Gestational Diabetes Mellitus - a Global Prevention Strategy - Thesis Example

Gestational Diabetes Mellitus: A Global Prevention Strategy Gestational diabetes mellitus is a common cause of perinatal maternal and fetal morbidity and mortality worldwide. The condition has been explored since the middle of the 1900s, and to date, several strategies for screening and treatment have been identified and developed. This principally involved identification of pregnant women who are most likely to suffer from glucose intolerance or hyperglycemia during the period of pregnancy and are, therefore, more prone to suffer from the adverse effects of too high a sugar in the blood. Treatment principally involves dietary modification or insulin injections, depending on the severity of the condition. This paper explores the possibility of instituting a global prevention strategy to decrease, if not totally eradicate, gestational diabetes mellitus. In the succeeding paragraphs, the definition of gestational diabetes mellitus is discussed, as well as the current epidemiologic burden of the condition. Then the literature is reviewed as to the possible sites of intervention to prevent the occurrence of gestational diabetes mellitus. Finally, a public health policy to prevent gestational diabetes mellitus is proposed based on the literature reviewed. Gestational diabetes mellitus: Definition and epidemiology Gestational diabetes mellitus is currently defined as variable severity of glucose or carbohydrate intolerance first recognized during pregnancy, which may or may not require therapy in the form of dietary modification or insulin injections, and which may or may not persist after pregnancy (Coustan 1995; Bottalico 2001; Brody, Harris, Whitener, Krasnov, Lux, Sutton & Lohr 2003; American Diabetes Association 2004; ‘Diabetes’ 2005). Gestational diabetes mellitus complicates 2 per cent to 5 per cent of pregnancies annually worldwide and has a reported prevalence of anywhere from 1 per cent to 14 per cent, with figures varying across regional groups as well as the test employed to make the diagnosis (Coustan 1995; Brody 2003; American Diabetes Association 2004). Identified risk factors for the development of gestational diabetes mellitus include advanced maternal age, a family history of diabetes in a first-degree relative, obesity (pre-gravid, measured through the body mass index), glycosuria, and a lack of pre-gravid exercise (Coustan 1995; Brody et al 2003). These risk factors have been utilized to stratify the risk of women to develop gestational diabetes mellitus when they become pregnant, as it was found that the prevalence of gestational diabetes mellitus actually increases as the number of risk factors also increases (Brody et al 2003). A woman is said to be low-risk when she is a member of an ethnic group with low prevalence of gestational diabetes mellitus, no known first-degree relative with diabetes, age less than 25 years, normal pre-gravid weight or a “body mass index less than 25 kilograms per meter of height squared, kg/m2”, with no history of glucose intolerance, and with no prior poor obstetrical outcome (‘Diabetes 2005). The prevalence of gestational diabetes mellitus in this low-risk segment is 1.4 per cent to 2.8 per cent (Brody et al 2003). Marked obesity, a strong family history of diabetes, prior gestational diabetes mellitus, or membership in certain ethnic groups (Hispanic, African, Native American, South or East Asian origin) confer on a woman a higher risk (prevalence = 3.3 per cent to 6.1 per cent)of developing gestational diabetes mellitus (Brody et al 2003). The same risk factors actually serve as a screening tool through the taking of a medical history during a prenatal checkup, in addition to measurement of blood glucose (American Diabetes Association 2004). Presently, a 50 gram oral glucose challenge test is the screening method of choice for gestational diabetes mellitus, although experts are still presently debating on the efficacy and cost-effectiveness of this methodology, as well as appropriate cut-off values that would have specificity, sensitivity, precision, accuracy, and good predictive values (Coustan 1995; Wen, Liu, Kramer, Joseph, Levitt, Marcoux & Liston, 2000; Bottalico 2001; Brody et al 2003; American Diabetes Association 2004; ‘Diabetes’ 2005). Rationale for intervention: Feto-maternal sequelae The importance of diagnosing gestational diabetes mellitus stems from the fact that maternal and fetal adverse outcomes, both acute and long-term sequelae, have been documented in women with untreated gestational diabetes mellitus. Brody et al (2003) performed a systematic review of literature and identified eight adverse fetal outcomes “(1) increased perinatal mortality, (2) brachial plexus injury or clavicular fracture secondary to fetal macrosomia or increased fetal adiposity resulting in shoulder dystocia, (3) hypoglycemia, (4) hyperbilirubinemia, (5) hypocalcemia, (6) polycythemia, (7) preterm birth, (8) the later development of diabetes, obesity, or neuropsychiatric disturbances] and four adverse maternal outcomes [(1) cesarean delivery, (2) third- and fourth-degree lacerations, (3) pre-eclampsia, (4) the later development of type 1 or 2 diabetes mellitus”. The same sequelae were identified by Ostlund et al (2003). Ornoy, in a recent review, added neurobehavioral anomalies as offspring sequelae of maternal gestational diabetes mellitus (2005). Most of the maternal sequelae noted above actually arise from fetal macrosomia (discussed below), causing disproportion between the birth canal and the fetus traversing this passageway (‘Diabetes’ 2005). A more serious complication is the development of overt diabetes mellitus later in life, which brings with it the systemic complications of the disease and has been extensively documented to occur in 50 per cent of women with gestational diabetes mellitus 20 years after the index case (Coustan 1995; American Diabetes Association 2004; ‘Diabetes’ 2005). Macrosomia, which is defined as a birthweight of more than 4000 grams, is one of the most commonly known fetal outcomes of gestational diabetes mellitus (‘Diabetes’ 2005). A positive correlation between macrosomia in the offspring and maternal gestational diabetes mellitus was established by Vohr et al (1980) when they studied 34 infants of diabetic mothers (13 mothers had gestational diabetes mellitus). Pezzarossa et al (1996), evaluating 60 newborns from mothers with gestational diabetes mellitus and 132 newborns of non-diabetic mothers, found a higher prevalence of macrosomia in infants of mothers with gestational diabetes mellitus. Finally, Coustan and Imarah (1984) found that control of maternal hyperglycemia prevents macrosomia in the offspring. Ricci et al (1998) also suggested that uncontrolled maternal hyperglycemia may contribute to fetal vascular pathology, when they found a transient increase in tortuosity and dilatation of the iris vasculature in infants of mothers with diabetes. Offspring of mothers with gestational diabetes mellitus are also at an increased risk for developing congenital malformations. Chung and Myrianthopoulos (1975) performed a prospective study involving more than 50,000 pregnant women, 372 of whom have gestational diabetes. They found that diabetes conferred a risk for congenital malformations double that of non-diabetic women [major categories of malformations, 17.94 per cent vs. 8.34 per cent; minor categories of malformations, 10.94 per cent vs. 6.25 per cent] (Chung & Myrianthopoulos 1975). These malformations could involve any organ system, and actually has a multi-organ involvement in several instances, which they inferred to be related to the time of exposure, i.e. diabetes has adverse effects more pronounced during the earlier stages of fetal development (Chung & Myrianthopoulos 1975). The investigators also found a positive correlation between the duration of uncontrolled hyperglycemia and the incidence of fetal malformations (Chung & Myrianthopoulos 1975). In a more recent study by Moore et al (2000) involving 22,951 pregnant women, they found a three-fold increase in risk [95 per cent confidence interval = 1.2–7.6] for congenital malformations (primarily craniofacial or musculoskeletal) in women with diabetes when compared to the non-diabetic population. But apart from these acute adverse outcomes, infants of mothers with gestational diabetes mellitus also tend to suffer from long-term sequelae of exposure to uncontrolled hyperglycemia. This has actually been proposed as early as 1980 by Freinkel, when he said that the hyperglycemic milieu in utero actually has long-term repercussions that affect behavior, metabolism, and anthropometrics of the offspring (Coustan 1995). Freinkel’s hypothesis has presently been substantiated by several animal and human studies. Pettitt et al (1985) studied the offspring of 1049 Pima Indian women and found that offspring of women with impaired glucose tolerance during pregnancy were more prone to become obese and suffer from impaired glucose tolerance later in life. In a subsequent study (Pettitt et al 1993) investigators also found a higher incidence of diabetes later in life among the offspring of diabetic mothers. These same findings were reached by Vohr et al who studied 119 term infants of mothers with gestational diabetes mellitus and found them to have an increased adiposity and elevated blood pressure in both the neonatal (1995) and childhood years (Vohr et al 1999). In addition, adverse neurobehavioral sequelae have also been documented. Rizzo et al (1994) studied 223 pregnant women and their offspring (99 had gestational diabetes mellitus) to assess the correlation of in utero exposure to hyperglycemia and intellectual development during childhood, and found minimal disturbance in cognition of these offsprings. However, in a subsequent study, they found a correlation between periods of hyperglycemia in utero and psychomotor development during childhood (Rizzo, Dooley, Metzger, Cho, Ogata & Silverman 1995). Intervention strategy The maternal and fetal sequelae of gestational diabetes mellitus discussed above actually necessitate the institution of a prevention strategy, especially in women known to be at high-risk for developing gestational diabetes mellitus. Unfortunately, no such prevention strategy has been implemented, making it imperative to formulate a policy that would be an adequate response to the problem of gestational diabetes mellitus; thus, this research paper. As was shown, multiple risk factors contribute to the development of gestational diabetes, and some of these are actually non-modifiable (i.e. age, race/ethnicity, heredity). Second, the presence (or absence) of these same characteristics actually stratify women of reproductive age into risk classes, and confer on them a higher probability of developing gestational diabetes mellitus. Finally, gestational diabetes mellitus has its onset during the period of pregnancy, with or without pre-conceptional symptoms. A feasible policy, therefore, should focus on these modifiable traits, and target moderate-to-high risk women, even during the preconceptional period. In the succeeding paragraphs, this paper reviews the available evidence in literature on the effects of modification of some risk factors on the course of gestational diabetes mellitus. These would principally be obesity, viewed through dietary modification and exercise, since Iqbal et al (2006), in a recent prospective cohort study of 611 South Asian women in Pakistan, found that per cent body fat, physical inactivity and diet quality are important modifiable risk factors for gestational diabetes mellitus. In their study, they confirmed that advanced maternal age conferred an increased risk for gestational diabetes mellitus [odds ratio = 1.13, 95 per cent confidence interval = 1.06–1.21], and found that increased per cent body fat also correlated directly with gestational diabetes mellitus risk [odds ratio = 1.07, 95 per cent confidence interval = 1.03–1.13], whereas there was an inverse association between gestational diabetes mellitus risk and physical activity [odds ration = 0.89, 95 per cent confidence interval = 0.79–0.99] (Iqbal, Rafique, Badruddin, Qureshi, Cue & Gray-Donald 2006). In addition, the contribution of psychosocial factors will also be evaluated. Key intervention: Exercise Exercise has been documented to reduce the glycemic level of women with gestational diabetes mellitus (Garcia-Patterson, Martin, Ubeda, Maria, de Leiva & Corcoy 2001; Avery & Walker 2001; Dempsey, Butler & Williams 2005), and actually is part of the comprehensive treatment program for gestational diabetes mellitus (Bottalico 2001; American Diabetes Association 2004; ‘Diabetes’ 2005), since exercise has been found to be safe in pregnancy (Hartmann & Bung 1999). There is, therefore, the possibility of using exercise as a preventive strategy for gestational diabetes mellitus, and this has been explored in several studies. Dye et al (1997) investigated the role of exercise in preventing the development of gestational diabetes mellitus. Using birth registry data from New York, they examined the association between gestational diabetes mellitus, pre-gravid maternal BMI and exercise, and found that exercise does reduce the risk of gestational diabetes mellitus by nearly half [odds ratio = 1.9, 95 per cent confidence interval = 1.2–3.1] but only in women whose pre-gravid BMI was greater than 33 (Dye, Knox, Artal, Aubry & Wojtowycz 1997). An explanation for this effect is that aerobic exercise decreases the hyperinsulinemia of obesity, causing an improvement in peripheral insulin sensitivity, suppression of hepatic glucose production, and an increase in insulin-stimulated glucose uptake (Dye, Knox, Artal, Aubry & Wojtowycz 1997). Dempsey et al (2004), noting the recall and selection bias of previous observational studies, performed a prospective cohort study of 909 women normotensive, nondiabetic women in Seattle and Tacoma, Washington to establish the relationship between gestational diabetes mellitus risk and pre-gravid and pregnant recreational physical activity. Interviews were conducted with these women, with particular emphasis on the type, frequency and duration of physical activity performed during the year before and seven days prior to the interview during pregnancy (Dempsey, Sorensen, Williams, Lee, Miller, Dashow & Luthy 2004). The investigators found that gestational diabetes mellitus risk, when compared to inactive women, was reduced by half if the mother has been physically active before pregnancy [relative risk = 0.44, 95 per cent confidence interval = 0.21–0.91], by one-third when some physical activity is done during pregnancy [relative risk = 0.69, 95 per cent confidence interval = 0.37–1.29, although this association was not statistically significant], and by more than two-thirds if there is physical activity both before and during pregnancy [relative risk = 0.31, 95 per cent confidence interval = 0.12–0.79] (Dempsey, Sorensen, Williams, Lee, Miller, Dashow & Luthy 2004). They also found that the amount of energy and duration of physical activity was also contributory to risk reduction, such that women spending ≥4.2 hours/week engaged in physical activity experienced a 76 per cent reduction in gestational diabetes mellitus risk [relative risk = 0.24, 95 per cent confidence interval = 0.10–0.64], and those expending ≥21.1 metabolic equivalent-hours/week experienced a 74 per cent reduction [relative risk = 0.26, 95 per cent confidence interval = 0.10–0.65] compared with inactive women (Dempsey, Sorensen, Williams, Lee, Miller, Dashow & Luthy 2004). Thus, pre-gravid exercise does reduce the risk of gestational diabetes mellitus. Zhang et al (2006), when they examined 1428 gestational diabetes mellitus cases, found an inverse correlation between vigorous physical activity or brisk walking and the risk for gestational diabetes mellitus. Rudra et al (2006), similar to Dempsey et al (2004), also found an association between the perceived degree of physical activity and gestational diabetes mellitus. In their case-control study, women who did very strenuous to maximal exertion in the year before pregnancy had a lower risk of gestational diabetes mellitus when compared to women with moderate [OR = 0.57, 95 per cent confidence interval = 0.24–1.37] or negligible [OR = 0.19, 95 per cent confidence interval = 0.15–0.50] (Rudra, Williams, Lee, Miller & Sorensen, 2006). They concluded that there is a direct inverse relation between perceived exertion and risk of gestational diabetes mellitus (Rudra, Williams, Lee, Miller & Sorensen, 2006). Ceysens et al (2006), in a recent systematic review of literature, found insufficient evidence for the association, both positive and adverse, between exercise during pregnancy and gestational diabetes mellitus risk. They noted, however, that despite the lack of benefit being conferred by exercise during pregnancy, this may be beneficial in preventing the onset of post-partum diabetes mellitus its long-term complications. This is consistent with the findings of Dempsey et al (2004), as discussed above, that physical activity during pregnancy does not pose statistically significant effects to the risk of gestational diabetes mellitus. In summary, available evidence from literature has shown that at least moderate physical activity a year prior to pregnancy reduces the risk for gestational diabetes mellitus. This risk is further reduced with maximal physical activity, or physical activity both before and during the pregnancy. What remains to be answered is how to engage women to exercise. This psychosocial dimension was explored by Downs and Ulbrecht (2006) in their postpartum survey of 28 women with gestational diabetes mellitus because exercise behaviors are correlated with exercise beliefs. They found that only 1) one-third of women engaged in exercise post-partum, 2) the strongest perceived advantage of exercise during pregnancy was controlling blood glucose and postpartum it was controlling weight, 3) the most common barrier to exercise during pregnancy was fatigue and postpartum it was a lack of time, 4) women’s husband/partner most strongly influenced their exercise during pregnancy and postpartum, 5) women exercised more during the postpartum period than before or during pregnancy, and 6) the number of exercise advantages was positively associated with women’s pregnancy and postpartum exercise behavior (Downs & Ulbrecht 2006). Their findings could be extrapolated to the pre-gravid period, and a successful exercise program would have to provide an atmosphere that would encourage women to exercise, either through support groups, or through engagement of both partners in the exercise program. The post-partum barrier of lack of time could also be a pre-gravid barrier, and an intervention strategy should address this problem. Key intervention: Dietary modification Dietary modification, or caloric restriction, could also serve as a point of intervention, since it is currently being utilized as a management for gestational diabetes mellitus. There is, however, a paucity of available information on the effects of pre-gravid nutritional status on the risk for gestational diabetes mellitus. Only three studies that focused on the association of pre-gestational diet on the risk of gestational diabetes were found, since majority of available literature focused on the efficacy of dietary modification as treatment for overt gestational diabetes mellitus (Nolan 1984; Algert, Shragg & Hollingsworth 1985; Gillmer, Maresh, Beard, Elkeles, Alderson & Bloxham 1986; Jovanovic-Peterson, Durak & Peterson 1989; Dornhorst, Nicholls, Probst, Paterson, Hollier, Elkeles & Beard 1991; Knopp, Magee, Raisys, Benedetti & Bonet 1991a; Knopp, Magee, Raisys, Benedetti & Bonet 1991b; Reece, Hagay, Caseria, Gay & DeGennaro 1993; Rae, Bond, Evans, North, Roberman & Walters 2000; Banerjee, Ghosh & Banerjee 2004; Ho, Benzie & Lao 2005; Bomba-Opon, Wielgos, Szymanska & Bablok 2006; Thomas, Ghebremeskel, Lowy, Crawford & Offley-Shore 2006) Lao and Ho (2004), performing a retrospective case-control study, suggested that nutritional inadequacy may actually prevent gestational diabetes mellitus, and used this hypothesis to correlate nutritional improvement and the increasing prevalence of gestational diabetes mellitus in the developing world. The investigators followed 242 women with iron deficiency anemia and compared them with 484 non-anemic individuals over a period of 24 months with respect to the prevalence of gestational diabetes mellitus (Lao & Ho 2004). Results of the study showed that, independent of other factors, anemia was confirmed to be significantly associated with decreased prevalence of gestational diabetes mellitus [odds ratio = 0.46, 95 per cent confidence interval = 0.23–0.90] (Lao & Ho 2004). Extending their findings, it could be said that nutritional excess is contributory to gestational diabetes mellitus. However, it is not the absolute numbers in the diet that matter, rather the quality of the diet being taken. In the same study by Iqbal et al (2006), the investigators found and inverse association between the risk for gestational diabetes mellitus and increasing protein in the diet [odds ratio = 0.75, 95 per cent confidence interval = 0.60–0.95]. In a larger prospective cohort study by Zhang et al (2006) that involved 13,110 women, 758 of whom had gestational diabetes mellitus, followed over an eight-year period, the investigators also came to the conclusion that pre-pregnant diet is associated with gestational diabetes mellitus risk. Zhang et al (200) found that women who had a pregravid diet that was high in fiber and glycemic load were on average leaner, more physically active, and less likely to smoke. In addition, dietary fiber and glycemic load were positively related to dietary carbohydrate, magnesium, total iron, vitamin C, and vitamin E and inversely related to alcohol, total fat, and saturated, monounsaturated, and trans fatty acids (Zhang, Liu, Solomon & Hu 2006). “The researchers also said that, after adjustment for age, parity, prepregnancy body mass indez, and other covariates, dietary total fiber and cereal and fruit fiber were strongly associated with gestational diabetes mellitus risk (Zhang, Liu, Solomon & Hu 2006). Each 10-gram/day increment in total fiber intake was associated with 26% [95 per cent confidence interval = 9–49] reduction in risk; each 5-gram/day increment in cereal or fruit fiber was associated with a 23% [95 per cent confidence interval = 9 –36] or 26% [95 per cent confidence interval = 5– 42] reduction, respectively” (Zhang, Liu, Solomon & Hu 2006). Dietary glycemic load was positively related to gestational diabetes mellitus risk (Zhang, Liu, Solomon & Hu 2006). Multivariate relative risk for highest versus lowest quintiles was 1.61 [95 per cent confidence interval = 1.02–2.53] (Zhang, Liu, Solomon & Hu 2006). The combination of high-glycemic load and low–cereal fiber diet was associated with 2.15-fold [95 per cent confidence interval = 1.04–4.29) increased risk compared with the reciprocal diet (Zhang, Liu, Solomon & Hu 2006). In summary, a high-fiber, high protein diet appears to have an inverse association with the risk for gestational diabetes mellitus. Nutritional modification could, then, serve as a point of intervention. Key intervention: Behavioral modification Another lifestyle factor that may be contributory to the development of gestational diabetes mellitus is smoking. “England et al (2004) evaluated the effects of smoking on glucose tolerance by studying a cohort of pregnant women who participated in the Calcium for Preeclampsia Prevention trial, a randomized study of nulliparous women conducted in five US medical centers from 1992 to 1995. Of these women enrolled in the study, 3,062 had gestational diabetes (England, Levine, Qian, Soule, Schisterman, Yu & Catalano 2004). The investigators found that adjusted mean 1-hour plasma glucose concentration (mg/dl) was elevated in women who smoked at study enrollment [112.6, 95 per cent confidence interval = 110.0–115.3] compared with women who had never smoked [108.3, 95 per cent confidence interval = 106.7–109.8; p < 0.01] (England, Levine, Qian, Soule, Schisterman, Yu & Catalano 2004). Women who smoked were at increased risk of gestational diabetes mellitus when criteria proposed by the National Diabetes Data Group were used [adjusted odds ratio = 1.9, 95 per cent confidence interval = 1.0–3.6] (England, Levine, Qian, Soule, Schisterman, Yu & Catalano 2004). These findings suggest that smoking may play a role in glucose tolerance during pregnancy and increase the risk of gestational diabetes mellitus”. The authors concluded that smoking may be an important modifiable risk factor for gestational diabetes mellitus (England, Levine, Qian, Soule, Schisterman, Yu & Catalano 2004). Finally, health behavior may also contribute to the prevalence of gestational diabetes mellitus. Kieffer, Sinco and Kim (2006) performed a cross-sectional study using the 2001–2003 Behavioral Risk Factor Surveillance System, a national population-based random sample telephone survey conducted by the US Centers for Disease Control and Prevention. Participants were 177,420 women aged 18–44 years with and without self-reported gestational diabetes mellitus (Kieffer, Sinco & Kim 2006). Outcome measures included meeting physical activity and fruit and vegetable guidelines, sedentary activity level, and current smoking (Kieffer, Sinco & Kim 2006). Three per cent (n=4,718) of the respondents reported gestational diabetes mellitus, and these women, compared to the non-diabetic group, were usually older, had higher body mass indices [mean body mass index 27.4 vs. 25.4 kg/m2, P < 0.0001; prevalence of overweight = 28.4 per cent; prevalence of obesity 25.6 per cent], were less often educated or employed, married, and living with children (Kieffer, Sinco & Kim 2006). The investigators also found that women with gestational diabetes mellitus had reduced, but not statistically significant, odds of consuming at least five daily servings of fruits and vegetables (Kieffer, Sinco & Kim 2006). In unadjusted and multivariate adjusted comparisons, there were also no significant differences in levels of physical activity or smoking among women with and without gestational diabetes mellitus (Kieffer, Sinco & Kim 2006). The study further showed that women with gestational diabetes mellitus who lived with children were significantly less likely to meet fruit and vegetable consumption guidelines [odds ratio = 0.78, 95 per cent confidence interval = 0.63–0.97; P < 0.05) and more likely to smoke [odds ratio = 1.21, 95 per cent confidence interval = 1.01–1.47; P < 0.05) than their counterparts without gestational diabetes mellitus (Kieffer, Sinco & Kim 2006). Prevention strategy The preceding review of literature and discussion has shown that physical activity, diet, smoking, and overall health behavior are potential modifiable risk factors for gestational diabetes mellitus. These same factors are actually potential points for a prevention program. This paper, therefore, proposes the institution of a health education /disease prevention program that involves a multidisciplinary team, and takes on a multisectoral approach as a global strategy to prevent gestational diabetes. Specifically, this would focus on the importance of lifestyle modification as a prevention strategy for gestational diabetes mellitus in moderate-to-high risk women, even during the preconceptional period. Since preconceptional counseling is not a global standard, gestational diabetes mellitus health education could be incorporated into the curriculum of school age women capable of reproduction who are in moderate-to-high risk communities. At the same time, gestational diabetes should be covered more comprehensively during routine prenatal care in moderate-to-high risk communities. The above strategies would involve educating and training school teachers, primary allied health professionals, and primary physicians on gestational diabetes mellitus, with particular emphasis on the effects of uncontrolled hyperglycemia to both the mother and the fetus, and the need for lifestyle modification as a prevention strategy. Lifestyle modification would involve weight reduction to within normal body mass index, through dietary modification (i.e. high fiber, high protein, low calorie diet) and regular exercise programs, as well as reduction in smoking. To sustain the above, a multisectoral approach is needed, with government and non government organizations teaming up to support this strategy for women’s health. Government could provide the resources and the legal framework for the institution and implementation of the program, while non-government organizations would aid in dissemination of information, and could also provide resource persons or groups that would educate and train trainors, or work at the grassroots level and interact with women at risk for developing gestational diabetes mellitus. Furthermore, international agencies would function as overseers, following the implementation of prevention programs in countries worldwide. Support for women and mothers to complete the program should be provided by their partners and community resources (i.e. support groups). Conclusion Gestational diabetes is a common comorbidity of pregnancy, affecting both mother and fetus with short-term and chronic sequelae. Among the risk factors for gestational diabetes mellitus, physical activity, diet, and smoking appear to be modifiable, and therefore, are potential areas for intervention. This paper presented a possible global prevention strategy for gestational diabetes mellitus that would involve health education/information dissemination, and which would primarily target women deemed at high risk for developing gestational diabetes mellitus. This program would involve a multisectoral, multidisciplinary approach, with governments providing the legal framework and the resources for the implementation of such a strategy. Non-government organizations, on the other hand, could serve as resources for trainor’s training or as a complimentary work force at the grassroots level. International organizations would function as overseers, checking government implementation of this strategy to prevent gestational diabetes mellitus. References Journal articles Algert S, Shragg P & Hollingsworth DR, 1985, ‘Moderate caloric restriction in obese women with gestational diabetes’, Obstet Gynecol, vol. 65, no. 4, pp. 487–491. 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