Transcription:

Melanie Cole (Host): Gestational diabetes is on the rise with pregnant women and there are many treatment options for women that are suffering from gestational diabetes. My guests in this panel discussion today, are Dr. Emily Szmuilowicz and Dr. Boyd Metzger. They are both endocrinologists at Northwestern Memorial Hospital. Dr. Szmuilowicz I’d like to start with you. Tell us about the current state of gestational diabetes. What’s the prevalence and what’s the impact on what we are seeing with pregnant women and their babies?

Emily Szmuilowicz, MD (Guest): So, gestational diabetes is the most common endocrine complication that we see during pregnancy. We estimate that gestational diabetes depending on the criteria used to diagnose it; occurs in approximately five to ten percent of pregnancies in the United States. And that estimate does vary depending on which criteria are used to diagnose gestational diabetes and it also varies on the number of risk factors including the race or ethnicity of the woman, the area of the world that we are examining, but generally speaking, we expect to see it in approximately five to ten percent of pregnancies.

Host: Dr. Metzger, tell us a little bit about what happens when a pregnant woman eats and why does she need to understand insulin and blood sugar? What really is gestational diabetes?

Boyd Metzger, MD (Guest): Well gestational diabetes is a mild elevation of blood sugar above normal. It tends to occur in people who have risks for ultimately developing diabetes in their lifetime and it occurs during pregnancy because as pregnancy moves along; the amount of insulin the pregnant woman’s body needs to keep her blood sugar normal, increases. The hormones that are produced during pregnancy, increase the body’s need for insulin to control the blood sugar.

Host: Dr. Szmuilowicz, tell us who is at risk. Is there a genetic component to this?

Dr. Szmuilowicz: Yes, there is both genetic and environmental components that are very important in terms of increasing risk of gestational diabetes. So, most commonly, the people who are developing gestational diabetes are those who are at risk for type 2 diabetes. So, those are all the common risk factors that we think about in people who are at risk for diabetes such as physical inactivity, first degree relatives who have diabetes, a higher risk race or ethnicity, women who have had GDM in the past, women with other cardiovascular comorbidities such as high blood pressure, high cholesterol. So, all of these risk factors put a woman at risk not only for the development of type 2 diabetes, but also markedly increase her risk of developing gestational diabetes.

And as Dr. Metzger was just saying, really the underlying problem in gestational diabetes is that when women become insulin resistant during pregnancy, meaning their body doesn’t – these women don’t respond as well to insulin; the level of glucose in their blood increases and this is actually an adaptive change during pregnancy. The idea is that if the woman were perfectly insulin sensitive, if she is outside of pregnancy; she would be taking up most of the nutrition into her own body and when she’s pregnant, the placenta wants to make sure that the baby has adequate nutrition also, not just the mother. And so, this leads to a state of resistance to the hormone insulin and an increase in the level of blood sugar or blood glucose in the woman’s body.

And so, we are really uncovering and when we diagnose women which gestational diabetes, is we are uncovering or unmasking a group of women who are otherwise at risk for developing type 2 diabetes and when they develop this massive insulin resistance that happens during pregnancy in all women; their bodies are not able to adequately compensate. Meaning they cannot make enough insulin to overcome what the placenta is doing. And so, in those women, they develop gestational diabetes and the blood glucose rises.

So, what we are really seeing here is that women who develop gestational diabetes are not developing a new condition. We are just unmasking a condition that really was underlying even before the pregnancy. We didn’t know about it because the blood sugars are normal outside of pregnancy. And then when we throw on all of these very physiologic and normal changes of pregnancy, we are bringing out this state of insulin resistance or unmasking a predisposition to diabetes.

So, what I’m trying to say is that women who develop this condition, are really the same women in the majority of cases, who are otherwise at risk for diabetes later in life and this as I’m sure you can imagine has really important implications in terms of their future risk of disease later in life and their future health.

Host: Well then along those lines, Dr. Metzger, if a woman is diabetic before she is pregnant, do you advise that she discuss this with an endocrinologist before she gets pregnant and or work with them and have that already planned out as she gets pregnant and goes through her pregnancy?

Dr. Metzger: Women who have diabetes prior to pregnancy have the best outcome if they are seen by an endocrinologist and have their glucose control made as good as possible before they conceive and are pregnant. Because diabetes at the level we call diabetes and not gestational diabetes has serious impacts on pregnancy from the moment of conception throughout the pregnancy. So, the best outcome is good control before pregnancy begins.

Host: What if they are only at risk for diabetes or have been diagnosed with prediabetes? What would you tell them then Dr. Metzger?

Dr. Metzger: If a woman has prediabetes or has had previous gestational diabetes; she should take all measures to improve her overall nutrition and blood glucose control which would be primarily to be at the best possible weight and be physically active throughout her lifetime and especially going into another pregnancy.

Host: Dr. Szmuilowicz, tell us a little bit about what you would tell a woman if she is diagnosed with gestational diabetes? What do you want her to know about lifestyle, exercise, insulin, you know pregnant women have the question. Are they able to take insulin? What affect does it have on mom and baby? What do you want them to know?

Dr. Szmuilowicz: So, these are really important questions, and this is what we spend a lot of time talking about in the clinic. In terms of risks of gestational diabetes; we talk about a number of things. We of course, talk about the complications to the pregnancy and the baby if the gestational diabetes were not treated. So, for example, you can imagine that based on what we just talked about in terms of causes of gestational diabetes; where the glucose levels rise above normal in the woman’s blood and the baby receives too much nutrition. One of the main risks that we counsel women about is the risk of excessive fetal or excessive nutrition to the baby and that can lead to a number of things such as excessive growth of the baby, which can lead to a number of complications such as injury to the mother or the baby at delivery.

We also talk a good deal about the risk of low blood sugar in the baby after delivery, because the baby who is seeing all of this extra glucose or sugar and nutrients is going to him or herself make extra insulin to try and compensate for that and then all that extra insulin can hang around for quite a bit after delivery and so after delivery when all the extra sugar goes away, and the baby is still making extra insulin; the baby is going to be at risk for low blood sugar.

So, we talk about those and a number of other complications. Again, that are at highest risk for untreated gestational diabetes. So, that leads us of course to a conversation about treatment and how important it is to treat gestational diabetes. And we talk about a number of things that you just alluded to. So, for every woman, whether she requires medication or not; we spend a lot of time talking about the importance of what we call lifestyle changes or lifestyle modifications.

That includes a healthy balanced diet, typically well-rounded in whole grain carbohydrates, proteins, and healthy fats. We emphasize very strongly to women that this is not a restrictive diet. We don’t want women to be starving themselves and that is not the treatment for gestational diabetes. We want women to be eating healthily and we want women to be eating a good balanced diet. And we go over that in detail in terms of what that looks like for the woman on a daily basis.

We also emphasize the importance of physical activity for women who can exercise during pregnancy, which is the majority of women. We tell them about the importance of walking primarily, we tell them to – we ask them to walk for approximately 150 minutes a week which breaks down to about 30 minutes on five days of the week at least. For busy active women, another really helpful strategy is walking for 15 minutes after their meals, taking a 15 minute walk after breakfast, lunch and dinner. And we see when we counsel women about monitoring, and we go over their blood glucose levels with them, we see that this kind of even short term exercise has a pronounced effect on glycemia on glucose levels after meals.

So, we tell every pregnant woman about the importance of those changes. And those what we call lifestyle modifications are effective in approximately 75 to 90% of women depending on the studies that have looked at this. So, the vast majority of women with gestational diabetes will be able to achieve optimal glycemic control with those lifestyle changes.

For the remainder of women who continue to have glucose levels above our target range; despite those healthy changes, we then recommend medical therapy and I always make sure that women know that this is not a sign of failure because I think that’s a really important notion that comes up in women. They feel defeated if they haven’t been able to optimize their glucose levels by all the strategies that they have under their control and that’s just not the case. Some women just do require additional therapy and we make sure that women know that.

When medication is required, our first line treatment is insulin. And there are a number of reasons for that. The main ones are that it’s quite effective. It’s more effective than the other what we call oral or pill treatments for diabetes. And a really important reason that we talk about commonly is that insulin does not significantly cross the placenta, meaning it does not reach the baby in significant amounts. Whereas the two pills that are used increasingly actually, in treatment of gestational diabetes; they do cross the placenta to a significant degree and the babies do see these medications. And the good news is that these medications have really – there’s not been any prohibitive short term negative outcomes that have been shown from using these medications definitely.

But we just really don’t have the long term data. We don’t have long term studies showing whether or not these pill forms that the babies do see during pregnancy whether they have any negative affects later in the children’s lives. So, for that reason, for the efficacy reasons as well as the just the uncertainties that we have in terms of long term safety; we typically recommend insulin therapy. And we customize it to each particular woman. So, for example, if their waking or fasting glucose levels are elevated only; we’ll give them only a long-acting insulin at night that will control the glucose levels when they are not eating.

If it’s only after one or more meals, then we give them short-acting or mealtime insulin at those meals where they have high blood sugar levels. As so, we really do customize it. It’s not a one size fits all approach and it just emphasizes the importance of working very, very closely with the healthcare team. There’s a lot of close contact, frequent monitoring and we really develop a close relationship during the pregnancy and frequent communication in terms of adjustment of the medications as is needed for each woman.

Host: What great information. Dr. Metzger, how would a woman know if she’s having issues with her blood glucose while she’s pregnant? Is she supposed to be checking her blood sugar? If so, how often and when Dr. Szmuilowicz talks about the close collaboration, tell us about the other providers that might be involved in this as a woman goes through her pregnancy.

Dr. Metzger: So, the women who are diagnosed with gestational diabetes are typically asked to learn the technique of glucose monitoring and do that at the beginning, several times a day both before meals and one to two hours after the meal to establish a pattern of how well the blood sugar is controlled and over time, as things go well, sometimes the frequency of doing the self-monitoring, the finger prick testing is decreased.

And as Dr. Szmuilowicz indicated, teamwork is important so, the obstetric care and the nursing services, if necessary, additional help from a dietician all contribute to the treatment and the team works together to inform each other as to what adjustments in treatment they made or what new recommendations they have made.

Host: Dr. Metzger, first last word to you. What would you like women to know that may be at risk for diabetes or prediabetes before they get pregnant, how important it is that they get that sort of situation under control or meet with an endocrinologist or speak with their gynecologist obstetrician about their fears and what they can expect? Give them your best advice.

Dr. Metzger: I think the best advice to people at risk for diabetes at any time, pregnancy or not, is to work very intensively at having the best lifestyle possible. And that includes a healthy diet, good physical activity, adequate rest, and just the same things that are lifelong protective factors and have been shown to reduce the chance of developing diabetes after something like gestational diabetes or from going from prediabetes to diabetes will also be helpful for someone who is at risk for gestational diabetes, if they are contemplating pregnancy.

Host: Dr. Szmuilowicz last word to you, what you would like women to know that have been diagnosed with gestational diabetes about the program at Northwestern Memorial Hospital and what you can do for them, how you can help them?

Dr. Szmuilowicz: I think that what Dr. Metzger just emphasized about the importance of teamwork is probably the most important feature of our program at Northwestern that is worth mentioning. We work on very, very closely together on a team with the referring obstetric providers, all over Northwestern and frankly all over Chicago and even surrounding states. We work very closely with the obstetricians, with the dietician that we work with, with the counselors at our Health Learning Center, health educators I should say at our Health learning Center as well as our ultrasonographers etc. The whole group of us that are thinking very hard about these women and we work very closely together and very closely with our patients.

And I think that is a very unique feature of the program at Northwestern. Where we are really looking at the care of the pregnancy as a whole and we are not looking through tunnel vision at just one aspect of the pregnancy each. And I think that’s a very unique aspect.

The other thing that I think is a really unique feature of our system at Northwestern is the extensive network of support that we have that will extend beyond the pregnancy. So, for example, one thing that I want to make sure that I speak about with all of my patients who have gestational diabetes is that the diagnosis of gestational diabetes while it can be very scary for women when they hear about the dramatically increased risk of type 2 diabetes for example, later in life; I really try to turn the conversation around into a glass half full approach to say yes, this is scary, yes this is information that you may not have quite thought about at this point in your life in terms of risk of future development of diabetes; but the good news is that we know about this information so early in your life and we know about this information at a time when we can do things that will dramatically reduce the risk of developing diabetes. Meaning, it’s not certain that a woman will develop diabetes and with all the lifestyle changes and in some cases medication treatment, but predominantly lifestyle changes that Dr. Metzger just described, that really apply to everyone, but particularly apply to women with gestational diabetes. With adoption of those changes; women really have it within their power to change the course of history. And I like to point that out to them when I meet them at such an early point in their life. That this is the time to make those changes and what a window we have into their future health and into their future life.

And so, I really like to point that out to women, and I like to – we all try very hard to make sure that they are hooked into the appropriate resources to act on those ideas. So, for example, every woman that graduates as we say from our program, we want to make sure that they are hooked in with an internist for example who is going to be monitoring every one to three years for the development of diabetes, who is going to screen for diabetes before any future pregnancies and who is going to be following these women lifelong.

And the wonderful thing about a place like Northwestern is that we have such a phenomenal network of not just obstetricians and endocrinologists, but of internal medicine providers and specialists across the spectrum, who can really help women get where they need to get in terms of optimizing their health lifelong. And I think that’s the message that we need to be giving to women when they have this diagnosis that we really need to emphasize the positive aspects of having information and the positive things that these women can do in their life to really change the course of their health.

Host: Such an important message and such an important conversation to have for both mom and baby. Thank you both for coming on with us today and sharing your expertise and telling us about the program at Northwestern Medicine. To learn more about gestational diabetes and any other Northwestern Medicine diabetes programs in your area, please visit www.diabetes.nm.org, that’s www.diabetes.nm.org. You’re listening to Northwestern Medicine PodTalk. I’m Melanie Cole.