June 2008 volume 24 number 06 Prevalence of Diabetes During Pregnancy in Georgia Overview Diabetes and Pregnancy Diabetes mellitus, or simply diabetes, is a group of diseases marked by high blood sugar levels due to defects in insulin production, insulin action, or both. Diabetes is a systemic and progressive chronic disease common in both Georgia (about 1 in 10 adults) and the United States (about 1 in 12 adults) (1). It can cause serious complications and premature death, but people with diabetes can take steps to control the disease and lower the risk of complications. Among three major types of the disease, type 1 diabetes is due to an autoimmune disorder that causes absolute insulin deficiency by destruction of pancreatic beta cells the body's only insulin-producing cells. To survive, people with type 1 diabetes must have insulin delivered by injection or a pump. Type 1 diabetes accounts for 5% to 10% of all diagnosed cases of diabetes (2). Type 2 diabetes usually starts as insulin resistance in which the body cannot use insulin properly, leading to relative insulin deficiency. As the need for insulin rises over time, the pancreas gradually loses its ability to produce enough insulin. Type 2 diabetes is the most common form, accounting for 90% to 95% of all diagnosed cases of diabetes (2). Depending on the stage of disease progression and severity, management of type 2 diabetes can include diet regulation with or without medications, either oral pills or insulin, and appropriate physical activity. The third most common form, gestational diabetes mellitus (GDM), is a state of glucose intolerance that is first recognized during pregnancy. GDM complicates 4% to 7% of all pregnancies (2). Although GDM usually resolves after childbirth, women who have had GDM have a 20% to 50% chance of developing type 2 diabetes in the next 5 to 10 years (3). Pregnancy has a profound effect on maternal carbohydrate metabolism, which must meet the demands of a developing fetus. Gestational diabetes is defined as any degree of glucose intolerance with first recognition during pregnancy (4). A pregnant woman may have diabetes diagnosed before becoming pregnant (pre-gestational diabetes), or undiagnosed, pre-existing diabetes (either type 1 or type 2) that becomes worse and noticeable during pregnancy, or new onset diabetes that develops during pregnancy for the first time. In fact, diabetes is the most common medical complication of pregnancy (4). About 150,000 pregnancies are complicated by diabetes each year in the United States, including 135,000 pregnancies in which the mothers develop GDM and another 12,000 and 7,000 pregnancies in which the mothers have preexisting type 2 diabetes and type 1 diabetes, respectively (5, 6). Diabetes during pregnancy poses serious risks to the mother and the fetus. If diabetes is poorly controlled, the risk of spontaneous abortion is increased. If diabetic ketoacidosis occurs, it can threaten both maternal and fetal lives. GDM can increase the risk of fetal macrosomia (large baby weighing more than 9 pounds) with secondary complications such as shoulder dystocia and birth trauma or the need for operative delivery. Following birth, neonatal complications can occur, including hypoglycemia, respiratory distress syndrome, and jaundice (4). Diabetes during PregnancyGeorgia To determine the prevalence of diabetes during pregnancy in Georgia, we used birth certificate data from the CDC WONDER natality data set (7). These data are The Georgia Epidemiology Report Via E-Mail To better serve our readers, we would like to know if you would prefer to receive the GER by e-mail as a readable PDF file. If yes, please send your name and e-mail address to Gaepinfo@dhr.state.ga.us. | Please visit, http://health.state.ga.us/epi/manuals/ger.asp for all current and past pdf issues of the GER. publicly available and are accessible on the Internet at http://wonder.cdc.gov/natality. Currently, the latest year for which the data are available is 2004. The 2004 national vital records data showed that the prevalence of diabetes during pregnancy in Georgia and the U.S. were 2.3% and 3.6%, respectively (Figure 1). The prevalence in Georgia has consistently been lower than that in the U.S. since 1995. In 2004, 3,125 Georgia women with live births had pregnancies complicated by diabetes, an 11.6% increase from 2003. The occurrence of diabetes in pregnancy has been increasing nationally as well as in Georgia during 1995 to 2004 (Figure 1). In 2004, the lowest prevalence of diabetes during pregnancy in Georgia was noted among young women aged 15 to 19 years. The older the pregnant mother, the higher the prevalence of diabetes (Figure 2). Among racial and ethnic groups, pregnant women with Asian or Pacific Islander racial background had the highest prevalence of diabetes (4.2%), i.e., nearly twofold higher than pregnant women in other racial or ethnic groups (Figure 3). Infants of Georgia mothers who had diabetes during pregnancy were more likely to be either low birthweight or very large babies compared to those of non-diabetic mothers (Figure 4). Serious pregnancy complications such as eclampsia, pregnancy-associated high blood pressure, and hydramnios or oligohydramnios (an excess or deficiency in the amount of amniotic fluid) were also 3 to 4 times more common in diabetic mothers than their non-diabetic counterparts (Figure 5). Prevention and Control of Diabetes in Pregnancy Diabetes in pregnancy, both pre-gestational and gestational, affects the health of the mother and the baby and can have a serious impact on birth outcomes. Diabetes is controllable and, in many instances, Figure 1. Prevalence of Diabetes in Pregnancy among Women of Childbearing Age*, Georgia versus U.S. (1995-2004) Percent of Total Live Births 5 4 U.S. 3 2 GA 1 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Note. * Women aged 15-44 Total live births in 2004: GA = 138,401; U.S. = 4,099,149 Source. CDC WONDER, Natality data, 1995-2004 Figure 2. Prevalence of Diabetes in Pregnancy among Women*, by Age Group, Georgia (2004) Percent of Total Live Births 6 5.5 5 4.2 4 3.1 3 2.2 2.3 2 1.3 1 0.7 0 15-19 20-24 25-29 30-34 35-39 40-44 All Groups Age Group (in years) Note. * Women of childbearing age Total live births in 2004 = 138,401 Source. CDC WONDER, Natality data, 2004 Figure 3. Prevalence of Diabetes in Pregnancy among Women*, by Race/Ethnicity, Georgia (2004) 5 4.2 4 Percent of Total Live Births 3 2.2 2.2 2.1 2.1 2.3 2 1 0 White Black Hispanic Native API** All Groups American Note. * Women of childbearing age ** Asian/Pacific Islander Source. CDC WONDER, Natality data, 2004 Division of Public Health http://health.state.ga.us S. Elizabeth Ford, M.D., M.B.A., F.A.A.P. Acting Director State Health Officer Martha N. Okafor, Ph.D. Deputy Director John M. Horan, M.D., M.P.H. State Epidemiologist Epidemiology Section http://health.state.ga.us/epi Georgia Epidemiology Report Editorial Board Carol A. Hoban, M.S., M.P.H. Editor Kathryn E. Arnold, M.D. Cherie Drenzek, D.V.M., M.S. John M. Horan, M.D., M.P.H. S. Elizabeth Ford, M.D., M.B.A., F.A.A.P. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer -2 - Georgia Department of Human Resources Division of Public Health Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-7517 Please send comments to: gaepinfo@dhr.state.ga.us Figure 4. Distribution of Birthweight Groups among Women*, by Diabetes Status during Pregnancy, Georgia (2004) Non-Diabetic Diabetic 100 83.6 77.1 80 Percent of Total Live Births 60 40 20 9.2 11.7 7.2 11.2 0 < 2,500 2,500 - 3,999 4,000+ Birthweight (in grams) Note. * Women of childbearing age Source. CDC WONDER, Natality data, 2004 Figure 5. Prevalence of Complications among Pregnant Women*, by Diabetes Status during Pregnancy, Georgia (2004) Non-Diabetic Diabetic 100 96.3 Number per 1,000 Live Births 80 60 40 19.2 25.0 20 5.0 30.4 9.7 0 Eclampsia HBP^ AFC" Pregnancy Complication Note. * Women of childbearing age ^ Pregnancy-associated hypertension " Amniotic fluid content (either too much or too little) Source. CDC WONDER, Natality data, 2004 Box 1. Risk Factors for Developing Gestational Diabetes 1. Obesity 2. Family history of diabetes 3. Advancing age (older than 25 years) 4. Past history of gestational diabetes 5. Member of a high-risk racial/ethnic group 6. History of a stillbirth or delivering a large baby 7. History of abnormal glucose tolerance preventable. Pre-conception counseling and care are important for all women of childbearing age, particularly for those with increased risks (Box 1). Proper screening can detect pre-gestational and gestational diabetes and helps primary care providers and their patients take appropriate interventions such as tight blood glucose control, medical nutrition therapy, exercise, and insulin, as needed. It is possible for women with GDM to have healthy pregnancies, healthy babies, and healthy lives. References 1. Centers for Disease Control and Prevention. (2008). Behavioral Risk Factor Surveillance System. http://apps.nccd.cdc.gov/BRFSS. Accessed on June 18, 2008. 2. American Diabetes Association. (2005). Diabetes 4-1-1: facts, figures, and statistics at a glance. Alexandria, VA: Transcontinental. 3. Centers for Disease Control and Prevention. (2005). National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services, 4. Strehlow, S. L., Greenspoon, J. S., Janzen, C., & Palmer, S. M. (2007). Diabetes mellitus and pregnancy. In DeCherney, A. H., Goodwin, T. M., Nathan, L., & Laufer, N. (Eds.), Current diagnosis and treatment: Obstetrics & gynecology. (10th. ed., pp. 311-317). New York: McGraw-Hill. 5. Engelgau, N.M., Herman, W.H., Smith, P.J., German, R.R. The epidemiology of diabetes and pregnancy in the U.S. (1995). Diabetes Care 18: 1029-1033. American Diabetes Association. 6. Homko, C. J. (2005). Women and diabetes. In Childs, B. P., Cypress, M., Spollett, G. (Eds.), Complete nurse's guide to diabetes care (pp. 277285). Alexandria: Port City Press, Inc. 7. Centers for Disease Control and Prevention. (2007). CDC WONDER online databases. Natality information: live births. http://wonder.cdc. gov/natality. Accessed on June 18, 2008. This article written by Pyone Cho, M.D., M.P.H., M.A. -3 - The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186 PRESORTED STANDARD U.S. POSTAGE PAID ATLANTA, GA PERMIT NO. 4528 June 2008 Volume24Number06 Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for Frebruary 2008 Selected Notifiable Diseases Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other ** Syphilis - Congenital Tuberculosis Total Reported for March 2008 2008 33 39 31 1 45 19 13 3 9 5 0 2 0 2 0 78 107 6 37 21 76 0 41 Previous 3 Months Total Ending in March 2006 2007 2008 133 124 119 10535 11573 4596 43 38 54 7 5 1 120 135 130 5014 4526 1675 40 38 54 8 18 12 34 37 30 1 9 9 1 0 0 5 6 5 0 0 0 7 4 5 0 0 0 206 296 218 186 226 293 27 23 15 107 132 130 96 116 80 271 293 264 3 3 1 110 108 110 Previous 12 Months Total Ending in March 2006 2007 2008 624 571 686 35450 41048 36243 173 276 256 32 41 44 713 694 674 16940 19914 15041 110 121 143 109 66 61 168 200 149 36 46 43 6 7 11 16 21 23 1 4 0 44 28 16 0 0 0 1950 1930 1955 757 1421 1714 130 120 93 523 507 582 412 405 391 998 1041 1131 5 10 8 500 505 474 * The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. ** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. AIDS Profile Update Report Period Disease Total Cases Reported* Classification <13yrs >=13yrs Total Percent Female MSM Risk Group Distribution (%) IDU MSM&IDU HS Unknown Perinatal White Race Distribution (%) Black Hispanic Other Latest 12 HIV, 28 3,170 3,198 27 21 2 1 4 72 <1 22 72 4 2 Months**: non-AIDS 2/06-1/07 AIDS 8 1,971 1,979 27 27 2 1 7 63 <1 19 73 5 3 Five Years HIV, - - - - - - - - - - - - - - Ago: non-AIDS 2/02-1/03 AIDS 7 1,948 1,955 29 36 7 2 16 38 <1 19 75 5 1 Cumulative: HIV, non-AIDS 221 11,549 11,770 32 27 6 2 11 52 2 21 74 4 1 07/81-1/07 AIDS 240 32,565 32,805 20 44 15 5 14 22 <1 30 66 3 1 Yrs - Age at diagnosis in years MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section ** Due to a change in the surveillance system, case counts may be artificially low during this time period ***HIV, non-AIDS was not collected until 12/31/2003 - 4 -