Hello, and welcome to today's webinar, Gestational Diabetes and the Impact of Race, Societal, and Lifestyle Factors on Black Maternal Health. My name is Terry Wiggins, I am the Senior Vice President of Health Equity and Community Impact for the American Diabetes Association, and I will be moderating today's webinar. This activity has been funded by an unrestricted educational grant from Blue Cross Blue Shield Association and support from the March of Dimes, both who have made this program a possibility, so I'd like to say thank you. Now, I am excited to introduce today's panelists, all of which bring an experience level that is beyond imagination. Each has a unique perspective on the maternal health space. First, I would like to introduce Dr. Ndidi Amaka Amutha Anuga. She is affectionately known as Dr. Ndidi. Dr. Ndidi is the Julia A. Okora Professor for Black Maternal Health in the Department of Public Health and Community Medicine at Tufts University School of Medicine. She is the founder and director of the Center for Black Maternal Health and Reproductive Justice and the Maternal Outcomes of Translational Health Equity Research, also known as the Motherland. She is also the founder of the largest conference on Black Maternal Health in the United States. Dr. Ndidi is an active scholar and a researcher with a focus on maternal health disparities, infant mortality, reproductive health, and social justice, as well as HIV and AIDS as experienced by Black women. She is a well-published author with over 80 manuscripts, six book chapters, a best-selling book, and a textbook on culturally responsive evaluation. Dr. Ndidi has been honored with many awards and is a prevalent leader in diversity, equity, and inclusion. Dr. Ndidi received her master's in public health from George Washington University, and she also received her Ph.D. in public health from the University of Maryland. She has completed the Kellogg Health Scholars Postdoctoral Fellowship with an emphasis on community-based participatory research and health disparities. Secondly, it is my pleasure to welcome Sue Ellen Anderson-Hayes. Sue Ellen is a nationally recognized nutrition and food expert who has been featured in various scholarly and popular media outlets, such as PubMed, Harvard Health Publishing, American Diabetes Association, Fox News, Forbes, and The Wall Street Journal, and more. Sue Ellen serves on various roles, including the chair of the Dietitian and Integrative and Functional Medicine Dietetics Practice Group, a board of directors of inclusion, diversity, equity, and access, also known as IDEA, liaison to the Women's Health Dietetic Practice Group. She is also a certified diabetes care and education specialist and holds a certificate of training in adult weight management and also a certificate of putting continuous glucose monitors, CGMs, into practice. Sue Ellen is the founder of 360 Girls and Women and the co-founder of Culture Health. Sue Ellen obtained a bachelor's of science in food service and human nutrition, specializing in dietetics with a minor in health science education from the University of Florida. And she received her master's in nutrition and wellness from Andrews University. Last but certainly not least, please join me in welcoming Erin George. Erin is a certified nurse midwife and has a PhD in nursing from Boston College, Connell School of Nursing. She is a postdoctoral research fellow at the Center for Black Maternal Health and Productive Justice and a medical abstractor for the Massachusetts Department of Public Health's Maternal Mortality Review Committee. Erin received her master's in nurse midwifery from Yale University School of Nursing and has since worked in various settings, including an academic medical center, community hospital, and a freestanding birth center. So we are excited to have this decorated group of panelists present today on gestational diabetes and the impact of race, society, and lifestyle factors on Black maternal health. So let's get started. All right. Thank you so much to everyone. Thank you so much to the organizers, Terry, Abby, Milva from the American Diabetes Association. Thank you to the March of Dimes, and thank you to Blue Cross Blue Shield. We are so excited to be here with you this afternoon to talk about a really important topic that's actually quite pressing in the conversation about maternal health inequities and how to improve outcomes for birthing people. And so our objectives for today are to talk about the etiology of gestational diabetes, recognize how it impacts pregnancy, birth, and postpartum care, identify the importance of focusing on solutions and implementing them to address systemic and lifestyle factors, what are some of the recall barriers in treating GDM, and determining key interventions that address this GDM risk. And so I wanted to start off my talk with this quote that I think is so impactful and really will kind of frame our time together today. The disparities in maternal and infant health outcomes are reflective of deeper societal and economic injustice that are rooted in racism and discriminatory practices. And this is so telling about where we are as a society and where we are regarding our maternal and infant health outcomes. I don't know if everyone here is aware, but the latest data that was released last week shows an increase in the infant mortality rate for the first time in two decades. So how did we get here? How did we start off in this place where we're seeing Black women dying at three to four times the rates of their white counterparts, and largely the maternal deaths are preventable? Well, thinking about the history of obstetric racism in the field of obstetrics and gynecology, up until quite recently, Jane Marion Sims was considered to be a leader in this space, a father of modern gynecology. But we know that his practices were actually quite barbaric and actually quite damaging to the bodies and lived experiences of Black and brown birthing people. Particularly he had a makeshift hospital behind his home in Alabama between 1844 and 1849, and he operated on Black enslaved women. And this is how he learned how to perfect his techniques in fistula repair and how to use a speculum. These gynecological surgeries were done without anesthesia, without consent on the bodies of Black enslaved women. There are three that we know their names, I'll show them in a minute, but there are many others that are unnamed. And once he actually perfected his techniques, he took his newfound surgical prowess to Europe, where he actually sedated women and made a lot of women, made a lot of money in that population. And so up until recently, he was considered a father of modern gynecology. So the three women that we know their names, and this is an artist rendering of what we think they look like, are Lucy, Betsy, and Anarka. This inhumane and painful experimentation really kind of set the tone for the field of obstetrics and racism and medicine as it pertains to racism and the Black experience. We know that Black and brown birthing people are less likely to be listened to by their providers, are more likely to have their symptoms ignored, and are less likely to get the care that they need. And this exploitation really was transformational for the field of obstetrics and gynecology. The procedures that were perfected on their bodies are still in practice today. So where are we today? Well, we know that we're still experiencing quite a bit of modern day challenges, hospitals and clinics that are designated for underserved communities continue to experience significant financial constraints. We're seeing a number of maternity care deserts popping up across the country. If people have to travel further to get the resources and to get the supplies and to access care that they need. We know that medical practices often use race as a proxy for genetic or biological differences. These algorithms are racist in nature and actually dissuade providers from providing the care that is necessary to their Black and brown patients. An example of this was up until recently was the VBAC, which is a vaginal birth after cesarean session that a lot of clinicians used to determine the likelihood of a Black woman being able to successfully deliver vaginally after having a prior C-section. And when you add race into the algorithm, it subtracts the likelihood of success. Systematic discrimination of patients based on race and ethnicity. And we know that insurance status is also a major player in this conversation as well. So these results all kind of add up to a system that is inequitable. It plays out in the access and quality and delivery of health care, which are major contributors to racial and ethnic disparities as experienced by Black and brown women. And these disparities exist despite the birthing parents level of education, socioeconomic status, there's not enough degrees or accolades to really protect you from a racist health care system. To kind of drill down a little bit more to what I'm saying, when you're thinking about the latest data that we have available, so this was released in February of this year, but it's actually from 2021. The maternal mortality rates continue to worsen each year. Looking at a stark increase of 17.4 deaths per 100,000 live births in 2018. Up until 2021, we're seeing 32.9 deaths per 100,000 live births. And that represents about a 40% increase. But overall, the estimated national rate is about 69.9 per 100,000 live births for Black women, and it was 55.3. And so this is almost three times higher than the rate for non-Hispanic white women. When you're looking at pregnancy related deaths, and this data comes to us from 36 states who have MMRCs or maternal mortality review committees, they look at all the cases, they look at the likelihood of what contributed to the person's death, what could have been done differently in a decedent's case. And we know that the rates were highest among non-Hispanic Native Hawaiian or other Pacific Islander, non-Hispanic Black women, as I previously stated, and non-Hispanic American Indian or Alaskan Native women. So these pregnancy related deaths are quite problematic. We know that when we look at it by age, it's even more stark. And so for women under 25, you see a death rate of 20.4. But when you look at women ages 40 and over, it's actually almost 6.8 times, almost seven times higher than for younger women. And so when we're having conversations about where the opportunity lies, we need to focus on not only the racial disparity that we're seeing in Black and brown birthing people, but also the age disparity for older birthing people. So what are some of the leading cause of these pregnancy related mortality? Some of this we're going to talk about today, but a lot of these things are exacerbated by underlying mental health conditions, excessive bleeding or hemorrhaging, cardiac and coronary conditions, infection, sepsis is on the rise as well, thrombotic embolism, hypertensive disorders related to high blood pressure, preeclampsia, and cardiomyopathy. And so these leading causes of death collectively make up the majority. But we also know that a lot of these leading causes have underlying symptoms that are exacerbated by things such as gestational diabetes. What is more stark to me is that 80% of these pregnancy related deaths that I've been talking about are actually preventable. And so the MMRCs have concluded from their research and looking at this data cumulatively and over time that the majority of birthing people who are dying in this country actually could be saved if we had a healthcare system that was equitable and prioritized all birthing people at the same level. So moving down a little bit more to talk specifically about our focus area today, looking at GDM and pregnancy, we know that GDM impacts approximately up to 14% of all pregnancies in the United States. Pregnant people are tested in their second trimester between 24 and 28 weeks. And six out of every 100 pregnant people develop GDM with risk factors, including age. So I talked about in a previous slide how age is also a consideration when you're looking at maternal mortality, but also maternal morbidity, obesity, perinatal depression, previous history of GDM and previous pregnancies, the high blood pressure, and a family history of GDM. So what exactly that means is that over time, the long-term health implications are huge. GDM increases a woman's risk of having type 2 diabetes in the future. This has long-term health implications that can contribute to maternal morbidity, as I mentioned, but also the management of GDM requires resources that need to be extricated from the healthcare system. So managing GDM requires increased healthcare resources, which can increase costs. This obviously has implications for the healthcare system, but also for the birthing person and their family due to the complications that could impact their care and increase the likelihood of maternal morbidity or mortality. So when you're looking at the percentage of mothers with GDM by age, we know that GDM diagnoses among mothers during pregnancy experience a considerable increase that I think is quite problematic and one that needs to be addressed. We went from 6% in 2016 to 8.3% in 2021. We saw these increases and they were observed across all maternal age groups with the rates progressively increasing as maternal age advanced. And so we know that there's a relationship between age and the likelihood of experiencing GDM. In 2021, mothers ages 40 and above had a GDM rate of 15.6, which is nearly six times higher than the rate among mothers ages 20 and below, which was 2.7. So I think there's a couple of layers to the conversation that we need to be thinking about, not only the racial lens, but the age of the mother, and also thinking about what does this mean across the life course for people who had previous GDM and how do we intervene in subsequent pregnancies? And with that, I'm gonna pass it over to my colleague, Dr. Erin George. Thank you. Thank you so much. So just as a little bit of a clinical overview of gestational diabetes and what we're really talking about in the clinical setting, as Dr. Ndidi pointed out, we have really witnessed a pretty stark rise in gestational diabetes. And I think this statistic is quite important to really think about. We've seen a rise in the rate of gestational diabetes by 3.7% each year since 2011. That's huge. And we're seeing it in practice, seeing many more people coming in and being diagnosed with gestational diabetes and or having early onset diabetes issues right at the beginning of pregnancy when people are kind of screening in for various risk factors that we're checking for right from the start. I think a really important piece of all of this to emphasize is that black women and birthing people do not actually have an increased risk of getting diabetes over non-Hispanic white women who typically have the lower rates of gestational diabetes. But yet if a black woman or birthing person is diagnosed with GDM, they are then at the most risk for complications of GDM. So right away in clinical practice, I mean, in an ideal perfect world, we should be channeling every possible resource into a situation where a person is being diagnosed with GDM at that 24 to 28 week mark and is also black because that should be the biggest red flag that we know that we need to be anticipating potential complications down the road. And as Dr. Nidhi pointed out, but it bears repeating, the long-term cardiometabolic risks associated with GDM are very stark. And really anyone who is experiencing GDM during pregnancy has a 2.3 fold risk of developing cardiovascular disease within the first 10 years postpartum. So again, an enormous red flag that should be noted in clinical practice. I have a picture of Mariah Carey here on the slide because she actually experienced GDM during her pregnancy with her twins. And now Mariah did have a couple of risk factors for developing GDM, notably her age at the time of her pregnancy and then also having a twin pregnancy. But what I find, what I've always been really interesting about her case is that when she has spoken about her pregnancy, she has specifically highlighted GDM as having been an incredibly stressful experience that required a lot of management during her pregnancy and was ultimately like a huge distraction during her whole pregnancy experience. And I just think that's incredibly important to be thinking about as we view how GDM is experienced by people during pregnancy. So again, just to repeat the underlying kind of maternal morbidity and mortality is that we know GDM really sort of lays the groundwork for. When people have GDM, they are more at risk for birth injuries and trauma. And that includes having babies who are considered high birth weight babies, which can then lead to things like shoulder dystocia or birth injuries for newborns, but also for the birthing person. An increased risk of preeclampsia, which we know is already a huge underlying factor for like longer term maternal morbidity and certainly for maternal mortality. And of course, a higher likelihood of cesarean birth, which comes with all the operative complications that we know also lead to maternal morbidity and mortality rates having increased in our country. So, when we're thinking through GDM in general, it's again, not something that happens just during pregnancy. We know the babies of mothers who are born or who have GDM during pregnancy are more at risk themselves for obesity during childhood and later in life. And then of course, when people have higher weight that they're dealing with during their adolescence and into young adulthood, that is starting to predispose them to higher risk factors for diabetes. And then of course, things like polycystic ovarian syndrome and eventually risks for preeclampsia in pregnancy. And so this really does affect the life course for not just the pregnant person, but then also their children and then eventually their children. And again, even though obesity is a risk factor for GDM, it is not the only risk factor for GDM. There are plenty of people who are considered average weight who develop GDM. And often again, are people who are overlooked as people who really need to be followed through the life course to think through ways to mitigate risk during the lifespan. So this screen is just kind of emphasizing the fact that, yes, we are screening and diagnosing gestational diabetes during pregnancy, but we should also be following up postpartum and then through the rest of somebody's life once they have been diagnosed with GDM because of all of the risk factors that lead to potentially higher incidence of developing type two diabetes and other cardiometabolic issues. So one huge clinical miss that we are constantly dealing with in practice is people not following up for postpartum care and having their sort of subsequent glucose tolerance test that is looking to make sure that their blood glucose is in better control or in sort of more normal control subsequent to their pregnancy. And of course, this is an opportunity that is often missed because of insurance issues. People miss their six week postpartum visit in many states, then they're off their insurance. They don't have insurance anymore. They have very limited insurance and can't get back in to see a provider. And we know that pregnant women and birthing people are at huge risk for big gaps in primary care once they have their babies, not just because of insurance, but then they're parents, they're busy. It's easy to cancel a primary care appointment and all of a sudden it's been five years and you haven't seen your primary care provider. And in all of that time, there should have been surveillance testing to sort of note if there are abnormal changes that are happening with blood glucose outside of the pregnancy, which again, we know what people are at higher risk for doing. And this blood sugar log is just emphasizing the burden of gestational diabetes surveillance during pregnancy. People are checking their blood sugar four times a day. And in most clinical practice settings, it's a paper log. You have somebody coming in, they forgot their log. We have no idea what their sugars were or blood glucose levels were between their visits. And it's all of a sudden very easy for things to snowball. Somebody who had diet controlled gestational diabetes all of a sudden really does need insulin, but we're missing the optimal window of getting that insulin to them because we're not getting as close monitoring of their blood glucose levels as we need to be. And that's part of the burden that Mariah Carey talked about during her pregnancy. I mean, the idea that you have to check your blood sugar so often and then communicating that with your provider team can be really difficult. Because of our sometimes missing technological links in the clinical setting. So on that note, I mean, we have many barriers that we need to address for all people with gestational diabetes in clinical practice, namely accessing glucometers and test strips, which can be really onerous. And again, depending on somebody's health insurance or lack thereof, sometimes difficult to get. So diagnosis of gestational diabetes to when people can actually start monitoring their blood glucose levels can actually sometimes be weeks depending on exactly how all of those resources align. I mentioned the paper log issue. We just often are missing those sort of technological advances in clinical practice where we could get instant readings from people's blood glucose levels and be really intervening as early as we can be if people are starting to be out of control with their glucose levels and requiring medication management during their pregnancies. Because of all of the risk factors associated with GDM, we are then, people are then getting into higher fetal surveillance and obstetric interventions often out of necessity based on how things are going for people during their pregnancies. And one intervention that we know would make a big difference for people when they're having much more contact with prenatal care and testing than they normally would would be having a doula accompany them through their process. We know doulas are strongly associated with increased experiences of patient satisfaction, but also really having a better grip on communication between a patient and their provider team, which is key in this situation and with all the risk factors that we know exist. And then of course, there's the piece around loss to follow up with postpartum care, and then bridging into primary care, which is a huge necessity that needs to happen whenever somebody does have GDM during pregnancy. And then finally, we are grappling with limited nutrition support services. I can tell you from the practices that I've been in that we usually have one or two super dedicated nutritionists that do always end up seeing our patients eventually, but sometimes our patients wait, again, many weeks or even longer to see a nutritionist. And usually they're only seeing them one time during their pregnancy, when if they were able to really be plugged into a more robust nutrition support team, that would probably make a huge difference in terms of how well their gestational diabetes could be controlled either with diet modifications alone. And if somebody does need insulin during pregnancy that the nutrition piece would really enhance the ability to kind of keep everything in a steadier state. And on that note, I'm going to pass the presentation over to my colleague, Sue Ellen Anderson-Haynes, who's gonna be really getting much more into the interventions that we know need to take place from a nutrition standpoint to really support, you know, the kind of prognosis and ongoing surveillance around GDM for people. Thank you, Erin. And thank you everyone for allowing me to be here today. It is National Diabetes Awareness Month. I'm grateful for this opportunity. And so my hope is that this presentation may be a catalyst to increase awareness, advocacy, and gestational diabetes research. So before I get started, we know that gestational diabetes is a gateway to type 2 diabetes, and it accounts for 95% of all diagnosed diabetes. And so today I'm going to first start with a comparison of GDM and type 2 diabetes risk factors in terms and discuss the type societal and lifestyle factors. So insulin is a key that unlocks the door, the cell's door. Has anyone ever heard of the lock and key analogy? You could drop a note in the chat if you have. Well, this mechanism is not working well in terms of the insulin and in terms of the blood glucose. So insulin is the key that unlocks the cell's door so glucose can come in. So when this mechanism is not working well, what happens? Glucose builds up into the bloodstream. So during pregnancy, the mother's hormones compete with the hormones produced by the placenta and causes insulin activity to be weakened or becomes less sensitive. So women with gestational diabetes not only face insulin resistance, but they also face beta cell dysfunction. And a study on beta cell dysfunction and gestational diabetes stated that gestational diabetes is very interesting disease because its course is similar to type 2 diabetes, which is characterized by two main pathogenic factors, insulin resistance, as mentioned, and the insulin secretion defect. So they found that the early converters, so these are type 2 diabetes converters in women with a history of GDM, had more pronounced defect in their beta cell dysfunction. So this may be an area of future research in terms of prevention and management. So, as you can see, the side-by-side comparison of GDM and type 2 diabetes, GDM has grown over 30% between 2016 and 2020, and GDM is a type of diabetes that only impacts women. So we're going to look at these risk factors quickly here. So as we can see, there are some commonalities here. The items in blue are modifiable, and there is some overlap between them. For example, physical inactivity and pre-diabetes are modifiable, whereas age is not modifiable, so you can't change it, even though many of us may want to change our age. So it is important to note that being over age 25 years is a risk factor for GDM, while the U.S. median age for women to give birth is 30 years and older. So already we have a problem, but even more so a problem since more than one in four women are overweight and two in five are obese. When we consider the facts, most women in the U.S. are at risk for GDM. So essentially, I want to bring to your attention that while GDM cannot per se be prevented, the rate at which it is being diagnosed can be greatly reduced by focusing on risk factors that are modifiable, in addition to other items that we'll discuss today. So when we think about societal factors, I'm reminded of the social determinants of health, and these are conditions that affect the environment and a wide range of health and quality life outcomes risks, and there are five domains. They're like economic stability, education access, health care access, neighborhood built environment, and social community context. And while I'm not going to go over all those today, I do want to highlight seven societal and lifestyle factors. So within these domain, I would like to talk a little bit about poor nutrition. So poor nutrition is due to food insecurity. Being that food insecure leads to being, excuse me, food insecure leads to poor nutrition, which is a leading cause of illness in the U.S. And poor nutrition increases risk for diabetes, heart disease, and obesity. So access to services like supplemental nutrition assistance programs, like SNAP, food as medicine programs can improve nutrition security. And the definition of nutrition security is consistent across availability. It consists of availability, affordability of food and beverages that promote well-being and prevent disease. And if needed, treat disease, and particularly among racial and ethnic minority individuals and lower income populations. So Black and Hispanic poverty rates are two to three times more higher, higher than a white American poverty rate. So in terms of Black maternal health, when you are food insecure, you're dealing with a poor nutrition, and ultimately your overall and maternal health suffers. Now food deserts, in terms of food deserts, the term was used first in 1970, and it describes areas with little access to healthy or affordable foods, such as like a grocery store, right? But food deserts are naturally occurring. Many argue that food deserts should not be replaced. Well many argue that food deserts should be replaced actually by food apartheid. So food apartheid is systemic, meaning there are racial demographic involved where low income neighborhoods, particularly Black and Latino neighborhoods, have grocery stores with little variety and little quantity of produce to choose from. So there's a high concentration of convenience stores, right? Convenience stores, like you may think of like liquor stores, fast food stores, so these are the stores that we're seeing these higher concentrations of. And so because we know this affects minority individuals at a higher rate, Black women with GDM will face these challenges as they try to purchase and prepare these healthy meals that the dietician and the health care provider tell them to prepare. So while we think about access and education and weight management, healthy eating on a budget should also be at the top of our list when we're doing education. And Black women not only face racial bias, but they also face weight stigma in the Black community. So this is also something to consider in terms of lifestyle factors. And then lastly, I want to talk about these briefly, the access to culturally competent nutrition appropriate recommendations. These are really important in terms of providing the patient with foods that they can relate to and providing someone that represents them, that they can understand their language, they can understand the cultural nuances. So culturally competent care and nutrition is extremely important in terms of addressing these factors that we see here. So societal pressures for Black mothers in the home and the workforce is a concern for many women. They are the breadwinners many times. Single home families, they are the breadwinners. They are working multiple jobs. They are the main caregivers in the home. So this is added stress and this affects the way women manage a household. Then there's apprehension and also bias in a medical setting. And this can be due to the history of medical experiments of Black women. This was already discussed by Dr. Ndidi, which is a factor of mistrust between patient and provider. And then last, access to health care and health coverage reimbursement is a huge factor. We know that co-pays can be a barrier for individuals to attend medical appointments. And then also Erin spoke about, you know, multiple finger sticks. Because that means multiple supplies. So, you know, cost of supplies is also a barrier with getting women with GDM the items that they need to test their blood sugar. Okay, so next I'm going to talk about registered dietitians, nutritionists, and key risk reduction for prenatal, pregnancy, postpartum, and beyond medical nutrition therapy. So I'm not sure if any of you have heard of NCP or nutrition care process, but the nutrition care process is a systematic method of a workflow that a registered dietitian uses to develop nutrition care. So let's say a doctor sends a referral, so we'll start at the top, and by the way, the way how we remember this acronym, we use it in school, ADIME, which means Assess, Diagnose, Intervention, Monitor, and Evaluate, and as you see with the circle, it discusses those words as well. So if we start at the very top, a doctor sends in a referral for a dietitian, and so there is a referral there, or there could be a nutrition screen, and nutrition screening usually applies to inpatient settings. If you work in a hospital, there may be a screen that the dietitian is reviewing charts and names, and that they find this particular patient a high risk, and so they're going to trigger a nutrition assessment. With a nutrition assessment, we develop diagnosis, intervention, and then monitor and evaluate to make sure those plans are accurate, and I'll give you an example in the next slide. So a registered dietitian, we are qualified healthcare practitioners that provide nutrition and health information, and we're considered food and nutrition experts, but in different specialties, such as diabetes specialty, sports nutrition, oncology, pediatrics, and so on. So we use medical nutrition therapy, which is a vital part of diabetes education, and it's evidence-based nutrition therapy, and it helps to treat medical conditions, such as gestational diabetes. So as I mentioned earlier, with the visit, like if there was a trigger from the physician, when we're talking of prenatal and maternal nutrition, the visit with the dietitian, we follow the A-dimer process, as mentioned earlier. And an example that I want to give to you in terms of the assessment is we'll review the past medical history, biomedical data, such as the weight, blood pressure, complete metabolic panel, iron, blood, lipids, and all that, and then from that information, we make a nutrition diagnosis. We provide then an intervention that works for the patients, and then we monitor and evaluate and treat the patient based on the plan we provided to make sure that the plan is working, and that we get the desired outcome. This is somewhat similar to the maternal nutrition. We go over all the assessments, we go through that circle, that care, but what's so different with the maternal evaluation is that we have specific treatment plans. They are individualized, but generally, an intervention would look like consistent carbohydrates for women with gestational diabetes, a low glycemic meal plan, so carbohydrates that are not particularly high in glycemic index, typically three meals a day with two or four snacks and the minimum of 175 grams of carbohydrates, because that's needed for not only for brain growth, gestational brain growth, but for fetal and brain development, and what we've seen sometimes is that those who are not registered dietitians, they may tell the patient to avoid carbs or reduce carbs, but this is very dangerous because it is needed, like I said, for brain, for fetal brain development, and for gestational brain growth as well during pregnancy. So we teach carb counting in terms of our intervention, what would be the intervention, treating, teaching the woman how to count carbohydrates with her meals, log in, blood sugars, ketones, testing ketones, and teaching her how to test her blood sugars, of course, something that a diabetes educator would use as well. And what is the goal? The goal basically is to reduce complications for mother and baby, preeclampsia and eclampsia, preeclampsia and eclampsia is a concern, and this is where a registered dietitian can definitely work to reduce some of these complications and risks, and then the ultimate goal is healthy mother and healthy baby. So in postpartum nutrition, the goal is to assist with healing and recovery. So if you think about the birth of the child, there's blood loss, fluid loss, skin tears, surgical incisions. And so we want to make sure that we're given the best nutrition as possible. So what does nutrient dense really mean? It's really high value nutritional profile food. So low in calories, but high in nutrition. And it's basically personalized for each individual, culturally appropriate. It typically includes, you know, protein, lean protein, mostly plant protein, low glycemic carbs, I mentioned fruits, vegetables, whole grains, far healthy fats, and vitamins and minerals, such as those for healing like zinc, magnesium, vitamin D, calcium are really important. So these are the things that we're talking about in this postpartum nutrition session with the patients. And an example of a nutrient dense meal will be something quick and easy for the mother to prepare, such as like smoothies that are really high in nutrition and quick to prepare and heart healthy soups and stews, one pot meals, or some things we speak about. And so every bite really counts and there's an art and science of preparing these meals and preparing them that is without excessive calories. And this is something that I teach in my class and with my patients as well. So proper nutrition and adequate calories are something that's needed for breastfeeding. We know that doing breastfeeding, it allows for additional calories, but also breastfeeding helps in achieving improved glycemic control. So we are always encouraging women with GDM to breastfeed if possible. Assisting women with achieving their pre-pregnancy weight is another intervention that we review with patients as well. And what the typical goal is losing five to 7% of body weight to prevent or delay diagnosis of diabetes. That's usually the goal, but it is individualized for each person. Women who have had GDM, if they have an increased risk of type two, right? That's actually a 50% increased risk of developing type two later in life. So we really want to stress, you know, getting back to your pre-pregnancy weight if appropriate for that particular person. So when we think of beyond postpartum, the goal is reducing the risk of future pregnancy complications and improving cardiometabolic profile. So this may look like education, application on food as medicine from a registered dietitian, meal planning, blood pressure control, glycemic control, healthy eating, fertility, nutrition, and of course support groups from others as well in terms of that mental and emotional support. So now I'm going to briefly talk about the specific role of a certified diabetes care and education specialist in the GDM journey in the fourth trimester. So when we think of the value of diabetes care, the research points to diabetes care and education specialists as the most effective clinician to provide support to people with diabetes on their healthcare journey, implementing lifestyle change and technology into everyday life. So when you utilize and implement this, they find that the cost, healthcare costs is definitely decreased. And when we utilize a diabetes care and education specialist and I'll talk a little bit more about the differences in the next slide over. So I mentioned before what a dietitian does and it's going to break down a little bit of what the certified diabetes care and education specialist roles are. So this diagram has the seven self-care behaviors which are a person-centered approach to diabetes and prediabetes and cardiometabolic care. So it's person-centered, meaning that we acknowledge the entire person, the whole person as it relates to their life. And there are seven behaviors. As you can see here, coping, healthy eating, healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk and problem solving. And so these form the framework of diabetes care and education, excuse me, education specialists and they partner to create a partnership with people with diabetes and prediabetes. And like I said, cardiometabolic issues. And the goal is to create a successful behavior change that is outcome-driven using these seven behaviors. So when we speak of improving cardiovascular health which is really important for women with GDM, it takes the entire healthcare team, not just the dietitian, not just the CDC, yes, but in the nurse, the endocrinologist, the PCP, everybody. And part of this team should be, like I mentioned, the CDC, yes, and the RD. What does the CDC, what can they do? They can address insulin doses. They could teach insulin administration when needed. We understand that women with GDM sometimes may need to take insulin if it's not, if their blood sugars are not being well-controlled with diet and lifestyle. So this is where the CDC, yes, comes in. I mean, we come in way before then, but this is a particular area where we come in. And we teach, you know, blood glucose monitoring, ketone testing, and things of that sort. So I purposely enlarged healthy eating because while an RD's focus is primarily MNT, which I mentioned, medical nutrition therapy, including meal planning, the CDC, yes, can engage in all seven self-care behaviors. So diabetes surveys show that healthy eating is one of the most important behaviors and reported as the hardest behavior for people with diabetes to follow. So when I speak with patients and the survey that were conducted, actually in the article of the Academy of Nutrition and Dietetics, it's easy for individuals to take a medicine. You tell them to take a medicine at a particular time, they'll take a medicine. You'll tell them to come into the appointment. Most times they'll come in. But when we think about healthy eating, that's one of the most difficult things to do for people with diabetes, gestational diabetes included. So an RDN and a CDC, yes, partners with women to reduce these risks before, during, and after pregnancy. So I'm going to address a little bit about the key interventions that talks, that address GDM risk, improve long-term care, and cardiovascular health. So the first intervention is just working with an RDN and a CDC, yes. And what I've often heard and seen is that the colleagues and outpatients said, and they're not actively referring dieticians to their patients. So in the hospital, you may, if you have worked in the hospital as healthcare provider, there are triggers in the hospital that sends forth a message to have that person be seen because they're high risk. Let's say they are newly diagnosed with diabetes. They need to be seen right away by a dietician. We should, why don't we have the same system set up in the outpatient setting? Because what we're seeing is that there's a lot of myths. There's, we're not getting these, we're not capturing people with gestational diabetes or diabetes. And so we've had PCPs managing people with diabetes for many months or weeks, years, and they haven't gotten a consult to the dietician. So this is an area to be looked into for sure. The first study here I want to talk about briefly is from the Journal of Clinical Nutrition that speaks about the dietician's role in a prediabetes as a meta-analysis. So they found that MNT significantly improves blood pressure, lipids, glycemic control. So MNT plays a vital role in improving all these factors, prediabetes, and which increased risk for gestational diabetes. So incorporating MNT is extremely important. Second study, Journal of Primary Care and Diabetes basically looked at 11 studies and they found that, they found a reduction in fasting and A1C and systolic blood pressure, BMI, and waist circumference when they were seen by a diabetes provider. And the last, obesity, diabetes-obesity metabolism, this was stated that the most effective approach was identified with those who were non-physician providers. So non-physician providers were those such as nurses, pharmacists, diabetes educators. So the partnership of those were very important. So moving on. So I'm going to briefly run through these, the second intervention. And these two studies basically point to that replacing red meat with plant proteins definitely improved glycemic control and reduces risk of diabetes. And the other study, which is from the Diabetes 2, diabetes type 2 diabetes, excuse me, and risk total animal and vegetable protein pointed to that no matter if it's processed meats or just red meats, there also was an increased risk with consumption of red meats. Okay, and I'm sorry, I'm not sure if you guys are hearing that I'm trying to silence the, okay. So the second intervention is a healthy weight. So being overweight and obese is a major factor, cardiometabolic factor, and it's highest among women, black women especially. So we find in this study that black women do not perceive themselves as being obese as classified, even when they were using BMI and waist circumference. And other studies also demonstrate that BMI is effective in conjunction with other tools. So waist to hip ratio, waist circumference BMI are strong predictors, but the point is that the perception is not there. And so we want to educate in terms of what a healthy weight is. And quickly looking at these diagrams here. So the American Heart Association states that black women are 60% more likely to have high blood pressure than Caucasian women, and they experience the highest rates of overweight and obesity. So as you can see the diagram on the right here, it talks about there's a direct link between high blood pressure and weight. So when there is at least a five kilogram reduction in weight there's significant decrease in systolic and diastolic blood pressure. And the top left chart here, you'll see the blue line is women, bottom line white women, and then middle is below poverty. So there's a few points here. The top chart shows that black women with BMI greater than equal to 30 is over 50%. So more than half of women, black women are obese, but 25 years ago, this wasn't the case. And the second chart basically talks about one in six, black women are also obese, grade three obesity over 40. So this compared to 10% of white women. So this is also increasing at a fast pace. So if we look at this closely at the below poverty line in the comparison of black women, we see that we are above the poverty line, the below poverty line. So it's important to know that black women are the only ethnic group where income doesn't affect weight. So cultural, behavioral, diet, and lifestyle strategies should be included here because the income is definitely not a factor at this particular study. And the third intervention is I want to share with you is to reduce the risk of GDNA-improved cardiovascular health is postpartum stage, known as the third trimester, excuse me, the fourth trimester, which is three months postpartum period. It's a critical stage of recovery for healing, but it's also extreme time of stress. So from my experience working in this area, women forget about following up. And so there's opportunity to follow up, but there are barriers, right? So I see that there are missed six to eight weeks follow-ups with the dietitian, with the educator. And many times we have to call them, tell them to come in. ACOG reports 40%, that's two out of five women don't attend postpartum visits. So this is significant. So while I can imagine there are multiple barriers, strategies should be put forth here to improve this. Also insulin resistance, understanding insulin resistance is reversed for some women. It's important because some women believe they have their baby and it's over and they don't have to worry about it anymore. So this is a place for education. ADA and ACOG recommend women with GDM to have glucose testing or glucose tests in four to 12 weeks after delivery. It used to be six to eight, but now it's four to 12. So that's important to note. And then postpartum testing is paramount with education, of course, because type two diabetes can return for mom, and it could be a risk for baby as well. And because many of these women are missing their postpartum appointments, their long-term health status may suffer. So opportunities are missed for preventive care and intensive lifestyle intervention with the dietitian and with the CDCS. So what are some barriers to care? So inadequate screening of high-risk women during the pre-pregnancy phase, that's a barrier. In-person appointments, you know, the telehealth is growing, but in-person, you know, for mom, busy mom and moms-to-be, that can be a hindrance. And multiple finger sticks, as Erin spoke about earlier, and as I mentioned on the next slide over, some ways we can battle that. And so wrapping up here, future research. So more robust screening for referral for planning phase, not just during the pregnancy phase, but the pre-pregnancy stage is very important. Every woman should be seen by a registered dietitian before they get pregnant. So we need to have triggers set in place for that. Grassroot efforts and having continuous glucose monitors be the new normal. There's a study that tested continuous glucose monitors with gestational diabetes women, and they found that the gestational diabetes, the CGM, excuse me, metrics helped identify women at risk. So I really hope that you guys can get a chance to review that study, but in implementing CGMs may be helpful in future research, excuse me. And support for community programs and preventing type 2 diabetes is important as well. Program that I use here is the Beat Gestational Diabetes Program. Our Beat Gestational Diabetes Program aims to reduce cardiometabolic risk factors for women before pregnancy, entering pregnancy, diagnosis of GDM through delivery and beyond. But you could visit our website to find out more about that program. And finally here, you know, research, research. Finally, we want to engage research dollars to spend and spend it on innovative ways to prevent gestational diabetes in management and also in treatment. And so I'll wrap it up here and turn it over to Dr. Ndidi. Thank you, Sue Ellen. So in a few minutes we have left, I'll talk quickly about GDM and how we can have a call to action. We know that this is a pressing public health issue and that there are extreme disparities as experienced by race. These disparities require additional investments in innovative and replicable technology in particular settings, including clinical settings, doula care. I saw a question around how do we integrate doulas into delivery of care? I think that's a really great opportunity. Happy to chat further offline. Accessible equipment are three key practice changes to enact and also really creating a research infrastructure that supports the fourth trimester or the consideration of postpartum care. Another thing that I think is really important, some of you all are mentioning it in the chat as well, ensuring that communities are actually better off than when the research began by engaging communities, patients, and stakeholders as partners in the process and the product of health research through community engaged research, framing research questions and opportunities around GDM, focusing on exploring maternal health care outcomes and reproductive justice, but also really thinking about how when you're designing, conducting, communicating health research, are we promoting justice for communities? These are especially important by considering that some communities, as we talked about here today, may be considered vulnerable in a research process and potentially have the most to gain from advances in these research for socioeconomic and historical reasons, as has already been mentioned, lack of trust, lack of access, transportation, and historical context around racism. So just quickly to highlight some of the work that we're doing here, the Center for Black Maternal Health and Reproductive Justice based at Tufts University in the School of Medicine has six units focusing on addressing maternal health inequities and strengthening our relationships with communities and centering the voices and those experiences of Black and Brown birthing people, but really our mission is to focus on academic and community engaged research, supporting our goals around looking at these research through the lens of the elimination of inequities and a prioritization of the birthing experience, of which includes reducing priorities around how we focus on GDM and creating opportunities for increased access. We have six units, as mentioned, research development, epidemiology, policy, community engagement, and the mother lab, which is my lab of students, some of who are seen here. I look forward to answering any questions. I know we're at time, so I apologize for rushing through these quickly. My contact information is listed on the slide. Thank you for your time today and thank you again to the March of Dimes, ADA, and Blue Cross Blue Shield. Back over to you, Terri. Fantastic. Wow, wow, wow. We tried to cram in all this fantastic information in a short period of time and we weren't that successful. We're down to 60 seconds, so a few things I want to say first. Thank you, Dr. Ndidi. Thank you, Sue Ellen. Thank you, Erin. That was fantastic. A lot of information to consume. I'm so glad that we're recording this so that I hope you all, if you have questions, comments, the chat box was blowing up, which is fantastic. Lots of engagement. I hope that you go back and listen. At this time, I want to share a few things as we wrap up. We would love to provide you some resources for your reference. These resources will also be provided via email at the conclusion of the webinar, but you'll also see some links in the chat. Diabetes and pregnancy, including gestational diabetes, is a growing problem in the United States, definitely globally, but certainly here in the United States. The ADA recognizes women's health deserves individualized study, care, and advancement. So you can learn more. We actually have a women's health initiative at the American Diabetes Association, and we're going to pop that link on into the chat. There's also an Institute of Learning that offers comprehensive curriculum aligned with the standards of care diabetes, which is the gold standard in diabetes practice guidelines. We have over 20 topics to explore and 70 plus free learning courses and tools. There's programs out there for everyone. Anyone that's part of the care continuum, I highly recommend that you log in and take advantage of that curriculum. So you can visit the Institute of Learning at the link that is in the chat. And so thank you. Thank you for everyone that hung around to the very end. We really appreciate the engagement, the questions. Again, thank you to our esteemed panelists for the robust dialogue and conversation. And without further ado, I would certainly love to also thank the March of Dimes, as well as Blue Cross Blue Shield Association. So with that, I will say thank you again, enjoy your day, and we look forward to hearing from you and seeing you soon. Take care. Bye-bye.

gestational diabetes

Black maternal health

race

societal factors

early diagnosis

complications

food insecurity

culturally competent nutrition

disparities