Healthy gestational weight gain

 

SAMANTHA:

Welcome to tonight’s Healthy Gestational Weight Gain webinar. We are joined tonight by Dr Linda Mann and Justine Salisbury. Tonight we will be working through a set of learning outcomes, which we will get to in a moment.

I’ll just give you a bit of background on both Linda and Justine.

Linda is a Fellow of the RACGP, she is also a member of the RACGP Antenatal and Postnatal Care Network. Linda has local and international medical experience in both genetics and women’s health; she is a GP (general practitioner) representative on various national and local government committees and is an experienced medical educator.

Justine is a Senior Project Officer of the NSW Get Healthy in Pregnancy Service as well as a midwife and registered nurse; she has been working in 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.

Before we make a start, I 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.

I will hand over to Linda now to go over the learning outcomes before we get started.

LINDA MANN:

Thanks so much.

During this webinar, we are going to describe what the Australian Clinical Practice Guidelines for Antenatal Care recommend for healthy weight gain during pregnancy, and think about how we as GPs can discuss this with our patients.

We are going to have an exploration of the free phone based service, which is available across New South Wales to help us support our patients to achieve a healthy weight gain during their pregnancy. The name of that program is Get Healthy in Pregnancy (GHiP) and you will hear more about this all the way through the webinar. We are going to look at how the program works, how it works within the consultation and how they work with us.

You may be aware that we now are concerned to ensure that primary care providers weigh their patients and estimate their BMIs. Some of you who have been around for a long time would know that that has not always been the case and in times gone by, we had some concerns about weighing patients in pregnancy and were concerned about anorexia and other such things. That is not the current view, as we will tell you shortly, we have a much greater concern about people who start pregnant overweight and develop excessive weight gain in pregnancy. For that reason there are national guidelines now that recommend that all pregnant women have their BMI calculated at the first episode of care during their pregnancy, well generally, that is with us GPs. Of course, pregnancy is a fantastic time to talk to women about lifestyle change because women are very receptive to doing the right thing for their baby and for themselves.

There is an organisation called the Institute of Medicine, which creates/develops evidence that can be used by colleges, for example, The Royal Australian New Zealand College of Obstetrics and Gynaecology, to develop the guidelines that we follow. The sort of guidelines that we are talking about today look at nutrition and weight gain and have recommendations that counselling in these areas should occur.

The sort of counselling that we would like to be able to give to our new antenatal patients would include weight, nutrition, and physical activity - of course, we should be doing that all the way through pregnancy and I think you all would agree that it’s a great thought, but takes time. Good job, there is a resource that might be able to help us!

In order to start the conversation we need to be able to give women an idea of where they are going. For me, in this webinar, this slide is the absolute kicker because until I saw this slide, I did not have specific ideas in my mind about how to give advice and what to aim for, so it is really useful to know that your BMI indicates what is recommended total weight gain during pregnancy. Underweight women who are less than 18.5 BMI, the recommended weight range is between 12.5-18 kilograms. If you are in a healthy range, which is 18.5-24.9 BMI, the recommended weight gain in pregnancy is 11.5-16 kilograms. If you are overweight, which is 25-29.9 BMI then the total recommended weight gain is 7-11.5 kilograms and if you are obese, it is 5-9 kilograms; 5-9 kilograms is really hard, but if you start the conversation early, it might just be possible.

We know that all women are at risk of excessive weight gain during pregnancy, we know that some women are at higher risk. The women who are at higher risk are the women who start out with excessive BMI, you will notice there is a theme here, it means you actually have to calculate the BMI, but you’d all know that your medical software calculates the BMI for you once you’ve got a height and weight to put in and press the right button.

People who have had excessive gestational weight gain in previous pregnancies certainly are at risk, as are people who have a significant weight gain early in pregnancy. In my experience, the people who have that problem are people who start underweight, so if you start with a BMI of 15 you will have a remarkable weight gain early in pregnancy that can lead to a dramatic weight gain later; there aren’t as many women in that circumstance, but you may see some in that area. People who are of Aboriginal and Torres Strait Islander background have a particular difficulty with excessive gestational weight gain, and people for whom food is difficult to access; so people who come from, or people who have food in-security, in our environment that might be refugees and certainly those in lower socioeconomic groups.

So, am I making a fuss about this, is it really a problem? Well, yes. We know that prevalence assessments done some years ago suggested that there were something like one-third to two-thirds of women who developed excessive gestational weight gain – that is quite a large range. When the studies were done more specifically and more recently, which is this year; we know that despite having the evidence in the past of this, still, 47% of women had gestational weight gain greater than the recommendations that I mentioned to you, so the problem is a real one, and it is there. What problem is it? It is a problem for babies, and it is a problem for mothers. The reason we are talking about babies first is because when you’re doing the conversation with the mum, her thoughts at this time are all about the baby initially, and this is a selling point. What you want to be able to explain to her is that low weight gain, that is lower than the advised amount, or excessive weight gain leads to problems. The kind of problems we are talking about relate to longer stays in intensive care for the baby, a big baby, with all of the difficulties that that carries with regard to birth injuries and indeed perineal injury, as well as difficulties for the baby to wake up and do the right thing in the first hours or days, it can certainly lead to difficulties with breast feeding, and for the babies there are ongoing, continuing issues.

We now know that if you have an energy dense diet when you are pregnant, you actually can change the environment in which the genetic inheritance of that baby produces its effect, and that is the epigenetic alterations that is mentioned in this slide. Now that’s kind of a new thinking, we are used to mendelian genetics where chromosomes carry information down the track, but we now know that there is information that is malleable and can be carried elsewhere, and that we know can be effected by, believe it or not, excessive weight gain.

We know that children of these women have more risk of obesity in adulthood and that carries with them, all of those syndrome X issues, type 2 diabetes, hypertension, increased cholesterol, all that stuff, even some forms of cancer. We also unfortunately know that the variation in nutrient supply during foetal development that occurs when you have these either low, or excessive, which is the commoner, gestational weight gain, carries with it the change in the way the baby learns, or the foetus if you like, learns how to metabolise and puts that foetus that becomes a baby at increased risk of diabetes.

So, let’s think about the mum’s. Many of us will have had the experience of looking after a mother whose excessive weight gain make it difficult to examine her, difficult to feel the foetal body parts when you are examining her antenatally, who needs a large cuff or a cuff that is even bigger than your large cuff, who has problems when they are in hospital, difficulties in commencing labour, increased need for operative or assisted delivery, problems with the actual delivery and perineal trauma that follows from that with all the consequent pelvic floor injury that occurs. We know that there is a direct relationship with hypertension in pregnancy, separate to pre-eclampsia, and we certainly know that there is a direct relationship with gestational diabetes, which I will mention in a minute.

There is an increase in pre-eclampsia in addition to hypertension in pregnancy; the hypertension in pregnancy issue is one that may very well carry over into the post-natal period. These women can have significant problems by having the weight stay, and we will mention that shortly as well. There is a direct measurable relationship between the BMI change and the risk of gestational diabetes; we know that the more people have gestational diabetes, the more people that will have diabetes because we absolutely know, with a huge amount of data, that 50% of women who suffer gestational diabetes will develop frank diabetes between 5-10 years after the pregnancy in which they had the gestational diabetes. This has been known for a long time and we are breeding more and more and more folk who are at this risk.

JUSTINE SALISBURY:

The NSW Get Healthy in Pregnancy Information and Coaching Service was …………………. .    developed to provide a free over the phone, telephone health coaching for women,

Monday to Friday between 8am-8pm to achieve a healthy gestational weight gain through the promotion of healthy lifestyle choices. These choices can be healthy eating, increasing physical activity, and complementing antenatal care. It really does help women along the way to stay along those guidelines of healthy gestational weight gain. We have university qualified health coaches who are dieticians and exercise physiologists, and it is available to all NSW residents, obviously women who are pregnant and 16 years and over.

Over 1,478 women have been referred to our Get Healthy in Pregnancy tailored program since November 2016, and we are now referring in all 73 maternity units’ state wide. As you can see in this diagram of preventative health measures, we are just one part of comprehensive approach to address this high-ranking premier’s priority.

Enrolment into the service, we have a little diagram here to explain this. We have two main ways of entering the service, one is self-referral, a woman can self-refer by phone, on the website or via email. This is fine and can indicate a high level of motivation, which is positive, but in 2014, a randomised control trial indicated that a referral form from a trusted health care professional increased the rates of graduation in the coaching arm. Your client will receive, once they have been referred a phone call within three working days, the purpose of this call is to gather information and consent for further calls, as well as sharing with the client the options available, then moving forward.

LINDA MANN:

Justine, one of the questions asked is whether or not this service is available for ACT residents?

JUSTINE SALISBURY:

No, not at this time.

LINDA MANN:

Not just yet.

JUSTINE SALISBURY:

The service started last year actually, rolling out in New South Wales, it has been trialled in Queensland, we are hoping to get it in more state, we hope.

This next slide describes the two levels or service that we provide at Get Healthy in Pregnancy. There is an information only program, which is one phone call with the coach of your choice. Whether the women is looking at exercise or diet, they will actually have a dietician or exercise physiologist they can speak to and they will receive an information booklet, a journey booklet and some information sheets on healthy eating, weight gain in pregnancy and physical activity in pregnancy.

There is a question that just popped up, if you look to the right of your screen, you can see there are five resources for the Get Healthy Service. You will be able to see the referral resources there; the referral form is the very first one. There is a GP referral form there and there is a health professional referral form. For those of you who are GPs, obviously, that is evident, any other registered health professional in NSW can use the Health Professional referral form. I’ll tell you a little bit further down the track about how to refer.

With the information only part of the service, they just get that one off advice; they can enrol in coaching any time down the track. If they enrol and choose the coaching service, they get 10 free coaching sessions over six months with their own coach; they set their own healthy lifestyle goals, they still get the information and journey book and they can re-enrol, so they can get up to 12 months of support.

The next slide actually shows you our tailored programs, remembering that Get Healthy in Pregnancy is just one part of the Get Healthy Service. The Get Healthy standard is for any New South Wales resident who may want some support with their healthy eating, physical activity and weight management, which is available to anyone 16 years and older. We have a Type 2 module; this is specifically for clients assessed by the AUSDRISK risk tool to be at risk of type 2 diabetes, with 13 calls over the six-month coaching period. We have an Aboriginal module that was introduced in 2012 to assist in healthy behavioural modification, especially for our Aboriginal and Torres Strait Islander clients, who when compared with non-aboriginal Australians are 2.7 times more likely to be hospitalised with diabetes; 1.6 times more likely to be hospitalised for Cardiovascular disease and 1.7 times more likely to be hospitalised following a cardiovascular accident. These clients will receive 13 calls over six months.

There was an interesting question that has just came through, so I will interrupt there. How do we refer to the other modules? It is all on exactly the same referral form, so the same referral form actually refers to all modules.

We also have an alcohol reduction module that exists for clients 18 years and over, for anyone who want to have an alcohol reduction goal. We also have an audit C tool that we do during our alcohol pregnancy program, which gears us towards the NHMRC guidelines of alcohol abstinence during pregnancy.

Over to Linda for the benefits.

LINDA MANN:

So, why would I use this program? Well, I’ll tell you what I think. This is a program that doesn’t teach pregnant women how to suck eggs. Pregnant women are aware of what they “should be doing” in terms of their diet and they know that they are supposed to be out there exercising. They know all that stuff, most women aren’t dumb, but you know it is really helpful to have a coach, it’s really helpful to have someone who can actually talk with you about what you, the patient want to achieve and give you some support and some different ideas about how to do it. It’s the big sister that isn’t your big sister, which is helpful.

We know that using coaches develops people’s skills and abilities; it means that they have their own knowledge and they can spread that within the family without too much drama, which is quite nice. We also know that the concept of coaching is currently quite popular for example, in business and obviously currently in sport. There is not very much information at the moment with regard to coaching with a specific focus in health, but the evidence that we have is that it is likely to help people achieve their health related goals as in other environments.

JUSTINE SALISBURY:

You can see in this slide that we don’t have a great deal of data for the Get Healthy in Pregnancy module as yet, although we did do a randomised control trial, I’ll tell you a little bit about that in a moment. In the past, we have been running the Get Healthy Service since 2009; these are our stats from that. Most of our coaching participants are classified as overweight or obese, with a nutritionally poor diet, and over two thirds didn’t exercise regularly if at all as you can see.

LINDA MANN:

Can I just say I have actually used this for pregnant teenagers, which is a very difficult group to access and they have found it quite useful to have a non-mother person giving them that kind of advice.

JUSTINE SALISBURY:

That’s a really good thing, remembering that you have to be 16 years or over, but that is a great tip!

When you look here at the program outcomes of our Get Healthy Service, over 43,000 people have used the Get Healthy Service since 2009, they stayed in the program and actually had really good results. On average, the weight loss was 3.8 kilograms in that 6-month period and an average loss of 5cm off their waist; this gets them out of that high-risk range. Improvements were made over all areas of goals set by our clients, with 56% of participants who completed the 6 months of coaching, they lost between 2.5% and 10% of their original body weight.

There was a really great question that just popped up - Is the Get Healthy in Pregnancy program recommended for healthy normal weight pregnant women?

Absolutely, there are people who start at a healthy weight but everyone is at risk of excessive gestational weight gain. On average every women, as an Australian average, 3.7 kilograms of weight is what women put on on average that they do not remove after pregnancy. So yes, it is definitely good for normal weighted pregnant women and it is also good after to get your ladies who have delivered, at their 6-week check-up just see how they are tracking, it might be worthwhile referring them into the general program as well, just to get that recovery for the next 6 months.

In 2014, the Office of Preventative Health and the Office of Kids and Families developed Get Healthy in Pregnancy to purposely look at how coaching as opposed to just information, would improve women’s outcomes in relation to gestational weight gain. There is a lot of information out there, but getting the help along the way as Linda was saying is really on the money.

Over 10% more women appropriately gained weight within the IOM (Institute of Medicine) guidelines when compared to those receiving only information. Other unhealthy lifestyle factors such as soft drink and take away consumption were also reduced. We also surveyed women afterwards to get some qualitative data, and they saw that there was a big gap in the current antenatal care that is provided in NSW Health and that the information supported their coaches mentored change in their lifestyle, which was likely to continue with benefits not just for themselves, but also for their families. Think about who actually does the cooking, who does the shopping, who actually promotes for the young children and what they eat? So if they are changing diet and lifestyle, they are going to change the diet and lifestyle for their children and their husbands.

All clinicians who were part of the trial in the five sites state wide were unanimously positive about the program and its implications for future management of gestational weight gain.

LINDA MANN:

One of the questions that has been asked is to discuss the expected weight gains over each trimester. I don’t have a slide that can demonstrate that to you, what I would say to you from my own clinical knowledge is it’s lumpy. The major weight gain factors are in the middle trimester for most people and should certainly be decreasing. The Delta, that is the rate of weight gain should go down in the third trimester. The majority of weight gain for the baby and therefore, theoretically for the mother would be in the middle trimester.

JUSTINE SALISBURY:

I think they say usually they try to keep it below 2 kilograms for all BMIs within the first 12 weeks. Remembering in those first 12 weeks that that’s when a lot of women do show a great deal of weight gain, but that is a real danger sign, obviously there is not a great deal of baby in that first 12 weeks. Just be careful that is mostly ado posed in those first 12 weeks, so if you are seeing a lady early on in pregnancy, it is good to let her know and map out her gain with her during that time and just give her a good guide. We are not judging anyone here; we are just giving them a guide like any other.

LINDA MANN:

I am just going to introduce two clinical thoughts on this very subject, which is not quite within this thing, but people might think about it. There are people who have reflux and morning sickness as a significant problem, they can actually go backwards and lose weight. If that is happening, we should be paying attention then from a medical and clinical point of view because their nutrition an in fact the psychological effect of that can be quite significant. The second thing I would say is that some people’s treatment of morning sickness is to eat a lot as often that works, a bit of good guidance from their antenatal shared care GP on how to do that best is well advised.

The question has been raised about tips on food and drinks that a good for nausea and morning sickness, I could talk for half an hour on that subject, but that is not what I am here for tonight! You need to go to your Local Health Districts resource on that. I work in Sydney Local Health District and they actually have a two-sided A4 page on that very subject, I suggest you talk to you PHN for more information on that subject.

On the subject of GPs and looking after patients, why would I use this program I ask you? Well, I will tell you why I think it is worthwhile, it is worthwhile because there is some evidence that it is effective, there is evidence that it is acceptable, it is helping the GP do something that most of us really find some difficulty in doing. We either find difficulty in doing it because it’s kind of teaching mothers how to suck eggs and it feels neolistic because no one ever loses weight, which is not quite true, or because I simply don’t have the time to do it properly.

I know what to do, I know what to say but you know what? Adding another 15 minutes to my consultation, which is already far too long is a problem. So hey, lets use the team! In this case, the team is the Get Healthy Service. I think it is actually a worthwhile resource, it certainly is useful in that information comes back to us, therefore the whole idea that this part of the team if you like that’s got to look after the patient is useful. Certainly accessing it easier that the whole EPC care plan phenomenon that you might use for an exercise physiologist and a dietician. Justine, how might I run this conversation during my consultation?

JUSTINE SALISBURY:

I have included the next few slides because I’ve found the hardest thing for many clinician is starting the conversation. Offering this program as standard to all women removes that stigma which is something that some of us have, starting that conversation is very difficult.

There is just a question sorry to interrupt – can patients self-refer themselves to this program, and what about those who are not overweight or borderline overweight?

Anyone can access the service, the pamphlet that it is in our resources and handouts at the side of your screen there, you can use. We have also given you a resource order form that you can order your own pamphlets to use in your clinics or your rooms, and yes, women can definitely self-refer – remembering that if you refer them, they are more likely to stay in the program though because they want to know that it is a trusted program by you.

Offering this program as standard to all women removes that stigma, enables women to understand that gestational weight gain goes beyond social implication, they also have to understand a little bit about the health of their baby and themselves. When approaching the topic of a woman’s weight, there is always benefit in asking permission, if the women indicates she is interested, only then should we explain the service.

Starting with the statement that is in front of you, we should include the positive effects of a healthy weight gain, and that recent evidence suggests that there are adverse risks resulting from excessive weight gain. This can counter the women’s past experience or history and the case that she might think everything was fine with her last baby. She might say ‘last baby I put on 20 kilograms and my baby is fine’, but we can sort of come back to the fact that the most recent research actually indicates that there can be a problem there, and that may definitely make the conversation and explanation much easier.

I can see there are people asking about the CALLS community, we do use TIS so we can organise 3-way conversations with our coaches.

LINDA MANN:

TIS, that means the Telephone Interpreter Service.

JUSTINE SALIDBURY:

Yes, and that is something in the referral form, there is a spot where you say

you would like an interpreter. If that’s filled out then the coach at the other end will arrange to have that interpreter with them on the phone when they make their first phone call with their women. Great question by the way!

Calculating the woman’s BMI on this next slide, when you are with the woman, sharing the BMI chart with the weight recommendations is really good as a visual resource. We have included this chart to explain where your client sits in the weight range and what her recommendation for the remainder of her pregnancy could be.

LINDA MANN:

However, if I just might interrupt for a minute. Personally, if you give me another piece of paper, I’m only going to lose it, so, can I suggest, if you like to use the chart, terrific! Personally, I won’t, but I use Best Practice. I discovered that Best Practice has in its graphic options the ability to graph the BMI of a patient just like we can graph the paediatric weight gain etc. If you don’t know how to access that, go home or go to work and have a noodle on your Best Practice software. Medical Director will do the same, I don’t know about the other software’s, but you actually already have this ability in the software you pay good money for!

JUSTINE SALISBURY:

Raising the importance of your findings and asking your clients opinion can allow her to come to a conclusion and we can gauge her interest from there – she may go ‘oh ok, what do I do from here’? So this is where we can actually provide that recommended target weight range, and remembering we are using the pre pregnancy BMI, we are not taking a BMI today; we are going back to that pre pregnancy, so we also have to take that amount of weight off.

Advice can include references to the evidence, it’s really important to speak with underweight women; it’s just as important as with the overweight women or the unhealthy weight women. Underweight women need as much support as those with the higher BMIs, we know that their babies have got higher risks as well of metabolic syndromes.

It’s important to share that women in a healthy weight range are also at risk to avoid complacency, even though we are saying it’s great that their weight is in a healthy range, we do know that it’s a time that women put on a lot more weight than they should. Everyone talks about baby weight, so just for them to keep an eye on it. We are not wanting to say this to make them panic, obviously there are clients that might have risk of eating disorders or have had eating disorder in the past. It’s positive and negative in this way, we have a motivational service that might be able to keep them on track and keep them from going backwards.

We’ve got a new question that has come up – Is there a part of Get Healthy that pertains to smoking knowing that tobacco consumption is related to weight as well as risks to the mother and child?

No we don’t, but there is a program run by NSW Health called Quit for new life, and that really addresses the smoking issue. Yes, we have heard recently that people think smoking is an issue as well, and that’s getting healthy, this is basically a gestational weigh gain module as well as an alcohol reduction module, but it doesn’t address smoking because that is already addressed elsewhere. So if you are happy to look up you LHD (Local Health District) websites, there is a lot of information about that, that’s the Quit for new life program.

Offering the service – The service can be offered to all, although we may be a bit like telemarketers here as not everyone wants a free services that ensures optimal health for themselves and their baby. There are people that aren’t quite on that motivational scheme, they might be more motivated one day and not the next. If they don’t say that they want to be in it the first time, hand them a pamphlet and maybe they might want to do it themselves in their own time, and they may even be more motivated at week 26 or 28 when they see you again and they feel like they need a bit of help.

Remember to when you are actually doing that referral, explain that it could be more convenient to take up the information only option as it may suit them better than the 10 calls over a 6-month period.

LINDA MANN:

Having had the conversation with the person and they go ‘ok, I’ll give that a bash’, it is actually quite easy to refer people. There is a referral system that you can download into the template part of both Medical Director and Best Practice. There is no template for the other software resources at this point, if you are really keen and there is a lot of you who use one of the other systems, go to your PHN and demand that the IT person create the template because they have the ability to do that.

JUSTINE SALISBURY:

You are probably wanting to know beyond how to refer and what happens after we refer, so this is just a quick little explanation of how that happens because your clients are more than likely going to ask you what happenes next. The first call is basically an explanation of the service, we carry out some screening, we find out about lifestyle behaviours, eating habits, activity levels and why women are actually in the program, or other participants.

After this first call has happened, you as a GP will get feedback in the form of a letter confirming their enrolment. After that, the second call is when they start their coaching journey if that is what they choose. Calls are approximately 10-15 minutes with the same health coach each time, they can discuss their own health goals, and action plans to achieve them.

At the half way point, which is the sixth coaching call, they get the assessment questions to see how they are progressing. They can make any adjustments to their health goal and GPs will receive a half way letter, and that will actually give them some biometric details that their clients have actually shared with their coach.

If your client self refers and actually shares the details of yourself as the GP then you may get feedback, but with the feedback letters there is actually a point where the woman can say ‘I have been referred by Linda Mann as my GP, but I’m not happy for her to actually see my data’, so they can actually refuse you feedback. You will then get a letter that states that ‘Ms Blogs has just taken on the Get Healthy in Pregnancy Program, unfortunately, she doesn’t want to share the data with you, but she has enrolled’. They will tell you the goal and then you will know for your next visit that they are in the program, but they may not be happy to share all of that data with you.

LINDA MANN:

Just to remind people this is NSW only, not ACT, not other states.

JUSTIN SALISBURY:

And no, it is not only just in English, it is using the translation services.

When the woman gets to the 10^th call, they graduate and the referring GPs will get a final progress letter with the final biometric data to see if they have actually reached their goal, which is really exciting for them because usually they have. They can reenrol after that, they can reenrol for another 6 months, so after they have had their baby they can actually reenrol for another 6 months in the program. Once they have finished those 12 months, they can actually opt for SMS coaching as well, they might want to get healthy messages via SMS.

LINDA MANN:

One of the benefits of that of course is that will help that, what did you say it was?

JUSTINE SALISBURY:

3.7 Kilograms

LINDA MANN:

Which is the wonderful legacy of having had a baby, thank you so much! We know that the inability to lose weigh between pregnancies is a huge driver of excessive gestational weight gain. If people actually decide to continue on, this is fantastic and it’s really worthwhile thinking about mentioning this at the post-natal visit, and making sure that people remember they’ve got this option, that it’s free, and they have already met this particular coach, they understand how the program works.

JUSTINE SALISBURY:

Sometimes we might refer them on a home visit or something like that after they have had their baby, and it is nice to know that they don’t have to get out of their pyjamas to have the conversation.

LINDA MANN:

Yes, and on that subject, of course it’s not just the GP who needs to continue to facilitate, if you like, the journey that we are talking about. There is value for thinking about involving both the patient and your practice nurses, for example, in aspects of this program, certainly there are many practices that have a weighing scale out in the corridor so that it becomes an ordinary thing for patients to hop on the scales and see how much they weigh. We all know there are people whose method of weight control is just to never ask the question. It is worthwhile having the practice nurses upskill in the program, you guys are learning this in less than an hour, so I reckon the practice nurses could do it pretty quick too so that they can facilitate it.

If a practice nurse wanted to refer a patient, would that be possible Justine?

JUSTINE SALISBURY:

Absolutely! If they are a registered nurse, enrolled nurse, physiotherapist, dietician, they can be any type of AHPRA registered health professional they can actually refer – so they are using the health professional referral form, which is number one resource on your handouts of five, the second is the GP referral form that you will be using as a GP.

LINDA MANN:

So what resources exist for the practice?

JUSTINE SALISBURY:

We have free promotional materials, we have included in your resources a resource order form so you can order brochures, you can order handouts, and you can order posters for your rooms. I can also come out and give you an in service for your rooms as well, obviously, we have some infographics, we have today’s testimonial that is available. We are on the website as well, you can go on to Get Healthy NSW and go to ‘Refer your patients’, and there is lots of information there and there is a part that gives you all of those resources which you can have a look at, there is also some testimonial videos and infographics there for you. We can also get the infographics installed into your TV screens in your waiting rooms.

LINDA MANN:

Justine, if a GP mentioned the Get Healthy program but the woman did not take it up, has a baby ends up 20 kilos too heavy and thinks, bugger, I should have taken up that program when they offered it to me, I’d like to take it up now in my puerperium because I think now is the time for me to get active and do it – can they use one aspect of the Get Healthy program to do that?

JUSTINE SALISBURY:

Absolutely! The general Get Healthy Service is there for any NSW resident, male or female, so they can definitely go into that after they have had their baby.

LINDA MANN:

And if she then got pregnant down the track would she then be able to transmute into the pregnancy module?

JUSTINE SALISBURY:

Absolutely! All the coaches are the same coaches. All the coaches are across every program in the Get Healthy Service. They [the woman] might be in the general Get Healthy Service and be wanting to lose weight prior to their baby to get pregnant, and they might fall pregnant and then they fall into the Get Healthy in Pregnancy Service, so they will get that good support all the way through.

LINDA MANN:

And we do know that if you took 100 women who presented to a fertility clinic and got them to do exercise and lose about 10% of their body weight, 30% of those women with infertility would spontaneously get pregnant if they had a body with which to do it.

This is the end of the program. I think you would agree that we have learned some things during this program. We have looked at what healthy weight gain is during pregnancy. We have looked at the Australian Clinical Practice Guidelines for Antenatal Care and the details of that, and we have looked at his fabulous program, which we have discovered covers pregnancy and a whole bunch of other stuff, which is rather wonderful.

We have discovered that it costs nothing. Now a number of people have asked this over and over again, that is right, it costs nothing, the cost of a telephone call, and in fact, the coach will ring the patient. My teenagers, for whom making a phone call is vastly more expensive than sending a text, they are very happy that the coaches ring in; quite seriously, it makes a difference which is really good.

Thank you so much.

SAMANTHA MILAT:

We still have about five minute left so we will hang on the line for a moment, if anybody has any further questions they would like to ask, please feel free to send them through your chat box now and we can address them for you.

LINDA MANN:

Justine, the Healthy Pregnancy program that you have got going at the moment, about how many patients at any time are involved in it?

JUSTINE SALISBURY:

We have had over 780 women participate in the program since November [2016] so that quite a few, we have over 300 active participants currently.

LINDA MANN:

One of the questions asked was about women who want to join the program into their pregnancy, for example, the question is ‘I’ve seen patients quite late into their pregnancy, for example 24 weeks. How would I go about calculating their recommended weight gain’?

You can’t just divide it into 24 weeks, there’s 16 weeks left, let me just do a calculation – you can’t do that. You can certainly make some assessment about how much weight they have gained from the time they started and look at where they are going, the trajectory.

There was a question about bariatric surgery; I actually was going to mention that! Bariatric surgery is an increasingly difficulty in terms of pregnancy; it certainly can make quite a difference to the internal environment and the growing uterus, it also may have quite significant psychological issues. If you take someone who has had bariatric surgery who has lost weight and is now getting pregnant, it’s a little bit like our sensitive people who look at themselves in the mirror and have a conniption. My suggestion is there is great value in revisiting the psychologist that was part of the bariatric surgical team at that time.

Clinically, these patients can also have difficulty, especially if they come to caesarean section. For me as an antenatal shared care doctor, I seek some help from my obstetrics colleagues with those folk.

JUSTINE SALISBURY:

There is a question also – If they develop gestational diabetes can you still keep coaching them?

Absolutely, in fact we do have GDM clinics or gestational diabetes clinics in the hospitals referring as standard in some sites. The reason for this is because they are very over stretched with their dietician support, and it does improve if they decide they want to have a healthy activity goal, our exercise physiologists can coach them along as well. Obviously, we are not a prescriptive service, we’re not going to give them a diet, we’re not going to give them an exercise program, but we are going to motivate them to improve their lifestyle and make that more healthy. We are not going to come up against what the dietician is already doing in the gestational diabetes clinic, and yes, it definitely can work alongside. Also we do suggest that the ladies that have had GDM during their pregnancy, that postnatally, this is the danger period for them. 6 months after they have had their baby if they are being coached by our coaches and just really watching their diet and exercise and changing their lifestyle that can reduce their risk of type 2 diabetes later on as well. We do suggest at that postnatal visit if your woman has had GDM, you’ve just done that 75 gram, you really need to look at maybe getting them into a program like this and getting  good support for them for the next 6 months to make sure they have good lifestyle for that time.

LINDA MANN:

Samantha, that slide that has what the weight gain is according to BMI, is that something that the attendees can get access to?

SAMANTHA MILAT:

Absolutely! The whole presentation tonight is recorded and it will be uploaded to the RACGP website in the coming weeks. If you keep an eye on the website, you will be able to view the slides and the audio, everything that you saw tonight will all be available for free, online.

JUSTINE SALISBURY:

There is one more question – What qualification do the coaches have?

For those who missed it, the coaches are exercise physiologists and dieticians, we do have a registered nurse as well. We have a fair few coaches that are both dieticians and exercise physiologists.

LINDA MANN:

One of the other questions was recommendations for underweight women who become pregnant?

If you can possibly get them to have the help of a dietician, it really, really ,really helps a lot. They may be underweight from their own physiology and they just gain weight in a nice ordinary fashion. Some of them in fact gain excessive weight and need some help in monitoring and changing what is a new experience for them, they benefit from dietician a lot. They [dieticians] have an experience that we GPs are not very good at advising about, they are much better at advising about people who are overweight in my experience.

How can a 50 kg woman, with a BMI of 21 be allowed to gain the same amount of weight as an 85kg woman with a BMI of 21 as per one of the initial slides?

Well BMI is all about how tall and how big you are. If the BMI is 21, then the BMI is 21, the actual weight is not the issue, it’s how is your weight for the size you are. If you have a BMI of 21 and your 85kgs, you are probably about 6ft tall, if you’re 50kgs and you’ve got a BMI of 21 you are about 5ft tall. They will both produce a baby whose average weight is about 3.5 kilograms. Makes sense to me.

SAMANTHA MILAT:

Great, so that brings us to the end of this evening session, I’d just like to thank

Linda and Justine again for joining us tonight. If anyone feels that there were any question that were not answered tonight, you can send them through to us via email, you can respond to any of the email that we have sent you with your registration confirmation and we will be able to get back to.

Thanks again for joining us, and enjoy the rest of your night.