In Episode 52, Dr. Sarkar welcomes Dr. Michelle Ogunwole, MD, PhD, who will speak with us about gestational diabetes with a special focus on marginalized populations. Dr. Ogunwole is an assistant professor of medicine at the Johns Hopkins University School of Medicine and faculty member at the Johns Hopkins Center for Health Equity. She is a health disparities researcher, social epidemiologist, and general internal medicine physician who has additional board certification in obesity, medicine and lifestyle medicine.

She has advanced training and quality improvement in patient safety science. Dr. Ogunwole is research is focused on health disparities and maternal health outcomes among African American women specifically in the role of the general internist in optimizing chronic medical conditions in the preconception period, postpartum chronic disease and long-term health outcomes related to complications of pregnancy, African-American women’s experience with the healthcare system and barriers to primary care follow-up after pregnancy, and creating equitable community-driven quality improvement interventions around the transitions of care, from obstetrics to primary care for racial and ethnic minorities who experience medically complicated pregnancies.

Sudipa Sarkar:  Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Sudi Sarkar at Johns Hopkins. We develop this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy to understand resource for diabetes or to listen to previous podcasts, please visit hopkins diabetes info.org.

Today we are excited to welcome Dr. Michelle Ogunwole MD PhD, who will speak with us about gestational diabetes with a special focus on marginalized populations.

Dr. Ogunwole is an assistant professor of medicine at the Johns Hopkins University School of Medicine and faculty member at the Johns Hopkins Center for Health Equity.

She is a health disparities researcher, social epidemiologist, and general internal medicine physician who has additional board certification in obesity, medicine and lifestyle medicine.

She has advanced training and quality improvement in patient safety science. Dr. Ogunwole is research is focused on health disparities and maternal health outcomes among African American women specifically in the role of the general internist in optimizing chronic medical conditions in the preconception period, postpartum chronic disease and long-term health outcomes related to complications of pregnancy, African-American women’s experience with the healthcare system and barriers to primary care follow-up after pregnancy, and creating equitable community-driven quality improvement interventions around the transitions of care, from obstetrics to primary care for racial and ethnic minorities who experience medically complicated pregnancies.

Welcome, Dr. Michelle Ogunwole.

Michelle Ogunwole: Thank you so much for having me. I’m thrilled to be here.

Sudipa Sarkar: Thank you for joining us. So I wanted to start off with some general questions. So first I’d like to ask you to please give our audience a  general overview of what is gestational diabetes.

Michelle Ogunwole: Sure that’s a great way to start. Gestational diabetes is a special type of diabetes that develops during pregnancy. So it’s not the diabetes that people have before pregnancy, but the one that you only get during pregnancy. And it happens when the body really can’t handle the sugar. That’s in our bodies as well as usual.

It usually goes away after birth. But it’s also an important signal about women’s long-term health and if it’s useful, sometimes I think about a little bit of a metaphor about how, we can think about gestational diabetes. If it’s useful, then I sometimes share that with people.

I think about a drill sergeant, I was in drill team growing up, so I think about that. So during pregnancy, I’d say that your insulin is like a drill sergeant and its job is to tell the glucose where to go move it, get inside the cells. But when the : pregnancy hormone comes along, it acts like a bunch of new rebellious recruits who don’t really wanna listen.

And so you think that, trimester after trimester, as you grow in your pregnancy, you’re getting more and more of these recruits and they’re. Starting to ignore orders, they’re dragging their feet, they’re pushing back. And so the drill sergeant insulin is having a harder time managing them.

And so they’re having to yell more and louder and work harder. And, eventually the recruits stop responding. So that’s basically how I explain what insulin resistance is. And that can happen in pregnancy. And some people get gestational diabetes, right? And some people don’t. And I think there’s a lot of factors as to whether or not your drill sergeant and your pancreas, which supports like your insulin is able to handle those recruits as they grow. That’s one of the ways that I try to explain it to people.

Sudipa Sarkar: That’s very helpful. What risk factors might make someone more susceptible to : developing gestational diabetes?

Michelle Ogunwole: That’s also a great question. There are things like your medical history. We know that weight overweight and obesity, carrying kind of excess fat in our bodies definitely increases the risk. There’s other things like having a family history of diabetes. As well as, any prior pregnancy that you have with gestational diabetes definitely increases the risk in your next pregnancy.

And then we know that certain groups of people are more likely to get gestational diabetes. Black, Latinx, Asian and indigenous women are more likely to have the diagnosis or. To have less control of their glucose if they get gestational diabetes. But that is usually related to the social risk factors or social things that go along with being members of some of these communities.

The other one I would say too is just because diabetes is gestational diabetes and diabetes is so closely related to : nutrition as well. When you think about people who have limited access to healthy foods and have less resources and obtaining some of those healthy foods also, or higher risk.

Sudipa Sarkar: So it sounds there are risk factors that predispose people to gestational diabetes. So weight family history and then social factors and economic factors. Can you tell us a little bit more about these social and economic factors , that play a role in gestational diabetes, in including nutrition access?

Michelle Ogunwole: Yeah, that’s a, it’s a good point. I think that it’s. One of the things I like to say is a lot of these things are related to one another. In research we think of the root cause of all of these things. You think about, a tree and the roots that are in the ground and everything that spouts off the tree, then we can start to think about is structural kind of disinvestment in certain communities. We also refer to that as structural racism. Kind of the totality of all of the ways that : structures and systems are set up to make certain communities fail in certain communities thrive. Some of those dis investments that have happened along the course of history for certain communities.

I do a lot of work with black and African American population. Thinking about things, as far as chattel slavery and then Jim Crow and , even the GI Bill not being open to black people coming back and how redlining, which is when certain groups or black people were denied access to home ownership.

Because of discrimination, all of these things really set up communities to not be able to obtain generational wealth. Also it sets them up to be in cycles of poverty and then that poverty from that tree, if you think about going up and. The things that kind of bloom, the leaves that you see come off when you don’t have access to resources it’s really difficult for you to make great choices in terms of even things like : your nutrition. We talk a lot about as a doctor and trying to help people to make healthy choices, but in order to make a healthy choice, you have to have a healthy choice. And not everybody has access to healthy choices based on some of these factors.

Things like that really. Contribute to whether or not you can buy healthy foods when you’re supposed to, whether or not your neighborhoods are safe enough to walk and do the exercises that you need that support your overall health and your healthy weight. There’s other kind of contributors , in the environment that might make it more stressful to live in an environment.

Certainly anybody who’s had some of those experiences growing up when you have limited socioeconomic resources or just money, this is the point to say if you have limited means. it’s stressful. It’s stressful to be poor. It’s stressful not to be able to afford things.

And we know that kind of chronic stress also affects our health, our weight, and things like diabetes. So we have research that supports those ideas. Hopefully, I’m trying : to paint a picture of what the roots of this tree look like and how that tree grows.

And what we see on the outside is different risks for different communities of things like gestational diabetes based on this.

Sudipa Sarkar: Thank you. That really helps kinda build a very comprehensive picture of all of the factors and variables that can affect women’s health specifically when it comes to gestational diabetes.

Could you discuss a bit about why blood glucose control is so important. During pregnancy for someone who has gestational diabetes and what are the major types of treatment that are available for women with gestational diabetes?

Michelle Ogunwole: Yes. Blood sugar control in pregnancy is extremely important. I would say that. In terms of the baby’s outcomes, of course we know that how high your blood sugar is and how out of control it is really affects the complications that you have at birth. Whether your baby : is much bigger than they’re supposed to be, we call that large for gestational age, which can affect a lot of things related to your delivery outcomes and make it difficult with vaginal deliveries and for complications to occur.

And there’s other more serious complications in terms of the early pregnancy and the formation of the organs in the baby itself. We know that having poorly controlled blood sugar can affect that development of organs for the baby. It’s really critical. That we, have really tight glucose, there’s the forming of the baby and the complications , even the complications, the birth complications that can happen.

And then too for the mom, we know that, people who have worse control of their sugar during pregnancy also have an increased risk of having diabetes after pregnancy. So it’s a really big predictor of the people who will go on to have diabetes. And we also know now that there’s more data. It’s really fascinating that what happens in pregnancy, it can actually be a  predictor for your child’s future metabolic health. Whether or not they, your child has obesity, whether or not they may be at risk for diabetes can be determined by what happens during the pregnancy. And so that’s why the blood sugar is so important.

Going back to my metaphor about the unruly recruits. There are different levels of that unruliness, right? And so some people have only a few unruly recruits, and those are people who can maybe be managed with just diet.

They have gestational diabetes, but there are things that we can do to reduce their blood sugar. To the ranges that we would like during pregnancy, just through diet modification. That’s why working with a nutritionist is so critical because, you can really see it in real time. It’s incredible.

We have people who have more unruly recruits and sometimes they require more support to get them in order and that’s what I would call people who need insulin therapy to help  them manage their blood sugar and pregnancy. And so there’s other medications that people might be familiar with.

Metformin is a pill that we also can use in pregnancy to support this overall approach to improving our body’s ability to handle the glucose levels, the sugar in our bodies. So those are the main treatment modalities. And then along with the diet piece, I’ll go back to that.

There’s some interesting studies that, and we know this true, this is outside of pregnancy, but physical activity can also be supportive in this. So like sometimes we’ll have people after big meals going to take a walk and there’s really people who do very well with that and supporting like this plan to get their sugar into a better controlled range. And you may or may not ask me about this later, but it’s really fascinating because now we have more and more women wearing these continuous glucose monitors, which allows you to see the effects of your blood  sugar changing in real time. It’s a monitor that’s it’s painless and you attach it to your body and it’s continuously measuring your blood sugar all the time that you’re wearing it and you get alerts on your phone about what your blood sugar is in the moment. You can actually eat something and then see what happens to your blood sugar. You can take a walk and see what happens. I think that can be really empowering and helpful for people to really see the way that diet and activity can influence your blood sugar and how this is happening all throughout the day.

All of the things that you do really contribute to that, even the stress and the amount of sleep, all of those things come together to contribute to these rises and falls. So it’s nice for people to be able to really see that in real time.

Sudipa Sarkar: Are goals for women who are pregnant with gestational diabetes different , as opposed to someone who’s not pregnant but has diabetes and when would someone need medicationoutside of metformin more than diet and exercise intervention? Are the glucose goals different between those two groups of people?

Michelle Ogunwole: When we think about the way that we design our targets for glucose during pregnancy… because of everything that’s going on with the pregnancy, we have much tighter blood sugar parameters for pregnancy because of the baby’s organs forming and all of these things that are happening. And so yes, we do have slightly different targets in pregnancy.

Non-pregnant individuals, we are still looking at the same parameters. So when you wake up after you have slept and you haven’t eaten, we look at fasting blood sugar. We tend to look at our sugar right after we have meals one or two hours after that. And so we’re looking at the trends for all of these things.

I’m very interested in continuous glucose monitors, they’re really interesting because they can give us a little bit more information too. Even for that, when we set the parameters, we actually 1: set them differently for pregnant individuals to when they alarm, and we have goals for how often we want them to be in the ideal range for blood sugar for pregnant women. And that’s how we also guide our therapy. So it’s really interesting to see that too.

Obviously diet and exercise is one component. Then we sometimes add things like metformin which can help with our overall, sensitivity, to insulin and in our bodies.

And then we have insulin itself. We sometimes, despite our best efforts, especially with the pregnancy growing, we have this growing pregnancy every week, as that placenta grows, that baby grows, we just have more and more of those unruly recruits. That’s what I keep saying.

So it’s just. At some point, sometimes we cannot manage it and we actually have to give people insulin to help them manage their blood sugar. And particularly as the trimesters progress,we really see that increased need for insulin in the later trimesters, which makes sense. Because the baby’s growing as well.

Sudipa Sarkar: It sounds like there’s three phases that we think of for the woman with gestational diabetes kind of preconception period during the pregnancy and then post-delivery. And so in an ideal situation, what does the care of the woman who has had gestational diabetes look like after delivery in kind of 1, 5, 10, 20 years later in terms of, helping to prevent complications or the cardiometabolic diseases that we see that are associated with gestational diabetes.

Michelle Ogunwole: That’s a great question. Gestational diabetes, which is diabetes and pregnancy increases the risk of developing diabetes outside of pregnancy, and that is by seven to 10 times. So, it’s pretty significant. And we talked a little bit about the things that predict whether or not you will go on to get diabetes, so your blood sugar control in pregnancy, whether you needed insulin. These are the kinds of things that really predict whether you’ll go on to have diabetes in, after your pregnancy. But in addition to that we also know that gestational diabetes independently increases the risk of other diseases like cardiovascular disease. So, things like, stroke, high blood pressure having a heart attack. We know that this risk is like one and a half to two times higher for people who’ve had gestational diabetes.

It really is important I talk about pregnancy as a stress test, which kind of reveals some things to us. So when you get these diagnosis, it reveals something, but it’s also showing us that there is an important opportunity, I think to intervene to try to prevent these kind of long-term diseases from developing, and we can, and I think that’s what’s exciting about the work that I do, is that we can support people so that we could try to prevent progression to some of those outcomes that I talked about. Also, if they want to have another pregnancy right, that we can put them in the healthiest state that they can be to go into that next pregnancy and hopefully reduce the complications from happening again.

The other predictor after people have their babies, they also get another test of their insulin sensitivity or how well their body is managing glucose after they’ve had the gestational diabetes. Because this diagnosis usually goes away for a lot of people after the baby is delivered. So, we do another test about one to three months after delivery. It’s called an oral glucose tolerance test. We do another one to check to see if you still have some clues that your body is not managing your sugar as well as it should, even though the baby’s delivered.

Sometimes people have borderline or higher numbers, and that also predicts whether or not they end up getting diabetes in the long term as well. Some of the work that I have been doing is thinking about, what can we do in that or that postpartum period to reduce the risk of these chronic disease happening.

And one of the things I’ll say is that a lot of people don’t even come back for those follow up tests to check to see if they have that continued problem with their glucose. I’d say 50% of people don’t always show up for that test. That’s one thing that I think is really important that women who’ve had gestational diabetes recognize that the risk isn’t over just because the baby has been delivered. And so it’s really critical that we follow up with your primary care, your ob, your primary care team, just to continue to monitor that risk and see if there’s some things that we can do.

Then going back to diet and exercise and what we know is that, and maybe people have their own experiences with this, but we gain weight during pregnancy. That’s common. Some people gain more than the recommended amount as well, and those are kind of predictors of whether you get these chronic diseases too.

We often have weight gain during pregnancy. And then we have postpartum. And what we would like is for people to return to their pre-pregnancy weights within a year. But a lot of people retain that weight. So we call that postpartum weight retention. And that also predicts whether or not you go on to have diabetes.

It can become a cycle where you think about when you have multiple kids, if you never lose that weight from the first baby, and then you go into your your next pregnancy and you gain weight and you never lose the weight and you go into your next pregnancy. So it can happen that way for a lot of people. I will tell you that I have been very humbled myself, I, after having children that it’s not easy. To just go back to your pre-pregnancy weight in a year. I could share personally, I’ve gained 60 to 70 pounds with each of my pregnancies despite trying to eat the best that I could and be active.

It still happens that way, and it’s not an easy thing to tell people to just lose all of that weight in a year. And really the idea is how do we support  people to make small lifestyle changes, especially in the very early postpartum period when they’re already managing and dealing with so much.

Mostly everybody is sleep deprived and so it’s challenging to lose weight when you’re not getting rest. Some people are breastfeeding and they are really working towards making sure that they have enough calories and intake to support that and they’re just managing this kind of new normal of their life and dealing with kind of the hormonal changes that happen postpartum.

What it really is about is just having people make manageable changes. We start with things like trying not to drink soda trying to drink more water, trying to, get in a 10 or 15 minute walk once you’ve been cleared to exercise. Just small things that you can incorporate in that early phase that also make you feel more like yourself is really important. Then later on, discussing what other therapeutic options there are.

Sudipa Sarkar: It’s very insightful. I  wanted to ask, you mentioned the oral glucose test that’s done after pregnancy to see whether or not that person still is not responding to insulin in their own body. Are there other tests that are less cumbersome? The oral glucose tolerance test is a tough test, especially for someone who’s just given birth, a few weeks before.

Michelle Ogunwole: Outside of pregnancy we use a hemoglobin A1C, which is like a three month average of what your blood sugar has been doing in your body. We cannot use that in pregnancy just because that test relies on factors that change in pregnancy.

But after three months, we actually do use that test. So for people who haven’t had an oral glucose tolerance test, I will. Give them a hemoglobin A1C later. I do know that there are scientists working on this very issue right now. People don’t like doing the oral glucose tolerance test in pregnancy. It’s not a fun test. I know that there are some researchers that are working on a hemoglobin A1C that can be : during pregnancy. So that’s a grant funded study in Boston. I know that they’re working on that, so I think that’ll be very paradigm shifting. The other thing is, and I know that we do this sometimes in our high risk OB clinic because some people, let’s say if they have other complications like hyperemesis, which ratu, which means that you’re throwing up all of your pregnancy, and it’s just more than more than typical kind of morning sickness. It’s just excessive. It’s really difficult for people to handle the oral glucose tolerance test, which requires you to drink a very un tasty but sweet beverage. And some people really can’t tolerate that.

And so it’s been really interesting to think about, again, about continuous glucose monitoring and how some people we’ve been able to extrapolate for some people who are not in the range, that they may have some dysfunction in how they’re handling glucose from that test.

We know that those tests are the continuous glucose monitor. There was a big study on it actually to see, hey, if we use continuous glucose monitors in pregnancy versus having people  stick prick their fingers, do we have better birth outcomes? And there wasn’t really a difference in birth outcomes, but the thing is that the patients liked it better. It was less finger sticks and stuff. That’s also promising and that matters. I think it matters a lot about whether people are willing to accept a therapy because it helps us to get the data that we need. That’s something that I’ve seen used for people who really can’t tolerate the oral glucose tolerance test. And in my own work, we’ve been doing some postpartum measurements of the oral glu using continuous glucose monitoring. And there’s another huge study in Boston that’s looking at that. And I think in a couple years we’ll have enough data to say how we can, use the measures that we get from continuous glucose monitoring to actually diagnose people. I think all that’s in the pipeline.

One of the challenges with CGM, both inside of pregnancy and outside of pregnancy it’s not covered unless you’re on insulin. We have challenges getting it for people. Those people let’s say they don’t tolerate oral glucose tolerance test, but they’re not on insulin. Because we haven’t diagnosed them what happens is the : clinic has a sample or I have a sample, so they get to have it. We’re actually doing a policy brief on continuous glucose monitors for patients who are not on insulin in pregnancy, because I think that population is much more likely to get support because they still need tight glucose control, even if they’re not on insulin. It’s so important for the baby. It’s a easier narrative cell when you go to testify and say you can really paint a picture for people. I think that they’re using. It just depends. Like they have type two diabetes and they have poor control, and they’re seeing those numbers early. They’ll still slap it on there early because they already know that these people have type two. But for gestational diabetes, they have to have the diagnosis first, which typically happens around 8 weeks. Then it becomes this challenge of do they need insulin or not? Is it gonna be covered? So I think that’s what is tricky.

Sudipa Sarkar: Dr. Ogun Ole. How can we as clinicians incorporate a history of gestational diabetes when we’re seeing a patient in clinic who’s had gestational diabetes? How do we  incorporate that knowledge into helping the patient reduce their risk of cardiometabolic diseases in the future? And how can we better close the gap between different populations of patients, close the gap from someone who comes from a more marginalized population.

Michelle Ogunwole: I think number one, as non obstetric folks like primary care endocrine I think one of the important things is just making sure that we’re asking the questions because sometimes we feel like pregnancy is not necessarily our lane because we have our obstetric colleagues, but for providers that take care of women across their life course, so we see them, in other stages of their life when they’re trying to get pregnant, potentially when they’re postpartum. It’s really important to incorporate that in our history, all their complications from pregnancy. We can get a lot of clues from that. So I think number one is just asking the question. I think it would be surprised that how much it’s left off of our primary care  evaluations. So that’s one piece.

And then recognizing that if they have had certain complications. In this example we’re talking about gestational diabetes, then it does put them at risk for diabetes. So we should be more attentive in our screening for diabetes for those populations. That’s another piece.

We also wrote a perspective piece for, about this very topic and how we really should consider how these things that are showing up in pregnancy really are almost a warning or something that we should really take seriously as we think about our other therapeutic options, particularly with women in with obesity. And we have different medication approaches now, and whether or not considering gestational diabetes because we know obesity increases the risk.

We wrote a piece that said we should really take this into account when we’re considering whether or not to escalate therapies for managing obesity. So now we have a lot of different options for that. There’s a new class of medications that people are familiar with or may  have heard of the GLP-1s. So things that people might have heard of Ozempic or Wegovy. The way that we prescribe these, this is outside of pregnancy, usually has to do with obesity and then having, another disease that is related to obesity, that’s putting your health at risk.

And so we said, gestational diabetes is an indicator right of some other dysfunction. And for reproductive age women, we should really consider this as a reason to escalate and be more aggressive in our approaches to giving them options for weight management. And there’s other studies going on about postpartum populations, people who are struggling with obesity and the use of these medications, which right now, they’re not approved for use when you’re breastfeeding. But in people who aren’t breastfeeding, were there’s studies that are looking to see, do those medications reduce the risk of developing type two diabetes.

So we know things like metformin and certainly diet and exercise do.  There’s new kind of studies to seeing what else does. So I think just making sure that we’re really thoughtful in identifying these people and then making sure that we are creating plans that are aligned with their goals and offering them the full kind of array of options available to them.

To your point, I think that the same way I said, that kind of nutritious foods and all these things are not always available to certain groups. I would say the same thing is true about some of our newer medications and the the things that we have to treat obesity and potentially prevent and improve diabetes and its control.

Those things are not always available to certain populations based on their insurance status and some other things. The medications can be very pricey as well. I think there’s just a lot of work to do. The work that I’m have been really interested in is making sure that as we design therapies and options to support healthier lifestyles for people which ultimately improve  their risk of getting diabetes, that we also think about how our systems and structures can be accountable in helping to support that process. How should our hospital systems and how can government programs really support in giving resources for healthy food so that way when we prescribe them, people have a way to get them. That’s the work that I’ve been interested. I think that whatever things that we offer patients, particularly when we’re talking about dis health disparities or health equity, we have to ask ourselves, what is the structural and system solution that can support this recommendation that I’m giving? And work really hard to identify that, whether that’s with our social workers or through other programs or assistance programs that can support people in healthy eating as well.

Sudipa Sarkar: Dr. Ogun Ole, thank you so much for a wonderful conversation. This is very nice, very helpful.

Michelle Ogunwole: Thank you so much for having me. This has been delightful.

Sudipa Sarkar: I’m Dr. Sudi Sarkar and you’ve been listening to Diabetes Deconstructed. We developed this podcast as a companion to our Patient Guide to Diabetes website. Our vision is to provide a trusted and reliable resource based on the latest evidence that people affected by diabetes can use to live healthier lives.

For more information, visit Hopkins diabetes info.org. We love to listen from our listeners. The email address is Hopkins diabetes [email protected]. Thanks for listening and see you next time.