Australian Diabetes Educator Volume 17, Number 3, August 2014 Diabetes in Pregnancy GDM Model of Care the Role of the Credentialled Diabetes Educator GDM a New Era in Diagnosis and the Impact for Diabetes Education Services New ADIPS GDM Diagnosis Criteria Questions from Women Living with Diabetes Policy Discussion General Practice Management of Type 2 Diabetes, 2014-15 a Focus on SMBG Recommendations
Australian Diabetes Educator, Volume 17 Number 3, August 2014 Contents ADEA Update Credentialling Update Diabetes Education Offers Chance to Save Lives and $3.9 Billion Constitutional Review Update New Membership Card Feature Articles Diabetes in Pregnacy Gestational Diabetes Model of Care the Role of the Credentialled Diabetes Educator Consumer Perspective Complementary and Alternative Therapies ADE Publication team P. 02 6173 1009 E. ade@adea.com.au Sustaining members 6 7 8 8 12 20 24 Gestational Diabetes Mellitus a New Era in Diagnosis and the Impact for Diabetes Education Services New ADIPS GDM Diagnosis Criteria Questions from Women Living with Diabetes Gestational Diabetes under the Microscope 26 GDM The Shock of a New and Unexpected Diagnosis Complementary and Alternative Therapies: Use by Women with Diabetes during Pregnancy and Women with Gestational Diabetes Policy Discussion General Practice Management of Type 2 Diabetes, 2014-15 a Focus on SMBG Recommendations 18 30 36 Editor s Note 4 CEO Update 4 NDSS Update 10 Diabetes and Technology 28 Research Insights 34 JDRF Update 40 Book Review 42 Our sustaining members make an important contribution to our ongoing growth. Their financial support assists ADEA in pursuing its goal of achieving optimal health and wellbeing for all people affected by, and at risk of, diabetes, through education, advocacy, support and research. 3
Feature Article Australian Diabetes Educator, Volume 17 Number 3, August 2014 Gestational Diabetes Mellitus a New Era in Diagnosis and the Impact for Diabetes Education Services Alison Barry The seeds for developing type 2 diabetes are sowed during the pregnancy, when the baby is in the womb. If we can help mothers with gestational diabetes there may be a chance of reducing the burden of diabetes 20 to 30 years down the track. Professor Paul Zimmet 20 GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. 1 Background Gestational diabetes mellitus (GDM) and the associated increased obstetrical risks were first described in a paper written in French by DR J.P.Hoet in the post World War 11 period. This paper was translated into English for publication in Diabetes in 1954. 2 After the establishment of a program focusing on the epidemiology of chronic diseases in Boston, Massachusetts, Dr John B. O Sullivan from Ireland joined this team. It was a time when there was great controversy about diagnosing GDM. This was in the mid to late 1950s and in the following years Dr O Sullivan and his group went on to conduct a number of studies using the glucose tolerance test to evaluate the glycaemic levels during pregnancy. Studies during the 1960s looked at the longterm follow up of women who had been diagnosed with GDM Corresponding author: Alison Barry BN, RN, RM, CDE GDM Project Manager, Mater Health, Mater Research Alison.Barry2@mater.org.au and their subsequent glucose intolerance at 10 years post partum. The significance of GDM grew gradually during the 1970s and O Sullivan s work on establishing screening criteria was recognised by the National Diabetes Data Group (NDDG) which led to widespread screening for GDM by the mid 1980s in America. 3 Recommendations by the Australasian Diabetes in Pregnancy Society (ADIPS) for testing and diagnosing GDM were first made based on expert opinion and have been used in clinical practice by obstetricians, endocrinologists, obstetric physicians, midwives, diabetes educators and dietitians since 1991. 4 The International Association of Diabetes and Pregnancy Study Groups (IADPSG), which includes members from Australia, formulated new consensus guidelines for the testing and diagnosis of GDM after considering the results of the Hyperglycaemia and Adverse Pregnancy Outcome study HAPO study. 5 This study identified significant correlation between increasing maternal glucose levels between 24 34 weeks and adverse maternal and fetal outcomes. Table 1 The future There has been considerable confusion since the recommendation of the new ADIPS diagnostic criteria and clinicians have been challenged within their health care facilities with two sets of diagnostic criteria being reported and used in some institutions. There is now a timeline for implementation of the recommendations. The random 50g glucose challenge test (GTT) is to be deleted from the diagnostic algorithm from 1 July 2014 and a recommendation has been made to transition to the use of the new diagnostic levels by 1 January 2015. See Table 1 for new GDM Diagnostic criteria. GDM Diagnostic Criteria 5 Old New Fasting < 5.5 < 5.1 1 hour - < 10.0 2 hour < 8.0 < 8.5 Note: Currently not all laboratories report the 1 hour glucose level. All 3 levels will be reported with the new diagnostic criteria. One elevated level will confirm a diagnosis of GDM.
Australian Diabetes Educator, Volume 17 Number 3, August 2014 The new ADIPS Guidelines recommends all women should be offered a GTT at 24 28 weeks gestation, however any woman considered to have high risk factors for GDM (see Table 2) should be offered a GTT at the first opportunity after conception. If this result is normal, it should be repeated at the usual testing time of 24 28 weeks. 6 Table 2 High risk factors for GDM Previous GDM Previously elevated blood glucose level Impact of the new diagnostic criteria Clinicians have been concerned that the introduction of the new diagnostic criteria will significantly increase workloads with more women being diagnosed with GDM. A study was conducted in Wollongong, New South Wales assessing the impact of the new criteria. The conclusion of the study was that rates of diagnosis of GDM in their population would increase from 9.6% to 13%. 7 Although not as considerable an increase as initially projected, as diabetes educators we need to be ready to meet this demand and ensure we have the required skills and knowledge to provide appropriate education for women diagnosed with GDM. The role of the diabetes educator A diagnosis of GDM often brings about a number of emotional issues and concerns for a woman and her partner. Pregnancy blogs are filled with statements such as So many thoughts quickly ran through my head - did I do something wrong to trigger this? Have I put my baby at risk? What the heck comes next? Women frequently present for education in a heightened state of anxiety. The challenge for us as diabetes educators is to ensure the woman understands Ethnicity: Asian, Indian, Aboriginal, Torres Strait Islander, Pacific Islander, Maori, Middle Eastern, non-white African Maternal age 40 years Family history of diabetes (1 st degree relative with diabetes or a sister with GDM) Obesity, especially if BMI > 35 (kg/m2) Previous Macrosomia (baby with birth weight > 4500g or > 90 th centile) Polycystic Ovarian Syndrome Medications: corticosteroids, antipsychotics her diagnosis of GDM and is equipped with necessary self management skills to optimise her outcomes when her pregnancy is complicated by GDM. Key components of education include: An overview of GDM and the effects for a mother and baby Self blood glucose monitoring, testing times and target ranges Medical nutrition therapy - preferably with an Accredited Practising Dietitian Benefits of physical activity to improve glycaemic control Appropriate gestational weight gain Use of Metformin or Insulin therapy if required The importance of having a post natal glucose tolerance test Increased risk of developing type 2 diabetes GDM risk and future pregnancies Diabetes educators primary qualifications are varied. To be able to engage in meaningful conversations and education with women and other members of the health care team we should aim to increase our knowledge of the stages of pregnancy and the metabolic changes and insulin resistance which occur. Understanding the terminology of pregnancy will enable us to achieve this. It is vital that education is provided promptly after diagnosis, preferably within one week. Regular review and support will assist a woman diagnosed with GDM to gain confidence quickly with the new self management skills required. All this needs to be achieved while working within a limited time frame as diagnosis to birthing is only a matter of weeks. A clear explanation of the hormonal effects of human placental lactogen and cortisol and the resulting insulin resistance which occurs during pregnancy will help a woman to understand her diagnosis of GDM. Some women are unable to increase their insulin production, leading to elevated maternal blood glucose levels. It can be frustrating and challenging for women when their best efforts with dietary modifications and physical activity don t translate to achieving the desired glycaemic control. Nutritional advice should be delivered by an Accredited Practising Dietitian when possible. Ensure a woman understands the need to continue to eat regularly and include choices from all food CONTINUED ON PAGE 22 21
Feature Article FROM PAGE 21 groups to meet the nutritional requirements of pregnancy. Being too restrictive with food intake can be seen when a woman tries to achieve glycaemic control with severe dietary modifications to avoid the need for medication. Recommended weight gain in pregnancy is provided in Table 3. Regular physical activity is recommended according to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) guidelines. Thirty minutes each day of low impact, moderate intensity physical activity is considered safe provided a woman has no other pregnancy complications e.g. premature labour or bleeding. Advice should be obtained from the woman s maternity care provider. Changes to glycaemic treatment targets are yet to be agreed upon and it is advisable to check with local facilities and clinicians regarding agreed treatment levels. This has been identified as an area requiring further research. Table 3 Recommended weight gain in pregnancy* Pre pregnancy Body Mass Index < 18.5 12.5 18kg 18.5 24.9 11.5 16kg 25 29.9 7 11.5kg Above 30 Conclusion GDM is one of the most common medical complications of pregnancy. Professor Paul Zimmet, Co-Chair, National Diabetes Advisory Group, has asked for a greater focus on GDM as women and their children are at an increased risk of developing diabetes in the future. He has stated that health experts needed to start as early as pregnancy if they were to lower the rate of diabetes in Australia. Australian Diabetes Educator, Volume 17 Number 3, August 2014 Recommended weight gain 5 9 kg *Institute of Medicine Recommendations 2009 8 A multidisciplinary team approach to care is considered the gold standard (figure 1). Diabetes educators are valued members of this team. Ensuring we are up to date in our knowledge of GDM, familiarising ourselves with local management protocols and being well versed in pregnancy terminology ensures our ongoing value as part of this team. It is unknown what the exact impact will be on workloads with the introduction of the new diagnostic criteria, but if we achieve these goals we will be ready to meet the challenge. References: CDE Dietitian Pregnant Woman Midwife Obstetrician Endocrinologist Figure 1: The multidisciplinary team work collaboratively with the pregnant woman diagnosed with GDM - aiming to achieve the best outcome for the mother and her baby. 22