Gestational Diabetes and Predisposition to Pediatric Metabolic Disorders
Amanda Anderson, ND
We know optimal nutrition starts in utero. We know about folic acid preventing neural tube defects. We even know about DHA helping develop fetal neural and ocular tissue. What we have yet to realize is the effect of sugar on infants growing in the womb – the effect not only during pregnancy and infancy, but well beyond into childhood, adolescence and even adulthood.
Gestational diabetes mellitus (GDM) affects up to 13% of the pregnant population in the U.S. The incidence of GDM in the U.S. is on the rise, as is the incidence of childhood and adolescent obesity. China, Brazil and the U.S. have had dramatic increases in childhood obesity over the past 15 years. In the U.S., 16% of 9-16 year-olds are obese, having a body mass index (BMI) greater than 30 or a weight above the 95th percentile measured against height. A BMI of 30 or above is considered obese.
Childhood Obesity Epidemic
Many reasons underlie the childhood obesity epidemic, poorly managed GDM being one. As a part of standard prenatal care, every woman is recommended to screen for GDM between weeks 24 and 28 of pregnancy. In one study, 16% of the women already had GDM by the end of the first trimester. Several recent studies show that glucose intolerance in the first trimester leads to increased risk of developing GDM during the second trimester. Another study found that C-reactive protein and TNF-alpha were elevated by the second trimester in pregnant women without conventional risk factors for gestational hyperglycemia, whose insulin resistance seems less explainable. The hypothesis here is that low-grade inflammation is associated with GDM and can have possible predictive value even in the first trimester.
Hyperglycemia in the mother during pregnancy causes improper glucose and insulin metabolism in the fetus, which can set up the child for a lifetime of metabolic dysregulation. We see increased insulin production in fetuses exposed to too much glucose from maternal excess. This starts as early as week 12 of pregnancy, after the islets of Langerhans develop (around week ten). Insulin promotes fetal somatic growth and potentiates lipid, glucagon and protein synthesis. The largest amount of fetal weight gain occurs during the third trimester. Women with hyperglycemia tend to give birth to macrosomic, or large for gestational age (LGA) infants, because the fetuses are producing more insulin to cope with the excess glucose crossing the placenta.
Numerous studies now show LGA infants as having increased risk for being overweight in preschool, grade school and adolescence. These kids are also at risk for developing Type II diabetes during childhood, having not developed pancreatic tissue properly. In fact, the reason Type II diabetes is no longer called adult-onset diabetes is because so many children are being diagnosed. Kids as young as four years old are now suffering from Type II diabetes and other obesity-related health problems. Children who are LGA at birth and exposed to either diabetes or maternal obesity in utero are also at increased risk of developing metabolic syndrome during childhood and adolescence.
So why are we waiting until week 24 to screen? It’s true that if a woman is going to develop GDM, it is more likely to occur during the late second or third trimester. Around 60% of women who have GDM will not show blood sugar irregularities until then. However, there remains the other 40%, in which early screening for GDM or blood sugar irregularities may be key in prevention of fetal metabolic disturbances and the ensuing childhood sequelae.
Then vs. Now
Not only are more children becoming overweight, but kids who are overweight are 20%-30% heavier than they were 10 years ago. The sequelae of childhood obesity are abundant and serious. Overweight teenagers are at huge risk for becoming overweight adults. Adults who have been obese since childhood have a life expectancy nearly 25 years shorter than those who maintained an average weight. This is because they are developing disease processes in their teens and 20s that people generally don’t deal with until their 50s, 60s or 70s.
NDs have an important role in preventing the obesity epidemic in adults and children. Though most of us might not treat women during pregnancy, many do treat couples trying to get pregnant. It is important to educate patients regarding the impact of healthy choices, even during the pre-conception period. Preparation for a healthy pregnancy is key to maintaining a healthy pregnancy. Sugar and carbohydrate consumption need to be monitored in all trimesters to minimize the possibility of children having to deal with a lifetime of metabolic disorders.
Also, keep in mind the children who are already overweight. This article exposes only one etiology of increased weight in children. Taking a thorough history of the mother’s health and diet during pregnancy may illuminate areas that need to be addressed. It’s possible that we need to address pancreatic function far earlier in children who have a known history of high glucose exposure in utero. Looking at the family’s diet and exercise habits in addition to restoring normal function of the pancreas, liver and digestive system may be the ounce of prevention that some of these children need to reach a healthy weight.
Long-Term Potential Consequences of Obesity
- Cardiovascular: high blood pressure, high cholesterol, high blood sugar and coronary artery disease.
- Respiratory: asthma, sleep apnea and ensuing concentration and attention problems.
- Cancer: Risk of adulthood cancer is 9% higher with each standard increment of childhood BMI.
- Liver damage: Nonalcoholic fatty liver affects up to 52% of overweight children.
- Orthopedic consequences: Feet, knees and hips are especially affected after years of excess weight bearing.
- Psychological issues: self-esteem problems, bullying and eating disorders.
- Surgery: In 2001, nearly 45,000 people in the U.S. had obesity surgery performed. In 2003, almost 100,000 people went under the knife. The exponential growth of this curve is only expected to continue.
Amanda Anderson, ND graduated from NCNM in 2006 and has a private practice at Zen Space Healing Center in Portland, Ore.
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