Ethnic Differences in pregnancy outcomes in women with GDM - An analysis of over 3000 births. Presented at ADS Annual Scientific Meeting 2014.

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1 MINUTES OF THE NSW DIABETES IG MEETING HELD ON Friday 16 th February at Large meeting room, Level 6 King George V Building, ROYAL PRINCE ALFRED HOSPITAL CHAIR: Robyn Barnes MINUTES: Fiona Pound Speaker: Robyn Barnes, Diabetes Centre, Bankstown Hospital Ethnic Differences in pregnancy outcomes in women with GDM - An analysis of over 3000 births. Presented at ADS Annual Scientific Meeting Background Bankstown Hospital Diabetes Centre rate of GDM has more than doubled from 2007 (8.6%) to 2014 (17.8%).This is without using the new diagnostic criteria. Recently added 1hr GTT diagnostic value. BG targets not currently ethnic specific. Aim of study: To compare adverse pregnancy outcomes in different ethnic groups Study Overview: Outcome measures = insulin use, caesarean delivery, large gestational age (LGA) and small gestational birth weight (SGA, <10th percentile) (customised percentile charts used, taking into account ethnicity) and 6-8wk post-delivery OGTT Looked at relative risk ratios for outcomes in: o European o Middle Eastern o South East Asian (Chinese, Vietnamese, Filipino, Indonesian) o And South Asian ethnic groups (Indian, Pakistani, Bangladeshi) 3077 birth records included in analysis Has 60% compliance rate with 6-8wk post GTT Results: Insulin Therapy o SE Asian group was 40% less likely to need insulin therapy vs European (relative risk 0.6) & Middle Eastern groups (relative risk 0.59) o South Asian were more likely to need insulin that South East Asian group (relative risk 1.47) SGA: o South East Asian more likely than Middle Eastern to have small for gestational age (SGA) infants (relative risk 1.68) o South Asian more likely than Middle Eastern to have SGA infants (relative risk 1.62) LGA: o Middle Eastern more likely to have large for gestational age (LGA) infants than European group (relative risk 1.31) o South Asian more likely than South East Asian to have LGA (relative risk 1.94) Abnormal post partum GTT: o South East Asian & South Asian more likely to have abnormal GTT than European (relative risk 1.42, 1.67 respectively) o South East Asian & South Asian more like to have abnormal GTT than Middle Eastern (relative risk 1.32, 1.54). 1

2 Summary & Implications for clinical practice: Middle Eastern background more likely to have LGA, therefore may need to consider excessive calorie intake more closely within this ethnic group. South East Asian & South Asian women are more likely have SGA baby need to closely monitor birth weight, and to ensure they are not over restricting intake to normalise BGLs. Post partum OGTT are important for all women with GDM, but maybe especially so for women of South Asian and South East Asian backgrounds. Ethnic Differences in GDM weight gain Background IOM guidelines for recommended weight gain in pregnancy: Pre-Pregnancy BMI Classification Single Pregnancy <20 Underweight Normal Overweight Obese Class Obese Class >40 Obese Class 3 0 gain or up to 4kg loss *Assume 0.5-2kg gain in first trimester Weight gain guidelines are currently the same regardless of ethnic group, as it is thought that there is no statistical difference in outcomes Most of weight gain data however assessed from American populations which have a different ethnic mix to Australia Method: Collected data on pre-pregnancy BMI/weight, and weight at time of last clinic visit Weight gain compared amongst same ethnic groups (Middle Eastern, European, South Asian & south East Asian) and pregnancy outcomes (caesarean delivery, large gestational age (LGA) and small gestational birth weight (SGA, <10th percentile) and 6-8wk post-delivery OGTT) Results: Median weight gain similar across all ethnic groups Large difference in interquartile range (i.e large distribution) of weight gain between different ethnic groups seen o South Asian group had smallest range in weight gain o European & Middle Eastern groups had largest range in weight gain Regardless of overall weight gain Middle Eastern population still less likely to have a SGA baby Even if South East Asian gained too much weight they were still less likely to have LGA baby Conclusion: Variable pregnancy outcomes seen between ethnic groups does not appear to be related to amount of weight gained during pregnancy Need to consider other possible contributors such as diet, genetics, and glycaemic control. 2

3 PRESENT NSW DIABETES IG MEETING HELD ON Monday February 16th 2014 at ROYAL PRINCE ALFRED HOSPITAL NAME WORKPLACE DAA Membership Number Raji Jayadev Fairfield Hospital Rula Milad Westmead Hospital Kylie Alexander RNSH Deb Foote RPAH Leanne Gregory Concord Hospital Fiona Pound Nepean Hospital Robyn Barnes Bankstown Hospital APOLOGIES 3

4 Geneveive Michael Sally Marchini Melissa Armstrong Katie Allison Shannon Lin Caroline George NAME 1. Acceptance of previous minutes Minutes accepted by Deb Foote & Rula Milad with the following amendments made: Natalie Viljevac , Diabetes Service with the Greater Newcastle Cluster (HNELHD) present via phone Leanne Gregory was also an apology 2. Business arising from previous minutes None 3. New Business There is currently no time frame for the renovations at the Diabetes Council, so all meetings for the year will be at scheduled at the RPAH until further notice. 4

5 4. CORRESPONDENCE Source- Nil Subject Action 5. JOURNAL ARTICLES None 6. NEW PRODUCTS Reduced Sugar Up and Go Drinks Available in chocolate ice or vanilla ice flavours Reduced Sugar up and go Original Energy 688kj 815kj Protein Fat, Total Saturated fat Carbohydrate, Total Sugars Dietary fibre Helgas Wraps mixed grain 5

6 Per Serve (70g wrap): Carbs = 33g, dfibre =3.7g, protein=6g, Tot fat=4g, sodium=255mg Vaalia Yoghurt Whipped Raspberry & Lemon Flavours Per serve (90g pot): Lemon Raspberry Energy Protein Fat, Total Saturated fat Carbohydrate, Total Sugars Calcium 113.4mg 113.4mg 6

7 7. CASE STUDY DISCUSSION 17yo male with Type 1 Diabetes on Insulin Pump o Medical Hx Asperger s Syndrome New Dx of SCURVY (Vitamin C level <3) o Social lives with mum o Diet consisted of only Bacon, Egg & Meat, cooked in lard No vegetables, No fruits, No dairy, No Wholegrain eaten at all o Pump& Hypo Mx Manually self-adjusted basal rates in pump according to BGLs on a daily basis No insulin boluses given as no carb eaten Treated hypos by suspending pump, and eating ++ protein til eventually came up o Biochem: Cholesterol total ~12, LDL ~8, TG levels ok HbA1c <7% Advice was given on Vitamin C supplement, and use of glucose tablets for hypo mx. Although despite diagnosis of scurvy both patient & mum still VERY reluctant to make even these small dietary changes. Following above case study, discussion had around approaches to manage patients following low carb diets: o?criteria to class low carb diet. Thought <40% is considered as lower carb diet, whereas <50g carb per day (ketogenic) low carb o For patients following very low carb diets it was suggested we can only present information in a very open way, and perhaps approach from nutrient angle. o Need to also consider hidden carbs consumed in sauces, large quantities of free vegetables etc, as patients may be consuming more carbs than reported. 8. NEW PROJECTS AND RESOURCES How much carbs in that? Book Produced by Julia Zinga Private APD Victoria Designed as practical tool to assist patients with carb counting Includes real life size pictures of common carbohydrate foods and Carb values Sections include Fruit & Starchy Veges, Breads & baked goods, Main meals & snacks Equivalent to this=that book, although for carbohydrate Book available from website Version specific to more ethnic foods in the pipeline 7

8 9. UPCOMING CONFERENCES/SEMINARS AND REPORTS Paleo or Plant-based? Tackling Current Controversies in Nutrition - 11th February No one present attended so will hold over till next meeting 10. BUSINESS WITHOUT NOTICE Discussed potential of getting a speaker to cover lipid management in diabetes Deb Foote will ask Doctor specialising in lipid management at RPA if interested. 11. NEXT MEETING DATE: Tuesday April 21st 2015 TIME: 2pm VENUE: Room 30.03, Charles Perkins Centre, Building D17 John Hopkins Drive (Off Missenden Road) The University of Sydney, Camperdown. TOPIC: Dr Alan Barclay - Lower carbohydrate Diets for the Management for Diabetes 8