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Gestational Diabetes Mother and


									 Gestational Diabetes:
Addressing the Needs of
  Women in Colorado
    CityMatCH Conference
     September 22, 2008
        Overflowing the System
 What can          we do to change this?
New GDM Diagnosis

                              GDM Tub

                     Postpartum GDM Woman

                                             Type 2
Public Health System
 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
    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                    Source: Colorado Pregnancy Risk Assessment Monitoring System, 2005

      Source: Colorado Pregnancy Risk Assessment Monitoring System, 2004-2006
Health Disparities

          Source: Colorado Pregnancy Risk Assessment Monitoring System, 2004-2006
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!!!

                         * Slide adapted from Dr. Linda Barbour, 12.6.06
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!!

                               * Slide adapted from Dr. Linda Barbour, 12.6.06
       Systems Approach
 Professional Webcasts with Physician
 Guideline Development
 GDM Toolkit Development
 On-Site Training
 Provision of Educational Materials
         Physician Champion
Linda Barbour, MD, MSPH – Associate
Professor in Endocrinology and Maternal-Fetal
Medicine at the University of Colorado Health
Sciences Center

   Presented webcast on current recommendations
   Advisor to guideline development
   Consultant for trainings, responded to technical
   Continues to present to professional
    organizations throughout Colorado and
         Gestational Diabetes: New
          Concepts, New Guidelines
   Provided 2 free webcasts in February & March
    2007 – 101 active participants, 20 online archive
   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
Clinical and Nutrition
Guidelines for GDM
                 Increase knowledge
            of standard of care for GDM

          •Partnered with Colorado
          Clinical Guidelines
          •More than 6,000 printed and
          distributed to date
          •Distribution to physicians,
          midwives, community health
          workers through variety of
         GDM Guideline
 Early screening & education for high-risk
 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.
    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
    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
             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
        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
        Educational Materials
   Free to training participants
     International Diabetes Center
     National Diabetes Education Program
 Changing medical practice is difficult to
 Specialty medical care for GDM can be
  difficult to obtain in rural areas
         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
         Future Data on GDM in
   Starting in 2009: New PRAMS Questions
    added to monitor universal screening rates,
    postpartum follow-up and adequacy of GDM
     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?
      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
          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
 Potential online learning module for clients
   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.
            THANK YOU!
      Mandy McCulloch, RD

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