Inclusion of diabetic retinopathy screening strategies in national-level diabetes care planning in low- and middle-income countries: a scoping review.

BACKGROUND: Diabetes is a major public health concern, with approximately 80% of the burden falling on low- and middle-income countries (LMICs). Diabetic retinopathy (DR) is one of the most common microvascular complications of diabetes, and early detection through diabetic eye screening programmes is essential to prevent visual impairment and blindness. Careful planning at a national level is crucial for effective implementation of such programmes. METHODS: A scoping review was conducted, and the protocol was published previously to explain the methods in detail. Data were collected from databases and searches, including grey literature. Furthermore, consultations were conducted with key informants from LMICs. RESULTS: Lower-middle-income countries (29/50, 58%) and upper-middle-income countries (27/59, 45.8%) are making more progress than low-income countries (4/29, 13.8%) in terms of DR policy planning. However, no identified data for published policies have actually implemented national DR policies. Compared to low-income and lower-middle-income countries, upper-middle-income countries are making the most progress in implementing national diabetic eye screening programmes; however, their progress is still slow, with only 5/59 (8.5%) having such programmes. CONCLUSION: There are significant gaps in the literature, with no data reported for 78/138 (56.5%) LMICs. Further research is clearly needed to support and document DR policy development in LMICs.

Pregnancy outcome of gestational diabetes mellitus using a structured model of care : WINGS project (WINGS-10).

AIM: To evaluate the impact of a structured model of care (MOC) prepared for resource-constrained settings, on the pregnancy outcomes of Asian Indian women with gestational diabetes mellitus (GDM). METHODS: Pregnant women were screened under the Women in India with GDM Strategy (WINGS) MOC for GDM using the International Association of Diabetes and Pregnancy Study Groups criteria. Women with GDM went through a structured MOC that included medical nutrition therapy (MNT), regular physical activity (PA); and insulin when indicated. Fasting blood glucose and post-prandial blood sugar were monitored every 2 weeks. The pregnancy outcomes of women with GDM who underwent the MOC were compared with those without GDM. RESULTS: Under the MOC, 212 women with GDM were followed through pregnancy, of whom 33 (15.6%) required insulin and 179 (84.4%) were managed with MNT and PA. The maternal and neonatal outcomes of women with GDM were similar to the non-GDM women: there were no significant differences in pregnancy complications such as cesarean section, macrosomia, pre-eclampsia, oligo/polyhydramnios, preterm delivery, neonatal death, fetal distress, hyperbilirubinemia and low birthweight. CONCLUSION: Implementation of a structured MOC for women with GDM helped achieve pregnancy outcomes similar to those without GDM.

Inclusion of diabetic retinopathy screening strategies in national-level diabetes care planning in low-income and middle-income settings: protocol for a scoping review.

INTRODUCTION: The diabetes mellitus (DM) epidemic is a major public health concern globally, with the highest-burden in low-income and middle-income countries (LMICs). Diabetic retinopathy (DR) is a microvascular complication of diabetes, and if left untreated can lead to visual impairment and blindness. Epidemiological studies suggest that the incidence of sight-threatening DR is decreasing in high-income countries due to improved treatments and management of DM; however, these trends are not replicated in LMICs. In this paper, we outline a scoping review protocol that aims to identify which LMICs have included DR in their national DM, non-communicable disease or prevention of blindness plans. The scoping review also aims to assess gaps when implementing national DR screening programmes in LMICs. METHODS AND ANALYSIS: This scoping review will follow the Arksey and O'Malley (2005) methodology and the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Review guidelines. A comprehensive search of peer-reviewed and grey literature will be conducted from October 1989 (St. Vincent Declaration) to February 2020. Studies will be identified from electronic databases; Medline, Embase and CENTRAL (Cochrane Library). To identify further relevant articles, a hand search will be conducted using the reference lists of included studies. Two reviewers will independently screen records for relevant data and disagreements about eligibility will be resolved through consensus or arbitration by a third reviewer. A quantitative analysis will be performed to highlight key findings and thematic analysis will be used to identify emerging themes and subthemes from included studies. The key themes will highlight countries progress in terms of national-level DR service planning and screening implementation. ETHICS AND DISSEMINATION: No ethical approval is required because the scoping review methodology aims to synthesise information from publicly available resources. The results will be disseminated through conference presentations and peer-reviewed publication.

Cardiovascular diseases and risk factors knowledge and awareness in people with type 2 diabetes mellitus: a global evaluation.

AIM: Cardiovascular diseases (CVD) are the leading cause of death in people living with type 2 diabetes mellitus (T2D). The aim of this study was to explore the knowledge and awareness of CVD and related risk factors in people living with T2D, globally. METHODS: A questionnaire consisting of 17 questions was used to conduct the Taking Diabetes to Heart survey, between September 2017 and May 2018 among people living with T2D. All categorical variables are presented as numbers and percentages. Pearson's chi-square test and Fisher's exact test were used to assess the association between categorical variables. RESULTS: A total of 12,695 respondents living with T2D in 133 countries completed the questionnaire. Almost half of the respondents (44%) reported having lived with diabetes for more than nine years. Only one in six (17%) considered themselves at high risk of CVD, which was surprising given that almost all the respondents had at least one CVD risk factor and around 28% of respondents had experienced one or more CVD events in the past. Although the majority of the respondents indicated they have had CVD risk factors, one in six (17%) had never discussed their risk with a health professional (HP). Furthermore, one in eleven (9%) did not know about CVD and its associated risk factors. CONCLUSION: To mitigate the prevalence of CVD in people living with diabetes, it is required to work with HP to increase knowledge and awareness of people with T2D about diabetes complications, in particular CVD.

Diabetes and global ageing among 65-99-year-old adults: Findings from the International Diabetes Federation Diabetes Atlas, 9th edition.

AIMS: The main aims are: (a) to draw attention to the nature and pattern of recent global and regional prevalence estimates and projections of diabetes in older adults (65-99 years), and (b) to describe the societal health implications of these changes on a global scale. METHODS: Diabetes prevalences and projections were estimated using a logistic regression method to generate smoothed age- and sex-specific prevalence estimates for 5-year age groups. RESULTS: In 2019, it is estimated that 19.3% of people aged 65-99 years (135.6 million, 95% CI: 107.6-170.6 million) live with diabetes. It is projected that the number of people older than 65 years (65-99 years) with diabetes will reach 195.2 million by 2030 and 276.2 million by 2045. For the regional distribution, the highest prevalence in 2019 being the North America and Caribbean Region at 27.0%. Countries with the highest number of people older than 65 years with diabetes are China, the United States of America and India. CONCLUSIONS: There is a need for more data from national and regional sources on those aged 65 years and over, but the prevailing evidence points to diabetes being a considerable global chronic illness burden in ageing societies.

Mortality attributable to diabetes in 20-79 years old adults, 2019 estimates: Results from the International Diabetes Federation Diabetes Atlas, 9th edition.

AIMS: To estimate the number of deaths attributable to diabetes in 20-79-year-old adults in 2019. METHODS: The following were used to estimate the number of deaths attributable to diabetes: all-cause mortality estimates from the World Health Organization life table, country level age- and sex-specific estimates of diabetes prevalence in 2019 and relative risks of death in people with diabetes compared to people without diabetes. RESULTS: An estimated 4.2 million deaths among 20-79-year-old adults are attributable to diabetes. Diabetes is estimated to contribute to 11.3% of deaths globally, ranging from 6.8% (lowest) in the Africa Region to 16.2% (highest) in the Middle East and North Africa. About half (46.2%) of the deaths attributable to diabetes occur in people under the age of 60 years. The Africa Region has the highest (73.1%) proportion of deaths attributable to diabetes in people under the age of 60 years, while the Europe Region has the lowest (31.4%). CONCLUSIONS: Diabetes is estimated to contribute to one in nine deaths among adults aged 20-79 years. Prevention of diabetes and its complications is essential, particularly in middle-income countries, where the current impact is estimated to be the largest. Contemporary data from diverse populations are needed to validate these estimates.

Global and regional estimates and projections of diabetes-related health expenditure: Results from the International Diabetes Federation Diabetes Atlas, 9th edition.

AIMS: Diabetes and its complications have a significant economic impact on individuals and their families, health systems and national economies. METHODS: The direct health expenditure of diabetes was calculated relying on the following inputs: diagnosed and undiagnosed diabetes prevalence estimates, United Nations population estimates, World Health Organization health expenditure per capita and ratios of health expenditure for people with diabetes compared to people without diabetes. RESULTS: The estimated global direct health expenditure on diabetes in 2019 is USD 760 billion and is expected to grow to a projected USD 825 billion by 2030 and USD 845 billion by 2045. There is a wide variation in annual health expenditures on diabetes. The United States of America has the highest estimated expenditure with USD 294.6 billion, followed by China and Brazil, with USD 109.0 billion and USD 52.3 billion, respectively. The age group with the largest annual diabetes-related health expenditure is 60-69 years with USD 177.7 billion, followed by 50-59 years, and 70-79 years with USD 173.0 billion and USD 171.5 billion, respectively. Slightly higher diabetes-related health expenditure is seen in women than in men (USD 382.6 billion vs. USD 377.6 billion, respectively). The same difference is expected to be present in 2030 and 2045. CONCLUSIONS: There were large disparities between high-, middle- and low-income countries with total health expenditures in high-income countries being over 300 times those in low-income countries. The ratio for annual direct health expenditure per person between these groups of countries is more than 38-fold.

Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition.

AIMS: To provide global estimates of diabetes prevalence for 2019 and projections for 2030 and 2045. METHODS: A total of 255 high-quality data sources, published between 1990 and 2018 and representing 138 countries were identified. For countries without high quality in-country data, estimates were extrapolated from similar countries matched by economy, ethnicity, geography and language. Logistic regression was used to generate smoothed age-specific diabetes prevalence estimates (including previously undiagnosed diabetes) in adults aged 20-79 years. RESULTS: The global diabetes prevalence in 2019 is estimated to be 9.3% (463 million people), rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045. The prevalence is higher in urban (10.8%) than rural (7.2%) areas, and in high-income (10.4%) than low-income countries (4.0%). One in two (50.1%) people living with diabetes do not know that they have diabetes. The global prevalence of impaired glucose tolerance is estimated to be 7.5% (374 million) in 2019 and projected to reach 8.0% (454 million) by 2030 and 8.6% (548 million) by 2045. CONCLUSIONS: Just under half a billion people are living with diabetes worldwide and the number is projected to increase by 25% in 2030 and 51% in 2045.

Elevated glycated hemoglobin predicts macrosomia among Asian Indian pregnant women (WINGS-9).

AIM: The aim of this study was to determine the optimal glycated hemoglobin (HbA1c) cut point for diagnosis of gestational diabetes mellitus (GDM) and to evaluate the usefulness of HbA1c as a prognostic indicator for adverse pregnancy outcomes. METHODS: HbA1c estimations were carried out in 1459 pregnant women attending antenatal care centers in urban and rural Tamil Nadu in South India. An oral glucose tolerance test was carried out using 75 g anhydrous glucose, and GDM was diagnosed using the International Association of the Diabetes and Pregnancy Study Groups criteria. RESULTS: GDM was diagnosed in 195 women. Receiver operating curves showed a HbA1c cut point of ≥ 5.0% (≥31 mmol/mol) have a sensitivity of 66.2% and specificity of 56.2% for identifying GDM (area under the curve 0.679, confidence interval [CI]: 0.655-0.703). Women with HbA1c ≥ 5.0% (≥31 mmol/mol) were significantly older and had higher body mass index, greater history of previous GDM, and a higher prevalence of macrosomia compared to women with HbA1c < 5.0% (<31 mmol/mol). The adjusted odds ratio for macrosomia in those with HbA1c ≥ 5.0% (≥31 mmol/mol) was 1.92 (CI: 1.24-2.97, P = 0.003). However, other pregnancy outcomes were not significantly different. CONCLUSION: In Asian Indian pregnant women, a HbA1c of 5.0% (31 mmol/mol) or greater is associated with increased risk of macrosomia.

Gestational Weight Gain and Pregnancy Outcomes in Relation to Body Mass Index in Asian Indian Women.

AIM: The aim of the study was to compare the weight gain during pregnancy (using Institute of Medicine guidelines) among Asian Indians across different body mass index (BMI) categories (using World Health Organization Asia Pacific BMI cut points) and to compare the pregnancy outcomes in each of the different BMI categories. METHODOLOGY: Retrospective records of 2728 pregnant women attending antenatal clinics and private maternity centers in Chennai, South India, from January 2011 to January 2014 were studied. Pregnancy outcomes were analyzed in relation to BMI and weight gain across different BMI categories. RESULTS: Overweight and obese women who gained more weight during pregnancy were at high risk of delivering macrosomic infants (overweight - odds ratio [OR]: 2.3, 95% confidence interval [CI]: 1.1-5.2, P = 0.02 and obese - OR: 1.6, 95% CI: 1.1-2.4, P = 0.01). In addition, obese women who gained more weight were also at high risk of preterm labor (OR: 2.1, 95% CI: 1.1-3.8; P = 0.01), cesarean section (OR: 1.9, 95% CI: 1.4-2.5; P < 0.001), and preeclampsia (OR: 2.8, 95% CI: 1.1-7.2, P = 0.03). Normal weight and overweight women who gained less weight had a protective effect from cesarean section and macrosomia. CONCLUSIONS: Overweight/obese women who gained more weight than recommended are at a high risk of developing adverse pregnancy outcomes. Normal and overweight women who gained weight less than recommended have low risk for cesarean section and macrosomia. However, they have a higher (statistically insignificant) risk for low birth weight and preterm birth. This highlights the need for gaining adequate weight during pregnancy.

Current practices in the diagnosis and management of gestational diabetes mellitus in India (WINGS-5).

AIM: To obtain information on existing practices in the diagnosis and management of gestational diabetes mellitus (GDM) among physicians/diabetologists/endocrinologists and obstetricians/gynecologists (OB/GYNs) in India. METHODS: Details regarding diagnostic criteria used, screening methods, management strategies, and the postpartum follow-up of GDM were obtained from physicians/diabetologists/endocrinologists and OB/GYNs across 24 states of India using online/in-person surveys using a structured questionnaire. RESULTS: A total of 3841 doctors participated in the survey of whom 68.6% worked in private clinics. Majority of OB/GYNs (84.9%) preferred universal screening for GDM, and screening in the first trimester was performed by 67% of them. Among the OB/GYNs, 600 (36.7%) reported using the nonfasting 2 h criteria for diagnosing GDM whereas 560 (29.4%) of the diabetologists/endocrinologists reported using the same. However, further questioning on the type of blood sample collected and the glucose load used revealed that, in reality, only 208 (12.7%) and 72 (3.8%), respectively, used these criteria properly. The survey also revealed that the International Association of Diabetes and Pregnancy Study Groups criteria was followed properly by 299 (18.3%) of OB/GYNs and 376 (19.7%) of physicians/diabetologists/endocrinologists. Postpartum oral glucose tolerance testing was advised by 56% of diabetologists and 71.6% of OB/GYNs. CONCLUSION: More than half of the physicians/diabetologists/endocrinologists and OB/GYNs in India do not follow any of the recommended guidelines for the diagnosis of GDM. This emphasizes the need for increased awareness about screening and diagnosis of GDM both among physicians/diabetologists/endocrinologists and OB/GYNs in India.

Women in India with Gestational Diabetes Mellitus Strategy (WINGS): Methodology and development of model of care for gestational diabetes mellitus (WINGS 4).

AIM: The Women In India with GDM Strategy (WINGS) project was conducted with the aim of developing a model of care (MOC) suitable for women with gestational diabetes mellitus (GDM) in low- and middle-income countries. METHODOLOGY: The WINGS project was carried out in Chennai, Southern India, in two phases. In Phase I, a situational analysis was conducted to understand the practice patterns of health-care professionals and to determine the best screening criteria through a pilot screening study. RESULTS: Phase II involved developing a MOC-based on findings from the situational analysis and evaluating its effectiveness. The model focused on diagnosis, management, and follow-up of women with GDM who were followed prospectively throughout their pregnancy. An educational booklet was provided to all women with GDM, offering guidance on self-management of GDM including sample meal plans and physical activity tips. A pedometer was provided to all women to monitor step count. Medical nutrition therapy (MNT) was the first line of treatment given to women with GDM. Women were advised to undergo fasting blood glucose and postprandial blood glucose testing every fortnight. Insulin was indicated when the target blood glucose levels were not achieved with MNT. Women were evaluated for pregnancy outcomes and postpartum glucose tolerance status. CONCLUSIONS: The WINGS MOC offers a comprehensive package at every level of care for women with GDM. If successful, this MOC will be scaled up to other resource-constrained settings with the hope of improving lives of women with GDM.

Glucose tolerance status of Asian Indian women with gestational diabetes at 6weeks to 1year postpartum (WINGS-7).

AIM: To determine postpartum glucose tolerance status among women with gestational diabetes mellitus (GDM) recruited under the Women In India with GDM Strategy (WINGS) Model of Care (MOC). METHODS: Through the WINGS MOC programme, 212 women with GDM were followed till delivery between November 2013 and August 2015. All women were advised to return for a postpartum oral glucose tolerance test (OGTT) 6-12weeks after delivery. A multivariate logistic regression (MLR) model was developed to identify the risk factors for postpartum dysglycemia which was defined as presence of diabetes (DM) or prediabetes. RESULTS: 203/212(95.8%) women completed their postpartum OGTT. Of the 161 women (79.3%) who came back for the test between 6 and 12weeks, 2(1.2%) developed DM, 5(3.1%), isolated IFG, 13(8.1%), isolated IGT and 5(3.1%) combined IFG/IGT [dysglycemia 25(15.5%)]. 136 women (84.5%) reverted to normal glucose tolerance (NGT). Of the 42 women who came back between 12weeks and a year, 5(11.9%) developed DM, 10(23.8%), isolated IFG and 1(2.4%) combined IFG/IGT [dysglycemia 16(38.1%)]. 26/42 women (61.9%) reverted to NGT. Thus overall dysglycemia occurred in 41/203 women (20.2%). MLR showed that BMI ⩾25kg/m(2) was significantly associated with postpartum dysglycemia (odds ratio: 4.47; 95% confidence interval: 1.8-11.2, p=0.001). CONCLUSION: Among Asian Indian women with GDM, over 20% develop dysglycemia within one year postpartum, and BMI ⩾25kg/m(2) increased this risk four-fold. Early postpartum screening can identify high risk women and help plan strategies for prevention of type 2 diabetes in the future.

Comparison of maternal and fetal outcomes among Asian Indian pregnant women with or without gestational diabetes mellitus: A situational analysis study (WINGS-3).

AIM: To compare the existing maternal and fetal outcomes in Asian Indian women with or without gestational diabetes mellitus (GDM) before the development of the Women in India with GDM Strategy (WINGS) GDM model of care (MOC). MATERIALS AND METHODS: Records of pregnant women were extracted retrospectively from three maternity centers in Chennai. GDM was diagnosed using the International Association for Pregnancy Study Groups criteria or the Carpenter and Coustan criteria. Demographic details, obstetric history, antenatal follow-up, treatment for GDM, and outcomes of delivery were collected from the electronic medical records. RESULTS: Of the 3642 records analyzed, 799 (21.9%) had GDM, of whom 456 (57.1%) were treated with insulin and medical nutrition therapy (MNT), 339 (42.4%) with MNT alone, and 4 (0.5%) with metformin. Women with GDM were older than those without (28.5 ± 4.5 vs. 27.1 ± 4.5 years; P < 0.001) and had higher mean body mass index at first booking (26.4 ± 5.2 kg/m(2) vs. 25.2 ± 5.1 kg/m(2); P < 0.001). Rates of cesarean section (26.2% vs. 18.7%; P < 0.001), preeclampsia (1.8% vs. 0.8%; P = 0.04), and macrosomia (13.9% vs. 10.8%; P = 0.02) were significantly higher among women with GDM. In women with GDM treated with insulin and MNT, emergency cesarean section (16.2% vs. 36.6%; P < 0.0001), preeclampsia (0.7% vs. 3.2%; P = 0.015), and macrosomia (9.9% vs. 18.6%; P = 0.0006) were significantly lesser compared to those treated with MNT alone. CONCLUSION: Pregnancy outcomes were in general worse in GDM women. Treatment with insulin was associated with a significantly lower risk of complications. However, in countries with limited access to insulin and other medicines may lead to poor follow-up and management of GDM. Data from this retrospective study will form the basis for the development of the WINGS GDM MOC, which will address these gaps in GDM care in low-resource settings.

Use of capillary blood glucose for screening for gestational diabetes mellitus in resource-constrained settings.

AIMS: The aim of the study was to evaluate usefulness of capillary blood glucose (CBG) for diagnosis of gestational diabetes mellitus (GDM) in resource-constrained settings where venous plasma glucose (VPG) estimations may be impossible. METHODS: Consecutive pregnant women (n = 1031) attending antenatal clinics in southern India underwent 75-g oral glucose tolerance test (OGTT). Fasting, 1- and 2-h VPG (AU2700 Beckman, Fullerton, CA) and CBG (One Touch Ultra-II, LifeScan) were simultaneously measured. Sensitivity and specificity were estimated for different CBG cut points using the International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria for the diagnosis of GDM as gold standard. Bland-Altman plots were drawn to look at the agreement between CBG and VPG. Correlation and regression equation analysis were also derived for CBG values. RESULTS: Pearson's correlation between VPG and CBG for fasting was r = 0.433 [intraclass correlation coefficient (ICC) = 0.596, p < 0.001], for 1H, it was r = 0.653 (ICC = 0.776, p < 0.001), and for 2H, r = 0.784 (ICC = 0.834, p < 0.001). Comparing a single CBG 2-h cut point of 140 mg/dl (7.8 mmol/l) with the IADPSG criteria, the sensitivity and specificity were 62.3 and 80.7 %, respectively. If CBG cut points of 120 mg/dl (6.6 mmol/l) or 110 mg/dl (6.1 mmol/l) were used, the sensitivity improves to 78.3 and 92.5 %, respectively. CONCLUSIONS: In settings where VPG estimations are not possible, CBG can be used as an initial screening test for GDM, using lower 2H CBG cut points to maximize the sensitivity. Those who screen positive can be referred to higher centers for definitive testing, using VPG.

Prevalence of Gestational Diabetes Mellitus in urban and rural Tamil Nadu using IADPSG and WHO 1999 criteria (WINGS 6).

BACKGROUND: To determine the prevalence of Gestational Diabetes Mellitus (GDM) in urban and rural Tamil Nadu in southern India, using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and the World Health Organization (WHO) 1999 criteria for GDM. METHODS: A total of 2121 pregnant women were screened for GDM from antenatal clinics in government primary health centres of Kancheepuram district (n = 520) and private maternity centres in Chennai city in Tamil Nadu (n = 1601) between January 2013 to December 2014. Oral glucose tolerance tests (OGTT) were done after an overnight fast of at least 8 h, using a 75 g glucose load and venous samples were drawn at 0, 1 and 2 h. GDM was diagnosed using both the IADPSG criteria as well as the WHO 1999 criteria for GDM. RESULTS: The overall prevalence of GDM after adjusting for age, BMI, family history of diabetes and previous history of GDM was 18.5 % by IADPSG criteria with no significant urban/rural differences (urban 19.8 % vs rural 16.1 %, p = 0.46). Using the WHO 1999 criteria, the overall adjusted prevalence of GDM was 14.6 % again with no significant urban/rural differences (urban 15.9 % vs rural 8.9 %, p = 0.13). CONCLUSION: The prevalence of GDM by IADPSG was high both using IADPSG as well as WHO 1999 criteria with no significant urban/rural differences. This emphasizes the need for increasing awareness about GDM and for prevention of GDM in developing countries like India.

Physical activity patterns and gestational diabetes outcomes - The wings project.

OBJECTIVE: To compare physical activity (PA) patterns in pregnant woman with and without gestational diabetes (GDM) and to assess the effects of an exercise intervention on change in PA patterns, blood glucose levels and pregnancy outcomes in GDM women. METHODS: For the first objective, PA patterns were studied in 795 pregnant women with and without GDM. For the second objective, the Women in India with Gestational Diabetes Strategy-Model of Care (WINGS-MOC) intervention were evaluated in 151 women out of 189 with GDM. PA was assessed using a validated questionnaire and a pedometer. Changes in PA patterns, glycemic parameters and neonatal outcomes were evaluated. RESULTS: Overall, only 10% of pregnant women performed recommended levels of PA. Women with GDM were significantly more sedentary compared to those without GDM (86.2 vs. 61.2%, p<0.001). After the MOC was implemented in women with GDM, there was a significant improvement in PA and a decrease in sedentary behaviour amongst women (before MOC, moderate activity: 15.2%, sedentary: 84.8% vs. after MOC-moderate: 26.5%, sedentary: 73.5%; p<0.001), and an increase in their daily step count from 2206/day to 2476/day (p<0.001). Fasting 1 and 2-h postprandial glucose values significantly decreased (p<0.001 for all). Sedentary behaviour was associated with a fourfold higher risk (p=0.02), and recreational walking with 70% decreased risk, of adverse neonatal outcomes (p=0.04) after adjusting for potential confounders. CONCLUSIONS: PA levels are inadequate amongst this group of pregnant women studied i.e. those with and without GDM. However, a low-cost, culturally appropriate MOC can bring about significant improvements in PA in women with GDM. These changes are associated with improved glycemic control and reduction in adverse neonatal outcomes.