Not all birth defects are currently preventable. Some are preventable but require “moms to be” to understand what causes these birth defects and take the necessary steps to prevent them. Some women were not planning to get pregnant and therefore were not taking the necessary steps (50% of US pregnancies are unplanned). Because of this fact, all reproductive age women need to take these steps. See my previous blog and follow me, for how to prevent neural tube defects (NTD). This blog will discuss how to prevent birth defects from diabetes (high blood sugar).
Diabetes is divided into two main types. The most severe is type 1. This is juvenile onset, insulin dependent, diabetes mellitus (type 1 IDDM). This usually occurs in young children with a pancreas that is unable to make insulin. Insulin is a hormone that acts as the “key” to unlock the “door” to the cell that lets glucose (sugar) enter the cell to act as fuel for the cell. Without insulin the cell starves and dies. Sugar stays in the blood (high blood sugar) but is unable to be used. The problem is not “too much sugar” in the blood but not being able to get it into the cell to act as fuel for the cell. Before the isolation and availability of insulin from pork pancreas, these children and young adults all died. This group only accounts for 3 % of diabetics. With the availability of insulin these children were able to lead a full and productive life. With control of their A1c to normal levels before pregnancy, these women were able to have babies with no increased risk of birth defects compared to a mom without diabetes.
Type 2 DM is a milder form with reduced insulin production and/or “insulin resistance” that usually does not start until the person is an adult. Their bodies can make some insulin, but not enough. It can also be caused by insulin “resistance”. The “key” does not fit “well” so it takes more insulin. Type 1 causes early and severe symptoms. Type 2 is mostly asymptomatic in its early stages and in the past some type 2 DM went 10-15 years without being diagnosed and treated. Being undiagnosed allowed irreversible, preventable damage to occur to their bodies. This form of diabetes makes up 97% of diabetes (DM). Uncontrolled DM is the leading cause of blindness, kidney dialysis and kidney transplants, and leg amputations in the US.
Doctors have recently become very aggressive in diagnosing, treating and preventing type 2 DM (1). The US is currently in the middle of a diabetic epidemic. The two leading causes of type 2 DM are getting older (that is a good thing) and obesity (that is a bad thing). Two out of every 3 adults in the US are now either overweight (BMI [body mass index] 25-29.9) or obese (BMI over 30). A BMI of 20 to 25 is the best, and associated with the longest life expectancy. Obesity (and lack of exercise) has caused our current diabetes epidemic. People undergoing gastric bypass for morbid obesity can often stop all their diabetes medicine once they have lost weight.
A “third” form is gestational diabetes mellitus (GDM). This is probably a variation of type 2 triggered by the extra stress of pregnancy on a women’s body. GDM occurs in the second half of pregnancy and “reverts” back to normal (or borderline diabetes) after delivery. An important point to understand is that without preconception testing (A1c) you may be misdiagnosed as GDM instead of preconception type 2. This is critical because GDM is not associated with an increase in birth defects because the A1c is normal at conception and only becomes abnormal in the second half of pregnancy. Birth defects are caused by an abnormal A1c at the time of conception. High blood sugars (high A1c) at the time of conception cause birth defects, GDM (high blood sugar in the last half of pregnancy) does not cause birth defects but can cause the baby to be large and need a caesarian section (C/S). All women should get a yearly A1c, so any abnormal result can be treated before you get pregnant. Diabetics that get their A1c back down to normal with medication, exercise, and weight loss have the same birth defect rates as normal women (no increase). Any mom that has a large baby (9 or more pounds) should be tested for diabetes at her 6-week post-partum visit. Most women with GDM will become type 2 DM within 10 years of delivery unless they start exercising, eat healthy, and lose weight. Twenty-seven percent can avoid type 2 DM and the necessary medications and medical complications if they are smart.
If your A1c is 5.5 or less (normal) your risk of a birth defect is about 2% (2 out of a hundred babies). If your A1c is 6.5 at conception your birth defect rate increases to 3 out of 100 babies (3%). If your A1c is 14 or over then your birth defect rate is 1out of 5 babies (20%). This high rate could have been prevented if you had a preconception test (A1c) and were treated for DM before getting pregnant. Protect your future baby by getting tested (A1c) once a year after you start having periods. Also start taking over the counter (OTC) folic acid to prevent NTD (open spine birth defect). If you are thinking about being sexually active get started on LARC (see my blog on the best “forgettable” contraception).
Fifty percent (50%) of US pregnancies are unplanned. Once you have the infamous “missed period” it is already too late to prevent these increased birth defects. If you are not already taking folic acid and have a normal A1c you will have caused your baby to be at increased risk for birth defects. It is very simple to protect your baby from these increased risks. Use the best current contraception (LARC) to prevent an unplanned pregnancy.
One out of every two adults in the US today now have DM or borderline DM. If your annual A1c at your doctor’s office is 5.5-6.4 then you are a “borderline DM”. You will not need any medicine but need to exercise at least 30 minutes each day, eat healthy (more fruits and vegetables), and lose weight. The DPP/DPPOS study (2) showed that this resulted in a 27% decrease in progression to type 2 DM when compared to not doing this. The people that progress to type 2 DM will require medication (usually pills) to control their A1c below 7.0. If not controlled with oral medication, then insulin shots may need to be added. If your A1c is 6.5 or higher you have diabetes (DM), you will need oral medication and possible insulin shots.
References
- www.acog.org/-/media/For-Patients/faq176.pdf?dmc=1&ts=20180623T1633372775
- Lancet Diabetes Endocrinol. 2015 Nov;3(11):866-75. doi: 10.1016/S2213-8587(15)00291-0. Epub 2015 Sep 13.