Medical experts debate new measure for gestational diabetes that could more than double cases

     In working on my project on health disparities affecting Native Americans for my California Endowment Health Journalism Fellowship, I discovered that doctors dealing with high-risk pregnancies are debating whether to lower the blood-sugar threshold for identifying women with gestational diabetes.  If they make this shift, which will be debated later this month at a National Institutes of Health consensus conference in Maryland, it is expected that the number of pregnant women treated for gestational diabetes will more than double.

    Here is the link to my story about this that ran today on the front page of The Oregonian:  http://www.oregonlive.com/health/index.ssf/2012/10/modified_blood_sugar…

     I've also included the story below:

Modified blood sugar test could lead to flood of gestational diabetes diagnoses

      Medical experts this month will debate whether to modify a blood sugar test used to detect diabetes in pregnant women, a controversial shift that would more than double the number diagnosed diabetic, at-risk and in need of intense, expensive prenatal care. 

Diabetes already complicates about 7 percent of pregnancies. That would jump to about 18 percent with the modified test, according to the American College of Obstetricians and Gynecologists. 

Advocates say the shift to the new test would mean better prenatal care to reduce complicated births that can harm mothers and babies and dramatically drive up medical problems and costs. Studies show diabetic mothers experience more complications in pregnancy, and their babies are more likely to be overweight, delivered early and by cesarean section, born with low blood sugar and high insulin and in need of intensive neonatal care.

Opponents to the modified test argue there is not sufficient scientific evidence to justify the higher costs at a time when the number of pregnant women with diabetes already is on the rise because of the nation's obesity epidemic and more older moms.

Everyone agrees the system isn't ready for the change.

The additional women could overwhelm high-risk pregnancy centers that provide specialized care for diabetic women, said Dr. Jorge Tolosa,  a specialist on the diabetic team at Oregon Health & Science University.

"We don't have the capacity to care for all those women at OHSU," he said. "No one in the country has the resources to do that."

It's true the change also would drive up health care costs, at least in the short run, as comprehensive prenatal care for diabetics is more expensive than conventional care.

"It involves a large team of experts including nutritionists, nurses and physicians to really provide this type of care, which has to be ongoing," Tolosa said.

Maria Elena Diaz,  42, of Troutdale, received such care after OHSU doctors determined she had developed diabetes in pregnancy, called gestational diabetes, with her fourth child.

"I was really sad and afraid I was going to lose the baby," she said.

She was assigned a nutritionist and urged to exercise. She stopped eating bread, bought fresh food, stayed on a strict diet and lost weight. She checked her blood sugar four times a day, injected insulin morning and night, and saw her medical care team, which included Tolosa, once a week.

Still, she developed pre-eclampsia, a dangerous condition related to her diabetes that could have damaged her placenta, kidney, liver and brain. That spurred doctors to deliver her baby by cesarean section five weeks early on July 22. Her daughter, Mia Camargo Diaz, weighed 6 pounds. The infant spent a week in intensive care because of jaundice related to low blood sugar, an over compensation for her mother's high blood sugar.

Mia, now healthy, has gained four pounds since birth.

Most doctors now use a two-step blood sugar test for gestational diabetes. If a patient tests high for blood sugar, she fasts overnight and comes back to the clinic for a second test.

But the International Association of Diabetes and Pregnancy Study Group two years ago recommended a simpler test that is completed in a single visit. First, doctors measure blood sugar at fasting, then the patient drinks a sugar solution and is tested one hour later. After waiting another hour, doctors test the patient's blood sugar a third time.

The single-day test also has lower blood-sugar thresholds for triggering a diabetes diagnosis. So just as a university would admit more students by lowering its SAT scores, doctors will identify more women with gestational diabetes under the test's lower blood-sugar threshold.

At a National Institutes of Health conference in Bethesda, Md., on Oct. 29-31,experts will attempt to agree on the best diabetic screening method for pregnant women.

The American Diabetes Association and World Health Organization are among groups that support the change to the simpler test. But the American College of Obstetricians and Gynecologists a year ago concluded there isn't sufficient evidence without more studies to justify the higher costs.

Kaiser Permanente Northwest doctors are sticking with the two-step test until they see what conclusions emerge from the consensus conference, said Dr. Kimberly Vesco,  an obstetrician who does gestational diabetes research for Kaiser's Center for Health Research in North Portland. It's not clear that treating women with lower blood-sugar levels will "lead to improved pregnancy outcomes," she said.

 

But across the country, some doctors and health organizations already have shifted to the new protocols. OHSU doctors switched in July.

"We kind of came down to the bottom line, if there is no harm in the treatment, it is the right thing to do," said Dr. Aaron B. Caughey,  director of the OHSU Center for Women's Health, who will speak at the NIH conference.

Since that shift, women diagnosed with gestational diabetes at the center doubled compared to the preceding three months, from 35 to 71 cases.

While initially more expensive, more aggressive treatment for newly identified diabetic women could prevent adverse pregnancy outcomes, such as birth injuries, premature births, overweight babies and other dangers, reducing costs in the long run, said Caughey. He helped conduct one study that suggested as much.

The hospital is gearing up to care for more diabetic pregnant patients by relying on cell phone texting and telemedicine, which many health organizations are using, to interact with patients and reduce prenatal visits, Tolosa said.

Pregnant women sometimes develop diabetes during pregnancy because the placenta produces hormones that make their insulin less effective in carrying sugar from blood to cells.

Diabetes occurs in pregnancy on a continuum, not as a discrete disease, writes Dr. Charles Lockwood, dean of the College of Medicine at The Ohio State University in Columbus.

Recent studies suggest blood sugar poses dangers to mothers and babies at levels below the current threshold for gestational diabetes. For such mothers, the rate of adverse birth results climbed with the level of their blood sugar, according to New England Journal of Medicine study of 23,316 pregnant women published May 8, 2008.

The findings suggest pregnant women with just slightly elevated blood sugar could benefit from the more intense prenatal care given now to diabetic moms.

Likewise, a study OHSU's Tolosa helped conduct showed diet changes, blood sugar monitoring and insulin therapy for pregnant women with mild gestational diabetes decreased birth weight and injuries, cesarean deliveries and pre-eclampsia.

Whether the diabetes test changes, health professionals are bracing for a diabetes epidemic fueled by obesity. More than a third of U.S. adults are obese, up from less than a fourth in the 1980s, and another third are overweight.

In turn, babies of obese women, particularly those who are diabetic, are more prone to chronic diseases and obesity, says Dr. Kent Thornburg,  research professor at OHSU.

"If a baby is born way too large because the mother is diabetic or too small because it is undernourished, the brain is rewired, the appetite increases and the baby is driven to eat more," he said. "We're looking at what some people in my field call the big train wreck."

-- Bill Graves