleansed her diet of rice and beans. "Spaghetti squash," she said, "has revolutionized my life."
What It Is and What It Does
GESTATIONAL DIABETES -- A temporary form of diabetes that occurs in about 4 to 8 percent of pregnancies and then typically disappears. As with the two chronic forms of diabetes, Type 1 and Type 2, it is characterized by high blood sugar levels.
In Type 1, which accounts for 5 to 10 percent of diabetes cases, the pancreas no longer produces insulin -- which helps sugar enter the body's cells -- because the body's immune system has destroyed the cells that make it. In Type 2, the predominant form, the body generally produces sufficient insulin, but the diabetic's cells can't properly use it.
CAUSES -- Unclear, but genetics, excess weight and age are risk factors, as is ethnicity.
It is known that hormones produced by the placenta, the organ that furnishes nutrients to the baby during pregnancy, increase the insulin resistance of the body's cells. The bodies of most pregnant women adjust by making more insulin. But some don't.
After the baby's birth, the mother's placental hormones disappear and her blood sugars typically revert to normal.
IMPACT ON BABIES -- For most, no impact if the condition is managed well.
But some are oversized and some develop jaundice. The babies also seem to run a higher risk of becoming obese and developing Type 2 later in life. Others are born with low blood sugar.
Those born premature are more likely to suffer from respiratory distress.
Stillbirths occur in rare instances, usually when the gestational condition was undetected.
IMPACT ON MOTHERS -- Some get pre-eclampsia, a dangerous form of high blood pressure. Most get gestational diabetes in subsequent pregnancies.
Oversize babies whose shoulders are too large for the birth canal must be delivered by Caesarean section.
Between 20 and 50 percent end up with Type 2 diabetes.
For additional information on diabetes and relevant links about the gestational form, visit: nytimes.com/diabetesContinue reading the main story