DIABETES AND IMPAIRED GLUCOSE TOLERANCE IN WOMEN AGED 20-39 YEARS

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DIABETES AND IMPAIRED GLUCOSE TOLERANCE IN WOMEN AGED 20-39 YEARS

World Health Organization Ad Hoc Diabetes Reporting Group•,b

Since 1988, the World Health Organization (WHO) has been assembling data from population surveys in which the diagnosis of abnormal glucose tolerance has been made after an oral glucose tolerance test, and according to the WHO criteria (1). To date, material has been received for over 150 000 subjects in 75 diverse population groups or subgroups in 32 countries. This made possible a first report of global, age-standardized estimates of prevalence of diabetes mellitus and impaired glucose tolerance (IGT) in adults {2).

Diabetes in pregnancy imparts a risk to both the mother and the fetus (3). However, there has been no standardized, comparative report of prevalence of abnormal glucose tolerance (diabetes and IGT) in women of childbearing age. Such estimates have now been derived from the WHO data base on glucose intolerance, and they are presented here for communities in all major geographical regions.

Methods

Details of the study design, population samples and the procedure for age standardization are provided in the original report (2). Diagnostic criteria were as follows:

Diagnostic category

Normal IGT

Diabetes mellitus

2-h venous plasma glucose concentration

< 7.8 mmol/1

;:: 7.8 and< 11.1 mmol/1

;:: 11.1 mmol/1

The principal criteria for inclusion in these studies were: (i) that each subject in a valid population sample should have received a 75 g oral glucose (anhydrous, or its equivalent) challenge after a suit- able period of fasting, and (ii) that the blood glucose concentration should have been measured exactly 2 hours later.

For the purpose of the present article, the age range 20-39 years was considered optimal: few of the surveys included subjects below the age of 20 years, and the majority of pregnancies occur in women below the age of 40 years.

'K.G.M.M. Alberti, M. Asfour, P.H. Bennett, V. Coli ins, G. Dowse, M.l. Harris, H. King, H.M. Kitange, W.C. Knowler, A. Lambourne, G.

Larenas, D. Mclarty, A.A. Motala, M.A.K. Omar, A. Ramachandran, M. Rewers, A.G. Schranz, M.A. Seedat, C. Snehalatha, A. Swai, R.

Taylor, A.C. Thai, J. Tuomilehto, A. Verrillo, M. Viswanathan, M.

Wijesuriya, D.R.R. Williams, and P. Zimmet contributed to the present report. For the full membership of the Reporting Group, see reference (2).

b This article was prepared for the Reporting Group by Hilary King and Marian Rewers (with the support of grant no. DK-30747 from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, United States). Address correspondence and reprint requests to Dr H. King, Diabetes and Other Noncommunicable Diseases Unit, World Health Organization, 1211 Geneva 27, Switzerland.

A minimum desirable sample size was considered to be 100 women examined in this chosen age range.

Data for some subpopulations (3 rural Bantu communities in the United Republic of Tanzania, urban Hindu and Muslim Indians in the same country, 2 Italian towns, 2 communities of Aboriginal Australians, 4 communities in Papua New Guinea, and 2 Polynesian islands) were pooled in order to achieve the desired sample size.

A total of 29 population groups from 19 countries qualified for inclusion according to all the above criteria. These are shown in Table 1 and further details may be found in the original survey reports {4-23).

Results

In most populations, diabetes was uncommon (< 1%) in women in this age range (Table 2). These include Bantu (United Republic of Tanzania), Chinese (Singapore), rural Indian and Sri Lankan women, and some rural Pacific populations. Prevalence in the range 1-3% was observed in Italian women, and in white, black and Hispanic women in the United States of America; it was 7% in rural Indian women in Fiji and in Aboriginal Australian women; and the highest prevalence was observed in the Pima/

Papago Indians in the United States and in Nauruans.

The prevalence of IGT was low (< 3%) only in Chinese and Malays (Singapore), Mapuche Indians (Chile) and in some rural Pacific populations. Preval- ence of IGT exceeded 10% in black and Hispanic women in the United States, urban Indian women in the United Republic of Tanzania, Pimas and Nauruans, and some other Pacific communities.

Age-standardized prevalence of total glucose intolerance (diabetes and IGT tolerance combined) ranged from 0 to 36% (Fig. 1). One-third (10/29) of the populations demonstrated > 10% prevalence of total glucose intolerance in women in this age range. In the Pimas and Nauruans, prevalence exceeded 30%.

The proportion of undiagnosed cases of diabetes in the various surveys is illustrated in Fig. 2. For women in the United States, the proportion undiagnosed was lowest in blacks, intermediate in whites, and highest in Hispanics. In three-quarters of the African and Asian communities, and in two- thirds of the Pacific populations, over 50% of diabetes was undiagnosed. While undiagnosed diabetes was rare in Maltese women (perhaps as a result of community screening programmes) it was common (> 70%) in Italian women.

Discussion

The main purpose of this article is to present standardized data on glucose intolerance in women of

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TABLE 1. CHARACTERISTICS OF THE STUDY POPULATIONS TABLEAU 1. CARACTERISTIQUES DES POPULATIONS ETUDIEES

Code ETHNIC GROUP - GROUPE ETHNIQUE Number of Date of Investigator

Population women aged study (reference)

subgroup - Sous~groupe 20-39 Date de I' etude Enqueteur (reference)

Nombre de femmes iigees de 20 a ²⁹

ARAB - ARABES Oman (national sample) -

Oman (echantillon national) 1 497 1991 Asfour et al.•

BANTU - BANTOUS United Republic of Tanzaniab -

R.-U. de Tanzanieb

2 rural - population rurale 1 929 1987-88 McLarty et al. (4)

3 urban - population citadine 462 1987-88 McLarty et al.•

CHINESE - CHINOIS

4 Singapore - Singapour 327 1984-85 Thai et al. (5)

INDIAN - INDIENS

India (Dravidian) - lnde du Sud (Dravidien)

5 rural - population rurale 243 1988-89 Ramachandran et al.•

6 urban (Madras) -

population citadine (Madras) 294 1988-89 Ramachandran et al.•

Sri Lanka

7 rural - population rurale 355 1987 M. Wijesuriya•

South Africa - Afrique du Sud

8 urban - population citadine 673 1984 Omar et al. (6}

United Republic of Tanzania - R.-U. de Tanzanie 9 urban, Hindu and Moslem -

population citadine, hindous et musulmans 426 1987-88 Swai et al. (7) Fiji- Fidji

10 rural - population rurale 142 1980 Zimmet et al. (8)

11 urban - population citadine 282 1980 Zimmet et al. (8)

MALAY- MALAIS

12 Singapore - Singapour 118 1984-85 Thai et al. (5)

AMERICAN INDIAN - AMERINDIENS 13 Pima & Papago (United States)b -

Pimas & Papago (USA)b 531 1982-87 Ben nett et al. (9, 10)

14 Mapuche (Chile) - Mapuche (Chili) 125 1982 Larenas et al.

NON-HISPANIC WHITE AMERICAN -

BLANCS AUTRES QU'HISPANOAMERICAINS

15 United States - Etats-Unis d'Amerique 2 502 I 643 ^c 1976-80 Harris et al. (12) BLACK AMERICAN - NOIRS AMERICAINS

16 United States - Etats-Unis d'Amerique 374/70° 1976-80 Harris et al. (12) HISPANIC AMERICAN - HISPANOAMERICAIN

17 S.W. United States -

Etats-Unis d'Amerique (sud-ouest) 1 139 I 282 c 1982-84 Harris et al.•

ITALIAN - ITALIENS

18 Sanza, Laurino 291 1982 Verrillo et al. (13, 14)

MALTESE- MALTAIS

19 Malta - Maltes 527 1981 Schranz et al. (15)

ABORIGINAL AUSTRALIAN - ABORIGENES D'AUSTRALIE

20 Bourke and Purfleet - Bourke et Purfleet 135 1982-85 Williams et al. (16, 17) MELANESIAN - MELANESIENS

Fiji- Fidji

21 rural (Sigatoka) - population rurale (Sigatoka) 124 1980 Zimmet et al. (8)

22 urban (Suva) - population citadine (Suva) 263 1980 Zimmet et al. (8)

23 Papua New Guinea -

Papouasie-Nouvelle-Guinee 341 1983-85 King et al. (18, 19)

MICRONESIAN - MICRONESIENS Kiribati

24 rural (Tabiteuea) -

population rurale (Tabiteuea) 289 1981 King et al. (20)

25 urban (Betio) - _population citasine (Betio) 650 1981 King et al. (20)

26 Nauru 568 1982 Zimmet et al. (21)

POL YNESIAN - POL YNESIENS Western Samoa - Samoa occidental

27 rural - population rurale 196 1978 Zimmet et al. (22)

28 urban - population citadine 186 1978 Zimmet et al. (22)

29 Rarotonga and Niue - Rarotonga et Nioue 567 1980 King et al. (23)

a Personal communication of previously unpublished data- Communication personnelle de donnees in8dites.

b Data concerning newly vs. previously diagnosed diabetes unavailable- Pas de donnees concernant les cas de diabete nouvellement diagnostiques par rapport au cas pr8c6demment diagnostiques.

c Denominator for diabetes prevalence/denominator for impaired glucose tolerance prevalence (subjects given oral glucose tolerance test) - D9nominateur pour la prevalence du diabete/d9nominateur pour la prevalence de l'abaissement de la tolerance au glucose (sujets sou m is-l'epreuve orale de tolerance au glucose).

Rapp. trimest. statist. sanit. mond., 45 (1992)

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TABLE 2. PREVALENCE OF DIABETES AND IMPAIRED GLUCOSE TOLERANCE AS A PERCENTAGE OF THE POPULATION IN IN WOMEN AGED 20-39 YEARS

TABLEAU 2. PREVALENCE DU DIABETE ET DE L'ABAISSEMENT DE LA TOLERANCE AU GLUCOSE (PAR CENTAINE D'HABITANTSI CHEZ LES FEMMES AGEES DE 20

A

39 ANS

ETHNIC GROUP - GROUPE ETHNIOUE Diabetes mellitus Impaired glucose tolerance

Population Diabete suerS Abaissement de la tolerance au glucose

subgroup

Population Crude Age- 95% Crude Age- 95%

Sous-groupe rate adjusted confidence rate adjusted confidence

rate interval rate interval

Taux brut Taux ajuste lntervalle Taux brut Taux ajuste lntervalle selon l'age de confiance selon l'§ge de confiance

95% 95%

ARAB - ARABES

Oman - Oman (echantillon national) 3.4 3.4 2.5-4.3 8.5 8.5 7.1-9.9

BANTU - BANTOUS

United Republic of Tanzania - R.-U. de Tanzanie

rural - population rurale 0.2 0.2 0.0- 0.5• 6.2 6.2 5.2- 7.5•

urban - population citadine 0.2 0.2 0.0- 1.2• 7.6 7.8 5.4-1 0.9•

CHINESE - CHINOIS

Singapore - Singapour 0.8 0.9 0.2- 2.6• 0.8 0.8 0.2- 2.2•

INDIAN - INDIENS

S. India (Dravidian) - lnde du Sud (Dravidien)

rural - population rurale 0.0 0.0 0.0- 1.2 3.3 3.1 1.3- 6.1

urban (Madras) - population citadine (Madras) 1.4 1.3 0.4- 3.4• 6.5 5.6 3.4- 8.8•

Sri Lanka (rural) - Sri Lanka (population rurale) 0.0 0.0 0.0- 0.9• 3.1 3.0 1.5- 5.4•

South Africa (urban) -

Afrique du Sud (population citadine) 3.1 3.4 1.9- 4.8 2.2 2.3 1.1-3.4

U.R. of Tanzania (urban) -

R.-U. de Tanzanie (population rurale) 2.8 2.0 0.9- 3.2 16.7 14.2 11.0-17.4 Fiji- Fidji

rural - population rurale 7.0 6.8 2.8-10.8 8.5 8.4 3.9-12.9

urban - population citadine 1.8 1.8 0.6- 4.1 7.1 7.6 4.6-11.7"

MALAY - MALAIS

Singapore - Singapour 0.8 0.8 0.0- 4.2• 0.0 0.0 0.0- 2.5•

AMERICAN INDIAN - AMERINDIENS

Pima & Papago (USA) - Pimas & Papago (USA)b 22.0 22.5 19.0-25.9 13.6 13.6 10.6-16.5

Mapuche (Chile) - Mapuche (Chili) 0.0 0.0 0.0- 2.4• 0.0 0.0 0.0- 2.4•

NON-HISPANIC WHITE AMERICAN -

BLANCS AUTRES OU'HISPANOAMERICAINS

United States - Etats-Unis d'Amerique 1.7 1.8 1.2- 2.3 5.9 5.7 3.9- 7.5

BLACK AMERICAN - NOIRS AMERICAINS

United States - Etats-Unis d'Amerique 2.4 2.4 0.8- 3.9 17.1 16.8 8.2-25.4

HISPANIC AMERICAN - HISPANOAMERICAINS S.W. United States -

Etats-Unis d' Amerique (sud-ouest) 2.2 2.2 1.3- 3.0 10.6 10.7 7.1-14.3

ITALIAN - ITALIENS

Sanza, Laurino 1.4 1.2 0.3- 3.1• 5.2 5.0 2.8- 8.3•

MALTESE - MALT AIS

Malta - Maltes 0.6 0.4 0.1-1.2" 1.5 1.2 0.5- 2.4•

ABORIGINAL AUSTRALIAN - ABORIGENES D'AUSTRALIE

Bourke & Purfleet 6.7 6.7 3.1-12.8 3.0 3.2 0.9- 8.2a

MELANESIAN - MELANESIENS Fiji- Fidji

rural (Sigatoka) - population rurale (Sigatoka) 0.0 0.0 0.0- 2.4 4.8 4.9 1.8-10.7"

urban (Suva) - population citadine (Suva) 1.9 1.8 0.6- 4.2 10.7 10.1 6.7-14.7•

Papua New Guinea - Papouasie-Nouvelle-Guinee 0.0 0.0 0.0-0.9 0.3 0.3 0.0- 1.6 MICRONESIAN - MICRONESIENS

Kiribati

rural (Tabiteuea) - population rurale (Tabiteuea) 1.7 2.1 0.7-4.8 9.0 9.2 6.0-13.5"

urban (Betio) - population citadine (Betio) 3.2 3.4 1.9- 4.8 14.0 14.0 11.4-16.7

Nauru 11.4 14.0 10.8-17.2 16.7 17.7 14.3-21.1

POL YNESIAN - POL YNESIENS Western Samoa - Samoa accidental

rural - population rurale 1.0 0.8 0.1- 3.0 1.0 0.9 0.1-3.2

urban - population citadine 1.1 1.0 0.1- 3.7 7.0 7.0 3.8-12.0

Niue & Cook Islands - Rarotonga et Nioue 3.4 3.2 1.8- 4.6 4.8 4.6 2.9- 6.4

a 95% confidence interval based on the Poisson distribution- lntervalle de confiance 95% d'apres la distribution de Poisson.

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FIG. 1

PREVALENCE OF TOTAL GLUCOSE INTOLERANCE (DIABETES MELLITUS AND IMPAIRED GLUCOSE TOLERANCE) IN WOMEN AGED 20-39 YEARS PREVALENCE DE L'INTOLERANCE TOT ALE AU GLUCOSE (DIABETE SUCRE

ET ABAISSEMENT DE LA TOLERANCE AU GLUCOSE) CHEZ LES FEMMES AGEES DE 20-39 ANS

Women aged 20 to 39 years Femmes agees de 20

a

³⁹ans

Mapuche Indian, Chile lndiennes Mapuche, Chili rural Melanesian, PNG ME!Ianesiennes rurales, PNG Malay, Singapore Malaisiennes, Singapour Maltese, Malta Maltaises, Malte Chinese, Singapore Chi noises, Singapour rural Polynesian, W. Samoa Polynesiennes rurales, Samoa occidentales rural Sri Lanka Femmes rurales, Sri Lanka rural Indian, India lndiennes rurales, lnde rural Melanesian, Fiji ME!Ianesiennes rurales, Fidji urban Indian, S. Africa lndiennes citadines, Afrique du Sud Italian ltaliennes rural Bantu, Tanzania Bantoues rurales, R.-U. de Tanzania urban Indian, India lndiennes citadines, lnde White, USA Blanches, USA Polynesian, Cook Islands PolynE!siennes, lies Cook urban Bantu, Tanzania Bantoues citadines, R.-U. de Tanzania urban Polynesian, W. Samoa Polynesiennes citadines, Samoa occidentales urban Indian, Fiji lndiennes citadines, Fidji Aboriginal Australian AborigEmes d'Australie rural Micronesian, Kiribati Micronesiennes rurales, Kiribati Arab, Oman Arabes, Oman urban Melanesian, Fiji Melanesiennes citadines, Fidji Hispanic, USA (Southwest) Hispano-americaines, USA (Sud-Ouest) rural Indian, Fiji lndiennes rurales, Fidji urban Indian, Tanzania lndiennes citadines, Tanzanie urban Micronesian, Kiribati Micronesiennes citadines, Kiribati Black, USA Noires, USA Micronesian, Nauru Micronesiennes, Nauru Pima Indian, USA tndiennes Pimas, USA

0

5

10%

•

10

Prevalence of diabetes(%)- Prevalence du diabete (%) Prevalence of IGT (%) - Prevalence de !'intolerance au glucose(%)

15

20 25 30 35 40

Prevalence- Prevalence (%)

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- 3 2 5 -

FIG.2

PROPORTION OF DIABETIC WOMEN AGED 20-39 YEARS UNDIAGNOSED PRIOR TO SURVEY

% DE FEMMES DIABETIQUES NON DIAGNOSTIQUEES

Women aged 20-39 years Femmes agees de 20

a

^{39 ans}

Malay, Singapore Malaisiennes, Singapour

Black, USA Noires, USA

Maltese, Malta Maltaises, Malte

non-Hispanic white, USA Blanches autres qu'hispaniques, USA

Hispanic, USA HispanoamBricaines, USA

Polynesian, Rarotonga & Niue Polyn8siennes, Rarotonga et Nioue

Chinese, Singapore Chi noises, Singapour

urban Melanesian, Suva M81an6siennes citadines, Suva

urban Indian, South Africa lndiennes citadines, Afrique du Sud

Micronesian, Nauru Micron8siennes, Nauru

urban Indian, Madras lndiennes citadines, Madras

Arab, Oman Arabes, Oman

Aboriginal Australian, Bourke & Purfleet Aborigenes d'Australie, Bourke & Purfleet

urban Hindu & Moslem, U.-R. of Tanzania Hindoues & musulmanes citadines, R-U. de Tanzania

Italian, Sanza & Laurino ltaliennes, Sanza & Laurino

rural Micronesian, Tabiteuea Micron9siennes rurales, Tabiteuea

urban Micronesian, Betio Micron9siennes citadines, Betio

rural Indian, Fiji lndiennes rurales, Fidji

urban Indian, Fiji lndiennes citadines, Fidji

~··

Oo:l

0

~

~ ~

I I I I

20

40 60 80

100

% women undiagnosed-% de femmes diab6tiques non diagnostiquees

childbearing age, which may assist planners and health care providers estimate the likely magnitude of the problem in their own community.

The results suggest that the frequency of diabetes in women in the age range 20-39 years generally re- flects its underlying prevalence in adults of all ages in a particular population. In most communities,

diabetes appears to be quite uncommon in young adult women.

Perhaps the most important observation is that IGT was found to be common in many populations among women of this age range, generally exceed- ing the prevalence of diabetes. The report of the WHO Study Group on diabetes (1) recommended

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that the management of IGT in pregnancy should be the same as that for diabetes. However, it is acknow- ledged that evidence for the beneficial effect of treatment on lesser degrees of abnormal glucose tolerance (essentially, for those in the IGT range) is scant (24). Furthermore, blood concentration is labile and a confirmatory test would be advisable.

Considering that the proportion of undiagnosed diabetes was > 50% in many of the surveys reported here, and that IGT is likely to be overlooked in routine clinical practice, these data suggest that a substantial proportion of abnormal glucose tolerance during pregnancy wilf go undetected In the absence of screening programmes.

The routine screening of all pregnant women has been recommended by the American Diabetes Association (25). However, some countries may find both the screening procedure and the resulting increase in clinical workload an unacceptable burden in the face of competing health priorities.

In the event that screening is considered warranted, two issues must be confronted. Firstly, the diagnostic criteria to be adopted, and secondly, the level of glucose intolerance at which to initiate active

treatment. Following the Third international work- shop-conference on gestational diabetes mellitus, held in 1990, it was proposed that an international, multicentre study be developed to investigate these questions in a variety of social and medical settings (24).

As a result of this proposal, an international diabetes in pregnancy working party was convened in Provi- dence, Rhode Island, United States, in June 1991 (D. Coustan and B. Metzger, personal communication). At this and subsequent meetings, a protocol for such a study was developed. A decision was made to adopt the WHO method for glucose tolerance testing (i.e. a 75 g glucose load). The primary objective will be to determine the risk to the mother and the fetus of various levels of glucose intolerance in different communities, with a view to formulating clinical guidelines at an international level.

In the studies reported here, one-third of the populations showed a prevalence of total glucose intolerance in excess of 10% in women aged 20-39 years. lt is hoped that these preliminary data will increase awareness of glucose intolerance in pregnancy, and will help to place it in its true perspective as a worldwide phenomenon.

SUMMARY

Age-standardized estimates of prevalence of diabetes mellitus and impaired glucose tolerance (IGT) are presented for women aged 20-39 years in 29 populations. In most cases, diabetes was uncommon

(< 1%). Prevalence of diabetes was 1-3% in women

in Italy and the United States, 7% in Fiji Indian and Aboriginal Australian women, > 10% in Nauruans

and > 20% in Pima Indians. IGT was common (> 3%)

in many communities. Prevalence of IGT exceeded 10% in black and Hispanic women in the United States, urban Indian women in the United Republic of Tanzania, Pima Indians and some Pacific popula-

tions. In one-third of the populations, prevalence of total glucose intolerance (diabetes and IGT combined) exceeded 10% in women in this age range. In many communities, over 50% of diabetes was undiagnosed prior to the survey. lt is concluded that a substantial proportion of abnormal glucose tolerance during pregnancy will go undetected in the absence of screening programmes. An international study is required to define the risk to the mother and the fetus of various levels of glucose intolerance, with a view to formulating international guidelines for clinical practice.

RESUME

Diabete et abaissement de la tolerance au glucose chez les femmes agees de 20 a 39 ans

Des estimations de la prevalence du diabete sucre (DS) et de l'abaissement de la tolerance au glucose (ATG), normalisees selon l'age, sont presentees ici pour les femmes agees de 20

a

39 ans de 29 populations. La plupart du temps, le diabete etait peu frequent (< 1 %). Sa prevalence etait de 1

a

³^%^dans

la population feminine d'ltalie et des Etats-Unis d'Amerique, de 7 % chez les indiennes de Fidji et les aborigenes d'Australie, superieure

a

¹⁰^%^{chez les}

indiennes de Nauru et superieure

a

²⁰^%^{chez les}

indiennes Pima. L'abaissement de la tolerance au glucose (ATG) etait frequent (> 3 %) dans de nombreuses communautes. Sa prevalence depassait 10%

chez les femmes noires et hispano-americaines aux Etats-Unis, les indiennes des villes en Republique- Unie de Tanzanie, les indiennes Pima et certaines

populations du Pacifique. Dans le tiers des populations, la prevalence de !'intolerance totale au glucose (diabete et abaissement de la tolerance au glucose combines) excedait 10% chez les femmes de ce groupe d'age. Dans de nombreuses communautes, plus de 50% des cas de diabete etaient restes non diagnostiques avant l'enquiHe. 11 semble done qu'une proportion substantielle des anomalies de la tolerance au glucose pendant la grossesse passe inapen;;ue en !'absence de programmes de depis- tage. Une etude internationals est necessaire pour definir le risque, pour la future mere et le fretus, de divers niveaux d'intolerance au glucose, afin de for- muler des directives internationales pour la pratique clinique.

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DIABETES AND IMPAIRED GLUCOSE TOLERANCE IN WOMEN AGED 20-39 YEARS

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