Third of women unaware gestational diabetes increases future risk

‘Women who’ve had gestational diabetes are 10 times more likely to develop type 2 diabetes, but only a third of these women understand that they are at high risk.’
 
That is lead researcher Kristy Gray, discussing the results of new research by the University of South Australia and University College Dublin.
 
The study, which involved a cross-sectional survey of 429 Australian women with a history of gestational diabetes, asked participants about issues such as their perceived risk of developing type 2 diabetes and potential barriers to weight loss.
 
Co-author Peter Clifton, a research professor at the University of South Australia, told newsGP he was surprised by these findings.
 
‘The striking thing about that survey was how few [women who have had gestational diabetes] – only about 30% – actually realised that it set them up to have an increased risk of type 2 diabetes,’ he said.
 
Even though women with gestational diabetes are advised to have a follow-up oral glucose tolerance test (OGTT) within three months of delivery, but Professor Clifton understands how that might not happen after bringing home a newborn baby.
 
‘There are so many things [to do] when you go home with a new baby that there isn’t that much time to think about it,’ he said. ‘It’s not a priority for them, really.’
 
Rather than asking new mothers to organise their own follow-up testing, Professor Clifton believes there needs to be more onus on the system to ensure new mums are followed up.
 
Dr Wendy Burton, Chair of RACGP Specific Interests Antenatal/Postnatal Care, told newsGP she is also surprised by the results of the survey, but believes the Australian system is well set up to support these women.
 
Firstly, she says, women who develop gestational diabetes are referred to a diabetes educator and dietitian during pregnancy. Patients who see an obstetrician during pregnancy will then be referred to an endocrinologist, while those who attend a hospital will be referred to the hospital’s clinic.
 
Furthermore, Dr Burton says the National Diabetes Service Scheme (NDSS) sends patients recalls and reminders for testing.
 
‘So there are a whole lot of systems in place to try to … make sure that women are appropriately followed up,’ she said.
 
‘There’s a whole lot of education that comes at them, so I would hope and expect then that they would take home from that they are at increased risk [of developing type 2 diabetes].’
 
According to the RACGP’s Management of type 2 diabetes: A handbook for general practice, women diagnosed with gestational diabetes should have a 75 g two-hour oral glucose tolerance test, preferably at 6–12 weeks postpartum, with classification according to World Health Organization criteria.
 
Despite these measures, co-researcher Associate Professor Jennifer Keogh from University of South Australia says ‘close to a quarter’ of the women in this study had not been tested for type 2 diabetes following a pregnancy with gestational diabetes. 
 
Dr Burton believes this finding highlights the need for more education.
 
‘We’re all doing what we can, but I guess we’ll keep trying,’ she said.
 
‘It’s just another reminder for us all to put them on a recall in our system [and] have those conversations.’
 
But having those conversations is not always easy.
 
‘It is difficult because, on the one hand, you don’t want to stress [these women] out too much or freak them out during the pregnancy,’ Dr Burton said.
 
‘And after the birth, they’ve got a lot of other things happening.’


Dr Wendy Burton says the new research acts as a reminder that more can be done to ensure women who have had gestational diabetes receive appropriate follow-up.

Professor Clifton says GPs are ideally placed to offer the follow-up these women need, but that the challenge lies in ensuring such patients see their GP in the first place.
 
‘Optimally, if the patient is told how much their risk [of type 2 diabetes] is increased, they would go to their GP,’ he said.
 
‘And the GP would certainly be best to handle it – if they go.’
 
RACGP guidelines also state that ‘postnatal education and support are important in preventing or delaying the onset of diabetes in the future, and women should be encouraged to attend postnatal testing’.
 
Another key aspect of the research, according to Professor Clifton, was the correlation between the weight of a woman who has had gestational diabetes and her risk of developing type 2 diabetes.
 
Ms Gray also said being overweight is a common risk factor for developing type 2 diabetes, making post-pregnancy weight loss important in preventing onset of this disease.
 
‘In our study, while 75% of the women surveyed understood that they were overweight, this knowledge didn’t translate into a high level of perceived risk,’ she said.
 
Associate Professor Keogh says the ‘most effective’ time to initiate and commit to a healthy lifestyle and behaviour change is up to two years after pregnancy.
 
‘Motivation to lose weight is a significant barrier to change, whether it be because of a busy family or because a lifestyle change can be hard to stick to,’ she said, ‘Consistent education, strong messaging and personalised care, can instigate positive change.’
 
Dr Burton agrees.
 
She says new mothers are a ‘motivated’ group and the post-pregnancy period is a ‘good time’ to initiate healthy lifestyle changes, and GPs can support such changes.
 
Professor Clifton believes GPs can help this process by making clear the significance of overweight and obesity on future risk of developing type 2 diabetes.
 
‘[Health professionals] probably need to say that if they haven’t lost their pregnancy weight and got back to their pre-pregnancy weight, any weight gain that persists and any further weight gain that happens obviously enhances their risk of type 2 diabetes,’ he said.
 
It is also important that women who have had gestational diabetes are aware of their risk of developing type 2 diabetes and its associated health implications.
 
‘Obviously the earlier the [onset of] type 2 diabetes, the longer the time for complications, so it’s important to make sure it’s identified and treated early,’ he said.
 
Rather than needing to treat type 2 diabetes, Professor Clifton says it is optimal to try and ensure that women who had gestational diabetes do not go on to develop the disease in the first place.
 
‘And certainly weight loss [or] weight restoration [to pre-pregnancy levels], if possible, is the optimal way to do it,’ he said.
 
But while the topic needs to be raised, Dr Burton says it is important to have an awareness of how it may be received by patients.
 
‘The language that we use matters,’ she said. ‘I think most people don’t like to hear that they’re obese, so language such as, “above an ideal weight” [is preferred].’
 
She says it also helps to explain to patients that weight loss does not need to be dramatic to yield significant health improvements.
 
Dr Burton advises telling patients that ‘even a 5–10% reduction in their body weight can improve their insulin sensitivity and make a big difference’, while patients also need to understand that efforts to lose weight can be supported by their GP.
 
‘We [can] continue to monitor this and be encouraging and supportive and open to information-giving,’ she said.
 
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