The Insulin Connection, Obesity and Maternity Care in Gladstone
The following discussion is an excerpt from the lecture I gave for “Low Carb Gladstone” in 2018 (when I was still actively delivering babies)…. Perhaps not such a palatable topic but one that has so much scope for improvements on many fronts as people can come to understand the role of a low-carbohydrate diet in managing PCOS, Obesity and Diabetes.
It was at the second Science of Nutrition in Medicine Conference in 2012 that I heard Professor Grant Schofield speak about LCHF. His presentation had a graph which showed the glucose and insulin response to different types of foods. I remember well the collective gasp that went up in the room full of doctors, dieticians, naturopaths, scientists and other health professionals when the line for oats shot up higher than all the others.
I, like most other doctors, regularly recommended a bowl of oats as an excellent breakfast, and I remember sitting in the audience trying to deal with the cognitive dissonance that my recommendation could be harming some of my patients.
That conference also had a speaker who discussed polycystic ovarian syndrome and how elevated insulin drove elevated testosterone. The two lectures dovetailed together nicely, and I came home from that conference with a better understanding of the management of PCOS, and a dawning realisation that we were getting diabetes all wrong.
The first patients who I discussed LCHF with were women who had been diagnosed with polycystic ovarian syndrome. Polycystic ovarian syndrome is associated with infrequent menstrual periods and often difficulty in falling pregnant.
My training had suggested that this was due to a problem with the ovaries, and that weight loss, or the drugs metformin or clomid were appropriate treatments.
Of course, weight loss when you are insulin resistant on a low fat diet is a difficult, if not impossible task, and I was used to referring these ladies on for fertility assistance, when their trial of dietary intervention failed.
With a low carbohydrate, healthy fat (LCHF) diet, a significant proportion of these ladies were able to establish a regular menstrual cycle, in response to the decrease in their baseline blood insulin levels, and subsequently fall pregnant.
Once somebody who has polycystic ovarian syndrome falls pregnant, she also falls in to the high risk category for developing gestational diabetes.
Gestational Diabetes affected about 5.5 percent of pregnant women in Queensland in 2009.
In 2016, it affected almost 12 percent of pregnant women. About one third of pregnant women treated for gestational diabetes in 2014 required insulin.
This is important to remember because an Insulin Requirement is one of the criteria we use to decide if a patient is able to birth locally.
Mothers with gestational diabetes are more likely to have
- pre eclampsia
- an induced labour
- a vacuum, forceps or caesarean birth
- Excessively heavy bleeding after birth
- Infections in the post natal period
Their babies are more likely to need to be admitted to the special care nursery in order to treat jaundice, low blood sugar, premature birth and a few other conditions. Babies born to mothers who have gestational diabetes are more likely to get stuck as they exit the birth canal, or suffer a fractured clavicle, or damage to the nerves of the arm. They are also more likely to die.
When they grow up, children of mothers who have diabetes of pregnancy are more likely to develop obesity and type 2 diabetes.
From a rural perspective, this lessens the options available to women. Both the Gladstone Mater** and Gladstone District Hospitals have sensible clinical guidelines which they employ for the safety of their patients.
High risk women, such as those with poorly controlled blood glucose levels, must be sent to places where there are special care nursery cots, just in case the baby needs care there.
It is safer to deliver the baby where the special care nursery is, than to transfer a sick baby after the event.
In preparation for this talk, I looked up the Queensland Health statistics on obesity for Gladstone. Obesity is defined as a body mass index over 30.0 kg per meter squared. To calculate it, the person’s weight in kilograms is divided by the square of the height in metres.
Normal values for BMI are different for different ethnic groups, but I will not explore that further in the interests of time.
The statistics regarding health and lifestyle determinants are gathered by a state- wide Queensland Health telephone survey.
In 2009-2010, 40.3 percent of people over the age of 18 were in the healthy weight range. In 2011-2012, that figure had dropped to 33.4 percent. In the 2015-2016 dataset, 34.7 percent of people were in the healthy weight range.
Like the rest of Queensland, the obesity incidence seems to have stabilised.
By comparison, in Brisbane, in the same 2015-2016 period, 45.6 percent of individuals over the age of 18 were in the healthy weight range. So statistically, a person is more likely to be overweight or obese if they live in Gladstone, compared to living in Brisbane.
At least 16 percent of pregnant women in Queensland were classified as obese during the year 2015, unfortunately I do not have the data for Gladstone, however I can say it is a common problem here.
The Queensland Clinical Guidelines for Obesity in Pregnancy, last updated in 2015, make sobering reading. They are available online, should anyone wish to further educate themselves on the subject.
As a very short summary, obese women are more likely to suffer miscarriage or stillbirth and are more likely to have a complicated antenatal course, requiring specialist care.
During labour, their anaesthetic is less likely to work, they are more likely to need an induction of labour, and to have a failed induction of labour. They are less likely to have a normal vaginal delivery, instead having a complicated vaginal or caesarean delivery. They are more likely to suffer life-threatening blood loss, infections and deep vein thrombosis in the postpartum period.
The ladies find breastfeeding more difficult and are more likely to suffer from postnatal depression.
Babies of women affected by obesity are more likely to be admitted to neonatal intensive care units, and to subsequently be diagnosed with asthma, autism, developmental delays and obesity.
Of course, many large women are able to have an uncomplicated pregnancy and birth, and women who are not obese sometimes have pregnancy complications, however it is important to acknowledge that these risk factors and consequences are real, and safety of the mother and child is paramount in shared- decision making around her care.
Queensland health directs each Hospital to make an assessment of it’s safety and capabilities to look after women affected by obesity.
The hospital must make sure it has infrastructure, such as “bariatric rated” operating theatre beds and wheelchairs and also instruments such as extra-long spinal anaesthetic needles to manage the physical reality of looking after obese patients.
Administration of an anaesthetic to and performing surgery on obese individuals is also technically more difficult, and the hospital needs to make sure it has staff available to perform these procedures, especially after hours.
So for hospitals like Gladstone, this means that women whose body mass index is over 40 must be referred to Rockhampton, where there are appropriate facilities and staff.
As one of the providers actually performing caesarean operations on women I can attest that operations on larger people are more difficult to do. One of the reasons I attend Pilates classes regularly is to maintain my shoulder strength in order to deliver babies!
Of course, it would be best if all of this could be avoided in the first place. It is much better to improve metabolic health (and in so doing perhaps lose weight) and correct vitamin deficiencies a good 6 months before falling pregnant, to significantly reduce the chance of a complicated pregnancy, and to reduce the risk of the child going on to develop their own health problems.
As I prepare this post in July 2019, I re-read some of the Qld Health Consumer Guidelines “Healthy Eating for Gestational Diabetes Mellitus”. Unfortunately, these have not been updated with the new science of carbohydrate metabolism (the guide was published in 2013, from references from 1990-2008), and continue to encourage women to eat plenty of carbohydrate containing foods every 2-3 hours. For women interested in the contemporary dietary management of Gestational Diabetes, I would recommend reading “Real Food For Gestational Diabetes” by Lily Nichol
Figure 1 from:
Krezowski et al “Insulin and Glucose Responses to Various Starch–Containing Foods in Type II Diabetic Subjects” Diabetes care 1987 Mar; 10(2): 205-212
**The Gladstone Mater’s team delivered their last baby in September 2018, and the Gladstone Mater itself was closed and sold to Queensland Health in 2020.