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Journal of Diabetology, October 2012; 3:4 http://www.journalofdiabetology.

org/

Review Article:

A systematic review of trends of gestational diabetes mellitus


in Asia
* J .E . Hi rst 1 , C .H . R a y n es- G re en ow 2 , H .E . J eff er y 3

Abstract
As Asian countries undergo economic, social and nutritional transition, type 2 diabetes mellitus and
Gestational diabetes mellitus (GDM) may be increasing. To determine trends of GDM prevalence in
Asian countries, a search of Medline and Embase using defined criteria was performed. Studies
included were conducted in Asia between 1990 - 2011, documented patient selection, defined GDM
criteria, were in English, had a quality grade of Scottish Intercollegiate Guideline Network (SIGN) 2+
and recruited 500 women. Data was extracted using a standardized form. Within country
comparisons of studies using the same diagnostic criteria were made; study heterogeneity limited
results to a narrative synthesis. From 1460 titles and abstracts, 19 papers were included. There was
evidence of GDM increasing in Tianjin, China (2.4% in 2002 to 6.8% in 2008), in Hong Kong (7.4% in 1986
to 10.4% in 1998 to 2001) and in Bangkok, Thailand (2.0% in 1987 - 89 to 3.0% in 2001 - 02). Prevalence in
India varied markedly by location and diagnostic criteria, with high rates in urban Chennai, 17.7% in
2001 and 17.8% in 2005 to 2007. There was no evidence of increase in GDM in Tokyo, Japan (1.8% in
1996 - 2000 to 1.6% in 2008 - 10) or in Seoul, Korea (2.2% in 1991-94 to 2.4% in 1993-97). Other countries
lacked data for comparison. Despite the lack of comparative data there is an increasing trend of GDM
prevalence in some Asian countries. The choice of diagnostic criteria greatly affects prevalence.
Key words: Diabetes mellitus, gestational diabetes, Asian countries

1 Department of Obstetrics & Gynaecology, experiencing a rise in obesity and diet related
Sydney Medical School, University of Sydney, non-communicable diseases. Type 2 diabetes
Australia. mellitus has been documented to be
increasing in Asia (1), although the increase
2Sydney School of Public Health, University of
seems to be greater in South Asia compared to
Sydney, Australia.
East and South East Asia (2). It was estimated
3Sydney School of Public Health, University of that globally in 2011, 366 million people were
Sydney, Department of Neonatal Medicine, living with diabetes. This is predicted to rise to
Royal Prince Alfred Hospital, Sydney, Australia. 552 million people by 2030 with half of these
living in Asia (3).
*Corresponding author: Gestational diabetes mellitus (GDM) is broadly
(Current Details)
defined as any level of glucose intolerance first
Jane E Hirst recognized during pregnancy (4), a definition
that formerly included undiagnosed type 1 and
Department of Obstetrics & Gynaecology,
2 diabetes mellitus. Whilst for most women
Sydney Medical School, University of Sydney,
glucose intolerance resolves after birth, there is
Australia.
up to 50% chance of developing type 2
E-mail: jane.hirst@sydney.edu.au diabetes within 5 years of delivery (5). Diagnosis
and treatment of GDM can reduce adverse
Introduction pregnancy outcomes, including stillbirth,
neonatal macrosomia, neonatal
In most Asian countries, the economic hypoglycaemia, birth trauma and neonatal
prosperity is increasing. This has implications for respiratory distress syndrome as well as
the way people live, what they eat and decrease the risk of preeclampsia in the mother
patterns of disease they experience. China, (6, 7). For the offspring there is evidence of
India and several South East Asian nations are potential lifelong metabolic programming as a

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Journal of Diabetology, October 2012; 3:4 http://www.journalofdiabetology.org/
consequence of exposure to a differences in classification were too
hyperinsulinaemic fetal environment (8). These heterogeneous before this time and we lacked
changes can predispose the offspring to resources for translation of non-English
obesity and metabolic diseases including GDM language publications. An attempt was made
(9). Thus GDM is a condition with great public to contact the corresponding authors by email
health significance, both for improving if insufficient information on the study period or
pregnancy outcomes and identifying women location was available from the published
and children at risk of future type 2 diabetes manuscript. Studies needed to describe the
and GDM in the female offspring. method of GDM testing and the criteria for
diagnosis in order to allow comparison
GDM and type 2 diabetes share several risk
between like studies and populations.
factors and the incidence of GDM has been
noted to reflect the prevalence of type 2 In order to determine prevalence and country
diabetes (10). Given the documented rise in trends for GDM, studies derived from highly
type 2 diabetes across Asia (1), it is timely to selected populations (such as diabetes clinics)
assess the evidence for trends in GDM. The and/or those that did not describe recruitment
purpose of this review was to determine trends method were excluded. To improve data
of GDM prevalence in Asian countries over the quality and the risk of small studies introducing
past 20 years. bias, only studies with more than 500 women
were included in comparisons.
Search strategy and Methods
Information was extracted from each study
A review of the published literature on GDM in
using a standardized data extraction form.
Asian countries was performed. This involved
External validity was determined by considering
searching Medline (Ovid platform, searched
the location of data collection, i.e. hospital,
March 2012) and Embase (searched March
clinic, community or population based
2012) databases using the search terms
samples, the study site (urban, rural, mixed) and
Gestational diabetes, Diabetes in pregnancy,
how women were selected for screening.
Pregnancy, pregnan*, antenatal, prenatal,
Studies were assessed for risk of bias and
diabet*, glucose intoleran*, Diabetes
confounding and probability that the
gestational, screening, prevalence,
demonstrated relationship was causal
epidemiology, cohort study, cross sectional
according to the SIGN (Scottish Intercollegiate
study, review and meta-analysis. Referenced
Guideline Network) Grading System (11). This
conference abstracts were included if sufficient
system judges studies on their design and risk of
information for data extraction could be
bias, confounding and the probability the
obtained. Included studies were conducted in
relationship is causal. Briefly, categories range
Asia, defined in accordance with the United
from 1++ for high quality meta-analyses or RCTs
Nations regions of Eastern, South Eastern and
with a low risk of bias, 2++ high quality
Southern Asia. Eastern Asia includes the
systematic reviews of cohort or case control
Peoples Republic of China, Peoples Republic
studies or well conducted cohort or case
of China (Taiwan), Japan, South Korea, North
control studies with a low risk of bias, 2+ for well
Korea, Mongolia, Macau and Hong Kong.
conducted cohort or case control studies, 2
Southern Asia includes India, Bangladesh, Sri
for case control or cohort studies with a high risk
Lanka, Nepal, Afghanistan, Bhutan, Maldives
of bias or confounding. Studies judged to be 2-
and Pakistan. South East Asia includes
were excluded from the analysis.
Indonesia, Malaysia, Singapore, Brunei,
Philippines, Viet Nam, Cambodia, Timor Leste, Data synthesis and methodological issues
Laos, Thailand and Myanmar. Country names
Trends in the prevalence of gestational
were combined with search terms. Reference
diabetes can be difficult to estimate, with
lists of retrieved articles were searched for
multiple definitions, screening and diagnostic
completeness. Duplicate studies were
approaches creating non-comparable data.
removed.
Several methodological issues were identified
Eligible studies were published in English which prohibited meta-analysis of results to
between January 1990 and December 2011, as determine actual change in prevalence of

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Journal of Diabetology, October 2012; 3:4 http://www.journalofdiabetology.org/
GDM in different settings with confidence In Tianjin city, China, a universal screening
intervals. Studies were mostly hospital or clinic policy for GDM was introduced in 1999. Over
based and thus extrapolation to population the next 10 years 92% of pregnant women living
prevalence was inappropriate. There was in the city were screened for GDM, using the
substantial heterogeneity between studies, with same screening and diagnostic criteria. Zhang
variations in populations sampled during et al, have summarized the prevalence data
different time periods. There was also variation by year from 1999 to 2008 (17, 18). There was a
in screening methods, definitions and progressive increase in the population-adjusted
diagnostic criteria used to define GDM, all prevalence of GDM from 2.4% in 1999 to 6.8% in
factors known to greatly affect the proportion 2008, p < 0.0001. This ongoing, large,
of women diagnosed (12-14). None of the prospective study is strengthened by the high
studies reported rates of undiagnosed type 2 penetrance of screening, standardized
diabetes, therefore prevalence of GDM may diagnostic protocols and the ability to
be overestimated in some studies. Comparison compare laboratory glucose values after the
was restricted to studies using the same same glucose load. It provides robust evidence
diagnostic criteria. GDM is also known to vary of an increase in GDM in Tianjin.
between race/ethnic groups (15), thus analysis
In Hong Kong, three studies were identified
of trends was limited to within countries and in
which demonstrated a rising trend of GDM 7.4%
large countries within cities. It was not possible
in 1986 (19) to 12.1% in 1994-96 (20), followed by
to control for differential exposure of variables
a decline to 10.4% in 1998-2001 (21). These
such as age, body mass index, parity,
hospital-based studies all used the same
economic status, dietary and physical activity
method to screen women for GDM. Women
between studies. We felt that this could
with risk factors, including advanced maternal
represent significant effect modification.
age, increased BMI, relevant obstetric and
For these reasons we present a narrative family history or recurrent glycosuria, underwent
synthesis of results based on the method a 75g 2-hour Oral Glucose Tolerance Test
described by Rodgers et al, (16) with broad (OGTT) in the first trimester. All other low risk
comparisons of prevalence trends within women, and high risk women negative on initial
countries using the same diagnostic criteria. screening, underwent random blood glucose
level around 28 weeks, with values greater than
Results
5.8 mmol/l within 2 hours of eating and greater
From 1460 titles and abstracts identified using than 5.0 mmol/l more than 2 hours after eating
the search criteria, 50 publications met the considered abnormal. These women then had
inclusion criteria and after obtaining the full a 2 hour 75g OGTT, with 2 hour values greater
articles, 19 were determined original, than 8.0 mmol/l considered positive for GDM.
comparable and judged to have low risk of
Two studies were identified from Japan, both
bias and sufficient quality (SIGN grading 2+).
using the Japan Society of Obstetrics &
Eligible studies were identified from China
Gynaecology criteria for screening and
(Tianjin), Hong Kong, Japan (Tokyo), Korea
diagnosis (22). The prevalence in two different
(Seoul), Thailand (Bangkok), India and Pakistan
Tokyo clinics was, 1.8% from 1996 to 2000 (23),
(table 1). No published comparable studies
and 1.6% from 2008 to 2010 (24). The earlier
fulfilling the search criteria were identified from
study reported a mean maternal age of
the Peoples Republic of China (Taiwan), North
32.6 4.3 years, which had increased to
Korea, Mongolia, Macau, Bangladesh, Sri
33.4 3.7 years by the 2008-2010 study. BMI was
Lanka, Nepal, Afghanistan, Bhutan, Maldives,
not reported in the first study. In the 2008 - 2010
Indonesia, Malaysia, Singapore, Brunei,
study, BMI was low overall, however slightly
Philippines, Viet Nam, Cambodia, Timor Leste,
increased in women with GDM compared to
Laos or Myanmar. A list of excluded studies is
normo-glycaemic women, 19.7 kg/m2
available from the authors on request. Six
compared to 20.1 kg/m . 2
different classification methods (including two
different WHO criteria) for GDM were identified In Korea, data from over 20,000 women
(table 2). attending the Samsung Cheil Hospital in Seoul

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for routine antenatal care, demonstrated a GDM in 2002-03. The overall prevalence of
low, stable rate of GDM in the 1990s using the 16.55% (30).
National Diabetes Data Group (NDDG) criteria,
Studies using the 3 hour oral glucose tolerance
from 2.2% in 1991-93 (25) to 2.4% in 1993-97 (26).
test report lower prevalence. In 1992
Information on maternal age and BMI was not
Ramachadran et al, in Chennai demonstrated
given to compare whether these had changed
a rate of GDM of 0.56% with OSullivans criteria
across the study periods. The women
(32). In New Delhi in 2007, Tripathi et al,
diagnosed with GDM were followed until 2003
screened 687 women for GDM using a 50-gram
with the recurrence rate in subsequent
challenge test (threshold 7.8 mmol/l). Women
pregnancies found to be 45% (27).
positive on screening went on to undergo a
In Thailand the two large prospective cohort 100g 3 hour OGTT using the Carpenter Couston
studies using the NDDG criteria indicate a Criteria. Using this method the GDM prevalence
possible modest rise in GDM prevalence in was 1.5% (33). Using the same criteria
Bangkok. From 1987 to 1989, 25,997 women prevalence was 6.2% in Mysore in 1997-8 (34)
underwent blood glucose screening with a 50 and 3.1% in Kashmir from 1999-2002 (35).
gram glucose challenge test followed by a
In Pakistan, both studies identified were from
3 hour OGTT if positive. Of these, 2.0 % of
the same large institution in Karachi. As the two
women screened positive for GDM (28). No
studies presented have a cross over in the
details were given on the overall characteristics
recruitment period and do not stratify results by
of the screened group. In 2001-02, using the
year, it is not possible to comment on whether
same diagnostic criteria, but screening only
the documented increase from 1.3% in 1988 -
women with risk factors with a 50g glucose
1989 (36) to 3.3% from 1989 to 1993 (37) using
challenge test, the rate of GDM increased to
the WHO 1980 criteria truly represents an
3.0% (29). As screening based on risk factors is
increase in the prevalence of GDM in the
potentially more likely to misclassify women as
population.
negative for GDM, it is likely there has been a
real increase in GDM prevalence in this hospital
Discussion
setting, although further evidence is needed to
support this statement. This review has found some evidence of an
increase in the prevalence of GDM in China,
In India, some of the highest and lowest rates of Hong Kong and Thailand. There was no
GDM have been documented, reflecting the evidence of a rise in GDM prevalence from the
complexity of generalizing data for such a studies identified from Japan and Korea. In
diverse and large population. Seshiah and India, rates of GDM in urban women in Chennai
colleagues have reported some of the highest appear stable around 16% between 2001 and
rates of GDM in Chennai. Prevalence was 2005, however these rates are far higher than
estimated at 17.7% in an urban hospital based have been reported in other parts of the
population in 2001 following a 50 gram glucose country. Heterogeneity in populations and
challenge test and 75g 2 hour OGTT using the diagnostic methods within India hindered trend
WHO 1998 criteria (30). Between 2005 to 2007 comparison to other locations.
this group undertook a population study in
Chennai and the surrounding semi-rural and This review highlights how differences in GDM
rural areas to determine GDM prevalence (31). criteria and screening methods can have
They demonstrated 17.8% of urban women had important implications for estimating burden of
GDM, diagnosed as serum glucose greater disease for international comparison. This is a
than 7.8 mmol/l at 2 hours, following a one- major issue in GDM research that has been
step, fasting 75g glucose load. Rural and semi- recognised by other authors (13, 14).
urban women had lower rates of GDM, 9.9% Whilst efforts were made to perform a
and 13.8% respectively. The authors referenced comprehensive search of the literature, this
unpublished prevalence data for GDM from six review is limited by the lack of published data
different centers across India using the same from many countries over several years and
method. There were 3674 women screened for studies being conducted in different locations
within the same country. It is possible that the

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review has been affected by publication bias, predisposition to obesity and metabolic
with countries experiencing little change in disease.
prevalence or not performing screening for
Saisho et al, have estimated insulin resistance
GDM, less likely to publish results. Most studies
and beta cell function in a cohort of Japanese
were limited to singleton pregnancies in
women with and without GDM (47). They
women without previously diagnosed diabetes,
demonstrated that beta cell function was lower
and thus the population prevalence of
in women with GDM compared to those
diabetes in pregnancy is likely to be
without GDM, irrespective of body mass index.
underestimated. As several studies were
This lends support to the argument that the
conducted in large tertiary urban hospitals
underlying pathophysiological problem in GDM
there may be selection bias with higher risk
in Asian women may differ from that in
women choosing or being referred for care at
Caucasian and other populations. In
these centres.
Caucasian populations overweight and obesity
Given these limitations, it remains likely that are thought to be major drivers of the
there has been an increasing trend in the increased prevalence in GDM, with an
prevalence of GDM in some Asian countries, estimated population attributable risk fraction
although extrapolation from the available data of 46% (48). Several associations with GDM
must be interpreted cautiously. have been made in Asian women that have
not yet been demonstrated in other ethnic
Several theories have been proposed to
groups. Lao and colleagues in Hong Kong have
explain why rates of GDM and type 2 diabetes
established an association with thalassaemia
are higher in some Asian populations, often at
and GDM in their population, with an increased
lower BMI than western populations. The topic
OR of 9.44, and 95% confidence limits 5.52 to
has been the subject of a comprehensive
16.13, compared to women without
review by Chan et al, (1). Owing to the
thalassaemia (20). The same group also
similarities in risk factors between GDM and
published data showing an association
type 2 diabetes, it has been suggested that the
between chronic hepatitis B carriage and GDM
physiological insulin resistance of pregnancy
(21). They demonstrated an adjusted odds ratio
may act as a stress test for glucose tolerance,
of 1.24, 95% confidence limits 1.01 to 1.51, for
with GDM developing in those prone to
developing GDM compared to women without
developing type 2 diabetes later in life. Genetic
hepatitis B infection. It has been hypothesized
studies of GDM and type 2 diabetes have
that both these conditions may directly effect
demonstrated several shared gene loci (42).
the pancreatic beta cell.
Ethnic differences in gene loci associated with
type 2 diabetes have been demonstrated In China, short stature has been associated with
between Thai and Caucasian women with increased risk of GDM. Ma and colleagues
GDM (43), supporting a genetic predisposition demonstrated that leg to trunk ratio and leg
to diabetes in some ethnic groups. It has also length itself were significant independent
been proposed that intrauterine growth predictors of GDM (49). These findings have
restriction and low birth weight can result in a been variably replicated in other ethnic groups.
decrease in the number and function of The proposed pathophysiology is that women
pancreatic beta cells predisposing to type 2 with smaller skeletal muscle mass are less able
diabetes later in life (44). This is potentially very to dispose of glucose after an oral load,
important in Asia, where an estimated 18% of although it may also relate to stunting in early
babies are born less than 2500g (45). Whilst life and reduction in pancreatic beta cell mass.
some of these babies will be preterm, many
The diagnosis and treatment of GDM provides
others will not have reached their growth
an opportunity to target women at increased
potential in utero. As countries undergo the
risk for future development of type 2 diabetes
nutritional transition with increased availability
and prevent childhood obesity in their offspring.
of cheap, processed and high calorific foods
There is emerging evidence that intensive diet
(46), the survival advantage of the thrifty
and lifestyle interventions or metformin can
phenotype is lost, and the result is a
delay the onset of type 2 diabetes in women

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Table 1: Details of studies included in review with comparable populations and screening/diagnostic methods for GDM to estimate trends

Country/First Author/ Year Sample Study type Location and population Screen OGTT Criteria GDM SIGN
Year of Publication size test rate grade
China
Yang, X 2002 (18) 1998-99 9 471 Prospective Tianjin, 6 urban district Antenatal 50g 1 h 75g 2 h WHO 1999 2.3% 2++
cohort Basic Care Units. Singleton
pregnant women without other
known medical conditions
Zhang F 2011 (17) 2008 17563 Prospective As above 50g 1 h 75g 2h WHO 1999 6.8% 2++
cohort
Hong Kong
Lee CP, 1994 (19) 1986 11 300 Retrospective Two University hospital clinics. Random 75g 2h Modified 7.4% 2+
cohort Universal screening of all BSL1 WHO (2h >
pregnant women 8.0mmol/L)
Lao T, 2001 (20) 1994-96 14450 Retrospective Single centre, general hospital. Random 75g 2h WHO 1980 12.1% 2+
cohort Universal screening of all BSL1
pregnant women
Lao T, 2007 (21) 1998- 13685 Retrospective Two University hospital clinics. Random 75g 2h Modified 10.4% 2+
2001 cohort Universal screening of all BSL1 WHO (2h >
pregnant women 8.0mmol/L)
Japan
Miyakoshi, K 2003 (23) 1996-00 2 651 Retrospective Tokyo. Keio University Hospital. 50g 1h 75g 2h JSOG 1.8% 2+
study Consecutive native Japanese
singleton pregnant women.
Yachi, Y. 2011 (24) 2008-10 509 Prospective Tokyo. Tanaka Womens clinic. 50g 1h 75g 2h JSOG 1.6% 2+
cohort Women with prior diabetes
excluded.
Korea
Jang, H. 1998 (25) 1991-94 9 005 Prospective Seoul. Samsung Cheil hospital. 50g 1h 100g NDDG 1.9% 2++
cohort Consecutive pregnant women. 3h
Previous GDM, known diabetes
and high-risk transfers excluded.
Jang, H. 2003 (26) 1993-97 16 654 Prospective Seoul. Samsung Cheil hospital. 50g 1h 100g NDDG 2.4% 2+
cohort No exclusions stated. 3h

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Thailand
Serirat, S 1992 (28) 1987-89 25 992 Prospective Bangkok. Rajavithi Hospital. Prior 50g 1h 100g NDDG 2.02% 2++
cohort diabetes excluded. 3h
Sunsaneevithayakul, P 2001-02 9 861 Prospective Bangkok. Siriraj Hospital. All 50g 1h 100g NDDG 3.0% 2+
2004 (29) cohort women presenting for antenatal 3h
care.
India
Ramachandran, A. 1992 944 Cross- Chennai. 2 general prenatal 50g 1h 100g OSullivan 0.56% 2+
1994(32) sectional clinics. Consecutive women, 3h
study gestation > 24 weeks. Diabetes
on insulin excluded.
Hill, J 2005 (34) 1997-98 830 Prospective Mysore. Holdsworth Memorial - 100g CC 6.2% 2+
cohort Hospital. Singleton pregnancy, 3h
known diabetes excluded, plan
to deliver at hospital
Zargar, AH. 2004 (35) 1999-02 2000 Cross- Kashmir. Cluster sampling of 50g 1h 100g CC 3.1% 2++
sectional antenatal clinics in 6 districts in 3h
study Kashmir (urban and rural). WHO 1999 4.4%
Previous diabetes excluded. 75g 2h
Seshiah, V 2004 (30) 2001 1251 Cross- Chennai. General antenatal 50g 1h 75g 2h WHO 1998 17.7%2 2+
sectional hospital population (fasting 7.0
study or 2 h 7.8
mmol/L)

Seshiah, V 2008 (31) 2005-07 11786 Cross- Tamilnadu state. Community - 75g 2h WHO 1994 (2 13.9% 2++
sectional based. 4151 Chennai (urban), 3 h overall
study 690 Saidapet (semi urban), 3 945 7.8mmol/L) 17.8%
Thiruvallur (rural). Consecutive urban
pregnant women attending 13.8%
public health centres. semi
urban
9.9%
rural

Tripathi R 2012 (33) 2007 687 Prospective Lok Nayak Hospital, New Delhi 50g 1 h 100g CC 1.5% 2+
cohort 3h

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Pakistan
Rizvi, JH 1992 (36) 1988-89 2 330 Prospective Karachi. Aga Khan University 75g 2h 75g 2h WHO 1980 1.3% 2+
cohort Hospital. Universal screening.
Known diabetes excluded.
Akhter J. 1996 (37) 1989-93 6830 Retrospective Karachi. Aga Khan hospital. 50g 1h 75g 2h WHO 1980 3.3% 2+
cohort Universal screening

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