Melbourne lockdowns see gestational diabetes cases rise, while experts warn women are missing out on funded-education and support.
COVID lockdowns could be behind an increase seen in the rate of gestational diabetes mellitus (GDM), along with the rise in the number of babies born large for gestational age, according to an ongoing study1 of public maternity services with the Melbourne metropolitan region.
The Collaborative Maternity and Newborn Dashboard or CoMaND project brought together seven health services in metropolitan Melbourne and is providing a picture of the effects of the pandemic on pregnant women and their babies.
“Our study showed an increase in the rate of GDM after the onset of lockdown, along with a rise in the number of big babies. This included an increase in the number of babies with a birth weight over four kilos, as well as babies with a birthweight over the 90th centile for gestation,” lead researcher Associate Professor Lisa Hui tells the AJP.
Prof Hui says the new findings are a cause for concern. “The increase has meant more than one in five women had GDM during the second half of 2020.
While the study hasn’t analysed why this occurred, the researchers suggest the strict Melbourne lockdown of last year had a knock-on effect on maternal weight.
“We haven’t looked at the individual factors to this increase but it may be due to the impact of pandemic restrictions on levels of physical activity, diet and maternal weight,” she says.
The researchers had feared they might have seen an increase in stillbirths due to women avoiding medical appointments, for example, but this was not the case.
“I think it shows the impacts of the pandemic have not been directly due to lack of access to medical care but due to lifestyle changes that were a consequence of the lockdown.”
Prof Hu says, “We should be paying more attention to encouraging healthy eating and exercise as this is where we could be making positive impacts”.
Women unware of risks
Weight management strategies such as diet and exercise, as well as attitudes to perceived type 2 diabetes (T2D) risk has been the focus of a new study2 of women with a history of gestational diabetes.
Women who have been diagnosed with GDM during pregnancy are 10 times more likely to develop T2D,5 but the research from the University of South Australia (UniSA) and University College of Dublin, found only a third of women knew their risk.2 According to lead researcher, UniSA’s Dr Kristy Gray, understanding the risks of developing T2D post-GDM is key.
“In our study, while 75% of women surveyed understood they were overweight, this knowledge didn’t translate into a higher level of perceived risk.”
It is also one of the few studies focusing on women with GDM who’d given birth more than 12 months prior.
“[Previous] studies tend to target women who have given birth within the last 12 months. Although this may be an optimal time to lose weight, women with a history of GDM who are greater than one year postpartum, may respond better to a weight loss program once a more stable lifestyle has resumed.”
When asked about weight loss strategies, the women revealed the most common barriers were family responsibilities taking priority and simply dealing with hunger—however, this tended to change the longer it had been since they had given birth. Exercise was the most popular method of weight management over diet strategies, but the women also felt having the support of a dietitian either in-person or an online program would be beneficial. When asked about how they sought information about weight management, the internet was the most popular choice—followed by a doctor, dietitian or nutritionist, online forums, family/friends, diet books, gym instructor/lifestyle coach, TV shows, midwife/nurse and a psychologist or counsellor.
According to co-researcher, Associate Professor Jennifer Keogh, successful diabetes prevention strategies must embrace education and lifestyle factors on the individuals themselves. “Women diagnosed with GDM often have a young family, which means any interventions need to be considered in line with small children, busy lifestyles and multiple priorities,” says Dr Keogh.
“We also know that the most effective time to initiate and commit to healthy lifestyle and behaviour changes is up to two years post-pregnancy, so interventions are likely to be more effective during this time frame.
“Motivation to lose weight is a significant barrier to change—whether it be because of a busy family or because lifestyle change can be hard to stick to—consistent education, strong messaging and personalised care can instigate positive change.
“Prevention is the key; making sure women’s needs, views, and situations are considered is an essential part of the solution.”
“The priority is to educate both women with GDM, and the health professionals who care for them to ensure greater communication and boost awareness of the risk factors these women have,” she says.
Antenatal appointments ‘too late’
But another recent study found healthcare professionals struggled to give advice to pregnant women around nutrition and diet. A recent Royal Women’s study3 found pregnant women had poor knowledge about a raft of important recommendations, including energy needs, weight gain recommendations, and daily food group serving recommendations for pregnant women. Concerningly, the study found that clinicians felt it was “too late” to begin dietary discussions by the time women had their first hospital appointment, which was often well into their second trimester. Clinicians also felt they had to rely on their undergraduate training, academic journals and their colleagues as a source of nutrition information, in contrast to pregnant women, who used the internet for much of their information.
“Many antenatal clinicians felt that by the time they saw women at 16-plus weeks, it was too late to begin nutrition discussions, but this is not the case. A change in diet at any point along a woman’s pregnancy can have great benefits for mum and baby, including reducing the risk of excess weight gain, lowering the risk of early labour, and increasing the likelihood of having a healthy size baby,” says study author, Dr Amelia Lee, a dietitian at the hospital.
Dr Lee says the results confirmed her suspicions about gaps in nutrition education for pregnant women and antenatal clinicians.
“This study highlighted many misconceptions that pregnant women had that could potentially be harmful to their unborn baby and themselves.”
“Ideally, women should begin discussions about their diet and nutrition with their GP or healthcare provider when they start to plan for a baby. There are [also] many reliable sources of information available online that practitioners can use to prompt these discussions. It is so important that women receive or are directed to reliable and accurate nutritional information during pregnancy,” says Dr Lee.
Likewise, another study4 looking at attitudes to weight gain in pregnancy among Canadian women attending antenatal clinics, found despite the importance of gestational weight gain on key maternal and infant health indicators, few women intentionally planned or did anything about a maintaining a healthy weight during pregnancy. The researchers said it was clear that healthcare professionals were mentioning the guidelines to them but not in a meaningful way to women who were not understanding the relationship between weight and health outcomes. “Despite regular weigh-ins during prenatal appointments, few women reported receiving notice from their care providers that their weight gain was a problem or receiving direction on how to manage weight gain.”
The researchers said it was essential all healthcare professionals tailor their advice about healthy weight gain so it is individualised and applies to women’s pre-pregnancy weight and circumstances. Women also need regular follow-up conversations with healthcare providers about keeping their weight within a safe range, as well other key nutritional information.
But providing women with ongoing support about diet and weight for GDM-prevention and management needs targeted resources given the prevalence of the problem, say experts.
With this in mind, a new Position Statement5 released in 2020 by Diabetes Australia, the Australian Diabetes Educators Association and the Australian Diabetes Society sets out the scale of the problem and the need for action. It also calls for changes to funding arrangements around education for women with GDM.
Associate Professor Glynis Ross, endocrinologist and Australian Diabetes Society president, points out that over the past 10 years the number of women with GDM has grown annually by almost 200%.
“There are a number of reasons for this including the increasing age of Australian mums, their health when they fall pregnant, and the changing ethnic makeup of Australia. Many of these factors are non-modifiable but there are a number of things we can do to help ensure pregnant women are in the best shape possible to reduce their risk of developing the condition.
“This could include ensuring all pregnant women can access dietetic support from dietitians with expertise in pregnancy.
“The condition makes pregnancy higher risk for both mother and baby. Babies born to mothers with GDM are more likely to be born early and more often by caesarean delivery, be larger babies, need support for managing glucose levels or breathing problems, and a range of other problems,” says Prof Ross. “Women with GDM need intensive nutrition and glucose management to avoid serious problems. With the best possible management and care, the risks can be reduced, and women can avoid complications.”
Call for Medicare changes
However, current Medicare arrangements do not cover optimal care for many women, says Australian Diabetes Educators Association (ADEA) president Brett Fenton.
“Specialised education is an important part of managing GDM, however GDM education and care is not covered by Medicare or many private health insurance funds,” Fenton says.
“This means many women either have to pay for private practitioner services, or to try and access services through an already over-burdened public system. This means some women miss out on diabetes education altogether. A new Medicare item is needed to help women with GDM access credentialled diabetes educators (CDEs), accredited practising dietitians and other essential allied health professionals.”
Award winning CDEs—consultant pharmacist Kirrily Chambers and registered nurse Jayne Lehmann—say they both see many women who “slip through the cracks”.
“If they’ve got GDM, they don’t meet the criteria to get a plan, so they have to go back into the tertiary institution. But hospitals are overloaded, so women are not getting supported,” says Chambers.
“I saw a woman the other day in her third trimester, and she had to wait six to eight weeks before she could get any support. That’s not okay. That’s not okay for the baby. Our systems are overloaded and the government doesn’t know what to do about it.
“It is so flawed on every level,” Chambers tells the AJP.
Providing support to women with GDM takes time as women need ongoing assistance, agrees Lehmann.
“Women with GDM need in-depth counselling, explaining what the condition is and how to manage it. A lot of women are still in a state of shock about the diagnosis as it’s come out the blue and they are upset. The pregnancy has changed to higher risk and scarier, especially if insulin is required. If that’s the case they need to know how to finger prick and do a blood glucose monitoring, understand what those results mean, as well as and know when they need to contact their doctor.”
On top of that, they need to know what it means for them post-delivery.
Both women say pharmacists can play a role in offering women advice, including guiding them where to go for special advice as they often see people more often than other healthcare professionals.
“If a pharmacist knows a person has had diabetes during pregnancy, they are very well placed to ask about follow-up, especially as women might be in the pharmacy asking about baby Panadol or cough and cold meds anyway,” says Lehmann.
Chamber agrees, suggesting pharmacists should even nag women to act.
“Pharmacists are in a great position to prompt women to get a follow-up and if they do it often enough the women might then do something about it,” says Chambers.
“They can also remind women who are planning another pregnancy to have a quick test and think about addressing the modifiable risk factors associated with GDM.”
If pharmacists make themselves aware of what support is available to women through the NDSS they can reinforce it in the pharmacy too with handouts which women can take home to read.
Diabetes Australia CEO Greg Johnson, also thinks pharmacists can be part of a comprehensive approach to tackling GDM that spans pre-pregnancy, during pregnancy and following the birth of the baby.
“Pharmacists need a good understanding of GDM,” Prof Johnson tells the AJP. “About a third of women diagnosed need insulin and this can be quite challenging to manage so pharmacists need to be able to advise women and to direct them to good sources of information. This might also involve encouraging them to see an endocrinologist or a diabetes educator to minimise their risks of complications to themselves or the baby.
“But there needs to be earlier discussion—even before pregnancy—about GDM. It’s really about women who might be thinking about having a child and planning for a healthy pregnancy so that they can help reduce the risk of developing GDM. So, it is not just about dealing with the problem when it happened. Therefore, earlier stage pregnancy planning and pre-pregnancy advice is really important—and pharmacists have a role to play in that.”
He also thinks GPs need to be more actively involved.
“We need to have GPs more actively involved in follow up testing to detect T2D or prediabetes and provide accessible T2D prevention programs for families in the years after gestational diabetes.
“We also need more funding for public health services, including diabetes centres, to ensure nobody misses out on essential care and support.”
Machine learning unravels GDM puzzle
A new computer algorithm can predict in the early stages of a pregnancy, or even before pregnancy has occurred, which women are at a high risk of gestational diabetes (GDM) according to a study by researchers at the Weizmann Institute of Science. The study analysed data from nearly 600,000 pregnancies available from Israel’s largest health organisation, Clalit Health Services, and used machine learning to build an algorithm of nine parameters to accurately identify the women who ultimately developed GDM.
The researchers said the results suggest by having a woman answer just nine questions, it should be possible to tell in advance the risks of developing GDM. And if this information is available early on—in the early stages of pregnancy or even before the woman is pregnant—it might be possible to reduce her risk through lifestyle measures such as exercise and diet. On the other hand, women identified by the questionnaire as being at a low risk may be spared the cost and inconvenience of the glucose testing.
You can access the self-assessment GDM questionnaire by going to weizmann.ac.il/sites/gd-predictor/
Source: Artzi NS, et al. Prediction of gestational diabetes based on nationwide electronic health records. Nature Medicine. 2020;26:71-6. https://doi.org/10.1038/s41591-019-0724-8
New glucose test a ‘COVID silver lining’
COVID-19-driven changes to the GDM oral glucose tolerance test (OGTT) developed by Royal Brisbane and Women’s Hospital (RBWH), may result in new permanent Australian guidelines.
Evaluation is now underway to establish if the majority of women could take a new one-off fasting blood test, and avoid the much lengthier OGTT that can take up to three hours of the women’s time. RBWH senior dietitian, Dr Susan de Jersey, says her team’s research would evaluate the impact of these changes on maternal and infant outcomes, and on screening process measures including cost.
“During the initial pandemic lockdowns, we didn’t want to put immunocompromised pregnant women at unnecessary risk by having them sit in a pathology lab for a number of hours, so we implemented the changes to testing,” she says.
“The goal of the research is to see if these changes are worth continuing beyond the pandemic in Australia. We hope our formal review will confirm that outcomes for mothers and babies is as good as sending all pregnant woman for an OGTT. These changes could save time for women and clinicians, as well as reduce costs associated with unnecessary testing.”
”A reduction in unnecessary glucose testing may well be one of the silver linings to the cloud cast by COVID-19,” says RBWH Foundation CEO Simone Garske.
“To think RBWH Foundation funded research may reduce the need for this test for potentially thousands of women each year is extremely exciting.”
With endorsement from the Australasian Diabetes in Pregnancy Society, Queensland was the first to introduce the new testing algorithm and it has since been adopted by clinicians nationally.
RBWH is now seeking clinicians who used the new blood test alternative to traditional glucose testing, to share their feedback in a telephone interview.
Interested clinicians can register by following this link: metronorth.citizenspace.com/nutrition-dietetics/3fc01bfa
App gets smart about GDM
Clinical researchers from Singapore’s National University Hospital (NUH) have found that a smartphone app-based lifestyle coaching program designed for women with GDM is effective in controlling blood sugar and preventing GDM-related complications among newborns. The research study, SMART-GDM, was based on a clinical trial conducted among 340 pregnant women in Singapore enrolled between September 2017 to November 2018.
NUH has partnered medical technology firm Jana Care to co-develop Habits-GDM, a largely automated smartphone app-based lifestyle coaching program designed to help women GDM independently manage and monitor their own condition.
Women with GDM who had completed face-to-face GDM education sessions as part of usual care were eligible for the trial. In addition to usual care, participants in the intervention group downloaded the app and were given a glucometer and a Bluetooth weighing scale linked to the app. Participants were prompted by automated messages to measure their blood sugar and weigh themselves regularly.
The program comprised of 12 interactive lessons, diet, self-monitoring of blood sugar, physical activity and weight tracking tools, and messaging platform with healthcare professionals. The lessons content was similar to the in-person education provided to both study arms, with additional modules on gestational weight gain, and more detailed dietary and physical activity guidance. A database of common foods in Singapore was also incorporated into Habits-GDM, and participants were cued via automated messages to record their diet. The app also had a manual chat function where the participants may pose questions and the healthcare team who would respond within 24 hours.
The average blood sugar readings were lower in the intervention group compared to the control group, with no differences in the frequency of self-monitoring of blood sugar. Overall neonatal complications were significantly lower in the intervention group (38.1%) than control group (53.7%).
“SMART-GDM is the largest randomised controlled trial to date focusing on the use of mobile technologies in supporting the management of blood sugar level in women with GDM. It is also the first to demonstrate an associated reduction in adverse outcomes among newborns,” said the researchers.
Source: Yew TW, et al. A randomized controlled trial to evaluate the effects of a smartphone application-based lifestyle coaching program on gestational weight gain, glycemic control, maternal, and neonatal outcomes in women with gestational diabetes mellitus: the SMART-GDM Study. Diabetes Care. 2021;44(2):456-63. https://doi.org/10.2337/dc20-1216
- Collaborative maternity and newborn dashboard for the COVID-19 pandemic. Mercy Perinatal. Available at: https://mercyperinatal.com/project/collaborative-maternity-and-newborn-dashboard-for-the-covid-19-pandemic
- Gray KL, et al. Women’s barriers to weight loss, perception of future diabetes risk and opinions of diet strategies following gestational diabetes: an online survey. Int J Environ Res Public Health. 2020;17(24):9180. doi: 10.3390/ijerph17249180.
- 3. Caut C, et al. Dietary guideline adherence during preconception and pregnancy: a systematic review. Matern Child Nutr. 2020;16(2):e12916. doi: 10.1111/mcn.12916.
- Vanstone M, et al. Competing priorities: a qualitative study of how women make and enact decisions about weight gain in pregnancy. BMC Pregnancy Childbirth. 2020;20:507. https://doi.org/10.1186/s12884-020-03210-5
- Gestational diabetes in Australia. Position Statement. Available at: https://www.diabetesaustralia.com.au/wp-content/uploads/Gestational-Diabetes-in-Australia-Position-Statement-2020.pdf