Gestational Diabetes: Addressing the Needs of Women in Colorado

1. Gestational Diabetes:Addressing the Needs of Women in Colorado Gestational Diabetes is glucose intolerance identified for the first time during pregnancy. Gestational Diabetes is glucose intolerance identified for the first time during pregnancy.

2. Overflowing the System What can we do to change this? Women with a history of GDM can lower their risk for later type 2 diabetes. The Diabetes Prevention Program (DPP) showed that participants randomly assigned to an intensive lifestyle intervention reduced their risk for type 2 diabetes by 58 percent. These individuals lost 5 to 7 percent of their body weight by following a low-fat, low-calorie meal plan and getting 30 minutes of physical activity five days per week. The powerful reduction in risk of diabetes shown in the DPP was found in all subgroups including several hundred women with a history of GDM. Women who have had GDM need to: Get tested for diabetes six to 12 weeks after their baby is born, then every one to two years. Talk to their doctor if they plan to become pregnancy again. Breastfeed to lower their child’s risk for diabetes. Reach their pre-pregnancy weight six to 12 months after the baby is born. Then, if still overweight, work to lose at least 5 to 7 percent (10-14 pounds for a person who weight 200 pounds) of body weight slowly, over time, and keep it off. Eat foods low in fat and calories and get 30 minutes of physical activity, five days a week. Help their children lower their risk for type 2 diabetes by learning to make healthy food choices, being physically active 60 minutes a day, and not becoming overweight. Encourage their family to follow a healthy lifestyle by eating small portions of healthy foods and moving more. Women with a history of GDM can lower their risk for later type 2 diabetes. The Diabetes Prevention Program (DPP) showed that participants randomly assigned to an intensive lifestyle intervention reduced their risk for type 2 diabetes by 58 percent. These individuals lost 5 to 7 percent of their body weight by following a low-fat, low-calorie meal plan and getting 30 minutes of physical activity five days per week. The powerful reduction in risk of diabetes shown in the DPP was found in all subgroups including several hundred women with a history of GDM. Women who have had GDM need to: Get tested for diabetes six to 12 weeks after their baby is born, then every one to two years. Talk to their doctor if they plan to become pregnancy again. Breastfeed to lower their child’s risk for diabetes. Reach their pre-pregnancy weight six to 12 months after the baby is born. Then, if still overweight, work to lose at least 5 to 7 percent (10-14 pounds for a person who weight 200 pounds) of body weight slowly, over time, and keep it off. Eat foods low in fat and calories and get 30 minutes of physical activity, five days a week. Help their children lower their risk for type 2 diabetes by learning to make healthy food choices, being physically active 60 minutes a day, and not becoming overweight. Encourage their family to follow a healthy lifestyle by eating small portions of healthy foods and moving more.

3. Public Health System Improvement Develop clinical care and nutrition guidelines for Gestational Diabetes based on the most current research available Disseminate and offer training on the guidelines to all medical and community health providers to promote the guidelines as the standard of care Integrate medical prenatal care with community based-systems Conversations with partners indicate statewide lack of resources and inconsistent quality care for GDM. There is limited access to quality care and education for women with gestational diabetes (GDM) throughout Colorado, particularly in underserved and disparate populations. Conversations with partners indicate statewide lack of resources and inconsistent quality care for GDM. There is limited access to quality care and education for women with gestational diabetes (GDM) throughout Colorado, particularly in underserved and disparate populations.

4. GDM in Colorado and the US ~7.4% of moms in Colorado have diabetic pregnancies1 (~5,000 women) Incidence has doubled in the last 7-8 years from 2-5% of population to ~4-12% Estimate about 200,000 women in the US every year (ADA, 2004) Most likely to develop GDM: Older (35+) Lower education (< 12 years) Previous birth Hispanic Lower income Medicaid In the United States, GDM affects about 7 percent of all pregnancies, resulting in more than 200,000 cases annually. The prevalence rate in Colorado, 7.4% (4,800 births annually), is above the national average of 7 % (200,000 births annually) In Colorado, the rate of GDM has doubled since 1996 and it is estimated that 4,800 women are affected by GDM every year, making it one of the top health concerns related to pregnancy. Women with diabetes during pregnancy also report less education (9.5% report < 12 years) and lower socioeconomic status (7.4% report < $15,999 annual income and 8.2% report $16,000 to $24,999). In the United States, GDM affects about 7 percent of all pregnancies, resulting in more than 200,000 cases annually. The prevalence rate in Colorado, 7.4% (4,800 births annually), is above the national average of 7 % (200,000 births annually) In Colorado, the rate of GDM has doubled since 1996 and it is estimated that 4,800 women are affected by GDM every year, making it one of the top health concerns related to pregnancy. Women with diabetes during pregnancy also report less education (9.5% report < 12 years) and lower socioeconomic status (7.4% report < $15,999 annual income and 8.2% report $16,000 to $24,999).

5. Now we are looking at results for women with diabetes during pregnancy. Based on results from the Pregnancy Risk Assessment and Monitoring System or PRAMS from 2004-2006, 4.5% of Colorado teenagers who gave birth had diabetes during pregnancy. As age increased, so did the percent reporting diabetes during pregnancy, such that, almost 11% of the women age 35 or older who gave birth reported having diabetes during their pregnancy.Now we are looking at results for women with diabetes during pregnancy. Based on results from the Pregnancy Risk Assessment and Monitoring System or PRAMS from 2004-2006, 4.5% of Colorado teenagers who gave birth had diabetes during pregnancy. As age increased, so did the percent reporting diabetes during pregnancy, such that, almost 11% of the women age 35 or older who gave birth reported having diabetes during their pregnancy.

6. Over 11% of the Hispanic women who gave birth during 2004-2006 reported having diabetes during their pregnancy. Disparate populations are at a higher risk of developing GDM According to Colorado PRAMS (Pregnancy Risk Assessment Monitoring System), the percent of women who report having diabetes during pregnancy has been steadily increasing, especially in women from high-risk racial and ethnic groups. The rate of GDM in Hispanic/Latino women (11.3%), and other ethnic populations (9.2%), is higher than that for Caucasian women (6.1%). African-American women have the lowest rate reported in PRAMS (5.1%). Over 11% of the Hispanic women who gave birth during 2004-2006 reported having diabetes during their pregnancy. Disparate populations are at a higher risk of developing GDM According to Colorado PRAMS (Pregnancy Risk Assessment Monitoring System), the percent of women who report having diabetes during pregnancy has been steadily increasing, especially in women from high-risk racial and ethnic groups. The rate of GDM in Hispanic/Latino women (11.3%), and other ethnic populations (9.2%), is higher than that for Caucasian women (6.1%). African-American women have the lowest rate reported in PRAMS (5.1%).

7. Why Is This A Problem for Mom? Intensive monitoring of blood glucoses, diet restrictions, insulin injections or meds, increased frequency of prenatal visits, financial burden Higher risk of infections Higher risk of C-section ~50-80% Maternal risk of developing Type 2 Diabetes in 5-10 years!!! Gestational Diabetes also has a conversion rate to type 2 diabetes of 50-80% within 5-10 years following the affected pregnancy. Gestational Diabetes also has a conversion rate to type 2 diabetes of 50-80% within 5-10 years following the affected pregnancy.

8. Why Is This A Problem for Baby? Babies have central obesity and can’t get through the birth canal?birth trauma Babies at ? risk of stillbirth because they can outgrow their oxygen supply Babies have problems regulating their glucose at birth and may need NICU Babies develop enlargement of their pancreas, heart, and liver Babies at ? risk for developing childhood obesity and Type 2 “adult onset” diabetes!!

9. Systems Approach Professional Webcasts with Physician Champion Guideline Development GDM Toolkit Development On-Site Training Provision of Educational Materials

10. Physician Champion Presented webcast on current recommendations Advisor to guideline development Consultant for trainings, responded to technical questions Continues to present to professional organizations throughout Colorado and nationally

11. Webcasts Gestational Diabetes: New Concepts, New Guidelines Provided 2 free webcasts in February & March 2007 – 101 active participants, 20 online archive participants Presented findings from the recent landmark trials which shaped the recommendations from the 5th International Workshop on Gestational Diabetes Offered 1.5 CME (through 3/08) - $15 Disk archive still available through DPCP 2 web casts – free to participants 1.5 CME - $15.00 (first 12 months) Remains available via archive Distributed statewide from DPCP Provided training opportunities for health care professional and paraprofessionals on GDM clinical guidelines ·  To understand the existing controversies in the diagnosis and management of gestational diabetes Also available online through 3/6/08! Viewer-login access: http://www.vcall.com/replay Replay # 1286132638 ·  To interpret the findings from the most recent landmark trials which shaped the recommendations from the 5th International Workshop on Gestational Diabetes ·  To describe how to use a fetal-based strategy for the optimal treatment of GDM To recognize the long term implications of GDM for both infant and mother and the appropriate postpartum recommendations 2-28-07 48 individuals representing 35 sites (10 CHC’s representing 18 facilities) + Wyoming, MN, Utah, NB, SD, ND, MT, ID 3-7-07 53 individual 15 requested CME Archive additional 20 and additional 8 requested CME Total = 121 documented participants 2 web casts – free to participants 1.5 CME - $15.00 (first 12 months) Remains available via archive Distributed statewide from DPCP Provided training opportunities for health care professional and paraprofessionals on GDM clinical guidelines ·  To understand the existing controversies in the diagnosis and management of gestational diabetes Also available online through 3/6/08! Viewer-login access: http://www.vcall.com/replay Replay # 1286132638 ·  To interpret the findings from the most recent landmark trials which shaped the recommendations from the 5th International Workshop on Gestational Diabetes ·  To describe how to use a fetal-based strategy for the optimal treatment of GDM To recognize the long term implications of GDM for both infant and mother and the appropriate postpartum recommendations 2-28-07 48 individuals representing 35 sites (10 CHC’s representing 18 facilities) + Wyoming, MN, Utah, NB, SD, ND, MT, ID 3-7-07 53 individual 15 requested CME Archive additional 20 and additional 8 requested CME Total = 121 documented participants

12. Clinical and Nutrition Guidelines for GDM Developed in collaboration with the Colorado Clinical Guidelines Collaborative – an organization dedicated to development of standard recommendations for medical care GDM Work Group, including nutrition professionals, diabetes educators and Physician Champion, worked to develop guidelines to increase provider awareness and engage community partners (paraprofessionals) in evidence-based approaches to GDM care. Distributed to physicians, midwifery clinics, other community health partners through a variety of methods: mailings, conferences, meetings, posting on CCGC and DPCP website. Developed in collaboration with the Colorado Clinical Guidelines Collaborative – an organization dedicated to development of standard recommendations for medical care GDM Work Group, including nutrition professionals, diabetes educators and Physician Champion, worked to develop guidelines to increase provider awareness and engage community partners (paraprofessionals) in evidence-based approaches to GDM care. Distributed to physicians, midwifery clinics, other community health partners through a variety of methods: mailings, conferences, meetings, posting on CCGC and DPCP website.

13. GDM Guideline Recommendations Early screening & education for high-risk women Universal screening between 24-28 weeks of pregnancy Follow-up glucose test at the 6-week postpartum appointment to determine if the woman has developed type 2 diabetes, pre-diabetes or has a normal blood sugar.

14. GDM Tool Kit Development 1-hour and 3-hour Instruction Sheet My Diabetes Record GDM Flowsheet Weight Gain Grid Postpartum Flyer & Reminder Card Educational Materials BASIC Materials Web Resources Used GDM Work Group as a resource againUsed GDM Work Group as a resource again

15. Regional On-Site Trainings Recognize Risk Factors for GDM Learn to relate all Guidelines to GDM practice Recognize client challenges and barriers to adequate care Be aware of educational resources and tools for GDM Understand long term risk of GDM in the development of type 2 diabetes in mother/child Discuss GDM network and current systems within each community and ways to expand these systems Provided 8 regional trainings for health care professionals and paraprofessionals on GDM nutrition guidelines and client educational. Provided print materials for the uniform treatment and care of women with GDM that would be linguistically and culturally appropriate for the target population. Partnerships with public health nurses, community health centers, WIC, and Prenatal Plus and others to identify the paraprofessional network to be trained to work with women with GDM in the local community. Provided 8 regional trainings for health care professionals and paraprofessionals on GDM nutrition guidelines and client educational. Provided print materials for the uniform treatment and care of women with GDM that would be linguistically and culturally appropriate for the target population. Partnerships with public health nurses, community health centers, WIC, and Prenatal Plus and others to identify the paraprofessional network to be trained to work with women with GDM in the local community.

16. Training Success 8 regional trainings were completed with 254 individuals attending the 6 hour workshop 66% of the workshop participants completed a personal action plan Of those who completed a personal action plan, 85% took actions in their work as a result of attending the training. Differences from pre ? post knowledge in the areas addressed in the objectives was statistically significant based on self assessment Most highly requested additional item: Educational DVD in English and Spanish featuring women of color with GDM explaining the dietary and lifestyle requirements for proper treatment of GDM. Most highly requested additional item: Educational DVD in English and Spanish featuring women of color with GDM explaining the dietary and lifestyle requirements for proper treatment of GDM.

17. Training Success (cont.) 3-6 months after the training, participants working in a clinical setting, related that they were following the recommendations in the clinical guidelines regarding: Early Risk Assessment at Initial Visit - 78% Universal Screening at 24-28 weeks - 68% Postpartum Follow-up with 2-hour OGTT - 56% 25% of individuals from the training contacted another participant who could be a resource 23% of workshop participants reordered educational materials

18. Educational Materials Free to training participants International Diabetes Center National Diabetes Education Program FY 08 FY 09 to date Basics 39 8 Taking Care of GDM 874 109 It’s Never too Early 790 107 What I need to know 879 140 GDM Prevention Series 77 60 12+ FY 08 FY 09 to date Basics 39 8 Taking Care of GDM 874 109 It’s Never too Early 790 107 What I need to know 879 140 GDM Prevention Series 77 60 12+

19. Challenges Changing medical practice is difficult to achieve Specialty medical care for GDM can be difficult to obtain in rural areas

20. Lessons Learned Having a physician champion was an integral component of our success Developing a standard of care brought together a network of providers offering the same message Using multiple methods of distribution helped us to reach as many providers as possible

21. Future Data on GDM in Colorado Starting in 2009: New PRAMS Questions added to monitor universal screening rates, postpartum follow-up and adequacy of GDM education During this pregnancy, did you have a blood test that required you to drink a very sweet liquid at 6-7 months of pregnancy? Since you new baby was born, have you been tested for diabetes or high blood sugar? Asking these question in PRAMS will tell us if we are making progress with health care providers in screening and diagnosing GDM in all pregnant women and providing appropriate post-partum follow up. This information can be used to influence policy decision and also to plan research activities. This information assists the CDPCP with program planning to target high risk women for interventions and to assure that CO health care providers are delivering high standards of pre- and post-natal care. Asking these question in PRAMS will tell us if we are making progress with health care providers in screening and diagnosing GDM in all pregnant women and providing appropriate post-partum follow up. This information can be used to influence policy decision and also to plan research activities. This information assists the CDPCP with program planning to target high risk women for interventions and to assure that CO health care providers are delivering high standards of pre- and post-natal care.

22. Future Data on GDM in Colorado (cont.) During this pregnancy, when you were told that you had GDM, did a doctor, nurse or other health care worker do any of the things listed below: Refer you to a nutritionist/dietitian Talk to you about the importance of exercise/being physically active Talk to you about getting to and staying at a healthy weight after delivery Suggest that you breastfeed your new baby Talk to you about your risk for developing type 2 diabetes

23. Continued GDM Work Update to the Guidelines based on review of recently released studies Hyperglycemia and Adverse Pregnancy Outcome Study (HAPO) National Institute of Child Health and Human Development (NICHD) MiG Trial Additional webcasts addressing GDM Clinical Guidelines and Nutrition Guidelines Potential online learning module for clients The Hyperglycemia and Adverse Pregnancy Outcomes Study (HAPO) is jointly sponsored by the ADA, NICHD, and NIDDK. This trial will examine the effects of hyperglycemia on pregnancy outcomes. It is a population-based study attempting to recruit all pregnancy women at 16 sites. It aims to recruit 25,000 women of all cultural and ethnic backgrounds. The study’s primary hypothesis is that hyperglycemia during pregnancy, less severe than diabetes mellitus, is associated with increased risk of adverse maternal, fetal, and neonatal outcomes that are independently related to the degree of metabolic disturbance. The study will examine glucose tolerance in the third trimester of pregnancy and aims to establish internationally acceptable criteria for the diagnosis and classification of gestationalThe Hyperglycemia and Adverse Pregnancy Outcomes Study (HAPO) is jointly sponsored by the ADA, NICHD, and NIDDK. This trial will examine the effects of hyperglycemia on pregnancy outcomes. It is a population-based study attempting to recruit all pregnancy women at 16 sites. It aims to recruit 25,000 women of all cultural and ethnic backgrounds. The study’s primary hypothesis is that hyperglycemia during pregnancy, less severe than diabetes mellitus, is associated with increased risk of adverse maternal, fetal, and neonatal outcomes that are independently related to the degree of metabolic disturbance. The study will examine glucose tolerance in the third trimester of pregnancy and aims to establish internationally acceptable criteria for the diagnosis and classification of gestational

24. Conclusion Create a standard of care for women at risk for, and diagnosed with, GDM to improve the health status of women during pregnancy and their birth outcomes. Use a systems approach to establish a powerful network of healthcare professionals and community workers that speak uniformly to women with GDM for improved access and quality care in Colorado.