Diabetes During Pregnancy has Long Term Implications


Welcome back to the Healthcare Trieste. podcast today my guest is Dr David. Ha's he is the Muncie professor and Vice Chair for research in the Department of of Obstetrics Gynecology at Indiana University School of Medicine. This episode of the Healthcare Trash podcast is sponsored by Indiana University. School of Medicine whose mission is to advance ads health in the state of Indiana beyond by promoting innovation and excellence in education research and patient care. We're GONNA be talking about justice diabetes. Today how was it. Different from other diabetes. Why's it important and what we might do about it? David welcome thank you very much. I'm glad to be here so let's talk a bit. We'd like to talk when we introduce someone on the PODCASTS. Komo sort of how they got to this position. How did you decide? Ob Gyn was for you. And and how did you get into this line of work. Sure so it was actually one of the things. I didn't didn't WanNa do going into medical school. I told my wife I didn't WanNa do pediatrics. Or Obgyn you made the wrong choice and you know I got to the end of my third year. It was my last rotation Sean and I realized that it had the three things I really loved. I loved to do surgery. You got to do a little bit of primary care and there's nothing in the world like catching babies. But how did you get interested in additional diabetes. So I got interested diabetes because we just see a lot of women who have it and it's something that leads to a lifelong as long health consequence in terms of just Asia. Diabetes can be the first sign that a woman has difficulty with their glucose metabolism and how they process sugar and then it can go away for a while but then they have a high risk for it to come back later in life. Diabetes is a major public health crisis with they'll be city that's prevalent in the United States and the sedentary lifestyles and so if we can do something about it while a woman is pregnant and they're engaged in the health system system then potentially we could have public health impact later on down the road so I guess we should backup for second province over. What exactly ease station diabetes? And how is that different from Diabetes in general or other diabetes distasteful diabetes is what develops during pregnancy. So that's the definition of justice diabetes whereas type one or type two diabetes develops in childhood or adulthood and they're all related in the fact that the people have difficulty D. N. processing and utilizing the Sugar and the glucose better in the blood stream. And that's what sells need to do all of the activities that happen inside the body and the processes processes and so what happens during pregnancy though is that there are changes in a woman's body in the development As the baby is progressing using and the placenta is getting bigger that can make it harder for her to process the glucose and so they can become insulin resistant so the normal insulin that their body produces uses which helps drive glucose sugar into the cells so that they can be active and do the processes that they need to do. That isn't handled very well. Well and the baby and the mom become resistant to it when in pregnancy does this happen typically happens the later you get in pregnancy. So it's mostly a disease in the third trimester astor but there are signs that it can happen earlier in pregnancy and just develops us on a continuous base. That is it show up. I mean do to women notice that there's something nothing wrong or is it something we try to screen for pickup and a lab test while we do universal screening now in prayer for everybody in pregnancy because the lowest I risk group was so small that they found that from a public health perspective. It was much better to screen everybody so that we would pick them up but typically. There's not a lot of symptoms that go along with just a diabetes as the blood sugars would tend to rise throughout pregnancy. You could get things like a lot of urination so women would have to go to the bathroom a lot. They could get a little bit more swelling but generally those are things that happen sometimes during pregnancy pregnancy even when there is no station diabetes so it is something that it's difficult to pick up and a lot of people are surprised when they have it because they could be totally otherwise otherwise healthy and not have any symptoms of it. So why does this occur during pregnancy so this occurs during pregnancy mostly because because of physiologic changes in woman's body as the pregnancy develops a lot of people point to the Placenta and the development of the placenta it produces a substance called human placenta lack. degen which is abbreviated. HP L.. If if people hear of it that way but it can interfere with a woman's ability ready to utilize the insulin. That's normally in her body and does it usually just go away once. They've had a baby usually once the placentas gone than the the Human Placenta lactogen is gone as well and so most women even if they have relatively severe station diabetes where they're needing medication. Therapy weather weather. It's insulin or Metformin or other things. Even if they have severe station diabetes a lot of them the day or two postpartum their blood glucose returns to normal normal values. How many women does this affect? And how many women actually need intervention with medications like you mentioned sure so about seven percent of women will have some form of diabetes during in pregnancy so about one in every fourteen women And most of those are stationed diabetes to they only medication or what not all of them. The majority of women actually can be treated just with diet modification and with more physical activity can. That's sort of the first line treatments and so we'll check women. Sugars will have them. Actually they do. Finger Stick Glucose checks for fasting in the morning and then two hours or one hour after every meal that they have and then we watch and see how abnormal they are. If they're too high then we can modify their activity in their diet or if they need medication because those Behavioral changes aren't enough so given that it seems to comes in late in pregnancy and it can go away a day or two after the percent is gone. Why is it such the big issue? We feel like pregnancy. oftentimes is a woman's I stress test. It's a big strain on the normal physiologic processes assesses and the ability of a person to compensate for those things and so what we find is the things that happened in pregnancy predisposes people to conditions later in in life. And whether it's this is the start of it or this is just the place we pick up these bodily changes is still open to some debate but we know for instance since with high blood pressure. That women who have high blood pressure problems in pregnancy have a much higher risk of developing high blood pressure later in life even if it goes away after pregnancy and also cardiovascular disease in other respects diabetes is the same way women who have station diabetes. have up to a seventy percent. Lifetime risk of developing type two diabetes later in life. Seventy percent so seventy percents okay. So that would seem to be like this is a major risk factor for for developing diabetes. It's the number one. Risk factor for developing type two diabetes. Okay and I WANNA I WANNA go deeper into that but before I do the pediatrician to me has to ask. It is their impact on. The baby is an impact on the child. There is depending on how well the blood sugars are. Control during pregnancy can impact the immediate health of the baby. Pretty pretty quickly because even though mom isn't utilizing her insulin very well. The baby's just fine with its insulin. And so if her blood sugar is high that that goes straight through the placenta to the baby babies. Insulin is fine but it has to put out a lot of insulin to keep up with all of that sugar. Coming in and so- oh insulin also has insulin like growth factor so babies tend to get bigger in MOMS who have uncontrolled diabetes and that can make the birth process harder higher risks of things like having to be borne by sincerity and delivery but also after the birth happens and the umbilical cord is cut. That sugar pipeline has gone John. And the baby's insulin though is really high so babies can have low blood. Sugars sort of counterintuitive. The infants initially have low blood. Sugar so they can have issues as with recovering from that and eating extra feedings and IV fluids and long term. We know that babies of MOMS who had diabetes have a higher risk of diabetes and metabolic problems as well so is that. Do we know that. That's causal that that's the something along something that they were exposed to in euros. What's causing net versus You know could it be the whatever predisposed mom to diabetes to begin with would make the baby more lucrative diabetes. I mean that's still an open area of research I know there's associations associations but I don't know if there's actually a causal link that's been found yet because remember correctly to is there. Is there a link of obesity. Well there is. Yeah that's always fascinating because of course you know whatever sorta terminate life or even genetic factors which predispose MOMS to be obese. Andrew Have Diabetes WanNa but you also wonder if there could be something in development in in utero. Are People doing research in that area. They are so there's a lot of people who are looking at whether there's EPA genetic or other changes that happened from generation nation to generation that just have an additive effect on these health consequences so given that you're concerned there for a baby's glucose level after they're born Lee. How long long does that hypoglycemia risk exist? Is it just a couple of days or Do you need to be worried for longer. No it's usually pretty much within the first day. Okay you worry about it. And that's why we're we spend a lot of time on labor and delivery optimizing MOM's blood sugar share so they get their fingers poked a lot more frequently if their blood sugars. Here's our abnormal. Because we really want them to. Have you know pretty steady blood sugar during the labor process so that the baby gets exposed to the right concentration. What's interesting you treating mom with insulin and right up until delivery sometimes if their blood sugars are too high we treat him with insulin all right? Let's get back to mom so first of all. We were talking about the fact that this seems seems to be a major risk factor for developing diabetes. Later in life. I'm assuming that's type. Two diabetes or diabetes. It's type two diabetes. Now we've identified a major risk factor in mom Rather that she's GonNa get diabetes. Do we do anything about that. The goal is to prevent it. I mean that would be the ideal and so. That's one of the things that we're doing with some of our research in the precision health initiative diabetes project is. We're really trying to find out. How do we predict women who are going to get station diabetes? Because then then what we can do is try to figure out the right mechanisms and pathways that we can try to treat to try to avert them getting just diabetes in the first place. Because if they don't get the station diabetes then the thought would be that they have lowered that major risk factor. So that's one of the things that we're trying to look at because if we can prevent it that will hopefully have better downstream effects. You're trying to prevent diabetes preventing type two. We're preventing at sort of both arms. So what we're doing with the with. The diabetes project is in two phases. One phase is trying to better predict and prevent justice diabetes and then face twos group is really working on in women who get station diabetes. How can we better prevent them? From from developing type two diabetes or trying to attack it actually on both ends of the station diabetes. And what can we do to prevent diabetes. Well right now. We feel like women who are in low risk are people who are at ideal body weight who are active who have healthy diets but that sort of is a small. Small percentage of people that get just diabetes. And so what we don't know right now is how we can prevent it. So that's what we're doing active research and trying into figure out from a genetic standpoint from a behavioral standpoint dietary are there certain protein biomarkers that are strongly associated associated with the development of station diabetes. That we could potentially see as predictive targets. So you're talking about looking for ways to prevent it with medication potentially okay because usually when we talk about preventing type two diabetes a lot of Diet and exercise which always you know the population base guy me as always like like. That's good advice for everyone. Not just people who are at risk for for just diabetes. But you're going beyond that you're actually thinking we might be able to find specific targets that we could it actually develop medications for the might specifically prevent generational diabetes correct. Would those same drugs used to treat regular I mean raillard up with those same drugs B.'s. The treat other type two who diabetes or do you think they'll be specific to just ational. I think they could be used. It depends on the pathways that we identify if they are similar to those is that we identify in women who have type two diabetes or even type one diabetes than those could be some that we would investigate in that area too so we think that women get just asional diabetes. And you were saying that. It's for the first stress test then. My mind immediately went to. We've just unmask. Ask the risk that now. We've identified the women who are at high risk for diabetes in general and we should therefore try to prevent type two diabetes. But if we're specifically trying to prevent diabetes medication is it that you think the actual development of justice diabetes somehow changes a woman in such a way that she's then at high risk ask for type two diabetes. That's a great question. And that's actually an area of debate that we've had with experts in the field and there are some who believe that. Just women have diabetes really. It's a spectrum disease and they've already been on this path and it just happens to be that this is the snapshot we've taken to identify. Identify it because a lot of people don't get a lot of routine healthcare right until they become pregnant and then they engage in the health system. There are those who though feel the other way that this is sort of that stress test and that they didn't have problems with their glucose before this is really the thing that's tipping them over the edge and starting cascade so there's discussion on both ends if it's a total spectrum and that this is just a snapshot of diagnosis is that we've come to. That is something. We can't stop just in pregnancy but we can try to maybe divert the course a little bit to improve their health. long-term long-term fascinating. Is this more common than it used to be. It's definitely more common than it used to be is that we're better picking it up or is that really it's comedies. It's really that it's more common. You know we've you've been doing. Universal screening for a long time but as the population in the United States has risen in the rates of obesity and sedentary lifestyle. That really has driven up. The rates is just diabetes. Like a marker for the broader problem that we have do you think or is it a specific entity that we need to get a handle on And doing so would actually reduce risk overall. I think it probably could be both okay to be honest with you. I think that it definitely is a byproduct of some of the behavioral things that we're doing as a society and some of the the lack of activity that that a lot of people are doing but I think in general I think we do have a potential here to impact health long term for people and if if this is the tool tool that we can utilize for women's health. At least that if you get if you have this condition developed while you're pregnant this is really the risk factor and maybe this is. What actually gets them to do something about it? Because you're right. Everybody talks about Diet exercise and at the end of the day. I think that we've become a little bit death to that as a society because everybody keeps Syrup Diet and exercise right and so if this is what gets them off of the couch and gets them into some kind of a program. That's the goal if it can impact public health. Yep General so do you. Is this the kind of thing that I think we're looking at are you. There is evidence that says we can use this as a moment. I think we're more looking at that. I think we're trying to capitalize relies on it as a moment rhino from Diabetes Prevention Program that we can reduce the rate of diabetes. If you engage in one of his healthy lifestyle style programs so what we're trying to do in our second phase really is take women who had just as diabetes. So we've gotten this snapshot we know that these women are at super super high risk and engage them better in programs figure out what works with their lifestyle do more of an individualized personalized is precision. Kind of way to get them engaged in a program whether it's with their family whether it's at a Ymca through weightwatchers programs of virtual online thing but try to figure out what is the best way to engage people in these healthy lifestyles that can be sustainable. Are there disparities with this or is it affect all women about the same or certain races or socioeconomic classes more likely to be associated with diabetes. The highest risk groups are women who are older when they're when they're pregnant and also there are racial and ethnic distribution so we tend to see a large risk of this in Hispanic women. Asian women women and one of the really sort of striking things about just as diabetes transitioned type. Two diabetes is. It's particularly really hard on Hispanic women in that. Fifty percent of the Hispanic women will develop this within five years of their pregnant diabetes. Build about tie to diabetes eighties fifty percent women who have just developed. Ib Five years in five. That's horrifying it's horrifying. Which is why this is such an important thing that that people don't talk about? I'm like I can't believe I did not know that and I can't believe that that's not you know front page news. That's horrifying we've talked about before we've seen a lot the news in fact that maternal mortality is a real problem. Right now. Is this diabetes part of the reason for that or is it true chewing unrelated. I wouldn't necessarily it's unrelated but I don't think that it's a major driver. Okay now we do know that. Women who have just ational diabetes have a higher rate of pre ECLAMPSIA and high blood pressure and pregnancy. And that that is a driver of maternal mortality. And so it's sort of quasi related it's sort of on that pathway because we know that people blue have one complication of pregnancy. Tend to develop more. So I'm going to get back to the horrifying statistic as I can't get that in my mind so I mean any group that has is a fifty percent chance of a bad outcome would seem to be right for an intervention. I mean I just can't believe that you know that's not a public health crisis. The people are not saying like we need an intervention. I've if I said you have a fifty percent chance of developing heart disease in the next few years we would have a drug in. Everyone would be on it yesterday. knowing that his is there a real move to try to figure out. How do we prevent this or at least get all of those people into a diabetes prevention program or something like it? There are a lot. AWW Health System based and community based program would seem. Just how an insurance stamp. When you're over weight those costs? Yeah like it'd be a massive. I mean we. We discussed before to help. Prevention rarely saves money. But if I knew that there was a fifty percent chance of a bad outcome and a certain population that will cost me a fair amount of money in the short term. It would seem like that would be where I'd want to invest right now. Well I think the one of the problems is we don't have a drug right. We don't have the the magic pill that's going to prevent diabetes right. Maybe we can find one maybe in all this research that we're doing we can find one that's part of the grand challenges L. Inches to prevent a chronic disease. We can do that but I think that there are a lot of programs that people are trying to engage in insurance companies will help Pay For some gym memberships and things where you can make lifestyle modifications have but I think it gets back to then people disengaged from the health system system until they get older and they just don't the momentum is really hard to maintain even when you tell people flat out there's a fifty eighty percent chance in five years you'll have diabetes. Yeah yeah that's amazing. I mean because again it's like I think we we. We scare people with numbers a lot. But that number is truly scary. It needs no fudging That's an absolute risk like that's just that's just amazing. So what are you most optimistic about like. Where do you think the Best Bang for the buck is or what do you think is GonNa make a big difference in the future in the future if we can prevent the women from getting stationed Jason Diabetes in the first place? I'm very excited about a lot of the collaborative work that we're doing with some investigators down at Iu Bloomington and in computer science and a lot out of interdisciplinary people. That are coming at this from a lot of different ways. Whether it's we put a fitbit or activity tracker on everybody and that helps motivate them during the early part of pregnancy or trying to do some interesting work with how do we look at nutrition content and can you take pictures of your food and figure out what your nutrition is. We're looking at but proteins in the blood that could be used as biomarkers. We've got genetics so I think it really gets me excited that we're trying to approach this from multiple aspects and then really smart computer. Scientists are going to try to throw this all together. And and come up with some really good predictive models and looking at pathways and proteins we could potentially use as early predictors. So that in the first trimester her during some of the early screening tests you know when they get blood tests to see if they're anemic or if there's any increase risks for baby they could get a test that would say this is your risk of diabetes and we need to do these things to help lower that rhys not to be a naysayer but since we just finished a few minutes ago talking about the fact that when I tell people where they have a fifty percent chance risk of developing diabetes in the next few years. That doesn't seem to be a motivator enough to prevent them. I'm an eternal optimist missile. That's great I'm just like but I'm thinking maybe we do need a drug. I mean maybe it is that You Know I. I love the idea of trying to pack the small angles. I believe me But I I just I am struck by this conversation about how difficult it is to try to get people to change their behavior even when their risk is truly known But but a drug is sometimes easier for people to reprehensible especially if you're only taking during pregnancy right well one of the things that I think is interesting about this. Grand challenges is it's not only has disease state teams. But it's got a lot of extra research pillars and a lot of them have to do with drug discovery and they have to do with different core laboratory facilities that can help find these pathways and discover these drugs. So that's why with a lot of these large pregnancy cohorts sports that were recruiting. We're recruiting five hundred more women here in Indiana to look at these things and collecting a lot of specimens and we can find these proteins scenes or these pathways that we could attack with draft and as part of this large endeavour of the precision health initiative is. We'll have partners. I who can think of these problems really carefully and say you know what this is potentially drug -able and maybe we could develop a small molecule that we would obviously have to then test to make sure it's safe in pregnancy because that's a big hurdle to get through because you not only have one patient the woman you've got the baby developed to and so. I think there are potentials to do that. And yes it's so much easier. And if I could tell every woman who had station diabetes to just take take an oral medicine right. It may not be as effective as lifestyle. What you're right? I'm not trying to talk people out of lifestyle change. I mean there's nothing more we could do probably for for public health in general than to get people to improve their lifestyle. I mean it's just that's been shown again and again that you you know. I remember writing a column years ago. There was a you know if you just make the simple lifestyle changes of if you you know. Th thirty minutes of moderate activity five days. A week stopped smoking thing. Don't drink too much and eat reasonably well. And that's like fifty percent of all chronic disease like right. There would be more than do you know any drug that we could take. But we've known that for so long and we just have so much trouble doing it And I'm certainly not advocating that. We find a drug but given there's a reasonably short window to try to change people's lives and we've got evidence in our face. This is so hard to get people to change their behavior. I agree we've gotTA WE'VE GOTTA try every avenue would every avenue which is why you know certainly sounds like you're doing that But it's such a hard problem to lick it is you know. Sometimes I I think I would say like well. We should raise awareness awareness and we should we should have you know. Make sure that women get too but it sounds like we do universal screening. It sounds like everyone is going to get checked for station diabetes if they're pregnant and they're getting healthcare correct having said that it's probably a good idea for everyone to engage in improved lifestyle. I mean all the things that I mentioned that make people healthier in general also make for healthier pregnancies and and babies it sounds like as well absolutely optimizing health before you get pregnant really important and we have a real struggle with getting people blend for preconception care where we can talk to people about. Oh you know what your sugar's high now. We know that that's going to increase your risk of problems in pregnancy or your blood. Blood pressure is high. Now let's work on that before you get pregnant or you're you're obesity is GonNa put you at a high risk during your pregnancy and and even afterwards you know just because you're done having babies doesn't mean you don't need to have healthcare and particularly for women with just diabetes. You're supposed to see a primary care doc and get your blood. Sugar checked every one to three year. You know you're so right and that's an excellent point. I think we we made a video not long ago about a lot of the warnings about alcohol. Use and pregnancy. Don't resonate well with women because they're brought up when women get pregnant as opposed to making healthy lifestyle choices even with alcohol important before pregnancy after pregnancy. It's part of women's health in general and that we shouldn't make it necessarily pregnancy thing. I think you're right. The healthy lifestyle and making good choices is a women's health issue It's not just a pregnancy issue And probably focusing on that would result in a lot more health for women in general even during pregnancy. I think another thing to focus on his walls. How's that pregnancy is not just a women's issue other other people are involved in pregnancy? And so are we should. We involve more than than just D- TO BE MOM. I think we have to. I think family health is really important and I think that maybe one of the reasons why we failed in the past with some interventions is that we haven't focused focused on the entire family unit. It's one of the pieces that we have with our face to prevention of type. Two diabetes is some of the programs that we're engaging in our family based I where women can come with their partners with their kids and do it as a family because if you can get the family into a healthy lifestyle the hope is that it would be sustainable. Because everybody's going to try to fall off the wagon a little bit and they're going to be days when it's like I just don't want to go for that run it's cold outside but if your kid then and says but were supposed to go for a run today or were supposed to go for a walk in the park or the partner can say you know you keep feeding off of each other things. Things tend to work better. When you've got partners going through this stuff with you all right? Well this has been fascinating David. Thank you for joining us here as these studies. Gather more data and we have more to talk about. We hope to have you back absolutely love to be back again. Thanks to Indiana University School of Medicine. Who's sponsoring this podcast? And whose mission is to advance health in the state of Indiana beyond by promoting innovation and excellence in education research Chen patient care. And if you'd like to support the show you can go to patriotdepot dot com slash healthcare. Triage we'd especially like to thank our research associate. Joseph and of course our surgeon Admiral Sam and all of you too can help make the show bigger and better

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