If we want to make inroads in addressing diabetes, we must also focus on globalisation, poverty and migration
Karoline Kragelund Nielsen’s background in public health science with a focus on global health shows through in her research, including her latest findings on the association between gestational diabetes, adverse pregnancy outcomes and mothers’ country of origin.
‘Our figures show that, if we really want to make some inroads in the diabetes field and facilitate better care and prevention, we also need to focus on social structures and their effects, including factors such as globalisation, poverty and migration’, says Karoline Kragelund Nielsen, currently a Senior Researcher at the Health Promotion Research Unit, Steno Diabetes Center Copenhagen.
Big difference in risk
Specifically, using a nationwide dataset from Danish registers covering 710,413 births in Denmark between 2004 and 2015, she has found that country of origin modifies the association of gestational diabetes with pre-eclampsia and with birth weight in relation to gestational age. The same was not found to be the case, however, for the risk of premature birth or caesarean section.
To be exact, she studied the association between the mother’s country of origin, gestational diabetes and six different birth outcomes (premature delivery, planned caesarean section, emergency caesarean section, pre-eclampsia and babies being born either large or small for their gestational age).
‘In a clinical context it is important to be attentive both to a possible gestational diabetes diagnosis and of the woman’s country of origin in combination with other risk factors’
One interesting result found by Karoline Kragelund Nielsen is that, while gestational diabetes is associated with a 28% higher risk of pre-eclampsia in women from Denmark, it is associated with a significantly (2-3 times) higher risk in women from Lebanon and Morocco. Similarly, Danish women with gestational diabetes have an 81% higher risk of having a baby with high birth weight for its gestational age, as compared with Danish women who do not have gestational diabetes. In turn, a woman from Sri Lanka with gestational diabetes has a 4.2 times greater risk of having a large for gestational age baby, compared to a woman from Sri Lanka without gestational diabetes.
Significant global variation
The overall goal of Karoline Kragelund Nielsen’s research in recent years has been to examine ethnic differences in the risk of gestational diabetes, and also in the possible consequences of the condition for mother and baby. Part of the background to this is that we know there is significant global variation in the prevalence of gestational diabetes. At the same time, about 1/5 of women giving birth in many Western European countries are immigrants.
In the first study, published last year, she and her colleagues found significant differences in the risk of gestational diabetes according to country of origin among women giving birth in Denmark – a difference, it should be noted, that could not be explained by variations in BMI, age, parity, socioeconomic status etc.
Her research is motivated by a desire to alleviate health disparities by focusing on the links between maternal & child health and diabetes. During her PhD studies, she researched how screening/diagnosis and treatment of gestational diabetes can be implemented in India and other low- and middle-income countries. The background to this is that the vast majority of people with diabetes, including gestational diabetes, live in low- and middle-income countries where resources in the healthcare systems are scarce and health professionals often lack the training and skills necessary to ensure prevention, diagnosis and treatment, particularly in the field of gestational diabetes.
‘While gestational diabetes is associated with a 28% higher risk of pre-eclampsia in women from Denmark, it is associated with a significantly (2-3 times) higher risk in women from Lebanon and Morocco.’
‘Most of our current knowledge and existing guidelines, recommendations etc. are based on research from our part of the world. That means there’s a huge gap in our knowledge in terms of how best to screen, diagnose and treat women with gestational diabetes, and not least how to implement effective preventive programmes in those countries’, she says.
Awareness important in a clinical context
What are the implications for the Danish healthcare system?
‘Ethnicity is not a risk factor included in the current Danish screening procedure for determining whether someone should be offered an oral glucose tolerance test for gestational diabetes, whereas in Britain, for example, it is. Our studies can’t tell us whether ethnicity should be a risk factor that triggers a test, because we cannot tell if we are currently missing some cases. But our findings do tell us that there is a marked variation in prevalence according to country of origin, and also that there are differences in both risk factors and the risk of some of the adverse pregnancy outcomes that are associated with gestational diabetes. So in a clinical context it is important to be attentive both to a possible gestational diabetes diagnosis and of the woman’s country of origin in combination with other risk factors’, she says.
She adds that, in the project, they also see differences between countries that are often grouped together, such as those in Asia. ‘We are able to study such differences because we have such comprehensive and unique register data in Denmark. This finding is also particularly interesting because the populations in some of these countries may resemble each other genetically, but their migration histories are very different. So this tells us that we also need to focus on and understand the social determinants, structures and systems that are impacting and in which we live our lives’, says Karoline Kragelund Nielsen.
READ THE ARTICLE HERE:
Migration, Gestational Diabetes, and Adverse Pregnancy Outcomes: A Nationwide Study of Singleton Deliveries in Denmark
Karoline Kragelund Nielsen, Gregers Stig Andersen, Peter Damm, Anne-Marie Nybo Andersen
The Journal of Clinical Endocrinology & Metabolism, dgab528, https://doi.org/10.1210/clinem/dgab528
Published 17 July 2021
Karoline Kragelund Nielsen
Steno Diabetes Center Copenhagen