Transcript Division of Reproductive Health Diabetes Prevention

Gestational Diabetes Mellitus:
An Opportunity to Prevent or Delay Type
2 Diabetes
Patricia Dietz, DrPH
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
Overview of Presentation
1) Definition of GDM and diagnosis
2) Prevalence, risk factors, trends
3) Risk of development of type 2 diabetes
4) Postpartum screening and prevention
of type 2 diabetes
5) Strategies to improve postpartum care
and long-term follow up
6) West Virginia and CDC activities
GDM – an Opportunity for
Prevention

GDM is typically viewed as condition that affects
infant outcomes.

Pregnancy provides an opportunity to identify highrisk individuals at a relatively young age and to
prevent the development of future type 2 diabetes

Pregnancy can be a “stress test” for diabetes.
Normal physiological changes of pregnancy such as
increased insulin resistance can unmask underlying
maternal predisposition to diabetes.
Physiologic Changes of Pregnancy:
Insulin Resistance


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Facilitates transfer of glucose to the fetus
2/3 decrease in insulin sensitivity by late pregnancy
 Levels of insulin sensitivity approximate those
seen in type 2 diabetics
Mechanisms
 Insulin desensitizing placental hormones
 Increasing maternal adiposity
To maintain euglycemia, insulin production is
increased by 200-250%
Overview of Presentation
1) Definition of GDM and diagnosis
2) Prevalence, risk factors, trends
3) Risk of development of type 2 diabetes
4) Prevention of type 2 diabetes
5) Strategies to improve postpartum care
and long-term follow up
6) West Virginia and CDC activities
GDM


Any degree of glucose intolerance with
onset or first recognition during
pregnancy
Glucose intolerance may have
preceded pregnancy
Typical Scenario

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At 24-28 weeks >95% of women are
given a 1-hr oral glucose screen
Values of 135 (140)-200 mg/dl second
screen
3-hr oral glucose tolerance test


2 abnormal values, cut points can differ
These cut points are different than
those used outside of pregnancy to
identify pre-diabetes and diabetes
Atypical scenario

Early in pregnancy
Obese women
 Women with previous GDM

Complications Associated
with Gestational Diabetes


Mother

Pregnancy-associated hypertension

Preeclampsia
Infant
Large for gestational age
 Birth Trauma
 Hypoglycemia

Guidelines for Screening during
Pregnancy

2008 US Preventative Services Task Force
concluded insufficient evidence to assess
benefit/harm for screening and treatment for GDM

Recent 2011 IOM report recommended women
receive the GDM screening/treatment
2011 IOM Report

Clinical Preventive Services for
Women: Closing the Gaps
Screening for gestational
diabetes in pregnant women
between 24 and 28 weeks of gestation
and at the first prenatal visit for
pregnant women identified to be
at high risk for diabetes.

Benefits of Treatment in Pregnancy

2 RCT found treatment effective

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Landon MB et al. NEJM 2009:361;1339-48
Crowther C et al. NEJM 2005:352;2477-86
Landon et al. study 958 women with GDM randomly
assigned to usual prenatal care or treatment
 Significant reductions in treatment group in
 mean birth weight
 neonatal fat mass
 large for gestational age
 shoulder dystocia
 cesarean delivery
 preeclampsia
Hyperglycemia and Adverse
Pregnancy Outcome Study

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6 year international study
Recruited approximately 25,000 pregnant women
at 15 centers in 9 countries
To explore the association of various levels of
glucose intolerance during the third trimester of
pregnancy and risk of adverse outcomes on the
baby
Results indicated strong, continuous associations
of maternal glucose levels below those diagnostic
of diabetes with increased birth weight and
increased cord-blood serum C-peptide levels.
Hyperglycemia and Adverse Pregnancy Outcomes, The HAPO Study
Cooperative Research Group; N Engl J Med 2008; 358:1991-2002
New Proposed Cut Points for GDM
Diagnoses during Pregnancy


Recommendation was proposed to lower the cut
points which would double the number diagnosed
with GDM
NIH consensus meeting planned for the fall of
2012
New Proposed Cut Points for GDM
Diagnoses during Pregnancy

Unanswered questions



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What is the burden placed on the health care system by
adding these additional GDM cases?
How effective is treatment at these lower levels of
glucose intolerance?
Are there any negative consequences of diagnosis at
these lower levels such as unnecessary c-sections,
maternal stress due to diagnosis and treatment?
What is the long term risk of developing type 2 diabetes
among women diagnosed at these lower levels?
Overview of Presentation
1) Definition of GDM and diagnosis
2) Prevalence, trends, risk factors
3) Risk of development of type 2 diabetes
4) Postpartum screening and prevention
of type 2 diabetes
5) Strategies to improve postpartum care
and long-term follow up
6) West Virginia and CDC activities
Prevalence in US

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4-8%, depends on the population
4.2% on US hospital discharge records
(NHDS) 2003-2004
Kaiser populations 3%-8%
Approximately 200,000 women
identified each year
Rates are increasing likely due to
increases in obesity
Prevalence in WV
The Pregnancy Risk Assessment
Monitoring System, PRAMS
 A survey of new mothers mailed a questionnaire 3
months on average after delivery, telephone
follow up
 Representative of all women who deliver a live
infant in the state
 PRAMS WV 2009 data
 9.7% of mothers self-reported they had been
diagnosed with GDM
 1,700 women affected

Non-modifiable Risk Factors
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Race/ethnicity
Age
Family history of diabetes
Age-Adjusted Incidence by
Race/Ethnicity
12
10
8
6
4
White
AA
2
Hispanic
A/PI
Overall
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Ferrara et al Obstet Gynecol 2004
GDM by Age,
PRAMS 7 States 2004-2006
9
8
7
6
% GDM
5
4
3
2
1
0
< 20 yrs
20-34 yrs
>=35 yrs
Family History

Women with a first- or second- degree
relative with diabetes mellitus type 1 or
2 have 2-3 times increased risk of GDM
compared to those without a family
history
Modifiable Risk Factors


Obesity
Weight gain between pregnancies
Percentage of pregnancies complicated by
GDM by prepregnancy BMI category
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2008
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1999
1990
2008
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Weight Gain Between Pregnancies


Women who gained 3 or more BMI units
between first and second pregnancy
 2x more likely to have GDM
 1.8x more likely to have gestational
hypertension
 1.9x more likely to have LGA infant
Associations held for normal weight women
Villamor E, Cnattinguis S. Interpregnancy weight change and risk of
adverse pregnancy outcomes: a population-based study. Lancet 2006;
368: 1164  1170.
Overview of Presentation
1) Definition of GDM and diagnosis
2) Prevalence, risk factors, trends
3) Risk for development of type 2
diabetes
4) Postpartum screening and prevention
of type 2 diabetes
5) Strategies to improve postpartum care
and long-term follow up
6) West Virginia and CDC activities

A history of GDM = Pre-diabetes
Future Risk

Women with a history of GDM have a
10-year risk for type 2 diabetes of up to
50%
RR for diabetes in women with GDM:
3 to 20
 RR for diabetes in adults with prediabetes:
3 to 20

Absolute Risk of Diabetes after GDM
Mean annual risk = 1.7%
Lee et al, Diabetes Care 2007
Overview of Presentation
1) Definition of GDM and diagnosis
2) Prevalence, risk factors, trends
3) Risk for development of type 2 diabetes
4) Postpartum diabetes screening and
prevention of type 2 diabetes
5) Strategies to improve postpartum care and
long-term follow up
6) West Virginia and CDC activities
National Practice GuidelinesPostpartum DM Screening for Women
with GDM
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ACOG

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ADA
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2 hr 75 g OGTT (preferred) or FPG
FPG (preferred) or 2 hr 75 g OGTT
5th International Workshop-Conference on
GDM

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2 hr 75-g OGTT
FPG misses 66% with IGT or Type2DM
ACOG Committee Opinion, 2009
ACOG Committee Opinion No. 435 Obset Gynecol 2009
Diabetes Prevention
Breastfeeding

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Protects the mother from developing type 2 diabetes
In 809 Latina women
 Non-lactating women developed postpartum
diabetes (9.4% vs. 4.2%) by 12 weeks postpartum
compared to lactating women
 Results still significant after adjusting for BMI,
age, and insulin use in pregnancy
Kjos SL, Henry O, Lee RM, Buchanan TA, Mishell DR: The effect of lactation on glucose and
lipid metabolism in women with recent gestational diabetes. Obstet Gynecol 82:451–455,
1993.
Diabetes Prevention

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RCTs: lifestyle modification and
pharmacotherapy can prevent or delay the
development of type 2 diabetes in high-risk
individuals (prediabetes)
DPP study:
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Lifestyle intervention reduced diabetes by 58%
Metformin reduced diabetes by 31%
Compared with unaffected women, those with a
history of GDM had…

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a 70% higher crude incidence rate of diabetes* (placebo)
a 50% reduction in diabetes risk with either lifestyle or
metformin therapy
Type 2 DM Risk in Women with
GDM: DPP Trial
Ratner et al, J Clin Endocrin Metab, 2008
Diabetes Prevention
YET

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Less than half of women with a diagnosis of
GDM obtain a postpartum glucose test
Even fewer receive an intervention for weight
management, physical activity
Linkages between obstetric care and primary
care are often missing
Overview of Presentation
1) Definition of GDM and diagnosis
2) Prevalence, risk factors, trends
3) Risk for development of type 2
diabetes
4) Postpartum diabetes screening and
prevention of type 2 diabetes
5) Strategies to improve postpartum care
and long-term follow up
6) West Virginia and CDC activities
Kaiser Permanente Northwest: Rates for Lab
Orders and Completed Postpartum Diabetes
Tests 1999-2006 among Women with GDM
100
Clinician orders
90
Completed tests
80
Percent
70
60
50
40
30
20
10
0
1999
2000
2001
2002
2003
2004
Year
Dietz et al. Postpartum Screening for Diabetes After a Gestational Diabetes
Mellitus-Affected Pregnancy Obstetrics & Gynecology: 2008 ;112:868-874
2005
2006
Intervention to Improve
Postpartum Screening

Updated clinical protocol and staff training

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Allows RN GDM care manager to place lab order for
postpartum diabetes test and encourages postpartum phone
reminders to complete test prior to postpartum visit
Education to all OB dept staff regarding longterm risk DM

Educational materials to clinic staff to give all GDM
patients

Changes in the electronic medical record to facilitate
reminders for lab orders and list of patients who need
reminders

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3 attempts to remind patient to return for postpartum diabetes
test
Preliminary data suggest significant increases in the
percentage of lab orders and completed tests
http://ndep.nih.gov/media/NeverTooEarly_Tipsheet.pdf?redirect=true
Periodic Screening
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Every year if IFG or IGT at postpartum
screen
3 years if normal at postpartum
screen
Before a planned pregnancy
Few studies have examined whether
women are screened for diabetes
after the postpartum period
Pap screening performed but not diabetes
screening
Smirinakis et al, Obstet Gynecol, 2005
Access to care a problem among women with histories of
GDM in the BRFSS
40
35
Percentage
30
25
Total
NHW
AA
Hispanic
NA/AN
Asian
20
15
10
5
0
No insurance Cost barriers
to doctor care
Kim, Sinco, Kieffer, Diabetes Care, 2007
No PCP
Exam over 1
year ago
Overview of Presentation
1) Definition of GDM and diagnosis
2) Prevalence, risk factors, trends
3) Risk of development of type 2 diabetes
4) Postpartum screening and prevention
of type 2 diabetes
5) Strategies to improve postpartum care
and long-term follow up
6) West Virginia and CDC activities
What’s Happening in West
Virginia
Collaboration with Association of
Maternal and Child Health
Programs and the National
Association of Chronic Disease
Directors
Activities to Date
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Kick off training in May 2009
Guidelines for diagnosis and treatment
GDM and Immunization Reminder Card
Addition of GDM information on
Diabetes Prevention Control Program
website
Survey of WIC participants to
understand barriers to postpartum
follow up (June-November)
West Virginia Team
Gina Wood – WV Diabetes Prevention
and Control Program
Belinda Summerfield –WV Diabetes Prevention and
Control Program
Melissa Baker - PRAMS project
Jessica Wright – Division of Health Promotion and
Chronic Disease
Mary Emmett – Charleston Area Medical Center
Dara Seybold – Charleston Area Medical Center
Anne Williams – Office of Maternal, Child, &
Family Health
Denise Smith – Perinatal Programs, Office of
Maternal, Child, & Family Health
WV PRAMS 2012 Births
During your most recent pregnancy, when you were told that
you had gestational diabetes, did a doctor, nurse, or other
health care worker do any of the things listed below?
a. Refer you to a nutritionist
b. Talk to you about the importance of exercise
c. Talk to you about getting to and staying at a healthy
weight after delivery
d. Suggest that you breastfeed your new baby
e. Talk to you about your risk for Type 2 diabetes
CDC Activities
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Expert meeting April 2007
Funding research on increasing postpartum
screening and adoption of DPP for postpartum
women
Ongoing surveillance
 Evaluation of PRAMS questions
 NYC and VT comparing to medical record
CDC Fact Sheet
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf

Summary
GDM Excellent Opportunity to
Prevent Type 2 Diabetes
4-8% of US pregnancies and 9.7% of WV
pregnancies are complicated by GDM
 Most pregnant women receive testing for GDM
during pregnancy
 Many postpartum women do NOT receive
postpartum diabetes testing
 Women with GDM=pre-diabetes


Prevention through diet and exercise effective in
preventing onset of type 2 diabetes
Summary
GDM Excellent Opportunity to
Prevent Type 2 Diabetes

WV
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Monitoring prevalence through PRAMS data
Reminding patients to get diabetes screen
postpartum with postcards
Educating OB/GYNS through distribution of
guidelines
Survey WIC participants to better understand
barriers to follow up care
West Virginia Example
17,550 births
9.7% GDM
1,700 with GDM
100% tested for DM
postpartum
35-85 (2-5%) identified
with diabetes
170-510 (1030%) IGT/IFG
1,615-1,665 (95-98%)-Need education on prevention of type 2 and referral
55
How Can We Get There?

The success of T2D prevention efforts for
women with hGDM lies in a multidisciplinary
approach
 All health care providers need to educate
women on the importance of postpartum
and periodic screening, prevention
activities, and provide referrals to DPP-like
programs
How Can We Get There?

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Obstetrician/perinatologist, gynecologist, nurse midwives
 Ensure clinical protocols have systems for reminders for
education and postpartum testing
Primary care/Internist/endocrinologist
 Ensure clinical protocols have systems for reminders for
asking about hGDM and last diabetes screen
Nutritionist, diabetes educator
 Educate women on the importance of postpartum and
periodic screening, prevention activities, and provide
referrals to DPP-like programs
Access to care, public health sector
 Explore ways to ensure diabetes screening is available and
affordable to those without insurance
Thank you!
Contact Information
Patricia Dietz, DrPH
Team Leader
Research and Evaluation Team
Applied Sciences Branch, DRH, CDC
[email protected]
770-488-5128
PRAMS Resource

http:/www.cdc.gov/prams/

WV PRAMS
Melissa A. Baker, M.A.
Epidemiologist II
Office of Maternal, Child, and Family Health
Division of Research, Evaluation and Planning
304-356-4438 New Number
304-558-3510 (fax)
[email protected]
[email protected]
304.558.0644