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NCD Prevention Begins in the Womb

By Priya Matzen and Nicolai Lohse

As little as 10 years ago, the prevailing wisdom held was that the major chronic diseases of Westernized societies were due to poor lifestyle choices or genetic inheritance. But recent research indicates that adverse environmental conditions in the womb – undernutrition, overnutrition or exposure to harmful toxins as a result of maternal malnutrition, obesity, stress, smoking, etc. – is an equal, if not more, significant determinant of a person’s future vulnerability to non-communicable diseases.

Diabetes during pregnancy, with its associated high blood glucose levels and link to maternal obesity, creates such an adverse environment and is a condition that poses a significant risk to both mother and child if it is not detected and managed. Diabetes often occurs for the first time during pregnancy, so-called gestational diabetes. Babies of mothers with diabetes are typically larger, which contributes to health problems like damage to shoulders during birth, low blood glucose at birth, a higher risk of breathing problems, and the need for delivery by caesarean section. Gestational diabetes is also associated with an increased risk of spontaneous abortion and pre-term delivery.

Women who suffer from gestational diabetes and their offspring are at a high risk of developing chronic diseases during their lifetime.  Pregnant women who experience gestational diabetes are more than seven times more likely to develop type 2 diabetes later in life – and their children are at a four to eight times greater risk of developing the disease – than those whose pregnancies were not affected by diabetes. 

In a recent Lancet series on stillbirth, screening and management of diabetes mellitus in pregnancy is recommended as part of the intervention package to reduce stillbirth prevalence in countries with moderate to low rates of stillbirth. However, the positive effects of this intervention on broader maternal and child health continue to be downplayed and underestimated, particularly in countries with high prevalence of stillbirth. Based on a conservative estimate, 5 to 10 million pregnant women of 136 million pregnancies worldwide have gestational diabetes each year. Despite scattered evidence, the global prevalence of gestational diabetes appears to be increasing, reaching 17.8 percent in urban areas in India. It varies from low rates in some countries to nearly 30 percent in others. New diagnostic criteria recommended by the International Association of the Diabetes and Pregnancy Study Groups operate with lower thresholds and are likely to increase prevalence two to three-fold, for example from 13 percent to 38 percent in the United Arab Emirates. Thus, the exact scale of the problem is likely to be underestimated, and screening is often not available or poorly implemented.

To address some of these challenges, Novo Nordisk has set up local public-private partnerships in India, Colombia and Nicaragua, working with local health authorities as well as academic and implementing partners to train health care professionals, build capacity in the health system for gestational diabetes screening and management, and test innovative ways to change the lifestyle of mothers with gestational diabetes and their families with the aim of identifying cost-effective ways of reducing the burden of diabetes-related disease both in the short and long term.

Prevention of Non-Communicable Diseases

There is a growing recognition that the development of many non-communicable diseases may have their roots in the uterine environment and up to the age of two years. A healthy pregnancy has been primarily thought of as a key to a healthy infancy and childhood, but new evidence is showing that the effects linger well into adulthood. Therefore ensuring optimal health of women and their children early in life is critical for the prevention of non-communicable diseases and intergenerational transmission of poor health

This new evidence underlines the importance of early intervention in the prenatal and early childhood years as a cost effective means of preventing later chronic diseases. Through strengthened maternal health policy and early interventions, current initiatives could be expanded to achieve multiple goals: preventing non-communicable diseases, ending the intergenerational transfer of ill health, reducing child mortality and advancing human development.

A Multi-Sector Partnership

The challenge presented by non-communicable diseases is of such a magnitude that we need to carefully consider how the global health community can have the greatest impact over the short and long term. Early Origins of Health is an initiative aiming to design timely early interventions that can reduce the risk of developing non-communicable diseases in adult life. This initiative needs a broader focus than diabetes only, and therefore Novo Nordisk is building partnerships with Johnson & Johnson, PepsiCo, Steno Diabetes Center, the World Diabetes Federation and the United Nations Foundation who will provide their expertise in the field of health literacy, nutrition, research, access to health, and connecting people, ideas and resources. In joining this effort, partners acknowledge the need for positively influencing the women’s standing in society, including the cultural, family-related, political, and societal contexts set for maternal and child health. The development of health literacy among mothers and those influencing their health will be a key indicator for the program. Our focus will be on women living in low- and middle-income countries where the unmet needs are most prevalent and where the full impact is greatest.

Policy Implications

The Early Origins of Health initiative provides a unique platform for bringing together actors from many health agendas, thereby breaking the silo focus that is too often predominating global health thinking. The initiative will foster a multi-stakeholder policy dialogue around the specific links between MNCH, non-communicable diseases, and the MDGs. The time is ripe for such a multi-stakeholder dialogue, and the concept of early interventions to address lifelong prevention provides us with a unique opportunity to bring together stakeholders also from the infectious disease communities to address integration of services at the programmatic level for a public health goal that reaches across the lifespan and across disease areas.

A strong policy statement in the outcomes document from the UN High-level Meeting on non-communicable diseases in September 2011 on the link between early environment and prevention of non-communicable diseases will spur the much needed innovation on early interventions required to turn the tide of the NCD epidemic.

Conclusions

Pregnancy provides an opportunity to intervene that may enable us to prevent non-communicable diseases over the entire lifespan. Policy makers need to recognize that the promotion of maternal health is a central component of diabetes prevention strategies. To achieve sustainable outcomes, the private sector needs to partner with other sectors and take an active role in designing practical and scalable solutions. This will also enable us to provide a healthy start to life that is passed on to future generations.

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Priya Matzen is program director, Early Origins of Health at Novo Nordisk. Nicolai Lohse, MD, PhD is program director, Changing Diabetes in Pregnancy at Novo Nordisk