Gestational Diabetes: Exercise and Tech

GDM: EXERCISE & TECHIRIS THIELE ISIP TAN MD, MSC Director, UP Manila Interactive Learning Center Chief, UP Medical Informatics Unit Professor, UP College of Medicine @endocrine_witch

NOTHING TO DISCLOSE

EXERCISE

TELECARESMS

POSTPARTUM

Several international guidelines recommend exercise in GDM management

No supporting evidence from a systematic review

Harr ison et al Journal of Physiotherapy 2016; 62:188-196

Exercise improves glycemic control in women diagnosed with gestational diabetes mell i tus: a systematic review. Harr ison et al Journal of Physiotherapy 2016; 62:188-196.

EXERCISE AND GLYCEMIC CONTROL GDM

P Pregnant women with GDM

I Exercise performed more than once a week, sufficient to achieve an aerobic effect or changes in muscle metabolism

O Postprandial blood glucose, FBS, HbA1c, requirement for insulin, adverse events, adherence

M Systematic review (8 RCTs qualitative n=588, 7 RCTS quantitative n=544)


Can adjunctive exercise improve acute postprandial blood glucose in women with GDM vs standard care? Does adjunctive exercise improve FBS and HbA1c? What kind of exercise programs are effective in lowering postprandial blood glucose levels? What variables affect adherence?

Circuit type resistance training n=2

Upright cycle ergometer n=2 (one trial combined with walking)

Recumbent cycle ergometer n=1

Arm ergometer n=1

Brisk walking n=1

Yoga n=1

Image from hammer-fitnes.ch

Image from runningonhungry.com

EXERCISE

Harrison et al Journal of Physiotherapy 2016; 62:188-196

http://hammer-fitnes.ch

http://runningonhungry.com


Frequency 3-7 sessions per week

Intensity Variable Predicted HR max 50-70% Between “moderate” and “somewhat hard”

Duration 20-45 min Including short warm-up and cool down periods 6 weeks or until 38 wks AOG or to end of pregnancy

EXERCISE

Delivery Individual session Center-based with direct supervision Home-based with direct, indirect supervision (phone) or unsupervised Both center- and home-based


POSTPRANDIAL BLOOD GLUCOSE


FASTING BLOOD GLUCOSE

HBA1C


INSULIN REQUIREMENT



Can adjunctive exercise improve acute postprandial blood glucose in women with GDM vs standard care? YES Does adjunctive exercise improve FBS and HbA1c? YES


What kind of exercise programs are effective in lowering postprandial blood glucose levels? Moderate intensity, minimum of 3x a week

What variables affect adherence? Not reported by the trials


Adding exercise to usual care of GDM reduces postprandial BG, FBG and HbA1c.

Exercise is safe.

EXERCISE

TELECARESMS

POSTPARTUM

Diabetes Res Clin Pract (2015), http://dx.doi.org/10.1016/j.diabres.2015.07.007

Included 3 RCTs only Convenience of reducing face-to-face and unscheduled consultations More trials that include cost evaluation are required

TELECARE APPROACH TO GDM

Perez-Ferre et al Int J Endocr inol 2010

P 100 pregnant women with GDM

I Telemedicine system for transmission of capillary glucose data and SMS with weekly professional feedback

C Traditional face-to-face outpatient clinic visits O Percentage of women with HbA1c <5.8%, normal vaginal delivery and LGA infants

M Randomized parallel group


VISIT 1 VISIT 2 VISIT 3 VISIT 4

Before 28 wks AOG

32-34 wks AOG

36-38 wks AOG

39-40 wks AOG

BODY WEIGHT, BP, HBA1C, URALB/CREA, CBG LOG, INSULIN REQUIREMENT

TELEMEDICINE group

BOTH groups

Image from accu-chek.com

Image from gsmarena.com

App to transmit CBG to central database via SMS

IR transmission of CBG from glucometer to phone

Patient sends CBGs once a weekEndocrinologist & nurse educator evaluate CBG dataTwo- way communication via SMS

Unscheduled visits allowed

http://v

http://gsmarena.com

62% reduction in clinic visits for telemedicine group

82% reduction in clinic visits for insulin-treated women p<0.03 More contacts (15.05 vs 9.11) taking less time (3.8 vs 4.6 h)


NS difference in HbA1c, vaginal delivery, LGA infants


Reduction in number of clinic visits saves time for both patient & health professional

Telemedicine connection increases accessibility to health team, at convenience

Reduces transportation, clinic waiting times

Minimizes intereference with woman’s work schedule

Particularly useful for insulin-treated who require more contacts to adjust insulin dose

INTERNET-BASED TELEMEDICINE FOR UNDERSERVED WOMEN WITH GDM

Homko et al Diabetes Tech & Ther 2007


I Internet group (n=32); provided computers & internet access for communication via website

C Control group n =25; maintained paper logbooks reviewed at each visit

O Use of system, self-efficacy, maternal glucose control, pregnancy and neonatal outcomes

M Randomized trial


7 women (22%) never accessed the system

3 women (20%) required a second visit for additional training and/or to correct technical problems

Women in intervention group had higher feelings of diabetes psychosocial self-efficacy

NS difference in glucose control, pregnancy and neonatal outcomes

Women sent average of 3 wks data in 8-wk follow-up

Daily responsibility of poor young single mothers with small children limited applicability of

telemedicine approach

Logistics of providing, installing & maintaining hardware was labor-intensive


TELEMEDICINE SYSTEM WITH AUTOMATED REMINDERS FOR WOMEN WITH GDM



I Telemedicine group (n=40); Interactive Voice Response telephone system

C Control group n =40; maintained paper logbooks reviewed at each visit

O Maternal glucose control and infant birth weight

M Randomized trial


IVR system can be accessed from any phone

Asynchronous phone messaging between clinicians and patients

Automated reminders for patients to transmit data


Option of dialing dedicated toll-free number or use Internet with unique log-in and password

Can append message IVR: 45 s speaking Internet: unlimited text input

Data and messages queued for clinician to respond via portal


Patient’s message from IVR plays back as wav file

Nurse can respond by typing IVR: text-to-voice function Internet: text


Automated 3 phone call reminders for missed data transmission

If still no response, the nurse can reset reminders (another 3 calls) or call the patient directly to follow up.


NS difference in maternal blood glucose

NS difference in LGA infants

Adding telephone access and reminders increased transmission rates of data in the intervention group.

Telemedicine system increased contact between women and their health team but had no impact on outcomes.

EXERCISE

TELECARESMS

POSTPARTUM

DIAMIND Randomized Tr ial

POSTPARTUM SMS REMINDERS FOR GDM

P Women with GDM in recent pregnancy, with mobile phone, normal blood glucose before discharge

I SMS group (n=140); SMS reminder for OGTT at 6 wks postpartum and 3 & 6 mos if required

C Control group (n =140); SMS at 6 mos postpartum

O OGTT at 6 mos postpartum

M Randomized parallel groupvan Ryswyk et al Diabetic Medicine 2015

SMS 1 SMS 2 SMS 3

6 wks postpartum

3 mos postpartum

6 mos postpartum

NATIONAL GESTATIONAL DIABETES REGISTER

Sends postal reminders 12-16 weeks after expected due date

SMS GROUP

CONTROL GROUP

if required if required

van Ryswyk et al Diabetic Medicine 2015

SMS sent automatically based on date of birth of baby using Clickatell bulk SMS gateway

DIAMIND Randomized Tr ial

POSTPARTUM SMS REMINDERS FOR GDM

OGTT attendance at 6 mos SMS group: 104 (77.6%) Control group: 103 (76.8%) RR 1.01, 95% CI 0.89-1.15

>83% received postal reminders from National Gestational Diabetes Register

van Ryswyk et al Diabetic Medicine 2015

EXERCISE

TELECARESMS

POSTPARTUM

@ENDOCRINE_WITCHIris Thiele Isip Tan MD, MSc

Director, UP Manila Interactive Learning Center Chief, UP Medical Informatics Unit

Professor, UP College of Medicine

Gestational Diabetes: Exercise and Tech

Healthcare

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