AND IN THE AMERICAS Final report of the Pan American Conference on and Pregnancy Lima (Peru), 8-10 September 2015 HYPERGLYCEMIA AND PREGNANCY IN THE AMERICAS Final report of the Pan American Conference on Lima (Peru), 8-10 September 2015

Washington, D.C., 2016. Also published in Spanish (2016): Hiperglucemia y embarazo en las Américas: Informe final de la Conferencia Panamericana sobre Diabetes y Embarazo (Lima, Perú. 8-10 de setiembre del 2015) ISBN 978-92-75-31883-6

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Pan American Health Organization.

Hyperglycemia and Pregnancy in the Americas. Final report of the Pan American Conference on Diabetes and Pregnancy (Lima Peru: 8-10 September 2015). Washington, DC : PAHO. 2016

1. Diabetes Mellitus. 2. Hyperglycemia. 3. Pregnancy. 4. Pregnancy in Diabetics. 5. Maternal and Child Health. 6. Americas. I. Title.

ISBN 978-92-75-11883-2 (NLM Classification:WQ248)

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The Pan American Conference on Diabetes & Pregnancy was supported by the World Diabetes Foundation This report was prepared by Alberto Barceló, Noël C. Barengo, Jose Roberto da Silva Jr., Sara Meltzer and Gojka Roglic with contributions from the following conference participants: Juan Daniel Aspilcueta Gho, Marcos Augusto Bastos Dias, Hector Bolatti, Adriano Bueno Tavares, Luis Cabero, Evelina Chapman, Anders Dejggard, Mina Desai, José A Escamilla, Maria Cristina Escobar, Ricardo Juan García Cavazos, Jacinto Lang, Silvia Lapertosa, Gloria Larrabure, Bent Lautrup-Nielsen, Javier Maldonado, Beatriz Martins da Costa Maciel, Lenildo Moura, Eloisa Nuñez, Socorro Parra, Vivian Perez, Ludovic Reveiz, Enrique Reyes, Aleida Rivas, Karen Roberts, Michael Ross, Susana Salzberg, Segundo Seclen, Suzanne Serruya, Andrea Srur, Angelica Valdivia The section Diabetes & Pregnancy in the Americas was prepared with data form Ministries of Health from Argentina, Barbados, Belize, Cuba, Chile, Dominica, El Salvador, Guatemala, Guyana, Mexico, Panama, Peru, Puerto Rico and Venezuela; the Public Health Agency of Canada; and the US Centers for the Disease Control and Prevention (Maternal and Infant Health, Division of Reproductive Health). Pictures included in this report (with exception of those appearing in pages 38, 42 and 44) are from the Pan American Conference on Diabetes & Pregnancy that took place in Lima Peru, 8-10 of September of 2015. Photos: Luis Eduardo Macchiu Photos pages 38, 42, 44: 123rf.com Design: Sandra Serbiano Contents

Acronyms...... 4 Introduction...... 7 Diabetes y embarazo en las Américas: análisis de situación...... 7 Diabetes Mellitus (DM) and its burden in Latin America & the Caribbean...... 17 Prevalence of diabetes in the Americas...... 17 The cost of diabetes in Latin America and the Caribbean...... 19 Diabetes screening and diagnosis in pregnancy...... 20 Cost-effectiveness of GDM screening...... 24 Treatment of diabetes in pregnancy...... 26 Education and ...... 27 Diet...... 28 Physical exercise...... 29 Medical treatment...... 30 Future risk for mother and child: Maternal health and noncommunicable diseases...... 31 Gestational diabetes: Puerperium...... 32 Fetal programming...... 32 Teamwork session...... 35 Health care organization...... 35 Community resources, public policies, creation of networks, communication ...... 35 Guidelines, protocols, and research...... 35 Health services delivery...... 37 Support for self-management...... 37 Information system...... 37 Organization of health care ...... 37 Community resources, public policies, creation of networks, and communication...... 39 Guidelines, protocols, and research...... 39 Health services delivery...... 40 Support for self-management...... 40 Monitoring and information system...... 40 Conclusions of the conference ...... 43 Recommendations of the conference ...... 45 Hyperglycemia in pregnancy: A call to action for improved outcomes...... 47 Why is hyperglycemia in pregnancy a health problem? ...... 47 The burden of diabetes in pregnancy in the Americas...... 48 Recommendations for health workers...... 48 Measures to be taken by health authorities and health professionals ...... 48 Action that the PAHO/WHO secretariat should take ...... 49 Annex 1. Data Collection Form Diabetes & Pregnancy...... 51 Annex 2. Meeting program and list of participants...... 61 References...... 69 4 / Final report of the Pan American Conference on Diabetes and Pregnancy GRADE: GPC: E DSME: DMP: DM: C ALAD: AD OGTT: NPH: LGA: IADPSG: HAPO: GDM: BMI: IGT: A1c: Acronyms LAC: IDF: CI: GDMP-ALAD: Q-5D: A:

Grading ofR Clinical practiceguides Gestational diabetes EuroQol quality Diabetes self-managementeducation Diabetes mellitusinpregnancy Diabetes mellitus Confidence interval Consensus GrouponDiabetesandP Body massindex Latin American impaired glucosetolerance American Diabetes glycosylated hemoglobin oralglucosetolerance test Neutral P Large forgestationalage Latin International DiabetesF International Hyperglycemia and group Association America andtheCaribbean rotamine Hagedorn ecommendations Assessment, DevelopmentandEvaluationworking Association ofDiabetesandPregnancy Study Groups -of-life questionnaire Diabetes Association Association Adverse PregnancyAdverse Outcomestudy ederation regnancy––Latin American Diabetes WHO: WHO-5: USD: SGA: SAD: Q PR: P OR: OHA: T2DM: AHO: ALY:

Quality prevalence ratio P odds ratio Oral h W WHO-Fi United Statesdollar T Small forgestationalage Argentine DiabetesS ype 2diabetes an American HealthOrganization orld HealthOrganization ypoglycemic agent -adjusted life years -adjusted lifeyears ve Well-being Index s ociety

5 / Final report of the Pan American Conference on Diabetes and Pregnancy

diabetes associations alsoattended. ofregionalandsubregional representatives PAHO MemberStates,but academicsand the participants were health officials from attended theconference. The majorityof One hundredpeople from31countries Americas. of pregnancy-related diabetesinthe to improve theprevention andcontrol disseminate evidence-basedguidelines was toprovide scientific informationand Lima (Peru). oftheconference The objective Pregnancy, held8-10 September 2015 in Pan American ConferenceonDiabetes and This documentisthefinalreport ofthe obstetricians, andgynecologists. especially primarycarephysicians, who provide caretopregnantwomen, issued in2013, arefor health professionals diabetes (GDM)in85%ofcases. hyperglycemia, corresponding togestational pregnant womenworldwidesuffers from It isestimatedthatoneoutofseven and perinatalmorbiditymortality. conditions increasetheriskofmiscarriage baby andthemother;inparticular, these consequences for the health both of the detectedinpregnancycanhaveserious first Preexisting diabetesandhyperglycemia Introduction Detected inPregnancy. Classification ofHyperglycaemia First (WHO) publishedDiagnosticCriteriaand In 2013, the World HealthOrganization undiagnosed. screening anddiagnosis,GDMoften goes is noglobal,standardized approach toits the frequency of GDM is scarce: since there consequences formotherandbaby. Dataon are notdiagnosed,withpotentiallyfatal but many casesofgestationaldiabetes 30% ofpregnantwomenmaybeaffected, 2 Tee guidelines, These 1 Upto analysis in theAmericas:Situation Diabetes andpregnancy Key points: ÎÎ ÎÎ ÎÎ ÎÎ ÎÎ programs. few GDM educationandprevention diabetes intheRegion, there are education programs on type 2 Although there are numerous GDM screening. countries didnothave policiesfor Almost halfofthereporting GDM for epidemiological surveillance of There is a scarcity of statistical data in theactual frequency ofGDM as well aspossibletrue differences screening standards andstrategies, in Canada)couldberelated to GDM (from 0.8%inBelize to 6.5% Variations in the prevalence of countries to establishcomparisons between which makes italmostimpossible cut-offs for GDM diagnosis, doses ofglucoseanddifferent the Americas, includingdifferent screening strategies are usedin The datashow thathighlydiverse

7 / Final report of the Pan American Conference on Diabetes and Pregnancy 8 / Final report of the Pan American Conference on Diabetes and Pregnancy the GRADEapproach. it ishardtofindguidelines developedwith guidelines producedby other institutionsand significant obstacles involved in adapting them fromscratch.Unfortunately, thereare or adaptguidelinesinsteadofpreparing Caribbean countrieshavechosentoadopt civil services in most Latin American and financial and human resources, most order tominimizedifficultiesinmaintaining scientifically validandofsufficientquality. In clinical practice guidelines that are There areseveralcriteriaforformulating health outcomesforthepopulation. and effectiveservicesand,ultimately, better clinical practice guidelines facilitate coherent different healthcareoptions.Evidence-based evidence andevaluatingtheprosconsof importance of systematically revising the population. PAHO/WHO emphasizesthe access toqualityhealthcarefortheentire is anessentialstrategytoimproveuniversal Strengthening nationalprogramsandpolicies f implementing A or dapting GDM

and

guidelines

Panama, Paraguay, and Venezuela) have (Belize, Cuba,theDominican Republic, Mexico, for thepreventionof GDM.Seven countries Suriname) reported havingnationalprograms pregnancy. Onlytwocountries(Canada, and prenatal visitandbetween weeks24and28of that screeningshouldbedoneinthefirst The majorityofthecountryguidelinesindicate screening of diabetes in pregnancy (Table 2). that theyhad policies for the systematic Sixteen of these 27 countries (59%) reported dose intotal. usea75-g or 100-g g ofglucose, while others which rangesfrom50to100 g.Panama uses50 of glucoseadministeredinthetolerancetests, differences among countriesincludethedose and Mexicousesingle-stepscreening.Other step screeningstrategy, whileCuba,Guyana, countries(19%)of glucose.Five useathree with variouscut-off valuesanddifferent doses use a two-step screening strategy for diagnosis, diagnosis of GDM. Eighteen countries (63%) use thecriteriarecommendedby WHO forthe States—26 %ofthecountriesthatresponded) Guyana, Nicaragua,Peru, andthe United seven countries(Canada,Colombia,Guatemala, GDM variedthroughoutthe Americas andthat the Americas. Itwas notedthatthe definitionof diagnose gestational diabetes in 27 countries of Table 1showsthecriteriacurrently usedto Information wasfrom27countries. received In all,37PAHO MemberStateswerecontacted. use theonlineformatSurveyMonkey. could respond on paper or in digital format, or all PAHO MemberStates.Participating countries was sent by email to the ministries of health of and dataonpuerperium (Annex 1). The survey pregnancyoutcomesduetoGDM, on adverse on GDMordiabetesinpregnancy, information screening, education,andpreventionprograms data onnewborns,guidelines,andmethodsfor had 80 questions on various topics, such as aspects of diabetes in pregnancy. The survey in ordertocompileinformationondifferent was conductedinallPAHO MemberStates From 1July to30September 2015 asurvey Table 1. Criteriaforthediagnosisofgestationaldiabetesinselectedcountries Americas, 2006-2015. Canada North America English-speaking Caribbean Puerto Rico Dominican R. Cuba Spanish-speaking Caribbean Mexico Mexico U.S. Honduras Guatemala El Salvador Costa Rica Central America Suriname Jamaica Guyana Dominica Belize Barbados Antigua &Barbuda Uruguay Paraguay Brazil Argentina Southern Cone Venezuela Peru Colombia Chile Andean Region Panama Nicaragua onr Year Country 031-275 1-2 2013 0321 5109/5151010131515-/140/145 153/155/165 2 180/190 2 1 92/95/105 2015 2008 1 2013 75/100 2009 1-2 2013/2015 052 2 2 2011 2015 2014 2 2007 2 1 3 2012 3 2008 3 2013 2011 2011 2006 063 2006 002 2 2 2 2010 2008 2012 2 2013 2 2 3 2014 2011 2015 2 2014 2 2009 2011 Diagnostic steps 100 75 75 75 75 100 100 75 100 75 75 100 100 95 75 75 75 75 75 75 75 75 75 75 100 glucose Dose of 59 9/8 162/153 191/180 95/92 95 126 100 95 2 8 5 140 140 92 95 155 95 155 180 110 180 95 92 120 105 95 0 8 5 140 155 180 100 100 105 110 100 140 100 92 155 92 100/125 180 92 126 FG (mg/dl) 8 15 140 155 180 155 180 8 5 140 140 153 155 155 140 180 180 180 155 155 140 180 180 155 180 8 153 140 180 - 155 153 180 180 h2 3h 2h 1h 140 140 140 140 140 140 140 140 153 140 mg/dl OGTT

9 / Final report of the Pan American Conference on Diabetes and Pregnancy 10 / Final report of the Pan American Conference on Diabetes and Pregnancy countries ofthe Americas Table 2.Scope ofeducationorpreventionprograms(type2diabetesgestationaldiabetes)inselected 4 =notspecified. * Screening policy: 1 = 1st prenatal visit; 2 = week 24-28 of pregnancy; 3 = 1st prenatal visit + week 24-28 of pregnancy; Paraguay Argentina Southern Cone Venezuela Peru Colombia Chile Andean region Panama Nicaragua Honduras Guatemala El Salvador Costa Rica Central America andTobagoTrinidad Suriname Saint Lucia Saint. Kitts Jamaica National Guyana Dominica 3 Belize Barbados Antigua &Barbuda English-speaking Caribbean Puerto Rico Dominican R. Cuba Spanish-speaking Caribbean U.S. Mexico Canada North/Meso America Country/Subregion Screening policy* National National 3 3 National 3 3 National 1 2 National Institutional National Institutional 3 Institutional National 4 National National 3 Institutional 3 Institutional 3 National National National 3 3 National 3 2 ainl ntttoa Ntoa Institutional National Institutional National National Regional National National National National National National National National DM Program

GDM Institutional Institutional Institutional Institutional National National Institutional National National National National National National National Institutional Regional T2DM Education program

GDM lected countriesofthe Americas, 2010-2014 Table births 3.Numberoflive andnewbornslarge forgestationalageandsmallage,inse- exception ofCanada(2010). Among countries Data were provided for 2013 or 2014, with the countries (63%ofthosethatsentinformation). (LGA) andsmallforgestationalage(SGA)in17 newborns thatarelargeforgestationalage Table births 3presentsthenumberoflive and GDM atthenationallevel. Only Canada has an educational program on institutional educationalprograms on GDM. Subtotal Venezuela Peru Panama Guyana Guatemala 2014 El Salvador Barbados Antigua &Barbuda Institutional data Total Puerto Rico Mexico Dominica Chile Cuba Canada Belize Argentina National data Dominican Republic Country 2014 2014 2014 2014 2013 2014 2014 2014 - 2013 2012 2014 2013 2014 2010 2014 2014 Year Live births 3,739,603 2,206,692 242,005 242,005 754,603 495,580 131,251 122,643 387,342 237,718 83,530 36,580 14,275 5,785 2,707 1,100 7,244 629 867 212 reporting thehighestproportion of LGAandin was somewhatlower, withinstitutionsinPeru data, thecombinedproportion ofLGAandSGA In thecountriesthatpresentedinstitutional reported thelowestproportion of SGA (2.5%). frequent inChile(10.2% births). oflive Puerto Rico reported by Mexico (21.9%). SGA was the most respectively. The highestproportion ofLGAwas prevalence ofLGAandSGAwas 16.5% and6.3%, births werereported. The combinedoverall sending nationaldata,atotalof3,739,603live LGA (%) 16.5 15.0 18.9 10.2 10.1 21.9 3.0 4.8 8.7 2.2 8.1 4.4 1.4 1.8 7.5 7.0 7.6 - SGA (%) 12.7 10.6 10.2 19.7 1 9 11. 4.7 6.0 2.5 2.5 6.3 2.5 5.4 8.9 3.0 4.4 8.0 7.6 7.4 11 / Final report of the Pan American Conference on Diabetes and Pregnancy 12 / Final report of the Pan American Conference on Diabetes and Pregnancy Americas, 2012-2014 (nationaldata) Figure 1. Prevalence (%)ofhyperglycemia inpregnancy(GDM[blue],DM[red])selectedcountriesofthe (Figure 2), the percentage of diagnosed GDM (Figure 2),thepercentageofdiagnosedGDM In thecountriesthatpresentedinstitutionaldata (data notshownintablesorfigures). Salvador reported anincidenceofGDM0.2% in Dominica. In overweight or obese women, El in pregnancyrangedfrom5.3%Chileto0.3% 6.5% inCanada,whiletheprevalenceofdiabetes diagnosed GDMrangedfrom0.8%inBelize to the countriesthatpresentednationaldata, regard, and50%was institutionaldata. Among (Figure 2).Only14 countriesreported inthis to nationaldata(Figure1)orinstitutional selected countriesofthe Americas, according hyperglycemia inpregnancy(GDM,DM) Figures 1and2showtheprevalence(%)of Peru (2.5%). lowest reported byinstitutionsfromPanama, and reported ininstitutionsof Antigua (19.7%) andthe respectively). The highestproportion ofSGAwas El Salvador reporting thelowest(8.7%and1.4%, 1 2 3 4 5 6 7 0 retn eieCnd hl Cuba Chile Canada Belize Argentina 4.7 0.6 0.8 6.5 0.9 5.3 of thepopulationincountriesthatreported as statisticsonpopulationanddiabetes. The size newborns reported bythecountries,aswell Table and 5showsnationaldataonmothers 20% ofGDMcases. cases ofGDM.Cubareported usinginsulinin also reported administering onlyinsulintomost including ElSalvador, Guatemala,andGuyana, . Othercountrieswithinstitutionaldata, Dominica reported treatingallcasesofGDMwith that presentedinformation.Saint Kitts and reported by the other countries andinstitutions Chile (51.3%); aconsiderablylowerproportion was cases withdietandphysical activity, followedby the Americas. Cubareported treating80%ofGDM with GDM during pregnancy in nine countries of Table 4showsthetreatmentprovided towomen ranged from3%inMexicoto0.2%Panama. while the prevalence of diabetes in pregnancy ranged from0.01% inPanama to7.8% inMexico, 2.8 0.4 Dominica 1.0 0.3 Rico Puerto 2.2 DM (%) GDM (%) Americas 2012-2014 (institutionaldata) Figure 2.Prevalence (%)ofhyperglycemia inpregnancy(GDM[blue],DM[red])selectedcountriesof Table 4. Treatment ofGDM/diabetesinpregnantwomenselected countriesofthe Americas Dominica Institutional data El Salvador Guatemala Guyana Mexico Saint Kitts Chile National data Cuba 1 2 3 4 5 6 7 8 9 0 Country niu abdsE avdrGyn eioPnm Saint Panama Mexico Guyana ElSalvador Barbados Antigua 0.7 0.6 Diet andexercise 65.0 80.0 51.3 2.1 0.0 9.8 0.0 0.0 1.2 (%) 0.3 0.4 3.8 0.6 25.0 25.0 35.0 OHA (%) 0.0 3.4 0.0 0.0 0.0 .8 7. 3 0.01 Only insulin 100.0 100.0 65.0 20.0 13.2 74.0 0.2 5.0 0.0 (%) Kitts 1.7 Insulin+OHA 32.8 0.0 0.0 2.0 3.0 0.0 0.0 0.0 (%) DM (%) GDM (%) 13 / Final report of the Pan American Conference on Diabetes and Pregnancy 14 / Final report of the Pan American Conference on Diabetes and Pregnancy

Table 5: Statistics on mothers and newborns in selected countries of the Americas (National Data), 2010-2014 United Argentina Belize Canada Chile Cuba Dominica Mexico P. Rico States of America Total population 42,155 348 35,871 17,924 11,249 74 125,236 3,680 325,128 (thousands) Total prevalence (%) 9.80 12.90 6.80 9.40 10.00 17.70 9.20 15.70 12.30 of DM Prevalence (%) of 10.40 17.60 6.40 10.40 12.90 12.30 16.80 11.40 DM in women Mortality (x100,000) 12.00 96.00 9.00 15.00 14.00 35.00 78.00 42.00 11. 6 from DM in women Live births 754,603 7,244 237,718 242,005 122,643 867 2,206,692 36,580 3,932 Perinatal deaths (%) 0.53 1.73 0.60 0.95 4.80 2.19 1. 11 0.00… Caesarean section 31.90 35.36 28.24 26.28 60.00 3.11 45.58 47.56 33.06 (%) Birth defects (%) 0.70 1.32 3.96 1.95 4.30 0.81 1.18 2.99 (%) 0.20 0.19 0.06 0.04 0.01 0.19 20.98 Preeclampsia (%) 1.50 1.16 0.05 5.00 0.46 0.13 3.52 11.37 Premature 8.50 8.35 7.70 2.39 12.00 5.31 6.45 14.55 deliveries (%) Postpartum 0.30 1.01 0.46 0.16 0.69 hemorrhage (%) Note: The data on prevalence of diabetes for Argentina, Canada, Mexico and Puerto Rico are self-reported. The data on prevalence of diabetes for Barbados, Chile, and Cuba are based on fasting blood glucose or self-reported diabetes. The data on prevalence of diabetes for Belize are based on fasting blood glucose and on OGTT, or self-reported. Data sources: Population and mortality data3; Prevalence data sources: Argentina4, Dominica5, Belize6, Canada7, Chile8, Cuba9, Mexico10, Puerto Rico11 , United States12; maternal and newborn data are from the national health authorities (data from Canada are for 2010-2012; data for other countries are for 2012-2014) occurred in Belize (96×100.000 inhabitants). occurred inBelize (96×100.000 highest mortality fromdiabetesamongwomen (15.7%) andthelowestinCanada(6.8%). The highest prevalence was found in Puerto Rico diagnosed orauto-reported diabetes,the (9.2%). Among the countries that reported to Dominica(17.7%) andthelowestinMexico estimated prevalenceofdiabetescorresponded inhabitantsinDominica. 74,000 The highest varied from325millioninUnitedStates to (2.39%) respectively. was reported inPuerto Rico(14.55%) andChile and lowestproportion ofprematuredeliveries (20.98% and11.37% respectively). The highest the highest frequencies in the United States Eclampsia andpreeclampsiawerereported with highest proportion ofcaesareansections(60%). in Argentina (0.53%).Cubaregistered the was observedinCuba(4.8%)andthesmallest The greatest percentage of perinatal deaths 15 / Final report of the Pan American Conference on Diabetes and Pregnancy

Americas Prevalence of diabetes inthe & theCaribbean its burden inLatin America Diabetes Mellitus (DM)and Key points: ÎÎ ÎÎ ÎÎ ÎÎ ÎÎ ÎÎ diabetes every year in the Americas are affected by gestational An estimated 1.8 million casesof of allpregnancies in2015 hyperglycemia inpregnancy was 16.2% The estimated globalprevalence of Tobago and4%inLima, Peru varies widelybetween 22%in Trinidad & In the Americas theprevalence ofdiabetes appearance ofcomplications Undiagnosed diabetes canleadto early not beendiagnosed with type2diabetes intheworld have It isestimated thathalfofthepeople important risk factor for type2diabetes all adultsare overweight orobese, an people haddiabetes in2015 andhalfof In the Americas, anestimated 73.9million one outofsevenpregnancies may pregnancies. At theworldlevel, in pregnancywas 16.2% ofall global prevalenceofhyperglycemia According totheDiabetes Atlas, the in 2015, 199.5 millionwerefemale. to have diabetes around the world Of the415 millionpeople estimated complications has alreadycausedseverehealth time adiagnosisismade,thedisease not beendiagnosedandthatbythe people withtype2diabeteshave world, itisestimatedthathalfofthe each yearintheRegion. Around the with morethanhalfamilliondeaths inactivity. Diabetesisassociated diabetes, togetherwithphysical an important risk factorfortype2 of alladultsareoverweight orobese, Furthermore, itisestimatedthathalf the Americas haddiabetesin2015. An estimated73.9millionpeoplein prevalence was inLima,Peru (4%) respectively). The lowestreported United States,Belize andCuba(12% reported inPuerto Rico(16%), the prevalence ofdiabeteshasalsobeen and 19% inDominica). A high speaking Caribbean(22%in Trinidad has beenreported intheEnglish- The highestprevalenceofdiabetes 1 . 6 . 17 / Final report of the Pan American Conference on Diabetes and Pregnancy 18 / Final report of the Pan American Conference on Diabetes and Pregnancy pregnancies cases annually, affecting about12% ofall subregions each have about 900,000 North America-Caribbean and South America pregnancies andthat theCentral America- It iscalculatedthatGDM affects 16% ofall diagnoses there wereanestimated17.8 millionGDM maternal hyperglycemia inpregnancy and 20.9 million newborns were exposed to corresponding toGDM.In2014, anestimated be affected byhyperglycemia, 85.1%ofthese Prevalence (%)ofdiabetes amongadults, asperresults ofpopulationbasedsurveys, 2016 Quito/Lima: CARMELA 2009; UruguaySTEPS 2013;Quito/Lima: CARMELA2009; DominicaSTEPS 2008 and LifestyleSurvey, CRica,STEPS CR2011; 2008); Argentina 3ra.EFR 2013; Brazil, VIGITEL 2011; Trinidad & Tobago(Diabetic Medicine);Panama: STEPS 2011; McDonald2013; Canada,Diabetesin2011; MexicoENSANUT 2012. Jamaica (Jamaica Health PanBolivia: Am JPublic Health10(5), 2001; Honduras,Guatemala,Nicaragua, Belize, ElSalvador: BarcelóDiabetesCare2012, Haiti Source: USA:2015;Barbados: NHANES,Menke Howitt 2015; US:PRico:PR-BRFSS2014; NationalDiabetesStatisticsReport, 2014; El Salvador (San Salvador) Nicaragua (Managua) Haiti (Port-au-Prince) Guatemala (Ciudad) rndd &TobagoTrinidad 1,15 15 . Puerto Rico* . Another calculationindicates Peru (Lima) Argentina* Costa Rica Suriname Honduras Colombia Barbados Dominica Paraguay Canada* Uruguay Mexico* Jamaica Ecuador Panama Bolivia Brazil* Belize Cuba Chile USA 4 6 6 6 6 7 7 8 8 8 8 9 9 9 9 9 10 10 10 11 12 12 12 ) undiagnosed (Fasting BloodGlucoseorOral Argentina, Canada,Brazil;allotherdiagnosed+ Only diagnosedorself-reported Diabetes:PRico, 16 18 19 22 obesity and diabetesresultinmore diabetes. diabetes, producing aviciouscycle inwhich predisposition tothedevelopment ofchildhood obesity anddiabetes withanincreased is anestablishedrelationship linkingmaternal morbidity andmortality. Furthermore, there babies, increasing the frequency of perinatal in particular and isdetrimentaltomothers disproportionately: Gestationaldiabetes care. Obesityanddiabetesaffect women which often have limited access to maternal inlow-occurs andmiddle-incomecountries, that 87.6% ofhyperglycemia inpregnancy billion, ofwhich $16.9 billioncorresponded to The indirect costsofdiabetes totaled $28.7 costs and$41.1 billioninindirectcosts. more thanUS$69.9billion, with$28.7indirect The overall costofdiabeteswas calculated at the Region haddiabetes thatyear calculation that over 34 million people throughout Latin America andtheCaribbean,basedon In 2014, PAHO studiedthecostof diabetesin America andtheCaribbean The cost of diabetes inLatin Key points: ÎÎ ÎÎ ÎÎ ÎÎ from $1,223 to $803 annual percapitacostdecreased been reduced by 29%andthe of diabetes in 2014 would have Fund prices, theestimated cost adjusted to the PAHO Strategic If insulinandmetformin prices are of metformin cost$0.89 insulin is$4.20, while100 tablets Fund, thecurrent price ofavial Through thePAHO Strategic average on tablets ofmetformin was $17 the commercial price of 100 vial ofinsulinwas $35, while average commercial price of a Caribbean, the estimated In Latin America andthe indirect costs direct costsand$41.1 billionin US$69.9 billion, with$28.7in the Caribbean, was more than in 2014, inLatin America and The estimated costofdiabetes 16 . while 100 tabletsofmetformincost$0.89 Fund, the current price of a vial of insulin is $4.20, cost $17 onaverage. Through thePAHO Strategic insulin was $35,while100 tabletsofmetformin treating diabetes. The averagepriceofavial cost of medicationand services necessary for PAHO compiled information on the commercial visits ($4.2billion),andtests($1.1 billion). each), hospitalcare($7.8 billion),emergency consultations anddrugs(over $9.0billion complications ($15.0 million), followed by billion, the main cost being the treatment of disability. Total directcostscameto$41.1 disability, and$2.9billiontotemporary premature deaths,$8.8billiontopermanent drop inthepercapitacost(from$1,223to$803). reduction inthecostofmedicationanda34% can bereducedby29%;thisincludesa78% PAHO StrategicFund prices,thecostofdiabetes If insulinandmetforminpricesareadjustedto ($3,044) andthelowesttoPeru ($500). cost ofdiabetescorresponded toPuerto Rico was estimatedat$1,223. The highestpercapita diabetes inLatin America andtheCaribbean The averageannualcostoftreatingacase The Cost(US$X106) ofDiabetes inLatin $41,165.50, Total estimatedcostofDM America &theCaribbean 2014 Direct, 59% $69,900.1 $28,734.60, Indirect, 41% 17 . 19 / Final report of the Pan American Conference on Diabetes and Pregnancy 20 / Final report of the Pan American Conference on Diabetes and Pregnancy diagnosis inpregnancy Diabetes screening and Key points: ÎÎ ÎÎ ÎÎ ÎÎ ÎÎ 199 mg/dl) hours of8.5-11.0 mmol/l(153- 10.0 mmol/l(180 mg/dl)ortwo of 75gglucoseonehour≥ OGTT after oral administration 6.9 mmol/l(92-125mg/dl), oran with afasting bloodglucose5.1- diabetes should bediagnosed recommends that Gestational based ontheHAPOstudy guidelines The WHO/IADPSG tional diabetes mellitus mellitus inpregnancy orgesta- should beclassified asdiabetes cy, establishes that thisdisease cemia firstdetected inpregnan - The WHO guidelines, hypergly and cardiovascular disease significant risk of future diabetes by gestational diabetes have a Women andbabiesaffected section andpremature delivery such aspreeclampsia, caesarean the risk ofobstetric problems Gestational diabetes increases to 35%ofpregnant women around the world, affecting 1% complications ofpregnancy of themostfrequent medical Gestational diabetes isone - syndrome, andinsomepopulations,diabetes develop futureintolerancetoglucose,metabolic to glucose. Macrosomicbabiesaremorelikely problems, hyperbilirubinemia, andlowblood the needforneonatalcareduetorespiratory shoulder dystociaandevenErb’s palsy)and (occasionally can cause injuries during delivery and jaundiceinoffspring. The baby’s largesize Premature birth canleadtopulmonaryproblems maternal diabetes and cardiovascular disease. risks, GDMindicatesasignificantriskoffuture macrosomic babies. With regard tolong-term section andprematuredelivery, mainlydueto preeclampsia, aswelltheriskofcaesarean increases theriskofobstetricproblemssuch as It hasbeendemonstratedthatgestationaldiabetes and Pregnancy StudyGroups(IADPSG) sponsored theInternational In 2008, Association ofDiabetes and of formulating the criteria for that diagnosis. OGTT forthediagnosis ofgestationaldiabetes, convergence toward universal adoptingthe75-g their pregnancy—created an expectation of after andweremonitoredthroughout twohours) with 75gofglucoseandbloodmeasured theoralglucosetolerancetest(OGTT,were given multicenter cohort studyinwhich pregnantwomen future riskofdiabetesintheaffected mother todescribeGDMasanindicatorof the first andMahanwere has increased.O’Sullivan importance has beengrowingas its frequency GDM wasrecognizedagoandits first 60years criteria. used, butrisesto30.1%accordingIADPSG 10-12% ofallpregnanciesif ADA 2010 criteriaare Mexico, forexample,theprevalenceofGDMis depending onthediagnosticcriteriaused.In affecting 1%to35%ofpregnantwomen, complications of pregnancy around the world, GDM is one of the most frequent medical Outcome (HAPO)study The Hyperglycemiaand Pregnancy Adverse withGDM in mothers insulinopenia orinsulinresistancebeforebirth that thereisahighriskofoffspring developing ithasbecomeclearlyunderstood last 30years more obviousinthe1980s and90s,inthe The obstetricrisksforthemotherbecame 20,21 . 24 —an international, —an international, 22,23 19 . . Source: PAHO, unpublished; American Diabetes Association (ADA) with the average for the population. with theaverage forthepopulation. adjusted logistic regressionmodels compared outcomes atmeanglucose values,basedonfully reached 1.75 timestheestimatedoddsof these percentile, andpercent bodyfat90thpercentile 90th percentile,cordC-peptide the averageglucosevalues atwhich oddsfor for thediagnosisofGDM,wherethresholds are IADPSG ConsensusPanel recommendedcriteria term effects onoffspring. Subsequently, the blood glucoseandperinataloutcomeslong- studies oftheassociationbetweenmaternal in ordertoexaminetheresultsofHAPOandother Gestational Diabetes Diagnosisand Classification the International Workshop-Conference on Estimated annualpercapitadirect cost(US$)ofdiabetes by countryinLAC, 2014 andtheUS2012 Dominican Republic *American Diabetes Association. EconomicCostofDiabetesintheUS2012. DiabetesCare2013:36:1033-1046 rndd &TobagoTrinidad Puerto Rico El Salvador Saint Lucía Guatemala Costa Rica Nicaragua Venezuela Argentina Suriname Honduras Colombia Barbados Paraguay Bahamas Uruguay Grenada Jamaica Ecuador Panama Guyana Mexico Bolivia Belice USA* Brazil Cuba Chile Peru 0$,0 200$,0 400$,0 600$,0 800$9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 $500 $591 $609 $648 $692 $681 $697 $692 $739 $806 $917 $1,010 $1,026 $1,033 $1,055 $1,113 $1,122 $1,155 $1,190 $1,207 $1,437 $1,494 $1,510 $1,534 $1,676 $1,711 $1,717 $1,762 $3,044 pregnancy recommendedby WHO in1999 The diagnosticcriteriaforhyperglycemia in GDM andtreatmentsprovide better results. other questions about the potential effects of convergence inthediagnosticcriteriaso that The new WHO guidelines seekpointsof Assessment, Developmentand Evaluation methodology (Grading ofRecommendations questionswasof key carried outandtheGRADE formulation ofguidelines. A systematicreview Such updating follows WHO procedures forthe updated in light of previously unavailable data. were notevidence-basedandshould be was used toevaluatethequality oftheevidence 18 . $7,900 Average estimated cost ofDMinLAC $ 1,223peryear 26 25 )

21 / Final report of the Pan American Conference on Diabetes and Pregnancy 22 / Final report of the Pan American Conference on Diabetes and Pregnancy in whichitcouldbeused. discussed, aswellthe differentsituations methodology. Finally, itsusefulnesswas that itiscompleteaccording toPAHO/WHO the draftingofdocumentandtoconfirm questions werealsopresentedtofacilitate considerations forimplementation).Key every phase(theproblem,options,and includes alltheinformationcollectedfor implementation; andiii)afullreportthat policy options,andconsiderationsfortheir ii) a3-5-pagesummaryoftheproblem, summary ofthe key messagesin list form; to include three sections: i) a one-page “evidence summaryforpolicies”tends phases andformats.Theformatforan There wasalsodiscussionofthepreparation different aspectsofahealthpolicyissue. and theavailablelocalevidenceon worldwide evidence(insystematicreviews) summary forpoliciesistobringtogetherthe the startingpoint.Thepurposeofanevidence the availablesystematicreviewsareusedas The processis“achievable”or“feasible”if relevant evidenceonthedifferentaspects. are set,thefocusisonfindingallkindsof Once thepolicyissueisclarifiedandpriorities what hasbeenproducedinthatspecificarea. policy issue is to present what is known or stakeholders. Thestartingpointinahealth results todecision-makersandother relatively newwayto“present”research “Evidence summariesforpolicy”area this includes,andhowitcanbeused. idea ofan“evidencesummaryforpolicy”,what There was alsoan explanation of the general evidence playsinhealthpolicydecision-making. of evidence-basedpolicies,andtherolethat translating knowledgeintopolicy, theconcept The presentation focused on the idea of s P ynopsis reparing

for

a

policy GDM

the following criteria are met: the following criteriaaremet: nosed atany timein pregnancyifoneormoreof Gestationaldiabetes shouldbediag- persons. diabetes bothinpregnant womenandallother al diabetes),usingthe same criteriatodiagnose glucose intoleranceduring pregnancy(gestation- tinguish betweendiabetesandlesserdegrees of tions oftheIADPSGConsensusPanel The WHO guidelines support the recommenda- preeclampsia, andhypertension inpregnancy. cases macrosomia,LGA,shoulderdystocia, Treatment of GDM is effective in reducing of hyperglycemia that required treatment. even after excluding the most serious cases newborn macrosomiaandpreeclampsia, pregnancyoutcomes,inparticularof adverse detected duringpregnancyhadagreaterrisk showed thatwomenwithhyperglycemia The systematicreviewofthecohort studies on consensus. appropriate, therecommendationswerebased GRADE methodologywas notconsidered (diagnosis ofdiabetesinpregnancy)orifthe gestational diabetes.Intheabsenceofevidence on thecut-off values forthediagnosisof and thestrengthofrecommendations 27 anddis- (birth weight90thpercentile,cordC-peptide 1.75 neonatal outcomes oddsratioforadverse define thediagnosticvaluesonbasis of a The IADPSGConsensusPanel decidedto diagnostic threshold is somewhat arbitrary. outcomes withincreasingbloodglucose,any However, thecontinuousriskofadverse given pregnancyoutcomes. on theriskofadverse The criteriaforGDMdiagnosisarebased • • • lsaguoeatroehu 7 ≥10.0 75g Plasma glucoseafter one hour Fasting bloodglucose glucose solution a75-g ofhaving taken hours Plasma glucoseafter two Random glucose mmol/l (153-199 mg/dl) administration of75gglucose:8.5-11.0 afterplasma glucosetwohours oral mg/dl) administration ofglucose≥10.0 mmol/l(180 plasma glucoseonehourafter oral mg/dl) fasting bloodglucose5.1-6.9 mmol/l(92-125 Test glucose Dose of 5g851. 5-9 11200 ≥11,1 153-199 8.5-11.0 75 g - - mellitus) (Recommendation3) GDM (gestational diabetes mllm/lmo/ mg/dl mmol/l mg/dl mmol/l .-. 215≥7,0 92-125 5.1-6.9 - as diabetesmellitusinpregnancy(DMP: WHO detectedinpregnancyshouldbeclassified first According tothe WHO guidelines, hyperglycemia glucose intheOGTT afterone hourandtwohours administering fasting bloodglucose,andplasmaglucose percentile) comparedwithmeanvaluesfor 90th percentile, andpercent body fat 90th ADA, andCanada the guidelines for GDM issued by WHO, IADPSG, OGTT. These recommendations are in linewith suggest thefastingbloodglucosetestor75-g The mostrecentdiagnosticrecommendations value shouldbebasedoneach country’s capacity. any cut-off valuewouldbearbitraryandthatthe The WHO expert groupreached theconclusionthat 180 - 2,21,27,28 2,27. . DM inpregnancy (DMP) (Recommendation 2) 11200 ≥ 11.1 - 126 23 / Final report of the Pan American Conference on Diabetes and Pregnancy 24 / Final report of the Pan American Conference on Diabetes and Pregnancy diagnostic guidelines proposed by ALAD in a multicentric studytocompare thecurrent Argentine DiabetesSociety (SAD) isconducting diabetes andpregnancy committee of the following thecriteria proposed by WHO. The Apparently, notallsocietiesare in favor of and socialcosts. both forfamiliesandintermsofpublichealth women atriskofdiabetesistrulyimportant for a 100-g OGTT the valuesobservedbyCarpenter-Coustan using (following IADPSGcriteria)wereverysimilarto diagnostic ratesforthe75-gtestinitsstudy two-step diagnostictests,observedthatthe et al.,comparingtheresultsofone-and Finally, testcarried aprospective outbyMeltzer mellitus (GDM: WHO recommendation3) recommendation 2)orgestationaldiabetes of having or developing diabetes of awomanwithGDMhas33%greaterrisk published article indicatesthatthehusband diabetes, orifherhusbandisobese. A recently develops cannot breast-feed,ifsheherself and thisincreasesifthemotherdoesnot or risk offutureobesityandglucoseintolerance, cardiovascular disease.Offspring haveagreater There is also a demonstrated, related risk of afterof womenwithin20years diagnosis. intolerance canbeseeninapproximately half (risk ratio=7.4); andsometypeofglucose increased riskofthemotherdevelopingdiabetes A diagnosis of gestational diabetes indicatesan 29 . 29 . Detecting 2 . 2008 2008 screening Cost-effectiveness of GDM after administering the75-gOGTT. glucose ≥100 mg/dlor≥140 mg/dltwohours These criteriadefineGDMasfastingblood Group on Diabetes and Pregnancy in 2007 Group onDiabetesandPregnancy in2007 pregnancy establishedbythe ALAD Consensus for thedetectionanddiagnosisofdiabetesin and proposescontinuingwiththealgorithm the new WHO criteriaforthediagnosisofGDM Consequently, itrecommendsnotadopting IADPSG criterianottobecost-effective. theproposed ALAD guidelines,asitconsiders the timebeing,SAD continuestofollowthe valueformacrosomia.For predictive positive 26.7% usingtheIADPSGcriteria,withasimilar 10.36% accordingtothe ALAD criteriaversus The prevalenceofgestationaldiabeteswas treatment followingthe criteria. ALAD 2008 women wereevaluatedafter diagnosisand for GDMdiagnosisand927pregnant is in progress. A cut-off value was established Key points: ÎÎ ÎÎ ÎÎ 30 the long-term healthbenefits criteria, especially considering use theIADPSG/WHO screening It appearsto be cost-effective to ria withprevious criteria recently proposed IADPSGcrite- evaluated whencomparing the Cost-effectiveness shouldbe GDM screening ating thecost-effectiveness of local preferences whenevalu- long-term results andadaptto It is important to include the with the IADPSG guidelines. The study 31 . Another study thatimplemented adecision were diagnosedandtreated forGDM. effective, aslonganother>2.0%ofpatients IADPSG diagnosticmethod remainedcost- at $61,503/QALY. They alsoreported thatthe moreeffective, andcost-effective expensive, that screeningwiththe2-hrOGTTwas more threshold of$100,000/QALY anddemonstrated established aquantifiedcost-effectiveness methods: 2-hr OGTT versus 1-hrmethods: 2-hrOGTTversus OGTT making modelcomparingsystematicscreening Mission etal.preparedananalyticaldecision- for IADPSG). $US 17,000 forCarpenter-Coustan and$20,000 adjusted lifeyear(QALY) cametosavingsof cost-effective (incremental costs per quality- into account––bothscreeningstrategieswere long-term benefits formaternalhealtharetaken strategy. Their resultsindicated that––whenthe Coustan diagnosticcriteriaandano-screening after the3-hr100-g OGTT, usingtheCarpenter- criteria usinga50-gglucosetest24-28weeks of theIADPSG/WHOcriteriawithprevious Werner followed guidelines. comparing IADPSG/WHOcriteriawithpreviously or usefulnessofGDMscreeningstrategies, that have evaluated the cost-effectiveness Following isasummaryofsixrelevant studies et al. 32 comparedthecost-effectiveness 33 . They effective that thescreeningstrategieswerehighlycost- inIsrael,meaning avoided inIndiaand$1,800 inQALYreported thatsome $1,600 costswere using bothlocaldataandpublishedcalculations, analysis tooltoevaluatecost-effectiveness, calculations has anenormousimpactoncost-effectiveness term benefits ofdetectingandtreatingGDM demonstrated that incorporating the long- Finally, a recent systematicreviewhas per 100approximately women. $19,000 the estimateddifference intotalcostwas than withtheCarpenter-Coustan criteriaand significantly lowerwiththeIADPSGstrategy maternalandneonataloutcomeswere adverse Carpenter-Coustan criteria. They reported that compared with the traditional two-step IADPSG forGDMscreeninganddiagnosis evaluated thecost-effectiveness ofone-step IADPSG criteria. examining the impactofrecently proposed the cost-effectiveness ofGDMscreening, and adapting tolocalpreferences whenevaluating suggested including the long-term results, anymake globalrecommendation. They also in theexistingdataset, itisunreasonableto methodology andthedifferent resultsobserved conclusion that,inviewofhighlyheterogeneous The St.CarlosGestationalDiabetesStudy 34 . 36 . reachedThe authors the 35

25 / Final report of the Pan American Conference on Diabetes and Pregnancy 26 / Final report of the Pan American Conference on Diabetes and Pregnancy resources of eachcountry. program, accordingto the healthcaremodeland women withGDMshould ideallyincludeaneducation 5, and10years)afterdelivery. As a result,treatmentfor history ofGDMareatgreater riskoftype2diabetes(2, or diabetes.Theywillalsobeawarethatwomenwith a neonatal period, and the possible risk of adult obesity possibility ofshort-termnewbornmorbidityduring the the perinatalperiod.Theywillbemoreaware of the and theroleofnormalweightgaininpregnancy and are morelikelytounderstandtheimportanceof diet section, andpre-eclampsia.Witheducation,women fetal macrosomia,injuryduringchildbirth,caesarean blood glucoseduringpregnancycanreducetherisk of should receive information on how proper control of a partoftheeducationprocess,womenwithGDM greater glycemiccontrol,andbetterqualityoflife.As diabetes haveshownbetteradherencetotreatment, of women with GDM, those who receive education on and qualityoflife.Duringthetreatmentsupervision a view to improving clinical outcomes, general health, and activecollaborationwiththehealthcareteam decision-making, self-management,problem-solving, general objectivesofDSMEaretoprovidesupportfor diabetes andfollowsevidence-basedstandards.The life experiencesofthepersonwithdiabetesorpre- diabetes. Thisprocessincludestheneeds,goals,and capacity forself-managementofpre-diabetesand at providingtheknowledge,skills,andnecessary Diabetes self-managementeducation(DSME)isaimed necessary, insulin. physical exercise,self-monitoringofglucoseand,if with GDMshouldbetreatedproperdiet, women GDM detectionanddiagnosisprogram.Onceidentified, The a first step to identifywomen with GDM is to set up used, butrisesto30.1%accordingIADPSGcriteria. is 10-12%ofallpregnanciesifADA2010criteriaare used. InMexico,forexample,theprevalenceofGDM women worldwide, depending on the diagnosticcriteria pregnancy, affectingbetween10%and35%ofpregnant GDM isoneofthemostfrequentmedicalcomplications cap D e v acity eloping

for

educational GDM

in pregnancy Treatment of diabetes perinatal morbidityandmortality is essentialtopreventmaternaland diabetes andhyperglycemia in pregnancy for thenewborn.Proper treatmentof maternal risksduringpregnancyand untreated GDMisassociatedwithgreater The evidence uniformly showsthat their health teams are adequately trained. their health teams areadequatelytrained. care topregnant womenwithdiabetes if and second-levelservices could provide andnewborns; butfirst- units formothers hospitals withspecialized care intensive care inthird-level these patientsreceive diabetes andGDM.In somecountries, for womenwithtype1and2 in high-riskpregnancies,particular to achieve thebestpossibleoutcomes an interdisciplinaryteamisidealinorder There isageneralconsensusthathaving Key points: ÎÎ ÎÎ ÎÎ system capacities education, andhealth depends onneeds, patient GDM andhealthservices between patientswith The frequency ofcontact trained teams are adequately first level ofcare ifhealth GDM canbetreated atthe mortality maternal morbidityand prevents perinatal and in pregnancy orGDM Treatment of diabetes 37,38 . diabetes and follows evidence-based standards. diabetes and followsevidence-based standards. withdiabetes orpre- experiences oftheperson This processincludes the needs,goals,andlife self-management of pre-diabetes and diabetes. the knowledge, skills, and necessary capacity for education (DSME) is the process of providing oral hypoglycemics. Diabetesself-management monitoring ofglucoseand,ifnecessary, insulinor treated withproperdiet,physical exercise, self- Once identified, women with GDM shouldbe set upaGDMdetectionanddiagnosisprogram. step to identify women with GDM is to The first diabetes Education andgestational pregnancy andchildbirth. resources andnationalregulationson The frequencyofmedicalvisitsvarieswith Key points: ÎÎ ÎÎ mothers andbabies present andfuture risks for on diet, physical activity, and should includeinformation Educational programs for GDM management is fundamentalfor diabetes Education for self-management quality oflife treatment, greaterglycemiccontrol,andbetter diabetes haveshownbetter adherenceto educationon with GDM,thosewhoreceive During thetreatmentandsupervisionofwomen outcomes, generalhealth,andqualityoflife. care teamwithaviewtoimproving clinical collaborationwiththehealth solving, andactive decision-making, self-management,problem- ofDSMEaretoprovide supportobjectives for or developing type2diabetesinthe future.Ideally, ofbecoming obese greater long-term likelihood period. Women with GDMandtheirbabieshavea short-term newborn morbidity during the neonatal Another important subjectisthepossibility of weight gain during pregnancy and postpartum. importance ofnutritionandtheoptimalgoals for Materials shouldalsobeincludedtoshow the , caesareansection,andpre-eclampsia. reduce the risk of fetal macrosomia, injury during control ofbloodglucoseduringpregnancycan informationonhowproper GDM shouldreceive As apart oftheeducationprocess,womenwith role management,andemotionalmanagement confidence todealwithmedicalmanagement, chronic disorders. These tasksincludegaining carries wellwithoneormore person outtolive Self-management involves asetoftasksthat follow evidence-basedstandards or pre-diabetes.Ideally, theprocessshould into accountpreviousexperienceswithdiabetes thattake objectives needs, establishingpersonal The educationalprocessisbasedonindividual 41–43 . 40 . The general general . The 39 . 27 / Final report of the Pan American Conference on Diabetes and Pregnancy 28 / Final report of the Pan American Conference on Diabetes and Pregnancy of theU.S. NationalInstitutesofHealth educational materialsforpatients,such asthose in each country. There areseveralexamplesof with themodelofcareandresourcesavailable include aneducationalprogramthatiscompatible case managementofwomenwithGDMshould ([email protected] ) Contact: SusanaSalzberg adding totheburdenin countries. of womenreceivingtreatment, unnecessarily threshold (92mg/dl)wouldincreasethenumber ethnic groupwasrepresented,andthatthelow on theHAPOstudy, inwhichnoLatinAmerican that theIASDPGrecommendationswerebased GDM orDM.CGDMP-ALADconsideredthefact aimed atpreventingthefuturedevelopmentof physical activityplan.Theseprogramsare for GDMandshouldbeofferedanutrition 85-99 mg/dlshouldbeconsideredathighrisk pregnant womenwithfastingbloodglucose The Groupconsideredthatobeseoroverweight different days or 2-hr 75-g OGTT ≥ 140 md/dl. as fastingbloodglucose100-125mg/dlontwo to adoptthedefinitionofgestationaldiabetes to pregnancy. TheConsensusGroupdecided to thecurrentWHOcriteriaordiagnosedprior as type1or2diabetesdiagnosedaccording 200 mg/dl.Pre-gestationaldiabeteswasdefined blood glucose ≥ 126mg/dlor 2-hr 75-g OGTT ≥ current WHOdefinitionofdiabetesasfasting 2015. TheGroupreviewedandacceptedthe Santa CruzdelaSierra(Bolivia)inSeptember Association (CGDMP-ALAD),whichmetin Pregnancy––Latin AmericanDiabetes in theConsensusGrouponDiabetesand Representatives of13countriesparticipated A L C D atin onsensus s iabetes sociation A merican

and G (C roup P GDMP-ALAD) regnancy D iabetes

on

44 .

– following nutritional plan for women with GDM: following nutritional planforwomen withGDM: The 2007 ALAD guidelinesrecommend the during pregnancy, evenobesewomen. It isnotrecommended thatwomenloseweight high-quality foodsinappropriate-size servings. diet for a pregnantwomanincludes a variety of a nutritionalplanandphysical activity. A good Diet lifestyle 70-85% of cases simply by making changes in It iscalculatedthatGDMcanbecontrolled in GDM management. in childhood. Educationisabuildingblock of current trend is to prevent obesity from starting measures thatshouldbeadoptedtoreduce the on thepopulation.Oneofmostimportant affect around 16% ofall pregnancies, depending an increased prevalence of GDM, estimated to and diabetes. This epidemicisalsoreflectedin an increaseintheglobalprevalenceofobesity habits in the general population are causing widespreadunhealthy In recentyears, eating Key points: ÎÎ ÎÎ ÎÎ ÎÎ between meals Do notgo more thaneighthours and proteins ingested carbohydrates, fats, while optimizingthequalityof meals, often withanappetizer, based onmore frequent, lighter Changes indietshouldbe physical activity according to weight gain and Adjust dailycaloric intake activity) lifestyle (proper dietandphysical by simplymakingchanges in Most GDMcasescanbetreated 45 . Treatment ofGDMshouldbeginwith and improves qualityoflife cardiovascular health,andreducesmortality glucose, lipoproteins, bloodpressure,and Physical improves controlofblood activity the preventionandcontrol oftype2diabetes. are oneofthemostimportant measuresfor physical andregular activity exercise Among thetherapeuticoptionsconsidered, Physical exercise and breakfastshouldnotexceed6-8hours. period between the last meal of the evening customs; however, itis recommended that the The frequencyofmealswilldependonlocal ofiodineshouldbe0.2mg. Daily intake hypertensionsensitive or cardiac insufficiency. day), minimallyrestrictedinthecaseofsalt- should benolessthan5g/day(2gofsodium/ gained bythepregnantwoman.Salt intake dependsontheweight trimester; caloricintake to add450kcal/day, starting inthesecond of multi-fetalpregnancies,itisrecommended kcal.Incase tobelow1,800 daily caloricintake in diet. It is not recommended to reduce total by making the appropriate adjustmentsintake maternal weightgain andadjusttotalcaloric consumption. Itisnecessarytocontrol trimester, kcals are added to daily energy 300 of physical activity. Starting inthesecond calculated accordingtobodyweightandlevel trimester,In thefirst is totalcaloricintake proven to improve thecontrol ofGDM combined with medicalmanagement, has Key points: ÎÎ ÎÎ and diabetes effect onthecontrol ofGDM Physical activityhasapositive diabetes the onsetofGDMandtype2 have aprotective effect against Physical activity and exercise 46 . Exercise, 47–49 . ([email protected] ) Contact: SusanaSalzberg of ALADstandards. double ifIADPSGstandardsareusedinstead the numberofcasesneedingtreatmentwill standards. ThenumberofGDMcasesand standards and10.67accordingtoIADPSG for macrosomiawas11.46accordingtoALAD cut-off values.Thepositivepredictivevalue thresholds, comparedto26.7%withIADPSG prevalence was10.36%usingALAD2008 on 927pregnantwomenindicatethatGDM progress, but the preliminary results of data ≥ 8.5mmol/l153mg/dl).Thestudyisstillin 92 mg/dl;ortwohoursafterglucoseoverload criteria (fastingbloodglucose≥5.1mmol/l, 140 mg/dl)werecomparedwiththeIADPSG hours afterglucoseoverload7.8mmol/l≥ glucose ≥5.6mmol/l,100mg/dl;ortwo Diabetes Association(ALAD)(fastingblood criteria issued in 2008bytheLatin American various diagnostic criteria forGDM. The conducted amulticentricstudytocompare of theArgentineDiabetesSociety(SAD) The DiabetesandPregnancyCommittee UATION st Ev (A rgentina andards al

)

in of B IADPSG uenos A

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29 / Final report of the Pan American Conference on Diabetes and Pregnancy 30 / Final report of the Pan American Conference on Diabetes and Pregnancy macrosomia protective effectprotective against GDM that physicalduringpregnancyhasa activity in somekindofphysical exercise. This suggests in thegroupofpregnantwomenwhoengaged developing GDMwas 28%lower(9-42%, CI 95%) randomized clinicaltrialsshowedthattheriskof A systematicreviewofrecentlypublished Medical treatment control is not achieved medication shouldbeprescribedifglycemic nutritional planandphysical activity, andthat that treatmentofGDMshouldstart witha There isaconsensusamongmany organizations women withGDMdevelopingtype2diabetes of that exercise reduces the future likelihood to insulin glycemic control, increase cellular sensitivity to increasemusclemassandthusimprove In thecasesofdiagnosedGDM,exerciseseems the preventionofGDM that evaluatetheefficacy ofphysicalin activity available reports arefromobservationalstudies on exercise and GDM remain scarce.Most developing GDM pregnant womenwas inverselyrelatedto have demonstratedthatphysicalin activity Key points: ÎÎ ÎÎ ÎÎ sensus orsupporting evidence OHA inGDM, butstillno con- There is a trend toward using possible glucose ascloseto normal as treatment isto maintainblood The objective of medical with insulininthe Americas Not allcasesofGDMare treated 54,55 56,57. , andreducetheincidenceoffetal Ithasalsobeendemonstrated 53 . 51,52 20,50 . All thesestudies 49 . Clinical trials . 58 . of glibenclamide supports theefficacy andshort-term safety However, recentrandomized testing the ADA evidence-gradingsystem) glulisine, which arecategoryC(accordingto drugs, exceptforinsulinglargineand All typesofinsulinareteratogeniccategoryB specialized centerisrecommended,ifpossible. management duringpregnancy, referral toa insulin. Due tothe complexity of insulin as basalinsulinandanotherpart asprandial of thetotaldailydosageshouldbeadministered achieve glycemicgoals.Ingeneral,aproportion increase inthedoseofinsulinisrequiredto rapidly, which meansthataweeklyorbiweekly the second trimester, grows reduction inthedailytotaldoseofinsulin; trimester,end ofthefirst theretendstobe a to meetchanging requirements: Toward the requires frequentadjustmentofinsulindoses subcutaneous injections a basalregimenofthree,four, ormoredailyrapid NPH humaninsulinisthepreferred treatmentfor types ofagents lack ofdataonthelong-termsafety ofother treatment ofdiabetesinpregnancy, duetothe state thatinsulinisthepreferred agentforthe The ADA guidelinesforGDMmanagement glibenclamide (especiallyinGDM), butthere done onthe useofOHAssuch asmetforminand Furthermore, studieshave been inrecentyears studies of their cost-effectiveness are needed. all thecountriesof Region. Inthisregard, but not by the health regulatory authorities in for useduringpregnancy (ADA categoryB), three drugshavebeenapproved bytheFDA metabolic control prior to pregnancy. These continues tobeusedifithadachieved good . Detemir, a long-acting analog, human insulinorinthecaseofseverenocturnal peaks isnotachieved regimenswith inintensive diabetes, ifgoodcontrolofpostprandialglycemic and Lispro),inparticular forwomenwithtype1 may berapid-actinginsulinanalogs(Aspart on theirlong-termsafety pass throughtheplacentaandthereisnodata treatment ofGDM.Nevertheless, bothagents metformin 60,61 20 (ADA categoryB)forthe . The physiology ofpregnancy 59 (ADA categoryB)and 62 63–65 . . Another option . Another 45 . (T2DM) in a given population. type 2diabetes (T2DM)inagiven impaired glucose tolerance(IGT), obesity, and by similarincreases intheprevalenceof Increased frequency of GDM is accompanied diseases and noncommunicable and child:Maternal health Future riskfor mother in GDM is stillnoconsensusontheuseofmetformin care andimmediateevaluation. adequateobstetric newborns shouldreceive fetal surveillanceshouldbeconductedand and chronic vascularcomplications. Exhaustive treatment of associated infections, hypertension, Diabetes inpregnancyalsorequiresdetectionand required. discussed withthepatient,whoseconsentis approved, thismustbe their useisdefinitively is availableontheirbenefits andrisks,until glycemic control.Untilmorescientificevidence often requireaddedinsulinforthenecessary friendly forphysicians andpatients,butthey anduser-OHAs arethat they areinexpensive Key points: ÎÎ ÎÎ ÎÎ diagnose diabetes inpregnancy WHO criteria shouldbeusedto Whenever possible, IADPSG/ mia inpregnancy examined to detect hyperglyce- All pregnant women shouldbe diseases health andnoncommunicable to thelinksbetween maternal Closer attention should bepaid 61 . The argumentsinfavor ofusing treat hyperglycemia inpregnancy. it necessary toprevent,screen,diagnose, and make diabetes andcardiovascular disorders increasedfuture vulnerabilityto as mothers’ hadGDMduring pregnancy,mothers aswell in childrenof diabetes.Disorders whose risk ofthemetabolicand cardiaccomplications withGDM,andapotentialincreased of mothers the imprintingofcertain genesintheoffspring negative outcomesofpregnancy, alterationsin lies in the links between hyperglycemia and pregnancy. The importance ofGDMprevention perinatal deaths,andnegativeoutcomes of worldwide, withover 90%ofmaternaland resources have80%oftheburdendiabetes diabetes inpregnancy. Countrieswithlimited are often notscreenedsufficiently to detect In countrieswithlimitedresources,women and diabetes,bothformotheroffspring. sequelae includeagreaterfutureriskofobesity the laterdevelopmentof T2DM. Long-term of pregnancy(includingpreeclampsia),and injuries in childbirth, hypertensive disorders caesarean sections,shoulderdystocia, of maternal,perinatal,neonatalmorbidity, GDM isassociatedwithahigherincidence 31 / Final report of the Pan American Conference on Diabetes and Pregnancy 32 / Final report of the Pan American Conference on Diabetes and Pregnancy Patients arereclassifiedwith a75-gOGTT, the beginning ofthesixthweek after delivery. Patients withGDM shouldbereclassifiedat well asnutritionaltherapy. in puerperiumrequires clinicalreevaluationas diabetes after delivery. ManagementofGDM Women with GDM have a high risk of contracting Puerperium Gestational diabetes: Key points: ÎÎ ÎÎ ÎÎ reduce thefuture risk ofDM should berecommended to The adoptionofahealthy lifestyle DM later inlife have a50%risk ofdeveloping Women whohave hadGDM glucose, 2-hrOGTT, or A1c test) test for diabetes (fasting blood delivery, using a diagnostic reclassified six weeks after Women withGDMshould be with women 16 years afterwith women16 years delivery and undergoannualmetabolicmonitoring. healthy eatinghabits,engage inphysical activity, puerperium should be recommended to maintain Patients whohavehadnormaltestresults during measuresatthisstageinlife. preventive take in thefuture,soitismorethanjustifiableto to determinetheriskofhavingtype2diabetes with GDM,puerperiumisaveryimportant time glucose levels women whohavepregnancieswithnormal susceptible tocontractingtype2diabetesthan Women withahistoryofGDMaremore administration ofglucose. aftertheir bloodglucoseleveltwohours the of DMinnon-pregnantadults,basedon following WHO standards for the diagnosis Fetal programming after delivery year prevalence oftype2diabetesinthefirst early in puerperium have revealed up to 38% Key points: ÎÎ ÎÎ ÎÎ that result inadultobesity preventing harmful outcomes newborn dietplansaimedat of gestational diabetes, and in pregnancy, management diet andoptimalweight gain care thatintegrates aproper It isrecommended to offer adult obesity a higher risk of childhood and High birth weight alsoposes childhood obesity diabetes, increases therisk of with or without gestational Exposure to maternal obesity, 65 66 andupto60%infollow-ups . Studies of how glucose acts . Studiesofhowglucoseacts 7. 6 In women Inwomen programming This principleisfundamentaltodevelopmental the wombandafter birth, inparticular duetodiet. clearly influencedbyenvironmental exposurein recognized thattheriskofobesityinadultsis in pregnantwomen(~30%).Itisincreasingly prevalence of obesity and gestational diabetes faced withaclearandcontinuousincreaseinthe is increasingaroundtheworld.Obstetriciansare obesity,The prevalence of type 2 diabetes, like hypertriglyceridemia in offspring, aswell asinsulinresistanceand diet resultingreaterhyperphagia andadiposity it hasbeendemonstratedthatthesechanges in maternal malnutrition (low birth weight) in rats, a fat-rich maternaldiet(maternalobesity)and epigenetic modifications.Basedonamodelof development, cellularsignalingresponses,and mechanisms, such asthealterationoforgan results, sheddinglightonpotentialprogramming models have reproducedhuman epidemiological with asignificantriskofadultobesity. Animal with acceleratedchild growthisassociated obesity. Inparticular, lowbirth weighttogether also implies a greaterrisk of childhood and adult gestational diabetes,orbeingoverweight atbirth Exposure tomaternalobesity, withorwithout pregnancy, especiallyobesity. long-term consequences ofhyperglycemia in and newborn diet plans will help reduce the optimal weightinpregnancy, treatment ofGDM, guidelines recommending aproperdietand childhood and adultobesity. Itisexpectedthat interventions thatcanpreventorreduce health, andthereisnowanopportunity for focusing onmaternal,fetal,andneonatal Prenatal carehasadvancedconsiderably by cells andincreasedinadipocytes. exogenous insulindiminished inneuralprogenitor in preadipocytes).Furthermore, responseto diminish inneuralprogenitorcellsandincrease insulin response(proliferationanddifferentiation changes inprogenitorcellsandtheirdifferent of adiposecells.Underlyingmechanisms include proportion to satiety neurons,and higher content changes toward more appetite neurons in subject tobothtypesofnutritionalstressshow 68 . 69,5 . Specifically, offspring [email protected] ) Contact: GloriaT. Larrabure-Torrealva (gloria. implications. has importantclinicalandpublichealth and itsassociationwithmaternalobesity evidence documentingtheburdenofGDM calculations basedonIADPSGcriteria.The in Limamatchestheinternationallyreported 1.4; CI 95% 1.2-2.5). The prevalence of GDM related toahigherprevalenceofGDM(PR= of diabetesinfirst-degreerelativeswas 1.6; CI95%1.1-1.8).Furthermore,ahistory times higherprevalenceofGDM(PR= (<20 years),those≥35yearsshowed1.6 3.8). Comparedwiththeyoungestmothers pregnancy ≥ 35 kg/m2) was 2.3 (CI 95% 1.3- extremely obesewomen(BMIatmidpointin women, prevalenceratio(PR)ofGDMfor 22%, respectively. Incomparisonwiththin (≥ 30kg/m2)womenwas12%,15%,and m2), overweight (25-29.9 kg/m2) and obese thin (BMIatmidpointinpregnancy<25kg/ (14-18%, CI95%).TheprevalenceofGDMin general, the prevalence of GDMwas16% GDM andmaternalBMIwerecalculated.In in Lima(Peru).Theassociationsbetween Maternal andPerinatalNationalInstitute 1,282 womenreceivingprenatalcareinthe between weeks24and28ofpregnancyto A 75-g2-hrOGTTwasadministered pregnancy andatthemidpointinpregnancy. and maternalbody mass index (BMI) before and evaluatetheassociationbetweenGDM prevalence ofGDMusingtheIADPSGcriteria This projectsoughttocalculatethe screening F (P easibility eru )

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33 / Final report of the Pan American Conference on Diabetes and Pregnancy

Health care organization • • • • • • • summarized below. tothesethreequestionsare Their answers 3. 2. 1. following threequestions: The participants torespondthe wereasked Teamwork session

Lack oftrainingfor health careteams and fortherestofawoman’s life) (prevention of diabetes in future pregnancies in pre-conceptionand postpartum check-ups Weaknesses levelofhealthcare and atfirst self-treatment) with diabetes(leadingtoself-monitoringand High costofmedicalcareforpregnantwomen continuity (frequentchanges) lackHealth personnel commitmentand insulin, etc.) ofsupplies(strips, and continuityofdelivery and difficulties intheavailability, distribution, Insufficient financialresources.Inequality Lack levelofhealthcare oftrainingatthefirst Fragmented healthsystems control ofgestationaldiabetes? in yourcountryorsubregiontoimprove the What arethenextstepsthatshouldbetak related topregnancy? overcome barriers forthecontrolofdiabetes Identify acti pregnancy? and managementofdiabetesrelatedto for improving prevention,screening In youropinion,whatarethebar diabetes related to pregnancy? screening andmanagement of barriers for improving prevention, In your opinion,what are the vities and actors foraplanto vities andactors riers riers en • • • • • communication policies, creation of networks, Community resources, public • • • • • • • • research Guidelines, protocols, and public entities Limited linksbetweenorganizations and diseases Lack ofhealthcarepoliciesaimedatchronic (obesity, processedfood,foodlabeling) Inadequate regulation of the social environment Insufficient societyparticipation civil Lack ofpoliticalwillandcommitment rate ofunnecessary caesareansections) women withdiabetes, and reducingthehigh criteria forthesurveillance ofpregnancyin departments (intermsofsetting andmeeting problems inobstetrics Administrative management andtreatment ofGDM Poor disseminationofCPGsforthe without reaching mutualagreement that formulate and publish recommendations ministries, oramongthedifferent societies anddiabetessocieties)health scientific andprofessionalassociations(i.e., Lack ofconsensusorcommunicationbetween results (usingCPGs) No monitoringofthecost-effectiveness of Poor adherencetoCPGsandprotocols guidelines Lack ofclinicalpracticeprotocolsand Lack ofregionallinesresearch health care practice guidelines(CPGs)intomedical Lack ofmechanisms toincorporateclinical physical therapists) nutritionists, (physician, nurses, , 35 / Final report of the Pan American Conference on Diabetes and Pregnancy 36 / Final report of the Pan American Conference on Diabetes and Pregnancy f A • • Improve • order to: An educationalinterventionwascarriedoutwithwomengestationaldiabetesinArgentina in Contact: SilviaLapertosa ([email protected]) associated withGDM. Conclusions: Theeducationalprogramforpregnant womeneffectivelyreducedthecomplications reference group(OR=0.77,CI95%, 0.27-2.18), as did caesarean sections (OR =0.61, CI 95%,0.22-1.68). number ofneonatal hospitalizations significantly declined intheintervention groupcompared withthe results. Allprocessindicatorsimproved,including BMI,eyeexam,EKGandproteinuria,p<0.01.The ± 3.5versus16.82.6(p<0.000),58%.Text messageswereusedtoadjusttreatment, withsatisfactory average ageof31.8years(±6.5)andBMI 32.5(±7.3)kg/m2;knowledgequestionnaires13.8 1 January2009and31December2011.Results: Intotal,43pregnantwomenparticipated,withan who werereceivingtheusualcareintheirhealth centers.Theinterventionwascarriedoutbetween and consultationsinthephysician’s office.Thereferencegroup wasmadeupofpregnantwomen 5D), and satisfaction. Project evaluation also included an analysis of clinical histories, house calls, one ofwhichreviewedtheirknowledgeDM,depressionandwell-being(WHO-5),qualitylife(EQ- organized byamultidisciplinaryteam.Theinterventionwasevaluatedthroughvariousquestionnaires, adjustment ofmedicaltreatment.Thepregnantwomenalsoparticipatedinphysicalactivitysessions measurements werealsocarriedout,includinganthropometry related issueswereaddressedthroughparticipatoryactivitiesanddemonstrations.Clinicaltests Eight-hour workshopswereheld,witheightpregnantwomenparticipatingineachone.Diabetes- or Provide Reduce progression towardT2DM. n

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• Information system • • • • • • Support for self-management • • • • Health services delivery of LGAand SGA. and gestational diabetesandthe frequency Lack ofdata on theprevalenceofdiabetes communications media Lack of health education programs in the local conditions andgroupeducationadaptedto individual Lack of culturally appropriate programs for healthy diet,managementofinsulintherapy) women withdiabetes(physical activity, for theintegratedmanagementofpregnant Lack ofstandardized educationalprograms workplaces, etc. secondary school settings, andatuniversities, concepts ofa healthy lifestyle in primary and on healthy childhood, incorporating Poor disseminationofeducationalmaterials our Region Lack ofapopular “healthy lifestyleculture” in of care Erroneous ideasabout diabetesandaspects (missed consultations) scheduled shifts withverydifferent schedules demand: rejecting demand and prioritizing Missed opportunities incasesofspontaneous care levels Inappropriate relationships between health counter-referral system disorganized andhighlycomplexreferral and Limited human resources and lack of training; Outdated standardsinhealthsystems • • • • • • • • • Organization of healthcare systems Inadequate surveillanceandmonitoring all stagesoflife mortality, andontheburdenofdiseaseat on maternalandperinatalmorbidity of gestationaldiabetesanditsimpact Lack ofregionaldataontheepidemiology medical education Improve staff expertise throughcontinuing prevention andcontrol Improve financingofprogramsfordiabetes medical andacademic experts) network, logisticalsupport andinfrastructure, Develop anappropriate setting (supplier chronic diseases) health,noncommunicable (reproductive Create linksamonggovernment programs budgets Include chronic diseasesinthehealthministry diabetes inpregnancy with aviewtothepreventionandcontrolof access tohealthcareforpregnantwomen Ensure timely, anduniversal comprehensive, and betweenweeks2428ofpregnancy prenatalvisit all pregnantwomeninthefirst screeningfordiabetesin Promote universal pregnancy? the control of diabetes related to a planto overcome barriersfor dentify activities and actors for 37 / Final report of the Pan American Conference on Diabetes and Pregnancy 38 / Final report of the Pan American Conference on Diabetes and Pregnancy Contact: Humberto Mendoza ([email protected] ) Contact: HumbertoMendoza ([email protected]) health agentscaneffectively empowerwomenwithGDMandimprovetheir adherencetotreatment. of diagnosedwomenreceivednutritionalguidance athome.Universalscreeningisthekey. Community beneficiaries. NuevaVidaeducated709pregnant womenwithGDMinthree-dayworkshopsand90% visited the public health centers were educated about GDM and healthy lifestyles, for a total of 28,687 8.8%. Amongthewomendiagnosed,29%showed noriskfactors;fouroutoffivepregnantwomenwho 21,169 pregnantwomenforscreening,1,853ofwhom werediagnosedwithGDM,foraprevalenceof 1,269 communityhealthagentsweretrainedinGDM andstandardsofcare.TheNuevaVidaprojectsent this, trainingwasprovidedto72%ofprimarycare staffandobstetriciansinthepublichealthsystem; with GDMwerereferredtotreatmentandparticipated inthreeeducationalgroupsessions.To accomplish blood glucose≥126mg/dl(7.0mmol/l)isconsidered toindicatepreexistingdiabetes.Women diagnosed administration ofglucose≥180mg/dl(10.0mmol/l);andtwohourslater153(8.5mmol/l).Fasting this purpose.Thecriteriafordiagnosiswere:fastingglucose≥92mg/dl(5.1mmol/l);onehourafter and 28ofpregnancy, inaccordancewiththeclinicaldetectionandtreatmentguidelinesdevelopedfor was screenedusingthe fasting glucose measurement in the first visitand anOGTTbetweenweek24 awareness-raising campaignswereimplementedinanattempttoensurethatthetargetpopulation monitoring ofclinicalguides,aswelltrainingforhealthprofessionals.Universalscreeningand the detection and treatment of GDM in Barranquilla, through the development, implementation, and Nueva Vida(NewLifeinEnglish)projectBarranquilla.Theobjectivesoftheweretoimprove been poorlyimplemented.Theturningpointinthisregardwasthedesignandimplementationof the Up-to-date globalcriteriaandstandardsforthetreatmentofGDMhavelongbeenoverlookedor (C diabetes and N ue ol v ombia

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• • • and communication policies, creation of networks, Community resources, public • • • • • • • • • • agriculture, NGOs, universities, social agriculture, NGOs, universities, (education, finance, culture, other sectors Promote strategic partnerships with physical activity healthy lifestyles,including ahealthy dietand interventions) that facilitate the adoption of industry andenvironmental guidelinesand Produce regulationsandpolicies(food and Pregnancy of thePan American Conference onDiabetes pregnancy, with referencetotheconclusions prevention andcontrolofdiabetesin Promote publicpolicy-making forthe Development Bank Federation, World Bank,andInter-American such asPAHO, InternationalDiabetes the support from international organizations Promote exchanges betweencountries and services forpregnantwomenwithdiabetes Evaluate theneedtocreatespecialized health ministries development incollaborationwithhealth Conduct research, training,andprofessional pregnancy the preventionandcontrolofdiabetesin the necessarycompetenciesformanaging educationthatprovides themwith receive should ensurethathealthprofessionals scientific societies,andmedicalschools theacademiccommunity,Universities, the PAHO StrategicFund Provide informationtothecountriesthrough and supplies Guarantee sufficient equipment, personnel, puerperium and treatmentofdiabetesinpregnancy relatedtoscreening care, includingindicators Guarantee a focus on improving quality of physicians the deficitgeneratedbymigrationsof Mitigate shortage ofspecialists,especially of gestationaldiabetes Strengthen primaryandsecondaryprevention Promote research ondiabetesinpregnancy • • • • • • research Guidelines, protocols, and • • • • • • • • • • • Training inthemanagement of oftrainers age andpregnant women campaigns toeducatewomen ofreproductive Offer trainingtohealthcareteams and workers andperinatal healthcare nurse-midwives, Provide continuing training to midwives, different levelsofhealthcareserviceproviders Create programsforcontinuingeducationat and scientificsocieties involving universities Promote continuingmedicaleducation and controlofdiabetesinpregnancy clinical practiceguidelinesfortheprevention Produce, update,adaptoradopt,andestablish MERCOSUR, CARICOM,RESSCAD health agencies:HipólitoUnanue Agreement, Promote work on GDM through regional health alerts indiabetes-related emergencies) Communicate throughthemassmedia(e.g., in theRegion implementation ofprioritylinesresearch Organize anetworktoensurethe subregions communication betweencountriesand Implement effective mechanisms forongoing diabetes inpregnancy topatientswithoratriskofhaving members In remote areas, promote visits by community of gestationaldiabetesandovert diabetes for theprevention,detection,andtreatment and theregulatingbodyfornationalpolicy The healthministryshouldbetheintegrating agenda in pregnancyareincludedthegovernment Ensure thatgestationaldiabetesand healthy diet Require foodlabelingthatfacilitatesagood, diabetes andinpregnancy Set aclearnationalpolicyforgestational Fund diabetespreventionandtreatment foods, alcoholicbeverages,andtobacco Establish taxregulationsforhighlyprocessed pregnancy the preventionandcontrolofdiabetesin prepare plansandprogramsthatsupport sector)to andprivate forums, lawmakers, 39 / Final report of the Pan American Conference on Diabetes and Pregnancy 40 / Final report of the Pan American Conference on Diabetes and Pregnancy • Support for self-management • • • • • • Health services delivery • • school. of life,starting inprimaryandsecondary Promote healthy lifestylesintheearlystages of support units. levels of health care or promote the creation Improve thecoordination ofthedifferent control ofdiabetesinpregnancy. Strengthen health units for the treatment and puerperium. gestational andprenatalstagesthroughto allwomen, fromthepre- that covers Ensure ahyperglycemia screeningprogram family planningprocess. Guarantee theentirecare,contraception,and consultations. Increase pre-gestationalandearlyprenatal referral system. Improve orstrengthenthereferral/counter- hyperglycemia inpregnancy glycemic thresholds for the diagnosis of Consider research needs,inparticular specific level ofhealth-care in each second,and third institutionoffirst, implementation ofclinicalpracticeguidelines Form facilitatingsitesfordisseminationand pregnant womenwithdiabetes • • • • • • • • • • • • system Monitoring andinformation phones in particular, usingsocialnetworksandcell written messages, radio,ortelevisionand, to communicatewithpatientsthrough Use availablelocalinformationsystems campaigns ondiabetesinpregnancy medical andscientificsocietiesineducational of Involve andleaders publicpersonalities gestational diabetes the preventionandself-managementof pregnant womenandtheirfamiliesabout raise thelevelofawareness andeducate particular, can communityhealthpromoters a viewtoeducationinself-management: Promote training for community groups with family members patients withgestationaldiabetesandtheir programs withparticipatory educationfor Strengthen orientation andguidance systematically engage inphysical activity. Sensitize thepopulationto andmotivate opportunities topromotehealth. Increase accesstomassmediaand in particular. of diabetesingeneralandduringpregnancy Promote healthy lifestylesfortheprevention of physical activity. healthy foodpreparationandthepromotion treatment ofdiabetesinpregnancy, including aspects oftheprevention,detection,and Launch educationprogramsthat include for themanagement ofchronic diseases Support thedesignofacomputerized system monitoring diabetesduring pregnancy. systems andofthe datanecessaryfor Carry out a periodic evaluation of information diabetes inpregnancy. information to generatehealth policies on Promote theuseofepidemiological Pregnancy. American ConferenceonDiabetesand the datacollectiontoolcreatedforPan Collect data on diabetes in pregnancy, using 5. 4. 3. 2. eport totheministriesofhealthontopics 1.

programs withintheframeworkofnational screening duringpregnancyandtoprevention P diabetes andpregnancy. support thedissemination ofinformationon Identify whic weeks 24and28ofpregnancy. prenatalvisitandbetween diabetes inthefirst they recommendthatwomenbescreenedfor and pregnancy, inparticular toensurethat R mass media). support and groups, community leaders, academia,NGOs,social sectors, private (publicand participation ofall stakeholders addressed intheconference,with pregnancy toexplainthetechnical issues by org Disseminate theresultsofconference specific needsofeach country. concretemeasuresaccordingtothe to take on Diabetes and Pregnancy, and on the need addressed inthePan American Conference R romote universal accesstodiabetes romote universal eview nationalpoliciesthataddressdiabetes control of gestational diabetes? or subregion to improve the should betaken inyour country What are thenext steps that anizing ameetingondiabetesand h communityorganizations could 6.

e. d. a. pregnancy, and: b. screening, andtreatmentofh Examine thestatusofprevention, sector.private health services,socialsecuritysystem,and c.

treatment ofhyperglycemia inpregnancy. training ontheprevention,screening,and pregnancy. of screeningandcarefordiabetesin support theevaluation andimprovement as theneedtoimprove datacollectionto diabetes inpregnancyandthroughoutlife. and onthepreventiontreatmentof acquiring diabetes (both mother and child) includes information on the risks of Evaluate thescreeningandcareof social securitysystems. and insurers, private health careproviders, implementation bypublicandprivate and protocolsfornational-level Modify Ensure thathealthprofessionalsrecei the cur Evaluate existingnationaldatawithin Launc availability ofspecialized services. quality improvement strategies,and diabetes, referral/cross-referral mechanisms, to pointsofaccess,treatmentgestational hyperglycemia in pregnancy, with attention h aneducationalprogramthat , update,orformulateguidelines rent informationsystem,aswell yperglycemia in ve

41 / Final report of the Pan American Conference on Diabetes and Pregnancy

Conclusions of theconference regnancy offers anopportunity toreduceobesity-related morbidityandmortality, 0 countries,screeningforhyperglycemia inpregnancyisbasedona75-gOGTT. rom the37consultedPAHO MemberStatesonly15 (41%)reported havingpolicies WHO groupthatformulatedthecriteriafordiagnosinghyperglycemia first 13 maternalandperinatal WHO/IADPSG guidelinesarebasedonadverse thereby alsoimproving thehealthoffuturegenerations. P medical treatmenttolowerbloodglucoseand reducetherisksformotherandchild. Nutritional In 1 dl inCanada,Colombia,Cuba,Guatemala,Nicaragua, Peru, andtheUnitedStates. thresholds forGDMdiagnosisvaryfromcountrytocountry, thelowestbeing92mg/ no uniformityintheirstrategiesanddiagnosticthresholds.Fasting bloodglucose for thescreeninganddiagnosisofhyperglycemia inpregnancy;however, thereis Overall 67% for thescreeningofdiabetesinpregnancy. F among countries. hyperglycemia inpregnancy. itdifficultThis makes tocomparethefrequencyofGDM ofstandardsforthescreeninganddiagnosis survey revealsadiversity Compilation oftheinformationrecei an oral75-gglucoseload(75-gOGTT). blood glucoseassociatedwithanoraltolerancetestaf The mostrecentIADPSG/WHOdiagnosticrecommendationsarebasedonfasting be arbitraryandthatvaluesshouldbasedonthecapacityofeach country. detected in pregnancy reached the conclusion that any established threshold would The outcomes bothforwomenandtheirbabiesduringpregnancypuerperium. outcomes thatreflecttheassociationbetweenmaternalglucoselevelsandadverse The 20 Untreated h guidance is recommended for GDM, together with physical exercise and yperglycemia inpregnancyincreasesrisksformotherandchild. of PAHO Member States reported having clinical practice guidelines ved fromLAC countriesthroughtheconference ter administrationof 43 / Final report of the Pan American Conference on Diabetes and Pregnancy

the conference Recommendations of romote greatercapacityforthepreventionandcontrolof h programs toimprove thetreatmentofhyperglycemia

future forthepopulationof Americas. in pregnancy:anecessaryinvestment for ensuringahealthy emphasizing theimpor Disseminate thecallforactioninallMember States, Hold nationalmeetingsinwhic collection, andimpro Begin compilinghealthsystemdataorenhancing clinical practiceguidelines GDM, includingtheadoption, review, or implementation of P medical treatment. in pregnancy, includingahealthy diet,physical exercise,and Launc after onehourand twohours. or througha75-gOGTTinwhich bloodglucoseismeasured Blood glucoselevelscanbedeterminedeitherduringfasting prenatal visit and between weeks 24 and 28 of pregnancy.first guidelines recommendingscreeningforhyperglycemia inthe Implement, asmuc prevention andcontrolofhyperglycemia inpregnancy. the Americas regarding theimportance ofprogramsforthe Hold acti scientific community, society, civil andhealthcareproviders. the policy-makers, plans arediscussedwithstakeholders, vities toraiseawareness throughouttheRegion of h aspossible,themostrecent WHO ve access. tance ofcontrollinghyperglycemia h specificneedsandfuture 45 / Final report of the Pan American Conference on Diabetes and Pregnancy

the health of mothers andnewborns! the healthof mothers medicines. We all play a role in safeguarding lifestyles andimproved accesstocare and and medical staff, while promoting healthy the awareness ofpatients and understanding To accomplishthis,itis necessarytoincrease to controlbloodglucoseduringpregnancy. physical and,ifnecessary, activity medication providing guidance towomenonnutrition, this probleminvolve diagnosingdiabetesand account. Effective andfeasiblesolutionsto into available health resourcesshould be taken As aresult,effective detectionstrategiesand certain countriesduetoalack ofresources. these criteriacanbedifficult toimplementin of hyperglycemiadetectedinpregnancy, first consensus concerningthecriteriafordiagnosis Although thereisgrowinginternational context ofthehealthsituationineach country. recommendations shouldbeconsideredinthe and puerperium. The implicationsofthese levels and negative outcomes in pregnancy association between maternal blood glucose and perinataloutcomes,recognize an are basedonshort-term maternal adverse hyperglycemia inpregnancy. These guidelines diagnostic methodsandforbetter controlof and offer agood opportunity tostandardize WHO guidelinesincorporaterecentevidence from theHAPOstudy. Furthermore, the are basedonIADPSGstandardsderived andchildren.of mothers WHO guidelines to significantnegativeimpactsonthehealth cases arenot diagnosed or treated,leading develop hyperglycemia inpregnancy. Many is calculatedthat11-12% ofpregnantwomen degree ofhyperglycemia. Inthe Americas, it is classifiedasDMorGDM,accordingtothe detectedinpregnancy Hyperglycemia first to actionfor improved outcomes Hyperglycemia inpregnancy: A call • • • • • considerable harmfulimpacts: Untreated hyperglycemia inpregnancyhas problem? in pregnancy ahealth Why ishyperglycemia being. improve the child’s future health and well- related maternalmorbidity andmortality, and opportunity toimprove health,reduceobesity- hyperglycemia, pregnancy offers an Due tothenegative healthimpactof macrosomia. glucose intolerance,especiallyinthecaseof higher riskofobesity, insulinresistance,and exposure tohyperglycemia mayhave In the long run, offspring with intrauterine need forneonatalcare. even Erb’s palsy). All ofthiscanincreasethe (occasionallyshoulderdystociaand delivery baby’s largesize can cause injuriesduring respiratory problemsandjaundice. The hypoglycemia and,ifbirth ispremature, as wellperinatalproblemssuch asneonatal to fetal malformations in the case of diabetes, Untreated maternalhyperglycemia canlead with large(macrosomic)babies. childbirth andcaesareansectionassociated and preeclampsia,aswellpremature of obstetricproblemssuch asmiscarriages hyperglycemia inpregnancyincreasestherisk It hasbeendemonstratedthatuntreated cardiovascular disease. syndrome withpotentialdevelopmentof intolerance ordiabetesandcancausemetabolic increases maternalriskoffutureglucose Untreated hyperglycemia inpregnancy 47 / Final report of the Pan American Conference on Diabetes and Pregnancy 48 / Final report of the Pan American Conference on Diabetes and Pregnancy • • • • • Despite theimportance ofthishealthproblem: pregnancy maybeevenhigher. in women,theprevalenceofhyperglycemia in those withahighprevalenceofobesityordiabetes cases. Incertain high-risk populations,such as corresponding to GDM inabout85%ofthese Central America subregions,respectively), the North America-Caribbean andSouth- (adjusted prevalenceof11.9% and11.5% in affects anestimated 11-12% ofpregnancies In theRegion ofthe Americas, hyperglycemia pregnancy intheAmericas The burden of diabetes in Most ofthe countriesintheRegion need for GDMprevention. Only three countries have national programs different countries. compare theprevalence ofGDMamongthe are usedintheRegion, itisnotpossibleto criterion forGDMand different standards accepted diagnostic As there is no universally WHO/IADPSG standardsforGDMdiagnosis. Only sevencountriesoftheRegion follow the glucosedosesandcut-off values. diverse screening inpregnancy, theyusehighly some typeofstandardforhyperglycemia Although 65% of countries supposedly follow policies forhyperglycemia inpregnancy. 45% ofcountriesintheRegion lack screening • • • • 28 ofpregnancy. prenatalvisitandbetweenweeks24 the first that womenshouldbescreenedfordiabetesin The participants in the conference recommended health workers Recommendations for • • following recommendations: The participants in the conference agreed on the health professionals health authoritiesand Measures to betaken by diabetes prevention. pregnancy anddonotoffer guidanceon monitor women’s bloodglucoseduring Most medicalstaff donotsystematically andbabies. outcomes formothers in pregnancyandonthemost common information onmonitoringhyperglycemia risk formotherandchild. possible tonormallevels,inorderreduce at loweringbloodglucosetoasclose exercise, alongwithmedicaltreatmentaimed and recommendationsmadeforphysical nutritional treatmentshouldbeinitiated Immediately after diagnosingDMorGDM, 75-g OGTT. based onthefastingbloodglucosetestor Diagnostic recommendationsshould be women whoarenotpregnant. based on the same criteria as that used for diagnosis ofdiabetesinpregnancyshouldbe WHO guidelinesrecommendthatthe • of hyperglycemia in pregnancy, including: Build capacitiesforthe prevention andcontrol screening. including universal treatment ofhyperglycemia inpregnancy, implementing control programs for better Raise awareness of the importance of clinical practice guidelines adopting, reviewing, orimplementing • • • consultation withtheappropriateexperts. according tothecountry’s capacityafter mg/dl)], if possible; otherwise, set values after takingglucose 8.5-11.0 mmol/l(153-199 ≥ 10.0 mmol/l(180 mg/dl);and twohours 125 mg/dl); one hour after taking glucose diagnosis [fasting glucose 5.1-6.9 mmol (92- Follow the2013 WHO guidelinesforGDM order toruleoutGDM. afterhour andtwohours takingglucose)in or 75-gOGTT(measuringbloodglucoseone pregnancy usingafastingbloodglucosetest diabetes; andbetweenweeks2428of prenatal visitinordertoidentifypreexisting with afasting blood glucosetestin the first Recommend screeningforhyperglycemia treatment. nutrition, physical exercise,andmedical hyperglycemia in pregnancy, including Launch programstoimprove controlof • • and children. guaranteeing access to care for mothers monitoring withinthehealthsystem improving orlaunching datacollectionand • • • • organization intheRegion, PAHO/WHO should: As theleadinternationalpublichealth secretariat shouldtake Action that thePAHO/WHO to identifyspecificneedsandfutureplans. community, society, civil andhealthworkers thescientific policy-makers, stakeholders, Hold nationalandsubregionalmeetingswith mg/dl). mmol/l (200 measurement ofbloodglucose)≥11.1 aftertwo hours taking glucose (or random glucose ≥7.0 mmol/l(126 mg/dl);orOGTT diagnosis ofdiabetesinpregnancy:(fasting Follow the2013 WHO guidelinesfor years. hyperglycemia surveyannuallyoreverytwo and programs,repeatingthediabetes Monitor theimplementationofnewpolicies diabetes preventionandcontrolinpregnancy in theimplementationofprogramsfor Lend technical support totheMemberStates 49 / Final report of the Pan American Conference on Diabetes and Pregnancy

of haveany question. send ittothePAHO localoffice [email protected] any difficulty link: https://www.surveymonkey.com/r/2T3KQ3M Ifcompletedelectronicallyorinhardcopy, please any availablereferenceforthedataprovided. This formcanbefiledonlineusingthefollowing This datacollectionform must becompletedwiththemostrecentdataavailable. Pleaseinclude Data Collection Form Diabetes &Pregnancy Annex 1. Glossary Read each questioncarefully. Itmaybenecessaryforyoutoobtainsomeoftherequested Question Column litus (GDM, WHO recommendation3)* Diabetes Mellitusinpregnancy(DMP, WHO recommendation2)orGestationalDiabetesMel- detectedatanyHyperglycemia first timeduringpregnancyshouldbeclassifiedaseither: such asstate,department, province, municipality, etc. Scope ofpolicies,guidelines,etc. The word “Regional” referrers tolevelsotherthannational GlucoseTolerance Test Oral OGTT: age (birth weight<10th percentile). SGA (Smallforgestationalage):newbornbirth smallerthanexpectedfortheirgestational Macrosomia: newbornbirth weight>4kg. weight >90thpercentile). LGA (Largeforgestationalage):newbornlargerthanexpectedtheage(birth toshare. additional informationyouwouldlike complete andsubmittothebestofyourability. Pleaseincludeinthecommentboxes any Some oftherequestedinformationmaynotbeavailablein somecountries,however, please prepared withtheprovided data. naire. anddepartmentsAll persons listedwillbeincludedascontributorinany document and organizationproviding informationforeach ofotherperson(s) sectionofthequestion- information fromanotherorganization, department orinstitution. Pleaseprovide thename WHO_NMH_MND_13.2_eng.pdf?ua=1 Detected inPregnancy. Geneva2013. Available athttp://www.who.int/iris/bitstream/10665/85975/1/ *Reference: World HealthOrganization. DiagnosticCriteriaandClassification ofHyperglycaemiaFirst glucose Fasting plasma glucose 1-hour plasma glucose 2-hour plasma Random Glucose Load 75g 75g - - Description (Recommendation 3) Gestational DM (153 -199mg/dl) (92 -125 mg/dl) 8.5-11.0 mmol/l 5.1-6.9 mmol/l ≥ 10.0 mmol/l (180 mg/dl) (DMG) - (Recommendation 2) DM inpregnancy ≥ 11.1 mmol/l ≥ 11.1 mmol/l ≥ 7.0 mmol/l (200 mg/ dl) (200 (126 mg/dl) (200 mg/dl) (200 (DMP) - 51 / Final report of the Pan American Conference on Diabetes and Pregnancy 52 / Final report of the Pan American Conference on Diabetes and Pregnancy ...... Section B:General Newborn Data ...... Comments/References/Links Dateofcompletion(dd/mm/yyyy) 6 5 4 Institution/Organization 3 reporting Nameofperson 2 Country 1 Section A:General Information Comments/References/Links 13 12 11 10 Whatwas thetotal(orestimated) numberoflive 9 Pleasestatetheyearthisdatawas collected 8 Whatisthescopeofdatareported inthis 7 E-mail Address providing data) Data source(nameofdepartment orinstitution viding informationforthissection,ifany Notknown=1 pro- Name andsurnameofadditionalperson(s) Notknown=1 What was thenumberofnewbornswithSGA? What was thenumberofnewbornswithLGA? births? (yyyy) section? Question Questions Not known=1 Institutional level Regional level National level Answer Answer 3  2  1  Section C:GDM/DMPPolicies &Guidelines 22 B 22 A 21 What isthefastingglucosecut-off pointfor 20 19 18 17 16 15 14 Write 999ifnotused OGTT fordiagnosingGestationalDiabetes? What isthediagnostic1hourvalueof report theoneusedinlaststep Write 999ifnotused,morethanoneplease diagnosis ofGestationalDiabetes? What istheglucoseloadusedforOGTTfinal Write 999ifnotused diagnosing GestationalDiabetes? How many stepsareusedforthediagnosis? tion, pleasespecify. If yourespondedotherinthepreviousques- Is any formofprescreeningused? What isthescopeofguideline? website a linkbelowiftheguidelinescanbefoundin of theguidelinestogetherwiththisformorenter If yourresponseis1,2or3,pleasesendacopy If Is thereaguidelineforDMG/DMPinplace? below ifthepolicycanbefoundinawebsite the policytogetherwiththisformorenteralink If yourresponseis1-4, pleasesendacopyof women forhyperglycemia (DMG/DMP)? Is thereanationalpolicytoscreenpregnant none ornotknown, continuetoSection D. Questions Not known Three Two One Other Not known None fasting bloodglucoseorOGTT Yes, and acombinationofriskfactors Yes, only riskfactors Yes, fastingbloodglucoseonly Yes, OGTTonly Not known None All Institutional level Regional level(state,municipality) National level Not known None ment For screening,diagnosis&manage- For managementonly For screening&diagnosisonly Not known None Yes, notspecified 24-28 weeks Yes, antenatalvisitandat atthefirst Yes, at24-28weeksonly Yes, antenatalvisitonly atfirst Answer mm l mg/dl gms mm l mg/dl 4  3  2  1  7  6  5  4  3  2  1  6  5  4  3  2  1  5  4  3  2  1  6  5  4  3  2  1  53 / Final report of the Pan American Conference on Diabetes and Pregnancy 54 / Final report of the Pan American Conference on Diabetes and Pregnancy ...... Comments/References/Links Datasource(nameofdepartment orinstitution 28 provid- Nameandsurnameofotherperson(s) 27 Whatyearwerethecurrent guidelinespro- 26 Whereisthescreeninganddiagnosisfor 25 24B 24 A 23 B 23 A providing data) ing informationforthissection,ifany duced orupdated?(yyyy) hyperglycemia duringpregnancydone? Write 999ifnotused OGTT fordiagnosingGestationalDiabetes? What isthediagnostic3hourvalueof Write 999ifnotused OGTT fordiagnosingGestationalDiabetes? What isthediagnostic2hourvalueof Not known None Unspecified Specialized service Second levelclinicorhospital levelofcare First 6  5  4  3  2  1  mm l mg/dl mm l mg/dl ...... Comments/References/Links Datasource(nameofdepartment orinstitu- 34 Nameandsurnameofotherperson(s) 33 2Isthereaneducationalprogramspecifically 32 1Isthereaneducationalprogramfortype2 31 0Isthereapreventionprogramspecificallyfor 30 9 Isthereapreventionprogramfortype2 29 Programs Section D:Type 2Diabetes &GDM/DMPPrevention/Education tion providing data) providing information forthissection,ifany for GDM? diabetes? GDM? diabetes? Questions Not known None Institutional level Regional level National level(alllevels) Not known None Institutional level Regional level National level(alllevels) Not known None Institutional level Regional level National level(alllevels) Not known None Institutional level Regional level National level(alllevels) Answer 5  4  3  2  1  5  4  3  2  1  5  4  3  2  1  5  4  3  2  1  55 / Final report of the Pan American Conference on Diabetes and Pregnancy 56 / Final report of the Pan American Conference on Diabetes and Pregnancy 7Number ofmaternalsepsis 57 Number ofpost-partum hemorrhage 56 Number ofpre-termdeliveries 55 4Numberofwomendiagnosed with Notknown=1 54 Numberofwomendiagnosed witheclampsia Notknown=1 53 Numberofcongenitalabnormalities 52 Numberofrespiratorydistress syndrome 51 Numberofshoulderdystocia 50 49 Number of neonatal intensive careunit(NICU) Numberofneonatalintensive 49 Numberofneonatalhypoglycemia 48 6Nme fnwon eiee yceaenNotknown=1 47 bycaesarean Numberofnewbornsdelivered 46 5Numberofperinataldeaths(latefetal,≥28 45 4Numberofnewbornsthatweresmallforges- 44 3Numberofnewbornsthatwerelargeforges- 43 2Numberofnewbornswithmacrosomia(> 42 1Whatwas thenumberofoverweight/obese 41 0Whatwas thenumberofwomenwith diabe- 40 9Howmany ofthemwerediagnosedwith 39 8Whatwas thetotalnumberofwomendiag- 38 7Pleasestatetheyearthisdatawas collected 37 6Ifyourespondedotherinthepreviousques- 36 5Whatisthescopeofdatareported inthis 35 Section E:GDM/DMPData (latest available year) pre-eclampsia admissions caesarean byelective Number ofnewbornsdelivered weeks +earlyneonatal,<7days) tational age(SGA) tational age(LGA) 4kg) women diagnosedwithGDM/DMP? tes thatbecamepregnant? GDM? year? nosed withGDM/DMPduringthereported (yyyy) tion, pleasespecify section? Questions Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Not known=1 Other level Institutional municipality, etc.)level Regional (state,department, province, National level Answer 4  3  2  1  ...... Comments/References/Links Datasource(nameofdepartment orinstitu- 65 provid- Nameandsurnameofotherperson(s) 64 Ifyourespondedotherinthepreviousques- 63 62 Where are women with GDM/ DMP receiving WherearewomenwithGDM/DMPreceiving 62 1 Whatwas thenumberofwomen withGDM/ 61 0 Whatwas thenumberofwomen withGDM/ 60 9 Whatwas thenumberofwomen withGDM/ 59 8Whatwas thenumberofwomenwithGDM 58 tion providing data) ing informationforthissection,ifany tion, pleasespecify treatment? DMP that received bothinsulinandOHA? DMP thatreceived DMP that received Insulin? DMP thatreceived (OHA)? oralhypoglycaemicDMP thatreceived agents and exercise? onlycounselingon diet / DMPthatreceived Other Unknown Unspecified service Specialized Second levelclinicorhospital levelofcare First Not known=1 Not known=1 Not known=1 Not known=1 6  5  4  3  2  1  57 / Final report of the Pan American Conference on Diabetes and Pregnancy 58 / Final report of the Pan American Conference on Diabetes and Pregnancy ...... Comments/References/Links 73 provid- Nameandsurnameofotherperson(s) 72 Isthereaprograminplacetopreventtype2 71 Whatwas theproportion ofwomendiagnosed 70 Whatwas theproportion ofwomenwith GDM/ 69 Pleasestatetheyearthisdatawas collected 68 Ifyourespondedotherinthepreviousques- 67 Whatisthescopeofdatareported inthis 66 Section F:Post-pregnancy Data providing data) Data source(nameofdepartment orinstitution ing informationforthissection,ifany diabetes forwomenthatpresentedGDM? with diabetesafter 6-12 weekspostpartum? ment oftheirglucosestatus? apostpartumDMP thatreceived re-assess- (yyyy) tion, pleasespecify section? Questions Not known Yes No Not known=1 Not known=1 Other Institutional level Regional level(state,municipality…) National level Answer 3  2  1  4  3  2  1  ...... Please includecommentsrelevant to thedataprovided in futurerelateddocuments. same timewehopetoidentifybestpracticesthatdeservebedisseminatedduringtheconferenceand Americas. Through thereviewofthisinformation needsfortechnical cooperationwillbeidentified. Atthe provided onthisformwillbeusedtoproduceareport onthestatusofGDM/DMPinRegion ofthe Thank youforansweringthisquestionnaire. Your contributionisgreatlyappreciated. The information Section G:Comments End ofData CollectionForm 59 / Final report of the Pan American Conference on Diabetes and Pregnancy

11:00 10:45 10:45 10:15 10:15 10:00 10:00 09:20 09:20 09:00 09:00 08:30 08:30 07:30 07:00 sept |82015 Meeting program andlistof participants Annex 2. 08:00 Moderator: MariaCristinaEscobar, Chile Lounge “Empresarial ”2ndfloor Session one:Screening &DiagnosisofDiabetesinPregnancy

Helard Manrique, Angelica V Anders Dejgaard, R Aníbal V Opening. J L Gr Cof J J Ex Questions Susana Salzberg Scr Sara Meltz Roundtable: S Gojka R The Evidenceaf WHO Guidelinesf Alberto B The statusofDM,GDM,andtheburdendiabetesinL Video. ConferenceIntr Screening &Diagnosis, therisk for mothersandnew-borns, ose Roberto daSilva, PAHO/WHODC Washington ose Raul Ruiz, Puerto Rico osé Raul Ruiz, Puerto Rico ounge “Sol deOro” 12th Floor aul GonzalezMontero,PAHO-WHO Representative toPeru ercise, DiabetesandPregnancy. oup Exercise (optional). eening &DiagnosisGuidelines, fee Break oglic, WHO elásquez Valdivia, MinisterofHealthPeru arceló, PAHO/WHO,DC Washington aldivia, Asociación deDiabetes dePerú er, McGillUniversity, Canada & Answers Latin American Diabetes Association (ALAD) Diabetes Association , LatinAmerican creening &Diagnosisofdiabetesinpregnancy SociedadPeruana deEndocrinología World DiabetesFoundation ter the2013 Consultation. WHO Expert or the Diagnosis of Diabetes First DetectedinPregnancy.or theDiagnosisofDiabetesFirst oduction. atin America&theCaribbean

61 / Final report of the Pan American Conference on Diabetes and Pregnancy 62 / Final report of the Pan American Conference on Diabetes and Pregnancy 17:30 17:30 17:20 17:20 Developing • Preparing • Adapting • 16:20 16:20 15:00 15:00 14:00 14:00 13:50 13:50 13:20 13:20 12:20 12:20 12:05 • 12:05 11:20 11:20 11:00 16:30 16:30

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63 / Final report of the Pan American Conference on Diabetes and Pregnancy 64 / Final report of the Pan American Conference on Diabetes and Pregnancy 16:15 16:15 17:30 17:30 17:15 17:15 16:00

Sept |102015 08:30 11:05 10:45 10:45 09:20 09:25 09:10 09:10 08:50 08:50 07:30 07:00 Moderator: KarenRoberts, Guyana Lounge “Empresarial” 2ndfloor Session three:Post-partum Follow-up andPrevention

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2 yfrecuenciadeaccionesparasuprevencióncontrol.Salud públicaMéx.2013;55:S137-S143. Transmisibles 1995-2010. Havana,Cuba;2014. Ottawa;Perspective. 2011. countries: theCentral (CAMDI).DiabetesCare.2012;35(4):738-740.America DiabetesInitiative multinationalstudyofnoncommunicablediseasesinsixCentralamong adultsfromthefirst American No Transmisibles. Primera Edición.Buenos Aires; 2015. pregnancy. Geneva;2013. component/attachments/?task=download&id=116. pmcentrez&rendertype=abstract. Accessed February 10, 2015. Care. 2013;36(4):1033-1046. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3609540&tool= php?option=com_content&view=category&layout=blog&id=1159&Itemid=452. Accessed January 13, 2016. the Caribbeanin2014. Bulletinofthe World HealthOrganization (inpublication) SP_6E_Atlas_Full.pdf. diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. the UnitedStates,1988-2012. JAMA 2015;8;3(10):1021-9. Juan, Puerto Rico;2015. Diabetes. 2011;60(7):1849-1855. doi:10.2337/db11-0400. Ann NutrMetab.2010;56(1):16-22. doi:10.1159/000261899. 1). of DiabetesinCanada.Can JDiabetes.2008;32(Suppl 2014;38(Supl 1):S77-S79. 1964;13:278-285. http://www.ncbi.nlm.nih.gov/pubmed/14166677. Accessed January 13, 2016. References 11. 10. 9. MinisteriodeSalud deCuba. Vigilancia deFactores deRiesgoEnfermedadesCrónicasNo 8. MinisteriodeSalud deChile.EncuestaNacionalSalud. Chile;2009. 7. 6. Barcelo A, Gregg EW, Gerzoff RB, et al. Prevalence of diabetes and intermediate hyperglycemia 5. Pan American HealthOrganization. Fact DominicaSTEPSSheet,2010. Survey2008. 4. Pan3. American HealthOrganization. 2015. BasicIndicators Washington, D.C.;2015. 2. 1. 19. 18. American Diabetes Association. Economiccostsofdiabetes in theU.S. in2012. Diabetes 7. 1 16. Barcelo A, Arredondo A, Gordillo A, Segovia J, Qiang A. The CostofDiabetesinLatin America and 15. International Diabetes Federation. 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