Gestational Diabetes, Obese Mothers Take a Toll on Texans and the Texas Medicaid Program
Public Health Feature — June 2015
Tex Med. 2015;111(6):51-55.
By Kara Nuzback
The most common form of diabetes found in pregnant women is more prevalent than experts once thought, according to a new Medicaid report. Gestational diabetes mellitus (GDM) is an impaired ability to metabolize carbohydrates, usually caused by a deficiency of insulin or insulin resistance in pregnant women. GDM disappears after delivery, but in many cases it returns years later as type 2 diabetes.
In obese women, the chances of developing GDM surge. A study published in the June 2010 American Journal of Public Health concluded, "If all overweight and obese women had a GDM risk equal to that of normal-weight women, nearly half of GDM cases could be prevented."
According to the American Diabetes Association, many women develop gestational diabetes around the 24th week of pregnancy; a diagnosis does not indicate the patient had diabetes before she became pregnant or that she will necessarily have diabetes after giving birth.
John Menchaca, MD, doesn't often see women with gestational diabetes. He sees the condition's aftereffects.
Dr. Menchaca says in his 35 years as a Fort Worth pediatrician, he frequently saw overweight children of diabetic mothers. Because of the mother's GDM diagnosis during pregnancy, these infants already have an increased risk for cardiovascular disease, high blood pressure, nonalcoholic fatty liver disease, obesity, and type 2 diabetes.
Dr. Menchaca says some new research suggests overweight babies also may be at risk for cognitive difficulties when they enter school.
"It's very bothersome," he said. "It has significant adverse effects on the offspring to have a mother with gestational diabetes, or maternal obesity, or having gained a lot of weight during pregnancy."
Dr. Menchaca says many of the babies are already overweight at birth. While their weight may level off after they are born, they often start packing on extra pounds as toddlers, known as the adiposity rebound. "A good number of them lose the weight, but many of them will gain it back in the following two to four years of life.”
Not only is gestational diabetes unique in that it affects two people — the mother and her child — but it also keeps the diabetes cycle going for the next generation of patients.
"If half of these children are girls, and they're already overweight in their teenage years and stay that way, the whole cycle is going to repeat," Dr. Menchaca said.
According to the American Diabetes Association, the risk for developing GDM is about twice as high for overweight women, four times higher for obese women, and eight times higher among severely obese women, compared with normal-weight pregnant women.
Texas Medical Association policy recognizes obesity during pregnancy as a preventable health condition that poses significant risks for mothers and infants. The policy says women receiving preconception counseling should be informed of the maternal and fetal risks of obesity in pregnancy and encouraged to undertake a weight-reduction program.
TMA encourages physicians caring for pregnant women to review current Institute of Medicine recommendations on gestational weight gain with patients throughout pregnancy and to assist with nutrition and exercise counseling postpartum. (See "How Much Weight Should Your Patient Gain During Pregnancy?")
Early Detection Reduces Costs
The Texas Health and Human Services Commission (HHSC) released Gestational Diabetes in Medicaid: Prevalence, Outcomes, and Costs just before the start of the 2015 legislative session. The report, commissioned by the 2013 legislature, finds the prevalence of diabetes among adults in Texas increased by 50 percent from 2002 to 2012. Diabetes prevalence among women of childbearing age grew 40 percent during the same 10-year period, according to the study.
Notably, the Medicaid report shows birth certificate and hospital discharge data may have drastically underestimated the prevalence of GDM in Texas. According to the report, "The Texas [GDM] rate, based on readily accessible vital records, indicated that fewer than 5 percent of pregnant Texas women were diagnosed with the disease during 2012. More recent analyses based on THCIC (Texas Health Care Information Collection) discharge data increased the estimated prevalence to 6 percent. This report, which focuses on Medicaid enrollees, suggests that as many as 9 percent of all pregnant women in Texas may develop GDM prior to delivery."
That 9 percent symbolized more than 18,000 women. Eight thousand more — 4.1 percent — had a diagnosis of pregestational diabetes (PGDM), which occurs when type 1 or type 2 diabetes exists in the mother before conception.
Texas Diabetes Council Chair Victor Gonzalez, MD, calls the rate "scary," especially because about half of the births in Texas occur through the Medicaid program. The fact that many women received a GDM diagnosis late in their pregnancy alarms Dr. Gonzalez.
According to the report, the majority of GDM diagnoses among Medicaid participants occurred between 25 weeks and 30 weeks gestation, but many women using emergency Medicaid services received a diagnosis later in their pregnancy, between 37 weeks and 40 weeks.
Dr. Gonzalez says the finding signals many women are not receiving appropriate prenatal care.
"The earlier you catch it [GDM], the more likely it is you'd be able to treat elevated blood glucose," he said. "We need to find a way to find these cases earlier."
Early detection not only helps manage GDM, but it also lowers costs associated with the condition, Dr. Gonzalez says. "You want to control the cost. If you find them earlier, you can avoid complications later on that continue to build on the cost of this problem.”
According to the report, in Medicaid, the excess medical and drug costs among women with GDM and their babies totaled $10 million. Women with PGDM cost Medicaid $60 million more than nondiabetic, normal-weight women.
"Obesity, regardless of diabetes type, is a significant cost driver. However, obesity co-occurring with diabetes substantially increases costs above what a normal-weight diabetic woman or her infant would incur," the study states.
Much of the cost associated with diabetes and obesity comes from more frequent hospitalizations for the mother and a higher likelihood the infant will be admitted into the neonatal intensive care unit (NICU).
According to the report, THCIC hospital discharge data show more than one-third of all hospitalizations among pregnant women with PGDM were for reasons other than delivery. After delivery, women with GDM stay in the hospital an average of one half-day longer than their nondiabeteic counterparts; women with PGDM stay one-and-a-half to two days longer, on average.
"These differences may be explained, in part, by the greater likelihood of diabetic women to deliver by C-section, which would increase their length of stay to three to four days, compared to one to two days typical of a vaginal delivery," the report states.
The frequency of C-section and early gestation — giving birth before 37 weeks — rises for women with GDM, PGDM, and women who are overweight or obese, the report finds. Obese women with PGDM are especially at risk; the report says they are four to seven times more likely to suffer poor maternal outcomes, including C-sections, hypertension, or ICU admission.
Based on data from the Texas Department of State Health Services (DSHS), 12.5 percent of all infants born to diabetic mothers were admitted to a NICU. "Medicaid data suggest that the likelihood of NICU admission appears to double if the mother had PGDM during pregnancy," the study says.
In addition, an April Journal of the American Medical Association article titled "Association of Maternal Diabetes With Autism in Offspring" features results of a study that shows women diagnosed with GDM by 26 weeks of pregnancy may have an increased risk of giving birth to a child with autism. The study's authors note the need for more research to determine whether autism risks can be reduced with early treatment of GDM.
Preventing Future Diabetics
The HHSC report says about half of the women participating in the Medicaid or Children’s Health Insurance Program (CHIP) perinatal program received screening for GDM in 2012. Dr. Gonzalez says the Texas Diabetes Council is working with HHSC to see that all women get screened for diabetes during pregnancy.
Early screening for GDM could play a major role in decreasing the prevalence of diabetes in the state, he says, adding “this is one of the sources of our future diabetics.”
In an addendum to the Medicaid report, the Texas Diabetes Council included its recommended strategies to reduce the impact of gestational diabetes among Medicaid patients.
Besides ensuring GDM screening for all pregnant women in the Medicaid program, the council vows to work with HHSC to arrange nutrition therapy, self-management education, and supplies for women with GDM. The council also says it will investigate ways to prevent complications, hospitalizations, and potential NICU costs associated with gestational diabetes.
The council further states it will work with HHSC to identify solutions to decrease poor birth outcomes caused by inadequate diabetes management in mothers.
Finally, the council says it will work with HHSC to ensure that new mothers diagnosed with gestational diabetes have access to programs such as the National Diabetes Prevention Program to help prevent or delay the onset of type 2 diabetes.
Dr. Gonzalez says an investment in educating women in the Medicaid program about the negative effects of GDM and obesity "can certainly pay off big dividends later on."
Primary care physicians can play a role by educating women about the importance of nutrition and exercise, especially if they plan to have children. Dr. Menchaca says in a perfect world, obstetricians would begin seeing would-be mothers before conception to identify their diabetes risk. "But unfortunately, the OBs are so busy," he said.
Private practice physicians — obstetrician-gynecologists and family physicians — don't often have the time to spend with women reinforcing proper diet and exercise, he adds.
"It takes time to sit down and emphasize this to families," Dr. Menchaca said. Not to mention, payers don't compensate physicians for the time it takes to educate patients about the benefits of healthy weight. "That's a big stumbling block," he said.
Identifying and treating overweight and obese young women "basically starts the prevention process, before the next generation is conceived," he said. "It's exceedingly hard to achieve … but we can't do nothing."
Dr. Menchaca says primary care physicians who see women after they give birth can offer some advice to keep their children out of the risk pool for type 2 diabetes. "First and foremost: breastfeeding," he said.
According to the article, "Breastfeeding After Gestational Diabetes Pregnancy," published in the July 2007 issue of Diabetes Care, breastfeeding lowers women's risk of breast and ovarian cancer and could protect against type 2 diabetes.
"For the offspring, breastfeeding confers protection against both under nutrition and over nutrition during early childhood and may lower risk of developing obesity, hypertension, cardiovascular disease, and diabetes later in life," the article states.
Dr. Menchaca says physicians should also tell parents to steer children away from sugar-sweetened beverages. But again, he says, lack of time often keeps physicians from getting the message across. Fewer and fewer physicians are accepting Medicaid patients, and "no one has time to spend with these mothers to explain what they need to do to reverse the situation," he said.
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