Hi, everyone. Welcome to today's seminar. This session is the first of the installments of the hands-on Tips to Improve Diabetes Care webinar series for 2023 to 2024. Today, we're going to be talking about the psychosocial and behavioral aspects of pregnancy in people with diabetes, and we're glad you've joined us. I'm Jessica Kitchler, and I will be moderating today's webinar. To share a little bit about myself, I'm going to tell you a little bit. I'm a clinical and health psychologist and an associate professor in the Department of Psychology at the University of Windsor in Ontario, Canada. I specialize in clinical intervention research related to psychosocial adjustment and coping in type 1 diabetes in youth and families. I previously worked as a diabetes psychologist and a certified diabetes care and education specialist in two academic medical centers, both at Children's Hospital Wisconsin and Cincinnati Children's Hospital Medical Center in the United States for almost 15 years before moving to the University of Windsor in 2020. Currently, I'm primarily interested in how to support college-age students with type 1 diabetes most effectively transition into young adulthood, but I'm also involved in improving diabetes education practices in transitioning to parenthood with diabetes, and I appreciate working collaboratively in an interdisciplinary setting. So for today's agenda, we're going to spend the next hour today by following the agenda on the screen. We'll be using interactive features during today's session. We'll use the chat box to ask you questions throughout the presentation, so be sure to pull it up and prepare to answer in the chat. We will also send you important links throughout today's session, so please locate it in your control panel now and be sure to click on it when you see the notification pop up or when you're asked to use it. And finally, we'll be using the Zoom Q&A feature at the end of the presentation for panel questions, so be prepared to answer questions when they pop up on your screen, and if you think of a question as one of our presenters are speaking, use the Q&A box in your control panel as well. There's no need to wait to the end. You can pop those Q&A questions in as they're speaking, and I'll collate them, and we'll address all questions that have been submitted once we get to the final Q&A session. So now I'd like to preview some of the other upcoming ADA webinars. If you look at the screen now, you'll see several upcoming webinars aimed at diabetes professionals. To learn more about them or register for any of the webinars on your screen, including the session this afternoon, please visit the link that will be posted in your chat box now. Hopefully everyone can see that. So to register for innovations and latest treatments in Type 1 diabetes webinar, click on the link in your chat box in Zoom. That is also going to be populated. All right, so I'd like to introduce the presenters for today's session, Dr. Deborah DaCosta and Dr. Jennifer Marcell. Dr. Deborah DaCosta is an associate professor in the Department of Medicine at McGill University. Her research focuses on conducting prospective studies to better understand determinants of psychological difficulties such as depression, anxiety, and stress, and health behaviors such as sleep and exercise for mothers and fathers during the transition to parenthood. These studies have laid the foundation for the knowledge transfer phase of her research program, which focuses on designing and evaluating evidence-based, gender-tailored, internet-delivered psychoeducational interventions to promote the mental health and well-being of expected mothers and fathers during this critical life stage. Dr. Jennifer Marcell is a licensed clinical psychologist specializing in diabetes mental health. She's a Type 1 diabetic herself, and the majority of her private practice work is with Type 1 diabetics and their families. She helps with new diagnoses, diabetes distress, burnout, comorbidities such as anxiety and depression. She has a professional relationship with local hospitals and local endocrinologists. So, at this time, I'll let our panelists introduce themselves and state their disclosures. Dr. Marcell? Unmute here. Hi, I'm Jennifer Marcell. I do not have any disclosures at this time. Dr. DaCosta? Hi, I'm Deborah DaCosta, and I do not have any disclosures at this time. Excellent. Thank you. Hi. So, I'm going to start, and the focus of my presentation is really going to be on postnatal care and how we collectively pull it together and create a system that works for everybody. So, one of the major challenges with Type 1 pregnancy is that while we are having more women who are Type 1 that are willing to attempt being pregnant and having healthy pregnancies, it's still not a major topic that has been really discussed overall, although 2% of women with Type 1 do become pregnant annually. So, when we look at the numbers, it's actually pretty significant. And with that, there are several mental health risks. Women with Type 1 have a heightened risk of postnatal mental health challenges, including anxiety, depression, emotional health, you know, and one of the things that we need to do as practitioners and clinicians is really make sure that we address these for both mom and baby in the aftermath of a pregnancy. One of the things that's really kind of an interesting fact is that women with Type 1 diabetes are more likely to have babies with higher birth weights. They may have complications, including C-sections, or babies may go to the NICU. They have complicated births. They're not what we consider more normal pregnancy trajectories. I can attest to this. I have had four babies. My smallest baby came in at nine pounds and my largest came in at almost 12 pounds, despite having a pretty tight A1C, just had a pretty high birth weight, which, you know, ended up requiring C-sections and a few other things. So, there are definitely challenges that Type 1 women face more so than other women who are non-diabetics or people with diabetes, and we'll address that. So, this is a question I want to kind of throw out there to everybody. Who do you think the key stakeholders are in the postnatal care? Who are the important players for both mom and baby in their provider team? And go ahead and throw those in the chat box and we can address those and kind of put those out there. Don't be shy. It's okay. Throw it in the chat box. Okay. Well, I'll circle back to it, but we'll move forward and then maybe you can address it after we talk about it on the next slide. Okay. So, I'm seeing endos, educators, mental health and behavioral health, nurses, pediatricians. Yeah, absolutely. OBGYN, that's a good one. I actually love that you have the question mark instead of the slash because that's a good, I want to address that in a second. The key stakeholders really in postnatal care are everything that you guys are listing, right? They are the mental health counselors. They are the OBGYNs. They're the psychologists, the therapists, the endocrinologists, the PCPs. They are the people that are kind of that support staff of lactation consultants. They are nutritional people. They are doulas, birthing people. Again, all of these staff and teams that women curate to make sure that they can have the most successful, healthy pregnancy they can as type ones. And so what I really want to do is start looking at how these roles change throughout the course of the pregnancy and also the importance of creating a care team for postnatal. So now that we have that list, let's maybe move to the move on. Okay. So the part that I want to focus on is really the mental health care in postnatal. And we have been, fortunately as a culture, I think we've been a little bit more attuned to understanding the importance of mental health care for women postpartum, but specifically in relationship to diabetes, my experience as both a clinician and a mother is that there isn't a lot of support after the baby's born. It is really, you are a hundred percent focused on getting that baby in the most tight range, healthiest birth possible. It's super stressful, lots of anxiety, lots of depression in the sense of like, am I doing something wrong? And then afterwards, it kind of all becomes focused on the infant, the infant care, and the mom gets sort of left by the wayside when in fact there could be something that's happening that is underlying where it's either a postpartum depression, or maybe there's a trauma that happened during the birth. And it's more of a PTSD like symptoms. I think as clinicians, we need to be more aware of how do we assess what tools do we need and being kind of having it on the back burner that the fragility really of type one moms, they have been through a marathon getting to that end point of a healthy, successful pregnancy. And we don't want them to just drop off and not have that support net to hold them moving forward. So some of the assessment tools that are out there that have been well-documented are pregnancy and postnatal wellbeing in type one transition questionnaires. The other thing is really taking that extra five or 10 minutes as a clinician to check in with the mom. I know for myself and also working with type ones that we're pretty programmed to give you the stock answer that things are okay. And our sugars are kind of in control. And because there's been a lot of shame, there may have been some trauma around being honest about blood sugar care. So my suggestion is digging in deeper and recognizing that you may need to kind of spend an extra few minutes to really gauge if this is the actual, what's occurring with the mom and if supports and therapeutic interventions do need to be implemented at this point. Okay. The other thing that I really want to recognize too, is identifying the primary patient. A lot of times in pregnancy, in the beginning, we are so focused on the infant and as the primary patient, right? Everything, the mom, the OBGYN, all of the care and support team educators are focused on making this pregnancy as healthy as possible. So it's almost as if this infant has become the primary patient in the pregnancy where a mom is sort of detached and removed. So when we're looking at postnatal care, how do we determine who is the identified patient? Is baby doing really well? Has a lot of support teams and health advocates outside of mom and his mom starting to kind of slip? Do we need to put mom into more of the primary care and primary patient role? It's recognizing where in fact we need to put the supports and have the energy and emphasis because a lot of times things can slip through the cracks. And while we're all well-intentioned you know, if we don't have kind of a concept of, of who is the person we're really trying to protect here, it's you know, it can, it can cause problems. And I think one of the, you know, classic examples is making sure that the oxygen mask goes on mom first so that she can ultimately take care of the infant and the family system as best as possible for her. So in essence, we need to really kind of take a second and, and figure out where we are in the healthcare team of who is the patient right now. And that these, these roles change, you know, stages of care are going to change throughout it. And that, you know, we may be kind of a shifting rollercoaster where at 16 weeks, maybe baby needs a little bit, some more support in utero and mom's doing okay. And flip to the other side, 38 weeks, mom's the one that kind of is emotionally falling apart because she's terrified of giving birth. Baby's fine. And they're happy cooking. And how do we support her? And the roles have flipped. So just kind of recognizing that this can be something that can, can, can vacillate throughout the pregnancy and aftercare too. Again, looking at, and this goes to the question, like identifying who the supports are. We've got a lot of supports for mom. We've got the OBGYN, the lactation consultant, nutritionist, maybe they need a PT for diastasis recti. If they had a really large baby abs ripped open, I know that I experienced that. Maybe they need psychological counseling. Maybe there was a traumatic birth that PTSD really is involved where that trauma is impacting their ability to function daily and take care of that baby. How do we recognize what those supports are and what the roles of each person are? Because I think a lot of times it becomes so disjointed that the mom is required to be the one advocating for herself and she might not be capable of that at that time. So in essence, what can we do before the birth and right after to kind of create a care team and a plan identifying where everybody's strengths and roles are to really give again, that kind of wraparound supports necessary for success in those early months after giving birth and same with supports for baby, you know, pediatricians, does mom have access to a lactation consultant? Does the baby need PT and physical therapy for maybe they have torticollis in the neck because they were really big and, um, during birth. And so they're having some neck issues. Does mom even know that that exists? That's something that could be more associated with a larger birth and subsequently type one, that these are things that may be available or necessary and kind of identifying again, where we can create a wraparound support team to really have a successful, um, pregnancy and postnatal care. Okay. So in a zoom chat, um, let's rate on a scale of one to five, how many of these options your patients realistically have access to, um, from OBGYNs to lactation, nutritionist, PTs. Um, a big thing right here is the psychological counseling. Do they have access to individuals who understand the mental health, like yourselves of, um, of being a type one and being a type one who has just experienced a pregnancy and a birth, um, endocrinologist primary care and support for babies? Um, do you think these are realistic to think that can be in a wraparound support that people actually have access to this information and these, uh, providers? Yeah, I'm seeing like too low, right? A lot of these services have long waiting lists, um, which I'm glad you guys are bringing this up. Like realistically, it's like, no, we don't have a lot of access, maybe kind of in the middle twos, threes coming up on the chats. So as providers, how do we get creative with creating care teams and roles and recognizing what is the support that that primary patient we've identified actually really needs and benefits and sort of triage it. Um, when we don't have necessarily the immediate access to maybe a PT or a counselor, are there ways that we can create, um, postnatal plans before birth so that we kind of have, we're catching it and we're being proactive instead of reactive on the other side. And I think that's kind of a big, um, issue that women, uh, type one women especially have faced with afterbirth care is that we tend to be more reactive than proactive with either finding care or something as simple as learning how to manage our blood sugars after birth. Like you tend to be a little bit more reactive. Oh, I'm high. I'm going to take more insulin instead of recognizing maybe that this is part of the natural, natural trajection or progression. So, um, you know, something we all kind of should remember that this isn't necessarily accessible. So the importance of family supports. Um, I love this because we have to really, again, I think assess in the beginning, what are the assets and, um, and strengths that this, uh, mother, this family system, if she has one comes in with, in having a pregnancy and where do we benefit? And maybe we provide education to spouses or, um, extended family caregivers that can, um, identify if they can't be in getting checked on psychological distress scales from endocrinologists or OBGYNs, how do we kind of give a basic checklist to family members so that they can provide support? Um, because what studies have indicated is that family support plays a crucial role in improving outcomes for mothers with type one diabetics, um, or diabetes. And I know this for myself. Um, I, on my first child, I had a really severe reaction to, I had a C-section to the medication and I had these horrific shakes and having given birth only a few hours before and not knowing, I really didn't know how to advocate for myself. And so it was the importance of my spouse and my extended family who were recognizing and saying, Hey, this doesn't seem right. We need to actually get you in. Is it related to the type one and asking the questions that I just didn't have the ability at that point from exhaustion of asking myself. So the more we educate kind of those around, I think the, um, the, the outcomes are going to be so much better for the moms and the family. And looking at that, that's also with mental health. How does the family dynamic influence the mental health? Do we have people that are stressing out the mom? Are we having people that are beneficial to the mom? Really, again, identifying that patient and how do we advocate for them in the best way possible? And maybe we get a little creative here. And again, down to the bottom, educating the entire family system. And that could come with my fourth baby. My oldest three had to be educated on the fact that they could not drink my juice, that mom needed to have juice by the nursing chair. And as much as I love to share with them that this was off limits because it was really important. And when you're six years old and looking at a new baby, that's not necessarily the lesson you wanna learn. But again, making it a comprehensive entire family system is gonna be crucial in improving those postnatal outcomes. Again, mental health screening, these are really important, but I think also just educating families on how to do it too, if you can't get out there. The other thing is recognizing how important peer support groups are. If it's possible to kind of pull people in together. Again, another personal on my first pregnancy, my OB happened to actually, it was the ultrasound tech. She had done a woman before me who also had an insulin pump and connected us. And we spent our whole pregnancy in the first year of our children's birth kind of muddling through new parenthood and type one. And it was really incredibly helpful having that support of understanding. So even recognizing that maybe a mentorship or whatever we can do to kind of connect is really gonna help those mamas on the other side. Do you guys suggest peer support groups to your patients? Do you have access to them? We can circle back to it too. And I know peer support groups are hard to find in any level, but definitely something to kind of keep in the back of our minds that those peer supports have been proven over and over again to be really effective in keeping mom stable in the outcome. So Northwestern Hospital was the first in my understanding, the first one to really create a protocol for mothers of diabetes on the outside. I know that it's definitely a little antiquated in that technology has caught up, but what I love about it is that it's an actual protocol and guideline to give infrastructure for caregivers, both medically and family to know where to look and what maybe needs to be checked off and understood. So it could be something that maybe gets implemented in wherever facility you work and however you handle that these kind of ubiquitous standardized protocols are really effective in catching things. Medical management. Also with that is that we are people, not everything fits into the standardized model. And again, that's that five minutes extra of just kind of knowing, okay, well, I've got a Type 1 mama coming in. I wanna really dig in and make sure that I'm assessing for some of these things that I may not normally check in with, again, the depression, diabetes, distress, PTSD, and overall living with diabetes. And again, one of the things I think is a big takeaway and I didn't touch too much on it earlier is that children of parents with Type 1 have a heightened risk of developing the condition, which also can be anxiety provoking for the parents as well as the children if they're aware of it when they're a little bit older. I think primarily because whether the parents are really focused on whether or not they're gonna be Type 1, it's definitely a conversation. If you live in a Type 1 household, you know what Type 1 is, you have a story, you have a trauma, you have something that's going to be probably anxiety provoking. So kind of recognizing that we also have to look at how that plays into how the mom's feeling after birth, after moving forward, because there is a heightened risk. So that's gonna, if I do something now, is it going to make it worse down the road? And I don't wanna take up too much time, but I think in this, it's a little tangential, is something to the effect of like, when looking at Type 1 care for postnatal, things like lactation consultants, when they say, oh, you know, to get the best milk possible, you have to drink a high or eat a high carb, high glucose diet. And as a Type 1, you're thinking, ooh, that's so contrary to everything I've been taught about not necessarily having high carbs and high glucose, but I also wanna get the best milk possible for if I'm breastfeeding for my infant. So there's gonna be these constant balances of how do I balance my health with what I'm being told is the best for my baby? And then how does that heighten the anxiety? And then to the second moving forward step of, is it something where I'm going to do something now that's gonna make it where possibly they're gonna have a heightened risk down the line of X, Y, and Z? So kind of educating mom in these decisions, and that goes back to that unique element of each situation and person and addressing it and taking that time to understand because potentially these anxieties can be quelled with more education and sort of a little out of the box thinking on how do we navigate the particular situation. And again, this last one, regular screening as we would do for any new mama and trying to provide as much comprehensive care. And I think also doing that pre-birth, having a set plan for the postnatal where you recognize those providers, you recognize the roles, what you actually have access to and how you can utilize the supports that you have accessible to really keep both mom and baby healthy. These are resources. I'm gonna move forward because... So Debra, take it away. Okay, great. So if we can have the next slide. So my talk is gonna be focused on looking at the psychosocial challenges experienced by birthing persons during the transition to parenthood, during the perinatal periods, as well as talking about some behavioral strategies to promote mental health during this critical life stage. So preparing for pregnancy, pregnancy and the transition to parenthood, normally it's a very highly anticipated event associated with positive emotions. People are excited, they're happy about becoming parents, but it's also a time where we may be more vulnerable to certain mental health conditions. In the general population without diabetes, we find that approximately 12% of pregnant or persons in the postpartum period following childbirth will experience elevated symptoms of depression. Anxiety is also common, probably even a little bit more common. Again, during the perinatal periods, about 15% of pregnant persons will, or during the postpartum will experience symptoms that are pretty clinically significant associated with anxiety. In individuals with pre-gestational diabetes, so here I'm talking about type one or type two, during pregnancy planning and in the perinatal period, they may be particularly vulnerable to symptoms of anxiety, depression and diabetes distress, concerns related to the management of their diabetes during pregnancy and in the postpartum period. Surprisingly, I have to say there is limited research. Most of the research has focused on the general population without diabetes. And even if there were some people in those studies with chronic conditions such as PTD, they weren't particularly focused on. So we have more limited research, but the good news is recently it has been identified as a top priority area for research in the area of diabetes and pregnancy. In specific, this paper which surveyed stakeholders, women and different healthcare providers identified the importance of targeting research to really determine what are the emotional and mental wellbeing needs of women with diabetes before and after pregnancy and during pregnancy and what are some of the tailored strategies that we need to implement in order to provide more support during this critical life stage. The handful of quantitative studies out there suggest that the rate of depression and anxiety may be higher in persons with PTD during the perinatal periods, but there isn't a whole lot of consensus largely because there are methodological constraints in the handful of studies that do exist, which makes comparisons across studies difficult. There's heterogeneity in terms of how they conceptualized and measure mental health outcomes. And there's also differences in timings of assessments, either early or late in the pregnancy or at various time points in the postpartum, which makes it difficult for us to really have some numbers. Now, the qualitative studies are interesting. This is where they interview pregnant or people in the postpartum period with pre-testational diabetes to kind of get more of a nuanced knowledge in terms of what it's like for them. And basically the studies suggest that women and birthing persons struggle in terms of uncertainties regarding diabetes management during this period. They certainly point out that they need support during pregnancy planning and throughout pregnancy to reduce pregnancy-related fears and anxieties and to really help facilitate the rigorous self-care regimen related to diabetes. A recent review of the qualitative literature evaluating risk perceptions in persons with chronic diseases, which also included people with pre-testational diabetes, found a high level of pregnancy-related fear, so concerns about complications during pregnancy, high levels of anxiety and stress in response to uncertainty regarding pregnancy outcomes and regarding infant health. So clearly the data point to emotional needs that really need to be better addressed in the context of the perinatal period among people with GD. A qualitative study from Sweden with 23 new moms with type 1 diabetes in the postpartum, they identified struggles related to breastfeeding, uncertainty and unpredictability related to caring for the newborn and living with diabetes, so how to balance all this, concerns about losing the professional support present during pregnancy, because during pregnancy, it's all about facilitating mom's health and baby's health, but once that baby is born, moms are at risk of losing that support and we need to really have better plan for mom in order to really promote their mental health. Mental health and diabetes distress is a strong theme that comes out of these qualitative studies in this area. We don't know a lot about what are some of the risk factors for mental health difficulties during pregnancy and the perinatal period in the context of living with predestinational diabetes. What we do know is having a history of depression places women and birthing persons at higher risk of experiencing depression during the perinatal periods. I know we talk a lot about postpartum depression, but really the few studies with PGD, as well as the studies in the general population, tell us that the numbers are pretty much similar. Women are at higher risk during pregnancy as well, not just in the postpartum period, so we really need to pay attention to that because we know it's one of the strongest predictors of postpartum depression. If you're already depressed or anxious during pregnancy, you're at much higher risk of continuing that trajectory into the postpartum period. Collectively, oh, I just wanted to make a point on the previous slide, the findings highlight the need for targeted assessments and support across the pregnancy planning and perinatal period in order to facilitate adjustment during this life stage. So why does mental health matter during this life stage? In the perinatal population without diabetes, there's an abundance of literature to show us that women who are depressed or anxious, particularly there's more studies with depression, but they tend to point to a higher risk of adverse pregnancy and neonatal outcomes. Hypertensive disorders of pregnancy can also be more common, as well as preterm births, Prenatal anxiety and depression, as I mentioned, is the strongest predictor of postpartum depression among studies in the general population. Mental health disorders in the postpartum period adversely affect not only maternal quality of life, their physical and their psychological health, it has an impact on the way they parent, and it can have an impact on family functioning. So it's important to understand that postpartum depression is not just a disease that can have an impact on family functioning, the couple relationship. But in addition, we also need to be mindful of the studies that show us that there are short and long-term implications on the child's development. We see amongst moms who are depressed, their infants are at higher risk of behavioral, emotional, cognitive, and physical development delays. In the context of predestinational diabetes, the findings, there isn't a lot, but the findings suggest that an association between anxiety and or depressive symptoms early in pregnancy, with less optimal glycemic stability later in pregnancy. There's also a relationship between mental health and higher risk of preterm birth, highlighting the importance of optimizing mental health as part of comprehensive diagnosis during the perinatal periods. And I also want to state that the pregnancy planning and the pregnancy period is a teachable moment. We find that people are more receptive to behavior change. They're more receptive to addressing their mental health and really trying to optimize their mental health because they know there's a new life stage coming. Their responsibilities are going to change. They are now going to be a parent and they're going to be a parent and their responsibilities are going to change. They are now going to be a parent and they're going to be responsible for a child. So they really want to be at their best. So in terms of intervening and having preventative programs, it is a good period. Tailored interventions to address the unique and diabetes-specific psychosocial and mental health needs of persons with predestinational diabetes during the pregnancy planning and throughout the perinatal period could have an important impact in terms of reducing psychological distress, as well as improving outcomes for the pregnancy and for infant outcomes. Now, we don't have a lot of tailored programs, at least in Canada. And one of the things that we are trying to do is to really identify what are some of the specific needs that birthing persons have during this period and to develop something that's more accessible to patients during this important life transition. That's something that myself and Dr. Kishler have received funding for in order to really try to develop something that's tailored to this life transition. So let's talk a little bit about promoting mental health during the perinatal period. In the general population without diabetes, there's compelling evidence to demonstrate the effectiveness of psychological interventions in terms of treating mental health symptoms during the perinatal period, as well as decreasing the risk of depression or anxiety, so secondary prevention. And really, these studies, and there's quite a few of them, they really tend to use cognitive behavioral strategies to optimize mental health either during pregnancy and or in the postpartum period. A universal prevention of mental health problems really focuses and targets women or birthing persons regardless of mental health risks. So really, it's about learning some effective strategies to promote your mental well, your mental wellbeing during a transitional period. And these two have been shown to be effective in preventing the development of symptoms either later in the pregnancy or in the postpartum, so really optimizing mental health. Studies with non-pregnant individuals with type 1 or type 2 diabetes have shown that CBT-based approaches are also effective in terms of improving symptoms of depression and anxiety, and importantly, improving diabetes distress. So particularly when these programs are tailored, they are also shown to be quite effective in terms of improving mental health outcomes. The problem is, how do we access these types of programs or interventions? The evidence-based looking at mental health interventions during the perinatal period with non-pregnant persons have largely been delivered and with pregnant people have largely been delivered face-to-face one-on-one format or in group format and some over the telephone. The problem is this can be costly and it's not accessible to a large segment of the population. With the COVID-19 pandemic, one of the things that came out of the COVID-19 pandemic is the need for innovative modes of delivering mental health interventions in order to increase capacity and accessibility to services. And I think that in the last few years, we certainly have come a long way. To again, emphasize the point of accessibility barriers from a provider perspective, providers don't routinely assess or address mental health concerns during the perinatal period and in the context of diabetes care, regardless of pregnancy status. There's a number of reasons, but the top ones that come out in terms of provider and system barriers include inadequate training. It takes time, which sometimes is not possible in a visit. And there, I mean, what's the point of screening? Many of my colleagues tell me when there's nowhere to refer or there's an eight month waiting list. So the limited referral pathways and resources available also pose a barrier to routinely screening and referring for mental health services for those who need. So there's also a person barriers. I think there's one slide that should have been there, but in terms of how do we increase accessibility, one of the avenues is e-mental health. Studies with diverse populations across the lifespan show that online psychosocial programs are effective in treating and preventing mental health problems. Up to 90% of women tell us that they would use the internet in order to help them cope and to address their mental health concerns. Studies in the general diabetic population also suggest a high acceptance of interventions delivered over the internet to address their emotional aspects of living with the condition, as well as to enhance their mental health. Individual barriers to mental health seeking in the perinatal period can include many different things. So we're gonna take this pause. What do you think are some of the barriers to seeking mental health help in the perinatal period? If you could just type in your answers in the chat box, that would be great. So what are some of the barriers to seeking mental health help in the perinatal period? Exhaustion, shame, stigma. For sure, those are all common themes. Lack of resources is a huge barrier. Competing priorities. Yep, thinking it's normal. I'm supposed to feel emotional during this period. Good. So some of the individual barriers that were mentioned, stigma, lack of time, limited access, it's costly. In terms of convenience, it's hard to take time off work to find childcare. There can be transportation barriers. Women report fear of being prescribed medication, which they may not feel open to taking during pregnancy. And there's also still a lack of knowledge regarding mental health issues. E-mental health refers to mental health services and information which is delivered or enhanced through the internet and related types of technologies. The advantages to e-mental health include it's anonymous. So it removes or addresses a little bit of that stigma barrier because you can just go on types of platforms and nobody needs to know who you are. They're low cost. Once it's developed, it's not that expensive to maintain. They can have a broad reach. People have access to them 24 seven. It can be easily disseminated regardless of where people live typically. And once you've developed the platforms, it can be easily tailored to specific populations. Have you had experience with recommending e-mental health services to patients? If so, which do you recommend? So that could be like a digital intervention, an app. It could be a website, for instance. Anything that you are familiar with that you have recommended to your patients. Okay, we can circle back to that. So in terms of behavioral strategies, well, in an ideal world, we would want to assess. We would want to screen. Some of the measures out there include the diabetes distress scale to assess anxiety specific to pregnancy, the pregnancy related anxiety questionnaire. These are all standardized measures that can be easily administered while the patient is in the waiting room. Specific tools to address or promote mental health during this period. These are self-care tools that we can have in a pamphlet or recommend credible websites. Of course, we already talked a little bit about enhancing social support. Exercising regularly is also something that we should be recommending to our patients if they can safely exercise, not only for physical health, but there's mental health benefits associated with it. And during pregnancy, there's still some sort of misconception out there that you shouldn't be exercising. And women tend to stop exercising or decrease their exercise patterns dramatically. Again, this is something that should be discussed with their physician. Practicing relaxation techniques can be very effective to promoting mental health during this period, progressive muscle relaxation, deep breathing. A healthy diet is also something that should be recommended. Not only, I mean, when you're depressed or feeling stressed or anxious, we tend to make unhealthy eating choices, which only makes our mood worse. So really trying to promote healthy eating is important. We underestimate the importance of sleep. Sleep is compromised during pregnancy and in the postpartum. So it's important to assess for that and to provide some strategies to help. Changing one's thinking or kind of learning some strategies to reframe our thinking can be helpful. Practicing mindfulness, either formal or informal techniques can also be useful. It's not a one size fits all. Some of these strategies are more effective depending on the situation and depending on the individual. So it's important to try to practice, see what fits and to track and monitor how you feel afterwards and see if they are useful for you. So if we can skip to the next slide. So I mentioned some relaxation techniques that help to elicit the response, the relaxation response that helps reducing stress. It improves the wellbeing and it can act as an antidote to future stress. I mean, the more you practice things, the more of a tolerance you build up. And people always ask me which relaxation techniques are the best for me. And I always say, and people always ask me which relaxation technique is the best, but really you have to try several ones to kind of see what works for you. But one of the common things amongst all these strategies is that we need to practice. You need to practice consistently. You need to do it at a time where you're not gonna be disturbed. 15, 20 minutes, ideally daily and adopt a passive attitude. You know, when you practice relaxation, it's normal to have distracting thoughts go through your mind. Don't focus on that. Focus on your breathing. Those thoughts will eventually pass. So I know I'd really like to emphasize the importance of good sleep. Sleep hygiene education is important during this time. For the longest time we've seen, we've thought about sleep as a symptom of depression, but really the literature shows us that there's a bi-directional relationship in that poor sleep for a prolonged period of time can actually increase your risk of depression, for example. So it's important to learn some strategies to enhance our sleep during this period. Protect your need for sleep. If you're gonna be waking up at six o'clock in the morning, don't go to bed at one. Keep a regular sleep hour. Make sure to get enough daylight. Really helps promote sleep at night. Be careful with daytime. I don't say don't nap. If you need a nap, it can be very energizing, but be mindful of when you nap. Should be earlier in the afternoon, not later in the afternoon, and not too long. So not more than 30 minutes. Other ones I want to point out is the importance of winding down before bedtime. Try not to go into bed with your iPad, for instance. It's really a time to just do some breathing, just do anything that helps you just relax and reset and start to turn your brain off so that you can actually fall asleep. And importantly, turn off your cell phone and other electronics on silent mode so that those annoying notifications are not waking you up in the middle of the night. So there are credible apps that I recommend. MindMom, Healthy Minds developed by psychologists, and it's free, in the University of Wisconsin-Madison. My patients love that one. So it's something that you may want to recommend. And of course, Calm and Headspace are commercial out there, but they are recommended by credible associations. So some takeaway messages. I hope I've convinced you that mental health matters during this period. Routinely assess for mood and diabetes distress. Self-guided behavioral strategies can be an important part of a stepped care approach to promoting mental health during this life stage. And do consider recommending digitally delivered resources so that we try to overcome some of the accessibility barriers and really universally promote mental health during this life stage. Thank you. You know, Debra, I actually just want to interject something that you triggered for me in your talk, discussing how that pregnancy is a big motivator, motivating time for change. You may have somebody who traditionally hasn't had a lot of motivation to be doing cognitive behavioral therapy or looking at their own diabetes care, and suddenly during pregnancy, it becomes a whole not about them and about having a healthy pregnancy for the infant. And I think that's a really good point in the sense that if we look at it from the lens that the vulnerability that it takes when a person with diabetes is not pregnant, a woman, and to ask for support and ask for help that you may have experienced in the past, shame or blame, or why did you eat that? Why did you do this? Why are your numbers? Like, you know, the bottom line is the buck stops with you as the person with diabetes as to why these things are happening for maybe dysregulation of your glucose levels. But when you're pregnant, that sort of vulnerability and support becomes more comprehensive for the woman because it's now about taking care of the infant and having that healthy pregnancy down the line. And so I look at it like, how do we also as providers try and keep that momentum of being able to ask for support and not feeling shame and blame and guilt? Because it is that vulnerability of asking and advocating when it's no longer about, you know, having a healthy pregnancy. It's about being a healthy mama and having an healthy infant where, you know, there can be that separation again of, you know, why are you not making these choices better for yourself? You know, instead of looking at the bigger picture, but how do we really try and implement change when people are a little bit more motivated? So I'm really glad you brought that point up because I know personally and professionally, it's right on the money. Yeah, and we see that for partners too. Yeah, absolutely. For full, again, it's understanding the family systems and the support networks around and where to utilize the assets that each pregnant mama comes in with because they're different and the needs are different as you address in those individualized plans. So thank you. Okay, great. Well, thank you to both Debra and to Jennifer today for their wonderful presentations. I know we have a couple of questions in the chat box, so I'm just going to look at them and ask a couple of them. The first question was a little bit of clarification of a member who said that, you know, when they were originally taught about type 1 diabetes and pregnancy, they were taught many decades ago that babies were often smaller among individuals with type 1, but in the reference today with Jennifer's talk, it was that the babies were larger. So they were wondering a little bit if you could clarify gestational size and how that's impacted in type 1 diabetes these days. I think that comes, and again, I'm not an OBGYN, so I can't speak to, or a maternal fetal, that typically in my own personal experience, and again, professionally and as a clinician, it's that the glucose levels tend to be higher. So when, especially in the third trimester, when babies are typically putting on weight to get ready to come into the world, our, as type 1s, we are a little bit more insulin resistant, and so we tend to use more. So the babies tend to just kind of take on a little bit more sugar and become larger. So it's, macrosomia is really kind of what I've been trained to understand. In addition to that, I don't really want to put this out there too much, but I know that sometimes on the flip side, if you have a really high A1C, it could be the opposite, where the baby could be a lower birth weight, given that there are complications with higher blood sugar numbers and things like that. So if you're really concerned about it and looking at it from that level, I would absolutely consult with a medical doctor and get those information pieces around the different weights of what can happen. But you're right, it is a spectrum of both sides. I personally just happen to have the macrosomia and the larger babies on my own experience. Great, I will just try to sneak one last one in here, the compliments to the talks, but one person wanted to know a little bit more about when the pregnant people are worried about the risk of their baby, their future baby having, growing up and having diabetes themselves, how do you manage some of that anxiety? Either one. Debra, you want to take this? I'm happy to, but- Yeah, I have less experience in actually doing clinical work with anxiety and type one. You know, I think that's one of those things. I was fortunate that I've been working with my endocrinologist for 20 years. She brought me through my first pregnancy and all the way through all four of them. And she said, you know what? You know type one and the symptoms better than anybody. You are going to be innately watching your babies like a hawk to see if they're type one. Let's just look at it through the lens that we're going to cross that bridge if we have to come to it and kind of managing the anxiety that way of knowing that there is a risk. We have the data to prove that. However, that it doesn't necessarily change how we are going to be looking at it in the future. It's going to be something that the pediatricians we're going to have to alert them and let them know, hey, I'm a type one, mom is a type one. You know, they're going to inherently have that in the charts to kind of keep an eye on it. But then I think the biggest thing as a mom is recognizing when you're kind of redlining and that anxiety of, okay, I'm not going to do, I'm going to, you know, you're noticing that you're starting to clamp down or get really anxious yourself about different areas of care because you're so concerned with that type one risk that maybe that's where you need to kind of step back and seek a professional or ask your OB-GYN or ask your pediatrician and look for those external supports because that's when the anxiety kind of ratchets because, you know, the truth is, is there is a risk but it's when you allow that fact and that risk factor to kind of control everything. So, again, it's all the controls. Yeah, exactly. You know, there's a lot that we can't control genetically but there's a lot we can control just in the here and now like you brought up, Debra, of like sleeping better and eating better and focusing on your health. Exactly. And your child, optimize what you can. And being able to ask and advocate for yourself when it's really hard to say, I'm falling apart because sleep deprivation is real and my sugars are crazy and I don't feel good and I'm really embarrassed to tell you that after nine months of like flawless type one blood sugars, I now can't pull it together. I need help. And knowing that that's okay. This is all part of the process. And really in the long run, your training and teaching and modeling for your child, some of the best things you possibly could do which is advocating for yourself and self-care. So, you know, those are the things that you can control. Excellent. So I wanna say thank you once again to Dr. Marshall and Dr. DaCosta for sharing their expertise with us today. I wanna thank each of you for joining us. We hope to see you at a future ADA webinar and this concludes the session and we hope everyone has a great afternoon. Thank you.

webinar

Dr. Jessica Kitchler

psychosocial aspects

behavioral aspects

pregnancy

diabetes

mental health

interventions

transition to parenthood

gestational size