Get healthy in pregnancy

 

Sammi: Good evening everybody and welcome to this evening’s Get Healthy in Pregnancy webinar. My name is Samantha and I am your host for this evening. Before we get started I just would like to make a quick Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present.

Alrighty, so I would like to introduce our presenters for this evening. We are joined by Dr Linda Mann and Justine Salisbury. Linda is a Fellow of the RACGP and member of the RACGP Antenatal and Postnatal Care Network. Linda has local and international medical experience, especially in genetics and women’s health. She is a GP representative on various national and local government committees and is an experienced medical educator.

And Justine in the Senior Project Officer for the New South Wales Get Healthy in Pregnancy Service, as well as a midwife and registered nurse. She has been working in both education and clinical services management for over 25 years in both public and private sectors with 18 years’ experience working in the fitness industry with a major focus on women’s health and pregnancy exercise. Justine is a keen advocate for women’s health in pregnancy. So welcome Linda and Justine and thank you for joining us.

Alrighty, I will hand over to Linda now to take us through the learning outcomes for this evening.

Linda: By the end of this online QI and CPD activity, you should be able to discuss how healthy lifestyle behaviour modification coaching can benefit women with gestational diabetes and hypertensive disorders in pregnancy, explain the importance of post-pregnancy health behaviours in the prevention of future chronic disease to patients and integrate referrals to the New South Wales Get Healthy information and telephone coaching service into routine consultations, and utilise feedback from the service.

One of the concepts that we are going to talk about today is the stress test elements of pregnancy and what happens as a result of that. You know all about gestational diabetes because the levels at which people are diagnosed with this have recently changed which means many more of our patients in fact are being allocated that diagnosis. Pregnancy is an accelerated stress test for the pancreas and placental hormones can block the action of maternal insulin or inducing insulin resistance. So the need for insulin is two to three times higher than when not pregnant. So if you are a person who has already got your own insulin resistance before you became pregnant and then you add the insulin resistance of pregnancy, the result can be gestational diabetes. The second biggest modifiable risk for GDM is being, the most modifiable risk is in relation to healthy weight and the thing you can change is how quickly you gain that weight in the first half of pregnancy. In fact, we now know that amongst the best managements for GDM is healthy eating, regular physical activity. I know, I know, it is a story we tell everybody for everything. But I cannot help it, it is still true! Unfortunately when that does not do the trick, then people go on to the requirement for treatment. We also now know that following birth, the risk of type 2 diabetes is increased in that cohort with 50% developing type 2 diabetes over the next 5-10 years. And that of course is why we continue to test women postnatally in order to try and catch that change if it happens. That is why we do the 75 gram oral glucose tolerance test at six weeks and then 1-3 years after pregnancy in a continuing fashion particularly while they are planning pregnancies. Wouldn’t it be nice though to prevent it rather than just test for it.

So what do we tell people? Well we do talk about the testing. We do warn them that they have an increased risk of developing diabetes. We have to of course use our own systems and processes to make sure there are recalls and processes for monitoring patients in an ongoing fashion. The other thing of course we can do, is to do whatever we can to help them maintain a healthy weight through diet and exercise. And we have a tool for that, which is what we are talking about today.

It is not just – can I have the next one – it is not just weight and gestational diabetes. It is part of this whole picture. Hypertension in pregnancy is also an issue and I will have no doubt that every single person in the audience has observed the fact that the identification of the different sorts of hypertension in pregnancy and the treatment of it is an increasing aspect of pregnancy care. One in ten Australian women will experience hypertension during this time and that can includes preeclampsia, gestational hypertension which is a separate condition, and also people who had chronic or essential hypertension as part of their context when they became pregnant. That comes up to about 30,000 women. And a third of that number are diagnosed with preeclampsia. Gestational hypertension which is a term you may not have come across, or pregnancy induced hypertension, which is sometimes called PIH – I am just letting you in there on another acronym – is the development of newly developed hypertension and their definition, the Institute of Medicine’s definition for this, is a systolic over 145 or a diastolic above 95 in pregnant women after 20 weeks of gestation without the presence of protein in the urine or other signs of preeclampsia. Clearly in someone below 20 weeks, you would have to think she had essential hypertension if that is found. And of course, you can actually have a whole bunch of them together.

If you do have preeclampsia, then that is a marker for an increased risk of things that can come. So there is a four-old risk that women will develop hypertension later in life and in particularly increases the risk of developing ischemic heart disease by two or three times. Why do I say particularly? Because I have to say until recently, that was news to me. I did not actually realise that the presence of preeclampsia increases your risk of ischemic heart disease. Hypertension, sure. Ischemic heart disease, a bit of a surprise really. Compared to women who had an uncomplicated pregnancy those who experience hypertension in pregnancy are at increased risk of these long term health issues. So, after the baby is born, we are talking about a twice likelihood of heart attack or stroke or diabetes and a three times likelihood of chronic hypertension. These risks constitute the kind of red flag that means we should be offering them everything we can to catch it. And one of the things that we need to be thinking about is the heart check that you know has been in conversation recently in relation to specific Medicare items. Do not write any questions about it, it is a conversation. There is no Medicare item for it, but people are thinking about the fact that the importance of doing a heart check is so significant that maybe it might attract extra funding.

So what are we talking about? We are talking about an annual blood pressure check. We are talking about appropriate checks for cholesterol and blood sugar. Do not forget, do not measure cholesterol during pregnancy. Pregnancy is a naturally hypercholesterol state. If you measure their cholesterol in pregnancy it will come out as eight. It is always going to be elevated. Just do not do it. I would think you would need to wait at least at least six months before you bothered to measure their cholesterol. But you do need to encourage people to maintain their healthy weight. To eat a healthy diet and to do the other things that you know is appropriate. So not smoking. The exercise. Like that.

One of the issues about this of course is that these risks continue life-long. So it is not just a question of doing it for a few years after the woman is pregnant. This is her continued risk. If she can reach and maintain a healthy weight and continue to eat healthily, engaging in physical activity and not smoking, then she can reduce the likelihood that she will go on to develop those complications. I would also point out to you that these people have actually got a slightly higher risk in their subsequent pregnancies, and these people warrant referral even before their next pregnancy to plan that next pregnancy, if you have not thought about that already.

As far as I am concerned, this slide is the kicker. I love this slide. But there is something even better than this slide which we are going to talk about in a minute which is we have a calculator which lets you actually give specific information for women. It is all very nice to say, do not gain too much weight in pregnancy, but how much is too much? This slide tells you. If your BMI is in the ordinary rate, then we are talking about the weight gain that you can see there which is you know, let us say 11.5 to 16 kg. But you know, two thirds of us, two thirds of the women we see are going to have BMIs higher than that and their weight gain actually should be less than that. Now think about the women you are looking after who are pregnant. It is very unusual to see someone who only gains the small amounts that are on this table unless you really encourage them. So we know that there has been some discussion in times gone by about whether you weigh a woman during pregnancy visits. The current recommendation is that women are weighed and that each occasion is an opportunity to have this conversation that we are talking about.

Can I have the next one? Around 67% of women exceed the Institute of Medicine guidelines and start their pregnancy overweight. And if you are a New Zealand person, it is even more impressive. One of the sad things about this, is it is like a growing lumpy slide in that you gain weight in pregnancy, you do not lose it, you start heavier than you started the last pregnancy. You have the same kind of step up weight gain. You have accrued that original 3.7, you have got another 3.7 you are accruing, and so you get fatter. 14% of previously healthy BMI women become overweight postpartum. This is what we would like to try and interrupt. There is a new concept of obese in pregnancy and there are some hospitals now that are actually offering group interventions on a hospital basis because they recognise the difficulties with this. We GPs have an opportunity to do something as well, and that is the program we are going to talk about in a minute. And I am hanging on to it on purpose just so you will get all interested.

So I am going on and on you know about the overweight pregnancy person. Does it matter? Well, actually it does. If you have a look at this slide, just follow along any of those risks. So let us look at for example, oh I do not know, Caesarean section. So if you have got a BMI of less than 18.5, the Caesarean section rate that is found in a group of 72,000 Australian women in this particular piece of research that came out not that long ago.

Justine: Diabetes Australia, wasn’t it?

Linda: 2018 I think. If of course your BMI is actually in the normal range, it is about 33%. That is amazing. It is up to 40% if you are a bit chubbier than that. If you have got a BMI of 30 to 35, it is 45% and for those with a BMI of over 40, it is 53%. And you know that there are increased risks associated with Caesarean section, especially if you have got a BMI of 50. And that also applies to the babies. And of course, if you look at the macrosomia line, you will see the same sort of increase. So for the person with a normal BMI range, macrosomia is about 11%. It goes up to 21% for the BMI greater than 40. This is of course a kind of predictable issue and it is not something that you should hide from your patients. And I am not saying you should threaten people or terrify them but they need to understand why we are encouraging these processes.

And what is the answer?

Justine: Okay. So the Get Healthy in Pregnancy Service. It really is quite a clinically proven intervention that works alongside your already great care as GPs. We, some of you may or may not have heard of the Get Healthy Service. It provides populations, all populations a service, 16 years or over women, either an information only one call or coaching calls over six months up to 10 calls with an exercise physiologist, dietician or registered nurse, completely free. So our coaches promote incremental weight gain as per the IOM guidelines as Linda was talking about, and exercise and dietary advice as per the national guidelines, and we also promote alcohol abstinence during pregnancy and breast feeding as per NHMRC.

We really aim to achieve that healthy gestational weight gain. As we know, excessive gestational weight gain is highly predictive of cardiovascular disease, metabolic diseases and overweight and obesity later in life for women and their babies. And we offer this tailored service also for Aboriginal women, where they receive the support of an Aboriginal liaison officer and culturally appropriate resources.

And it is all over the phone. So, participants of the program report that they like the phone contact, it is non-threatening. They like to have the continuity with their coach to build up a level of trust and accountability. And it is like a relationship they have built with a personal trainer that they do not have to pay, which is great. And research has shown that behavioural changes we sustain over six months are likely to be ongoing, so sticking to that six month timeframe is super important.

Linda: Justine, can people outside New South Wales access this service?

Justine: The service is actually available in Queensland and South Australia. However it is, yes, it usually is in New South Wales that has the best service there.

Linda: Thank you.

Justine: Okay, so just before we do move along there were a couple of questions relating to the oral glucose tolerance test and can HbA1c be used to test for GDM and also for ongoing monitoring when giving birth to the baby, or after giving birth to the baby.

Linda: So you would be aware that there is in fact a Medicare item for using HbA1c as for the diagnosis of diabetes. It is not however appropriate for the ongoing follow up of gestational diabetes because the research that has been done, all uses of the glucose tolerance test. Now having said that, I look after people who are pregnant and under the age of 20. Try and get them to do an oral glucose tolerance test is good luck. So at the end of the day, you do the best you can, but the oral glucose tolerance test is actually the test of choice and the one that has the academic understanding.

Justine: Okay, and there was a question, how do we refer people? Just stay on the line and we will tell you exactly how to refer, we will give you all that information. No, it is not – a couple have asked if it is available in the ACT, and no it is not. And I am not sure of any services in Victoria that are similar. Okay.

Alright, so the next slide that we have got on the screen. Oh, I have gone past it. In the first full financial year of Get Healthy in Pregnancy, we have produced some great outcomes, where only 18% of our graduates gained weight in excess of the Institute of Medicine’s guidelines compared to 47% of the general population. So this is a really great outcome. And you can see there that your women most at need are actually getting the most benefit. So 95% of obese women gained appropriate weight. So within or under those Institute of Medicine guidelines. And 67% of overweight women gained appropriate weight. And they are also preventing those healthy weight women that we were talking about earlier, so 88% of healthy weight women gained appropriate weight which is a really good outcome and one that is very positive and it shows significant clinical outcomes support the operation of service into the future. And the Government is backing it absolutely and that is why we are working into this more chronic disease prevention space, just to work alongside our clinicians as well.

So we are going to play a little testimonial for you, so you will hear some audio.

“I got referred to Get Healthy in Pregnancy through a brochure through my midwife. They discussed a little bit about the program with me. I was quite keen and they actually contacted Get Healthy who then contacted me within a few days. The same coach rings me every month on my designated day that I gave them and time. If I am not available I can just ring them up and they happily change me appointment. We focus on what I want every week, diet, exercise, we just discuss that together.

“Since starting the program I have not put on too much weight. The only weight I have put on is baby weight. When I got diagnosed with gestational diabetes my main goal was to not go on insulin. I have only got a month left before I am due and to date I still have not gone on insulin. They have helped me with my food choices and if I do have a higher reading then they give me advice on why that was high and what I should substitute it with.

“Yes, my husband’s eating habits have changed. He is definitely eating a lot more veggies and he sticks with me and my program. It is not all about weight. It is about changing your lifestyle. It is a permanent change.”

So basically this is a testimonial that appears on our website. The testimonial is from Christine who is a past Get Healthy in Pregnancy participant from the central coast and it really highlights the benefits of telephone health coaching in preventing the progression of gestational diabetes into insulin dependent gestational diabetes, or GDM. So, through behavioural modification she changed her potential outcome and that of her baby and even changed the behaviours of her husband so it really did create that flow on effect that we really hope to instil in people, making sure that if the mum is healthy, then the children are healthy. And they are ones who feed the family so we really want to promote that.

Christine then went on to re-enrol in the Get Healthy Service Type 2 Diabetes Prevention module, so that is part of our general population Get Healthy Service suite following the delivery of her baby girl, Charlie. And this module provides participants with 13 calls over a six month period with the bulk of the calls occurring in the first three months for more intense support.

So all clients referred to the Get Healthy Service, men, women, anyone 16 years or over in New South Wales, complete the AUSDRISK tool on first contact. And if they are at higher risk of type 2 diabetes they will be offered this program. And our recent evaluation shows some really great results which I will talk to in a minute.

So this slide shows our tailored program. So when you do make a referral there is then a registration call. Then the participant can go into either the information only service which sends them out an information only pack and I was just speaking with Young Hospital today and their women were really happy with the packs, they found them really informative, there is lots of interactive tools so they can work on that and they have one conversation with a coach to answer questions and make sure they know what is safe in pregnancy. And then they can go on to have coaching support. So if they are not pregnant they can go into these other modules that you can see on screen. So, the Get Healthy Standard which is just all populations, Type 2 Diabetes as we discussed, the Aboriginal modules, as we said there is a lot more support for the Aboriginal populations, and the Alcohol module. Now the Alcohol module in pregnancy promotes abstinence but the Alcohol module with the general population is based on the audit screening tool and they do actually make sure that if people are drinking at risky levels or have any addiction issues, we do pass them on to alcohol and drug services, or ADS.

Okay and this is just the information again about the two levels of service, and this is the cool little journal books. We also have an information book that goes alongside of that.

So benefits of the service. Linda.

Linda: It is not a prescriptive program and I think this is actually quite helpful. It is not the kind of program that wags a finger in a person’s face which is really good. It does actually explore what the patient is interested in and supports those aspects. So, you know, many women know what good healthy eating is, they just cannot actually make it all happen. So they do not need to be told amounts of eggs to eat, or you know, diets. What they need is some good structured ideas about how to actually deliver that sort of stuff. And the same thing about exercise. Coaching is something that is quite a popular approach, and certainly there is a huge amount of evidence in coaching in other aspects of the world like business and in sport, and this is actually health coaching using a different kind of approach to the sort of counselling that people have used in the past.

Justine: Okay, I am just going to answer a couple of questions, because I think they are quite relevant at this time. There was a question, do we to be pregnant to be in the program, or are there similar programs? If you have a look back on the slides previous to this, no you do not have to be pregnant, you can be anyone in New South Wales 16 years or over. So there are different programs for different people, but Get Healthy in Pregnancy is what we are actually talking about today. So we just wanted to share that there are tailored programs for all of your populations and all of your clients.

What if women are pregnant and under 16 years of age? Well there are two issues that align with this question. The IOM guidelines are actually based upon firstly only adults, so we do not have incremental weight gain guides for anyone that is under 18. But the 16 years and over we have picked because anyone who is 16 can give consent to be in the program. Under 16, they cannot. They need a parent’s consent to actually participate in the program. It just does not relate to them.

Linda: Can I also say, as the doctor who actually is the VMO who runs the under twenties pregnancy clinic at Prince Alfred, there are in fact different kinds of dietary and growing issues in terms of food for pregnant women under the age of 16. There is huge benefit in involving a dietician in the care of those people in whatever the system or PHN has available.

Justine: Okay. And yes we can give sample packs of information that we give to GPs. All you have to do is contact us and I will get back to you and make sure you have any resources that you require.

Okay, so Get Healthy Service postnatally is really important and this is where we come back to that risk, future disease risk. A healthy lifestyle can prevent up to 58% of type 2 diabetes and healthy eating can help reduce risks, and as we know these women actually have a higher risk. So we do have good outcomes postnatally and we do know that the type 2 diabetes program, on average the participants in this program lose 3.3 kg in six months, 4.3 cm off their waist and over one third have lost 5% of more of their body weight which is a great outcome.

We really like GPs to refer because on average they have better results. I think because they just feel like they are supported and it has come from a good place. You know, it is not a fad diet. What our coaches do, is they actually work with people to build better relationships with food. We are also aware that there are so many people with poor relationships around food and we do want to make sure they are not cutting out whole food groups and they are doing the right things for their diet.

Those who have experienced a fairly normal pregnancy as well. They are often keen to get back to their pre-baby body and this is not a bad thing as research shows the first six months is the ideal time to do this. So reducing the abdominal circumference to 80 cm is essential for preventing cardiac disease post-pregnancy.

Linda: So you would all be aware that there is an inflammatory component associated with insulin sensitivity, and we talked before about insulin resistance. One of the things that happens is that women with normal glucose tolerance during pregnancy who lose significant weight postpartum go back to their normal metabolic function and there is no particular increase in inflammatory process for them. But women with GDM, especially if there is no decrease in postpartum weight and particularly if there is no decrease in postpartum adiposity, they unfortunately continue to have that inflammatory milieu which you know we think is a contributor to, for example, coronary artery disease. And my gosh, it all makes sense. And the continued inflammation and insulin resistance leads on to all the other aspects of that syndrome that we are aware of.

So how do I do this referral and how do I think about it? I think about it when I do my first antenatal visit. Now for me, the first antenatal visit is about 80 minutes long anyway, God help me, by the time I have done the genetic counselling and God knows what. So I will flag it and perhaps give a pamphlet with a plan to actually talk about it at the next time. I will mention it or ask how they are going at each visit, where their weight gain is not in keeping with the weight gain that we talked about before. In order to work out how they are travelling, I may very well use the calculator that we mentioned before, which I think we are going to talk about in a subsequent slide. I also am keen that our practice nurse would be part of this program because the practice nurse is going to be seeing this patient postpartum probably before I do. So we see patients at two weeks postpartum, an appointment for them and an appointment for the baby. Normally we are looking at all the usual postpartum stuff, but these days one of the things we also want to do is get people to hop on the scales and just see how much weight they have lost during the pregnancy. Sometimes it is a surprise to patients that they have not lost as much as they thought – during the delivery, rather. They often have a surprise that they did not lose as much as they hoped they would. So we can start the process of that again. The influence that we have with patents is actually significant and I think we are all aware that a referral that comes from us or from our staff, let us say our practice nurses, has a lot of value. Once a person is not pregnant any more, they are not part of the hospital system, they do not see the midwives in a continuing fashion. They are unlikely to get this influence from the early childhood centres. It is going to come from us. So we are absolutely the people they would look for to start the conversation, you know, plan to prevent something they do not even know they are at risk of. I think there is a lot of value for us in bringing this conversation up with people, sometimes more than once. Very frequently patients will say, I have not got the time, I have a new baby at home, it is one more thing I have to think about. If we make the referral, then the person is rung it is less burden. There is less paperwork. It is not quite as Medicare rebateable stuff as some of the other things that we do but it is much simpler for the patient.

So just on your screen at the moment, there are some of the kinds of scripts that you might want to use. I would encourage you to engage with your practice nurses because there is certainly an age for this. And the resources in some of the medical software, certainly in MedicalDirector and Best Practice that actually include the referral forms if that is what you want, but you can make a referral by telephone. It is actually not that complicated.

I personally have used the telephone. I think it is useful though obviously to have a conversation with the patient and see what they are interested in. if the telephone does not work, if they are busy or I am busy, the paper system works. I always would encourage people with a pamphlet. Even if I have made a referral and the pamphlet talks about self-referral, I do not care if it doubles up. It still works as far as I am concerned.

Justine: Yes, and there is also, you can download all the GP referral forms on the website. You just go into “How do I refer?” and that is all your information that you need, there. And again, you can reach out to us in the office of preventative health and we can come out and actually give your practice nurses some in-services, no matter where you are in the state.

Linda: So one of the reasons I actually think this is worthwhile is because of the quality of what people get. Who are the people who do the coaching, Justine?

Justine: Okay, the coaches are exercise physiologists, dieticians, registered nurses. They have all got university degrees. Some have got double degrees. Some have got masters in dietetics. So we have got really good quality coaches on line. There are about 26 coaches now. So they look after thousands of people. As we say, we have had over 100,000 people since the start of the program. So…

Linda: So this can actually enhance the Medicare systems that allow us to access exercise physiologists and dietetics, because you know you only get five of those for everything, whereas how many conversations do they get?

Justine: Well, I have to say, we do say 10 calls over six months, but on average people go on for maybe a year and you usually end up getting about 20 phone calls, so we do actually have a lot of people who do stay online because they get really quite attached to their coach and they are making great gains, so we do see that benefit. And I will talk about the feedback that you get very soon. So the benefit is that they speak to the same person each time they call. The person knows them. They talk about all the healthy behaviours that they need to. They reach their goals and at the end they mostly like to stay with us. But we then have a service that is called Get Healthy, Stay Healthy which is a text messaging service that we can link them up to that their coach sets them up with. Little push notifications and text messages that are relevant to the goal they have made to make sure that they are on track. And if they have been out of the program for six months, they are very welcome to get back in it. It is all New South Wales and they are very happy to have them continue.

So I am going to talk to this slide. It just is really a very visual way of seeing what happens after you refer. So, yes a patient can self-refer, but after you refer on your referral form or online or via the phone as Linda was talking about, you will receive a welcome email or text saying we have received your referral, but remembering too that there is a part on the form that actually states if you would like feedback on this patient, tick this box. So if you would like feedback, make sure that you have actually ticked that box and you will get this. Otherwise you might have times where you refer a lot of people and you may not want those feedback letters coming to you.

So the participant is usually called within three working days, which is sometimes five days, and then they will get a registration call which is 15 minutes long. This will collect all the data. A lot of it is self-reported. It is also, when you are actually doing a referral form to the service, it is good to actually have a good lot of information on the form, indicating if you really want to guide the goal a little bit, maybe add their weight in, add that they have got cardiovascular disease, and also make sure that you have filled out the medical clearance which means that it will not bounce back to you for medical clearance as well, because we need to have medical clearance for people who have had a significant admission to hospital in the last three months. If they have a severe mental health disorder that is acute, if they have any cardiovascular disease. So yes, your women who have had preeclampsia will have to have a medical clearance from you. Remember that we are not prescriptive. So, what we do totally relies upon what the patient can do. So we are not going to ask them to go run a marathon. We are going to say, let us look at your healthy diet and let us make goals that are small, achievable goals, that might be walking around the Hills hoist five times a day. So that is what we are looking at doing.

Okay so then the client themselves will just decide on whether they want information only or coaching. We find that a lot of people are taking the information only up, but then down the track they will actually self-refer themselves back in because they find the pack is really informative and they feel like they would like the support. I guess it is just a feeling out. But if they do go on to do the coaching, we send out the packs as well and then they have their first coaching call with one of our qualified coaches. These are usually 5-10 minutes. They are usually capped, we have to cap them at 17 minutes because they want to talk constantly a bit like the first antenatal visit. You can imagine. And we do have a lot of the older population, but the younger population usually tend to stick to five to 10 minutes. It is usually an in and out process and it is just to check in to make sure that they are getting on board.

Now, during that six month period, a lot of people fall of the wagon and that is really what we want them to do. We really want people to fail and learn strategies to keep on track with their goals and learn how to actually come back from those failures and that is where we really celebrate those wins with them and then we move on to the next goal when they are ready to move on.

We use a method called Teach-Back which is a method of motivational interviewing. And that just is pretty much measuring their ability to go on, or their self-confidence or their self-efficacy in reaching their goals. And then once their graduation is achieved which is lovely, they have achieved their goal, they can actually graduate at between five calls if they want, but they can go all the way as I said, sometimes over their 10 allotment. And they can re-enrol with another goal if they chose to as well or go on to the SMS service.

So the feedback that you get, oh sorry we have clicked onto the page. Okay, so a lot of you were asking about the feedback.

Linda: So one of the things that happens when either GP referrer having ticked off the bit that says I want feedback, because if I do not click on the bit that says I want feedback, guess what, I will not get it. I get to hear that the referral has been received. That is always helpful. I get to hear that the patient was contacted and I get to hear that the contact worked. If the patient is in fact uncontactable because the phone number was wrong or the patient has you know, disappeared into the distance, then in fact the service will continue to attempt to contact that patient and if that does not work then I will get to hear that that occurred and if I see the patient and want to you know, re-encourage them. we can have another go. I also get to see what happens over time using the measures that are you know, part of the program. And of course I can incorporate this into the patient’s notes if that is what the patient would like me to do, and in my experience they all want to and I am sure they put that in their phones and everything too, I would guess. It is quite useful really.

Justine: Yes, and just a question which is relevant to that. How does the patient get medical clearance if he or she self-refers? We do have a medical check process where we will actually send out a medical clearance form to your client or directly to you as a GP if they tell us who you are, and you then, it is your responsibility then to complete that medical clearance with them and send it back to the service. So they will either come into your rooms with that letter or you will get it via the mail and then you will know that the client is wanting to enter the service. So that means that you just get that back to us and then we will re-contact the patient and start their coaching journey.

Sammi: Justine, can I ask a question? We have someone on line who has mentioned that they had referred to the Get Healthy Service a number of years ago now, over two years ago, and they were asking about the feedback and how that process more recently might have changed to make sure that the feedback if wanted is getting out to GPs.

Justine: Yes, absolutely. And it is getting out there now. We have got a new service provider who is providing a very good service now. Our feedback is really on point. But remembering too that you need to tick that you want that feedback to be given to you, because we will not send feedback unless you have actually indicated that you would actually like that feedback.

Linda: And the feedback only comes via email.

Justine: It only comes via email, yes. So you need to make sure that your email contact details are correct. Or the email of your practice if you do not want to give your own.

Justine: Yes.

Sammi: Awesome. So that feedback is an opt-in process, not an opt-out process. You need to make sure you indicate that on the referral.

Linda: That is right.

Sammi: Awesome.

Justine: Okay. So we will move on past feedback, and something I would like to share is our new pregnancy weight-gain calculator. This is something that does not exist anywhere else, we had to develop it ourselves. It is a free on line device that supports pregnant women to track their healthy incremental weight gain as we were talking about being so important. The Get Healthy in Pregnancy Service have released this to be interactive and completely free because it is embedded in our website, but it comes up like a little App that people can play with. It was based on the 2009 Institute of Medicine Guidelines and these are endorsed obviously by the World Health Organisation and the NHMRC.

So, as GPs you can use this tool to help women track their weight gain and you can also encourage women to use the tool to track their own pregnancy weight gain, to give it a little bit of ownership. And it is very visual and I am going to show you some screen shots of that. We use emojis, we have baby nicknames and you can save the results for future tracking and we do use it with our coaches, so they actually refer to it. And here is a little snapshot of what it looks like from the front, but I will show you more screen shots moving forward.

So it is a personalised chart that is based on the woman’s pre-pregnancy BMI, her gestational week and her current weight, and it can be used with singleton or twin pregnancies, because obviously the OIM guidelines do not relate to pregnancies of more than two babies at once. It has a frequently asked questions section that gives them lots of information on why it is important for them and it is relative to both their gestation and their weight outcomes on the actual tracker. It complements our clinical care. I tend to use it when I am booking in women. I think that giving them a sheet of paper like Linda said earlier and saying you can put on 16 kg in your pregnancy does not paint a very good picture, it sort of says, oh well I will just put on 10 kg all at once and then I will diet for the rest of my pregnancy. I think we have really got to stay within those incremental guardrails as we call them. So you can see those there. So I will show you.

So the target audience is all pregnant women. So even though it is all pregnant women in New South Wales, this tool is on our website, so you can actually use it if you are in any state, so please feel free to use it because we really want to make a difference for these women. As I said, antenatal care providers, child and family health nurses, anyone can use it and regardless of their pre-pregnancy BMI everyone is at risk. It supports weighing women at each antenatal visit because they have got to put it into the little graph, and yes, like I said, women take ownership of their healthy incremental weight gain.

Linda: Can I just say one thing. We talk a lot, all these women ask about being too fat, having too much weight. There are some women who in fact whose weight gain is inadequate. And they have starved babies. And I have looked after a few of those and the saddest one that I remember is a woman who was an intelligent professional person who thought she was doing the right thing, but her interpretation of the right thing in fact was not the right thing for her baby. And use of this tool would have demonstrated much earlier in the piece to not just her but to the care giver who was giving her what turned out to be not very helpful advice, that she was slipping down. Although we are obviously very concerned about the overweight, there are some people who we will look after who are not gaining an adequate amount. And I point out to you that this is relevant for example to slim young Asian women who start out at 40 kg and end up at 44 kg and that may or may not be the best thing for their babies.

Justine: Yes, and when we actually use the tool, I will show you how it looks. But I do encourage you to go on and have a little bit of a play with it because it actually does show the results relative to that and it does give advice for underweight as well as normal weight, within normal guidelines or above normal guidelines.

So how the calculator works. This is the landing page that the calculator will come to. We wanted to make it really interactive. We really like to have different colours and backgrounds. We use the baby’s nickname. We have every emoji that is available so they can have a little play with an emoji which makes it a bit fun and a bit like an App. They pop their expected due date in, what they are having. So you can see there is does have the opportunity to put in triplets or other multiples and this will come up with a disclaimer that you will need probably need to address this with your pregnancy carer, however you are very most welcome to track your pregnancy weight gain using this tool. Again, with 16 year olds and 17 year olds, there is a disclaimer that this does not, the IOM guidelines do not relate to them because BMIs are adult BMIs and, but there is a little bit of research that shows they should stay at the higher end of the IOM guidelines for their pre-pregnancy BMI. Same with the BMIs that are over 40. We do also, we are seeing now that in some obesity clinics where women are at very high BMIs, we are seeing weight losses under very close supervision. But only under close supervision. So that is obviously then something they need to go to their nearest high risk associated pregnancy clinicians to talk about.

Linda: This is sitting on the website, isn’t it? Is the website collecting information about these individuals?

Justine: Okay, that is a very good point. No it is not. We actually are just looking at people who have gone onto the website. We actually, there is no identifying data that is actually kept on our website relating to the calculator. So down the track hopefully we would like to do a trial to actually work this out. This has only just been launched in the last few months. But yes, at the moment it collects no identifying data.

So if you see here then, people will put in their height, their weight before their pregnancy and their weight now, and then they can click show results. So it can be used at any time during pregnancy and then the chart will look like this. So you can see the chart will show when the start of the pregnancy was, when they started that second trimester because you can see that pregnancy weight in the first trimester should be no more than 2 kg for any BMI. And you can see how it tracks. And you can see that it goes inside and outside of those lines and it will give good advice. Then you can click and save results to receive an email. You put your email address in and that will actually send you the actual results of it and or you can save the pdf and print that off or your client can print that pdf off.

And it does give really good advice and little tips. It also links to the “Having a Baby” book which gives good New South Wales advice. So little bits of advice that are quite fun and interactive without being too in your face. So, it is very user friendly. The ability to change the colour is great. We have had really good feedback. We have taken it to the Australian College of Midwives and you know, all the way up to the top of the Ministry and they are very excited about this world first tool. So we are really excited about this too.

So there are some examples of healthy lifestyle tips.

Sammo: We have had a question come through. Is it a free service, Justine?

Justine: Yes, this service is a free service. Completely funded by New South Wales Health. In South Australia and Queensland it is supported by their governments as well in the preventive health offices. So we are New South Wales Office of Preventive Health which sits under the Ministry of Health, and it is run out of there. The same as we work alongside programs like the Knockout Health Challenge, Get Healthy at Work, Live Life Well at School, Healthy Canteens, Go4Fun. All are under that banner of New South Wales Office of Preventive Health. Yes completely free. I think it costs, they did a bit of an average out, it costs about $380 per participant to actually put someone through this.

Linda: That is so cost effective.

Justine: It is. It definitely works well.

Linda: And is there enough resource do you think for every single pregnant woman say in New South Wales?

Justine: Our target for next year is to have all 10% of the birthing population referred in because obviously we are saving money for the future.

Linda: Yes, that would be good. Okay. Again, I am sad to say that it is limited to New South Wales, South Australia.

Justine: And Queensland.

Sammi: There was an earlier questions about resources as well Justine, are there pamphlets that can be ordered online, or requested, or printed off that people can give to their patients to have a look over?

Justine: Absolutely. We have a lot of free resources. So if you go onto the website and you go into “order resources for health professionals” you will find a stakeholder resource order form which you can print out or fax and scan and email to us, and we will send those resources out to you.

Linda: The other resource that actually has links to this program is of course, Health Pathways and Health Pathways I think covers all of New South Wales now. I can speak mostly about the Central Sydney version which is one of the oldest ones, but I would think that every single Health Pathways program that has got an antenatal page, and I think almost all of them would have, will have links to this program embedded in that antenatal resource. And that will lead you to all of these pamphlets, the referral resources, details of what the programs are, and looks at not just the one that we have been talking about that relates to an overweight person or a person at risk of gestational diabetes, but those other ones too, the ones relating to Aboriginal people and also to alcohol.

Sammi: Awesome.

Justine: Okay, so there is also a question, is there an upper age limit? No there is not. Anyone can be referred to the Get Healthy Service. I mean, people can even be immobile and still be getting good advice on diet and stopping alcohol or reducing alcohol at least.

Linda: And obviously it would make quite a bit of difference to someone, especially if they are not mobile or they are limited to the house, to get coaching by phone because in fact their access to those kinds of helpers that you have to physically go to another office is going to be very limited. So if you think about your patients with disability and with access and mobility problems, this kind of program is ideal. A lot of the patients who live for example in wheel chairs, have huge difficulties maintaining their weight because they just are not able to do a lot of exercise. And to have the advice of someone who has turned their brain on on their behalf, has got to be a good thing, especially since they are often of limited funds. You do not even have to add it to the NDIS option. It does not cost anything, how good is that?

Sammi: Awesome. Well it looks like that is all the questions. Do we know if there is anything in the pipeline Justine that is similar for other states?

Justine: I do not know. I would love the Get Healthy Service to be expanded out to other states, however we can only speak for New South Wales Health at the moment. I know that Queensland and South Australia are working quite well with it, so this is accessed from there. I know that there were other states that did use this program, but I am not sure of other programs that exist like it anymore, but they have dropped off. So you need to speak to your local government and see if that is something that you would like to actually have, because we are happy to provide the service from our call centre.

Linda: But certainly everyone has access to the calculator because that is web-based option.

Sammi: And we will send out the link to that calculator in the post-webinar email where you will all be sent a copy of the presentation as well. So any links and resources discussed in here you will get with the presentation and I will make sure that the link to that calculator is included as well. And just to reiterate, we have had a question about options for men. Obviously this webinar was the Get Healthy in Pregnancy program specifically, but Justine did touch on earlier that there is a standard Get Healthy program that is to help with advice on weight management in all people above 16 years of age. Is that correct, Justine?

Justine: Yes, correct. So men and women are able to access the service. When people are referred in, they actually go through a form of triage anyway. So even if your woman is, you want them to go into the Get Healthy in Pregnancy Service, they still needs to answer questions when they get called and if they answer the question that they are pregnant, then they go into Get Healthy in Pregnancy. If you are referring their husband because their husband is sitting next to them, you can actually refer them in and they will go through the same questioning process and they will be referred to whichever program best suits their needs. So yes, it is the same number, the same service and they will get sent exactly where they need to be.

Sammi: Fantastic. Well that looks like all the questions we have had come through. We might move on to a review of our learning outcomes now.

Linda: So in think you would agree that at the end of this education event, you would be able to discuss how healthy lifestyle behavioural modification coaching can benefit women with gestational diabetes and hypertensive disorders in pregnancy and in fact in pregnancy in general. I think we have actually looked at the importance of post-pregnancy health behaviours in the prevention of future chronic disease in patients. And we have talked at some length about how to integrate referrals to this program which is the New South Wales Get Healthy information and telephone coaching service, into our routine consultations. And how to incorporate feedback from the service. You know, I mentioned the stress test in pregnancy. I think the stress test that is pregnancy. I think for us to have a tool like this that has demonstrated value, costs the patient nothing, goes on for longer than the pregnancy and actually has the potential to be used by all of our patients is the sort of gift that GPs do not get that often. Thank you, Get Healthy.

Justine: Thank you. Thank you very much, Linda.

Sammi: Awesome. And thank you to everybody online for joining us this evening. We hope you enjoyed the session and as well I just want to say thank you to Justine and Linda for joining us. So thank you and goodnight.