Gretchen Miller: Diabetes and pregnancy today on Prevention Works. A pandemic, in fact, of diabetes is rocking the country, and it’s having a profound effect on prenatal care.
Chris Nolan: So we’re not really getting in and intervening before these women become pregnant, and once they have their baby, we don’t have the resources to have follow-up.
Gretchen Miller: Now, pregnancy’s meant to be a joyful experience. And, of course, it is. But it does bring with it a host of health risks. Pregnancy can trigger diabetes, and, our changing lifestyles mean there are more and more entering pregnancy who already have it, putting both themselves and the health of their baby at risk. The figures will surprise you. They’ve jumped by 10 per cent in a very short time, and medicos are having a hard time keeping up and following up.
I’m Gretchen Miller, bringing you the podcast of The Australian Prevention Partnership Centre in Canberra today. We’re with Louise Freebairn, who manages the Knowledge Translation and Health Outcomes Team in epidemiology at ACT Health. Louise is running a study for the Prevention Centre. And with her, Professor Chris Nolan from the ANU Medical School, who’s acting director of the ACT Diabetes Service. He’s seen the rising tide of diabetes in pregnancy firsthand. Let’s start by looking at why pre-existing and diabetes that develops during pregnancy are both on the rise.
Louise Freebairn: That’s right, there are two different types of diabetes in pregnancy. Gestational diabetes is diabetes that’s first detected during pregnancy and the other forms of diabetes are pre-existing diabetes, and so that could be type 1 or type 2 diabetes. What we’re seeing is a rise in gestational diabetes, as well as type 2 diabetes that is pre-existing before pregnancy. We’re seeing that rise in association with increases in a number of risk factors for both of those conditions.
Gretchen Miller: Why is that?
Louise Freebairn: We’re now seeing women having babies at an older age, so in the last 15, 20 years we’ve really seen a dramatic increase in the number of women or the proportion of women who are aged over 35 who are having babies. We are also seeing an increase in the percentage of women who are overweight or very overweight or obese before they become pregnant, and so both of those are quite important risk factors for diabetes alone and for gestational diabetes. We’re also seeing an increase in Australia in the number of women from some of the higher risk ethnic groups giving birth, so that’s also adding to the increasing rates. Actually, many of the women don’t possess just one of those risk factors. We’re actually seeing more women who have more than one risk factor, and when they interact that can significantly increase your risk.
Gretchen Miller: I had no idea that having a baby older was likely to expose you to more risk of developing gestational diabetes.
Louise Freebairn: Having a baby older means that you’re actually having your babies at a time in your life when you’re more at risk of developing type 2 diabetes. It’s actually just that age-related change in your metabolism and your physiology that’s leading to the increase there.
Chris Nolan: That’s exactly right. The rate of gestational diabetes at age 20 is actually very low, but for women having babies into their late 30s, it’s highly prevalent.
Gretchen Miller: So, Chris, we might ask you about working in the hospital. You’re a doctor working in the hospital with these women every day. What are you actually seeing?
Chris Nolan: Our clinic at the Canberra Hospital, I started our diabetes in pregnancy clinic about 13 years ago and initially, the clinic was just a morning and we managed to finish in time for lunch. Now it’s actually consumed the whole day and we struggle to get out by 6:00pm. There’s been an increase particularly in women with gestational diabetes, but also women with type 2 diabetes. There has been a dramatic increase in those for the reasons that Louise has already discussed, but type 1 diabetes and pregnancy seems to be increasing as well. Type 1 diabetes is the type of diabetes that younger people get and you need to go straight onto insulin therapy with type 1 diabetes.
Gretchen Miller: Why are younger people getting type 1 diabetes?
Chris Nolan: Type 1 diabetes, it’s an autoimmune disease where the immune system attacks the insulin-producing cells in the pancreatic beta cells. The big question is, what triggers that autoimmune attack? We know that there’s genetic factors that contribute that we can’t change. There may be environmental factors that also are difficult to change such as certain viral infections. But, in parallel with the increase in type 2 diabetes, which is usually related to increasing overweight and obesity, this is also having an effect on, we believe, triggering type 1 diabetes more often than it used to. Whereas we have a sort of a pandemic, really, of type 2 diabetes, at the same time, type 1 diabetes is gradually increasing as well.
Louise Freebairn: We’ve gone from 6 per cent in about 2005 to about 16 per cent of women who have babies in the ACT are diagnosed with diabetes in pregnancy. We’ve gone from numbers that were around 200 per year to numbers that are sort of getting over 800 and creeping close to 1,000 women per year. For a small jurisdiction like the ACT, that takes up a lot of resources. That’s a really significant increase. Larger jurisdictions might be able to absorb that, but for a smaller jurisdiction with limited resources, that places a lot of demand on our services that we’re possibly not able to cope with as easily.
Gretchen Miller: It’s extraordinary to hear you call it a pandemic, Chris. What do you mean by that?
Chris Nolan: Diabetes, it’s increasing in pandemic proportions. That means that it’s a global phenomenon. In Australia, we’re probably lucky with diabetes and we’re seeing a dramatic increase, but in countries such as India, such as China, the Middle East, the rates of diabetes are increasing much faster.
Gretchen Miller: Is that because of increasing wealth?
Chris Nolan: It’s certainly related to changes in lifestyle and moving from country rural areas into cities where the access to the types of food available are different. It’s changes in work-life balance and people working longer hours and then making poor choices on food on the way home, as we see in countries like Australia, and less opportunity for exercise than there used to be. All of those factors are contributing.
Gretchen Miller: What does diabetes in pregnancy look like for the woman? How might she become aware that she’s developed it?
Chris Nolan: Diabetes is screened for in pregnancy.
Gretchen Miller: So there’s no symptoms beforehand?
Chris Nolan: There’s usually no symptoms for gestational diabetes. It’s a diagnosis from laboratory tests and the standard test is the oral glucose tolerance test. Many women having pregnancies now are very aware that they’re going to have a glucose tolerance test sometime through their pregnancy. It’s usually between 24 and 28 weeks, so relatively late in the pregnancy. Many women are surprised by the diagnosis when it happens. It does cause them a lot of concern and challenges for them in actually needing to look after something they were not expecting.
Gretchen Miller: If you’re already diabetic with type 1 or type 2, what risk does pregnancy add to your illness? Apart from the risk to the baby, what about you when you’ve had the baby and you’re back to relatively normal life?
Chris Nolan: The experience of pregnancy for women with pre-existing diabetes is a challenge because the management of the diabetes and the associated factors such as high blood pressure impact on the outcomes of the pregnancy, so that’s a real challenge. If women do have underlying other complications of their diabetes like renal disease, that renal disease can accelerate through pregnancy. Eye disease, the retinopathy of diabetes, can accelerate through pregnancy and they need to be monitored very closely as well.
But one of the good things about pregnancy and women with pre-existing diabetes, it often is an opportunity for them to improve the way that they look after their own diabetes. Often having, for example, type 1 diabetes through adolescence is a real challenge, and adolescent kids struggle to look after their diabetes well. Sometimes it’s not until a major change in their life happens like a pregnancy, they learn for the first time how to look after it well, and so we’ve had many women come through our clinic that didn’t look after their diabetes very well before but through pregnancy, because they’re looking after a baby as well, they change, and those changes continue often after pregnancy.
Gretchen Miller: There is implications, of course, for the baby?
Louise Freebairn: That’s right. Women with diabetes in pregnancy have a high risk of having a large baby, a large for gestational age baby. There are higher risk of birth complications and there are also longer-term risks. There’s longer-term risks for both mother and baby, where the mum is at higher risk of developing type 2 diabetes later in life, as is the baby. The child is also at risk of having childhood overweight and obesity. Preterm birth is another one of the risks for women with diabetes in pregnancy, and as we understand it, the different groups have different risks at different levels of weight. If you’re from an ethnicity that has a higher risk profile, then your risk as actually higher at a lower BMI than somebody from a different group.
Gretchen Miller: I’m wondering whether it’s because of the mandatory testing that we’re picking up.
Chris Nolan: Over the last 20 years, there has been increasing rates of screening for gestational diabetes. Now it is very well accepted that it’s a screen that all pregnant women have, and the majority of pregnant women do get that test. Some of the increase is due to more universal testing, but that’s not the main reason in the last 10 years.
Gretchen Miller: Now, with some chronic diseases, things like, say, prostate cancer, over-testing … There is this notion of over-testing where too much testing sort of discovers disease that you probably would’ve died with otherwise and it’s led to issues of overtreatment as well, which has knock-on side effects. I guess this is absolutely not the case with gestational diabetes or any kind of diabetes? The sooner you get it, the better. Would that be right?
Chris Nolan: We believe so, but it is not as simple as we’d like it to be. To diagnose gestational diabetes there needs to be cut points of glucose levels. What we’re aware of is that there’s actually a continuum from the normal low blood glucose to quite elevated blood glucose. There’s a continuum of increasing risk according to that glucose and where you decide with diagnosis in a test that this is the level above which you’re going to call abnormal and below that’s normal, that’s really artificial.
With a very large study that was performed internationally called the HAPO Study, the Hyperglycaemia Adverse Pregnancy Outcome Study, they studied around 26,000 women and they did glucose tolerance tests on them all and without any treatment and they determined the pregnancy outcomes. From that study, they showed that the risk of having adverse outcomes such as large for gestational age babies, so big babies at birth, such as hypertension in pregnancy, increased Caesarean section rates. There were cut points for the levels on the glucose tolerance tests that those risks were increased and it’s on the basis of that we make or diagnosis now. For all women at that cut point, whether it really is significant for them or not, is continued to be debated. Certainly, at the upper end of the spectrum, it’s really important those women are diagnosed and treated. At the lower end it becomes a little bit more grey and I think we do need to be careful not to be overtreating women unnecessarily.
Gretchen Miller: Tell me a little bit about this study that you’re doing, Louise. You started studying gestational diabetes but you expanded it after input from clinicians and other stakeholders to include all forms of diabetes and I’m wondering why.
Louise Freebairn: The study actually involves a participatory process. We’re engaging with expert stakeholders and they include endocrinologists, we’ve got obstetricians, we have diabetes educators, public health physicians, experts on the food environment, health economists all coming together to provide input into the logic and the structure that we would include in a dynamic simulation model.
A dynamic simulation model is just … Essentially it’s computer model that can help us explore a complex issue. For many complex issues that we have now, we have a lot of information but we don’t necessarily have the tools to bring that information together into a single picture that we can use to inform decision making. What we’re exploring is how we can actually use dynamic simulation modelling as one of those tools to integrate information and really make best use of the information that we have.
Gretchen Miller: How did you work with the practitioners, with all these experts?
Louise Freebairn: What we do is we get the stakeholders into a room. Yes, we do interviews, so we go through a process of talking to people individually as well as bringing them together into large group workshops where we actually go through quite practical hands-on activities to map out a conceptual map of the issue. We would be looking at the risk factors that might contribute to a woman developing diabetes in pregnancy, and so we might actually look at each of those risk factors in depth and also map them to a transition in the model.
It might be that where a woman might transition from not having gestational diabetes to having gestational diabetes, and if you think about that process, well, she needs to be tested. She needs to be diagnosed. She needs to have a high blood glucose level in her physiology that needs to be represented in the model. We can also include other factors which could be her weight status. It could be her cultural background and her age and other demographic factors as well. We compile all of the information that they’ve given us into a conceptual map, which we then convert into a mathematical model, essentially, and we have some really sophisticated computer software tools now where we can look at the interaction between risk factors and you can also look at the combined effective different interventions and switch interventions on and off to work out how they interact and what the likely impact will be for those interventions.
Gretchen Miller: You started studying gestational diabetes and focusing there on diabetes which develops during pregnancy, but then you expanded it after discussing it with clinicians and other stakeholders to include all forms of diabetes. Now, why did you do that?
Louise Freebairn: It did expand to include all forms of diabetes, and that was from the discussions that we had with the expert stakeholders where the increase in pre-existing diabetes was seen to be a really significant factor that we should include in the modelling and would be an important gap if we had left it out. We really wanted to look at lifestyle prevention programs, population health interventions, and those are really relevant to the development of type 2 diabetes, as well as gestational diabetes.
Gretchen Miller: This is Prevention Works and we’re talking to Louis Freebairn and Chris Nolan about diabetes in pregnancy. I’m Gretchen Miller.
What are you hoping to learn from your research?
Louise Freebairn: I think there’s lots of things that we’re hoping to learn. This is quite an ambitious model. I think we really are breaking new ground internationally on the methods that we’re using. We’re actually incorporating a number of different types of modelling methods into the one model. That’s allowing us to actually look at the risk factors, as well as some of the underlying physiology right through to clinical service provision, so we’re really wanting to be able to ask questions about the population health type interventions that we can implement. Pregnancy is another one of those opportunities where people start to think about their health and it’s also an opportunity where you can actually have an impact on more than one person with the same intervention.
So you can actually have an impact on mother and baby but also whole families and improve their diet and their level of physical activity. It’s quite an effective time to intervene with people, so we’re really interested in exploring some of those intervention options and some of the questions around timing or perhaps target groups. Do we actually target an intervention to all of the people Canberra who are considering having a baby, or would you actually target women who already have some of the risk factors? Would you time an intervention for pre-pregnancy or would you time the intervention for between pregnancies? Would you target women who’ve had diabetes in pregnancy in their first pregnancy before they contemplate a second pregnancy? Those are the types of population health questions that we can ask in the model. We can also some questions around models of care. Can we implement a different way of providing services and what impact would that have on resources?
Gretchen Miller: That’s really significant because what you’re talking about there, going from what was it? 6 per cent to 16 per cent, that is an enormous increase. 10 per cent. You’re talking about services being stretched, so when I think about it I think, “Well, you’ve done the test. You’ve got to provide the service.” But how might you address providing services differently?
Louise Freebairn: Some of the options that we’ve talked about and are looking to test in the model might be things like providing group services rather than individual. If you can have a group education session rather than actually having a one-on-one with every woman, and how does that impact on resources. It might be around triaging care, for some of the lower risk women, perhaps they can actually be managed in normal antenatal services rather than needing to be seen by the specialist service.
Gretchen Miller: So perhaps a midwife or nurse might be able to say, “Yes, you’re at risk,” or, “You’ve got low-level diabetes. These are the things you can do”?
Louise Freebairn: That’s right. It might be a midwife under the supervision of an obstetrician with sort of regular check-ups.
Gretchen Miller: I think actually group therapies or group education sessions could be really good because then you’re less … When you’re a pregnant woman you often feel very much alone.
Louise Freebairn: Absolutely. I think sharing ideas and sharing resources could be a very useful thing. I don’t know if you want to add anything because you have already implemented some of these changes.
Gretchen Miller: Have you, Chris? Tell me about that.
Chris Nolan: With an increase from 6 per cent to 16 per cent over the years we’ve had to increase efficiencies of how we run the clinics. We already do run group sessions in pregnancy as an initial education for women who develop gestational diabetes. Then they do go on to an individual appointment with a dietitian, and from that point, they either go back to their usual antenatal care pathway if they’re traveling well. If their sugars are elevated they come to our high-risk diabetes and pregnancy clinic and join us on Tuesdays.
We already have implemented some changes. But I think a key point is that implementation of our service is from the time of diagnosis to the time of delivery, so we’re not really getting in and intervening before these women become pregnant, and, once they have their baby, we don’t have the resources to have follow-up appointments with them. We’re very keen to be able to have another group session after pregnancy for these women to sort of debrief and to plan for the future for them and talk about ongoing lifestyle modifications. We’re very keen, this is about women predominantly, but partners are at risk as well, and to actually get to the partners and assist them.
Gretchen Miller: Why are they at risk?
Chris Nolan: Often they come from groups that have the same risk factors for diabetes whether it’s ethnic group, age, family histories, etc.
Gretchen Miller: Or even just eating habits I imagine because you eat the same sorts of foods.
Chris Nolan: And it’s the same lifestyles. If we’re able to, after pregnancy, introduce lifestyle changes that is family-based, I think preventing the women themselves, their partners, and their children from being a future risk of diabetes and diabetes-related problems, I think that would be a major plus for public health.
Gretchen Miller: If you’re already implementing some of these ideas, you’re able to feed that experience, I guess, into your dynamic modelling system, yeah? How is that playing out? What are you seeing in the crystal ball?
Louise Freebairn: Yes, we can implement and have those different clinical pathways implemented in the model and look at the resourcing that’s required for those. Unfortunately, it’s too early for me to talk about results from the model, but we’re hoping over the next couple of months that we’ll but putting those results out there for discussion and for people to learn, including us.
Gretchen Miller: Of course, the issue here, as we’re alluding to, is, aside from health and provision of service to look after these women who we’re now discovering to have diabetes through this mandatory testing, the other issue is cost, of course, and what this is doing to service provision.
Chris Nolan: Cost of services is a major issue in this space and with a dramatic increase we need to look at how that service is provided. If there’s a rate of 16 per cent, it is a common condition in pregnancy and we need to really look at for the usual clinicians that work within midwifery and obstetric care that they learn to manage that themselves without needing quite so much input from specialist diabetes services. In specialist diabetes services, we have to look after children with type 1 diabetes and people with complex diabetes at all different stages of life, we need to look after women that have pre-existing diabetes in pregnancy. If we can teach the obstetricians and midwives to look after that as a common condition in pregnancy, I think that’s certainly a direction for us to go towards.
Another key is prevention in public health and to get that message across. I really don’t believe that women planning their pregnancies are really tuned in to how common gestational diabetes is and what risk they might be at. I think public health messages to women before pregnancy and aimed at trying to get these women to optimise their lifestyle etc before pregnancy, in planning their pregnancies, would be a major plus.
Gretchen Miller: That is really interesting, the idea of saying, “Actually, you do need to look after yourself more than you think.” It’s not just about stopping alcohol, for example, because you want to get pregnant and you don’t want to potentially affect the baby. There’s more than that. It’s not just about getting fit in order to maximise your chances of conceiving. It’s actually about more than that too.
Louise Freebairn: I think that’s quite a common picture is people are just not aware, women are not necessarily aware of how high their risk could be. They’re also not aware of the things they could be doing to actually decrease their risk such as improving their diet, really thinking about eating healthily with fibre and vegetables, having their two and five, and making sure that they’re getting enough physical activity just to really reduce their weight status before, so losing some weight before you become pregnant so that hopefully you’re at a healthy weight before you actually conceive.
Short-term risks include preterm birth, so being born early before 37 weeks gestation. Being large for gestational age, so having a large baby, and that’s associated with more risk of interventional births. You’re much more likely to actually be admitted to an intensive care unit, a neonatal intensive care unit as well.
Gretchen Miller: Where’s your point of contact on this? Are you going to be targeting, for example, GPs on this issue?
Louise Freebairn: Potentially there could be a GP intervention and it might be around educating GPs to highlight gestational diabetes as one of the risks when they’re having a preconception discussion with a woman or her partner. Other things might be using new technology, so it might be actually creating something like an app or extending a current app to actually include more information about the things that people can do to reduce their risk.
Chris Nolan: Women often use apps to track their pregnancy and to remember how many weeks they are and when the baby’s due, and what happens when through the pregnancy. To have an app that women actually find useful and add into that extra things such as a risk score for their risk for gestational diabetes to bring it to pre-pregnancy and what sort of things they have to tick off before they actually conceive. Do they need to go to their GP for a pre-pregnancy health check? To add all of that into an app that is truly useful, then it might be used.
Gretchen Miller: Chris, being a doctor, as these programs are already being introduced for women in the ACT or you’re already sort of trying out some of these ways of dealing with low-risk diabetes, what do you think the implication and the outcome will be for women in the ACT and also for the ACT health budget?
Chris Nolan: The value of this model is that we when we have a set budget, we can work out from the model how we might best spend that budget. For example, at the moment, we spend that budget really between around 24 weeks of pregnancy and the delivery of the baby. If we shifted some of that budget to pre-pregnancy with a public health campaign to increase awareness of gestational diabetes and the need for a healthy lifestyle, would we actually achieve better outcomes or should we use those same dollars after pregnancy in following up these women and their families to improve their long-term health?
Women with gestational diabetes, we know that they’re at very high risk of developing permanent diabetes later in life and if we could prevent that diabetes or even delay it by a decade or two decades, then it has a dramatic impact on the whole health system and the quality of life for the people involved. If we’re able to intervene early with the children at those first years of life, probably the most important for their long-term health, and to be able to spend their health dollar on them, that might be the best bang for our buck within this space. The model will be able to help us to determine where we should be focusing our health dollar.
Gretchen Miller: Hard decisions though. I mean, really, to choose between, okay, dealing with the kids who are already born, or dealing with the mother while she’s in this very vulnerable state of pregnancy, or waiting until … The either-or scenario there is pretty tough.
Louise Freebairn: It is really tough, but those decisions are being made now and what we’re looking to do is actually to improve the tools that are being used to guide those decisions.
Gretchen Miller: What should women who listen to this podcast who want to get pregnant be doing and what should the government be doing to actually support them in that?
Chris Nolan: For women planning pregnancies, I think it’s a really important time in life to have the best healthy lifestyle, and that means being active. That means looking at the sort of foods that we’re eating, and I guess my strongest advice is to try and avoid junk food. I think junk food, fast foods, a lot of takeout foods are very poor quality and are contributing a lot to this increasing prevalence of gestational diabetes. I think that’s the simplest message that would have the biggest impact.
Gretchen Miller: Louise?
Louise Freebairn: I agree. I think Chris is spot on. You really need to be thinking about your health when you’re contemplating pregnancy. Gestational diabetes is, as Chris has said earlier, often a surprising outcome from the oral glucose tolerance test for many women, so just being aware that it could affect you and to really make as many changes as you can to be as healthy as you possibly can when you become pregnant to try to reduce your risk.
Gretchen Miller: That’s Prevention Works for today. Thanks to Louise Freebairn, managing the Knowledge Translation and Health Outcomes Team in epidemiology at ACT Health, and Professor Chris Nolan, who’s the acting director of the ACT Diabetes Service. Of course, more details on our website and you can also see a transcript there. I’m Gretchen Miller and I’ll catch you next time.
About this episode
Dr Chris Nolan used to see all his pregnant mothers with diabetes in a morning. Now, he’s swamped. He joins Louise Freebairn to discuss why so many pregnant women are presenting with this dangerous condition, and how dynamic simulation modelling is providing some answers on how to intervene in the ACT.