Professor Louise Maple-Brown is senior principal research fellow with Menzies School of Health Research, senior endocrinologist, Royal Darwin Hospital (RDH), and Chair of the Northern Territory (NT) Diabetes Clinical Network.
Louise leads a clinical research program within the Wellbeing and Preventable Chronic Diseases division of Menzies, with a focus on diabetes and related conditions in Aboriginal and Torres Strait Islander people. Louise established and leads the Diabetes across the Lifecourse: Northern Australian Partnership, which started as the NT Diabetes in Pregnancy Partnership. The partnership includes several large NHMRC-funded projects, including the NT and Far North Queensland Diabetes in Pregnancy Partnership and The PANDORA (Pregnancy And Neonatal Diabetes Outcomes in Remote Australia) Cohort Study.
Can you provide an overview of your current work in relation to COVID-19?
Each of my roles have required a lot of consultation, assessing guidelines and developing key messages for various stakeholders throughout the constantly changing environment.
As a member of the Australian Diabetes Society Council, I have been involved in developing national guidance on how to safely screen for diabetes in pregnancy (gestational diabetes) during the COVID-19 pandemic. We have also been communicating with health care professionals about care provision for people with diabetes, the medical management of diabetes and related complications in light of COVID-19, and specific issues relating to availability of supply of diabetes consumables and stockpiling.
There is a constant balancing act between managing risk of COVID-19 infection and ensuring ongoing appropriate management of chronic conditions, which is so important both in the short and long-term.
I have been working closely with other clinicians in the NT to adapt these national recommendations for our local context, especially in relation to screening diabetes in pregnancy. We know that there are significant risks to women and their babies, in the immediate and long term, if diabetes during pregnancy is undetected and untreated.
Standard screening practices rely on the oral glucose tolerance test (OGTT) which requires women to attend a health or pathology service for more than two hours. The guidelines aim to minimise risk of COVID-19 while providing safe antenatal care with respect to diabetes. Within our Diabetes Across the Lifecourse: Northern Australian Partnership (the Partnership) we have undertaken extensive research since 2011 on diabetes in pregnancy in the regional and remote context which has assisted with developing relevant framework for the COVID-19 approach.
Are people with diabetes at greater risk of COVID-19 infection?
The risk of catching the virus that causes COVID-19 is likely to be the same for people with and without diabetes. However, early evidence suggests that people with pre-existing medical conditions, such as diabetes, appear to be more vulnerable to becoming unwell with COVID-19.
What messages do you have for people with diabetes during this time to ensure their health is optimal? Is it still safe for them to visit their GP or local hospital?
It is more important than ever for people with chronic medical conditions to take care of their health and receive any clinical support they require. Specific advice for people with diabetes can be found on Diabetes Australia’s website.
While changes to service delivery have been implemented to aid social and physical distancing, primary care and specialist services for people with chronic conditions remain available and we encourage people to use them as needed. For example, people are increasingly using telehealth options to check in with their specialist or diabetes educator. We are continuing all our regular diabetes clinics at RDH, with the majority of appointments in recent COVID-19 times being conducted by telephone or video instead of face-to-face.
We’ve also developed a checklist for people with diabetes during COVID-19. We are encouraging all people with diabetes to sleep well, maintain physical activity and healthy eating. This will assist in managing blood glucose levels. It’s important to stay connected to people who support you such as your family and friends.
What are the implications of diabetes management for people with COVID-19?
People with diabetes who are diagnosed with COVID-19 should receive personalised advice from their health care team about their diabetes management. It is helpful for people with diabetes to develop a sick day plan. In general, when unwell, it is important to check blood sugar levels more frequently. Adjustment to medication doses, particularly insulin, may be required. Some tablets like metformin, empagliflozin and dapagliflozin may need to be withheld temporarily if someone is very sick, but this should only be done in discussion with a health care professional.
Recently, the screening process for gestational diabetes mellitus (GDM) has been adjusted in accordance with COVID-19 social distancing regulations. Can you provide information on the new screening guideline?
GDM screening approaches currently differ throughout Australia according to the local risk of transmission and the ability of clinics to accommodate spatial distancing recommendations.
The Australian Diabetes in Pregnancy Society (ADIPS) and Australian Diabetes Society (ADS) have distributed guidelines that incorporate three approaches for screening based on whether health services identify as ‘green’ (low contagion risk), ‘amber’ (moderate contagion risk) or ‘red’ (high contagion risk) sites.
‘Green’ sites are encouraged to operate as per standard operating practice, which would be early screening in pregnancy for women at high-risk of diabetes (for example women from high-risk ethnic groups, women with a family history of diabetes and women over 35 years of age).
Green sites are encouraged to continue to use the oral glucose tolerance test, during early screening and during universal screening, for all women between 24-28 weeks of pregnancy.
For sites that are ‘amber’ or ‘red’ sites, alternative screening approaches are suggested using different glucose tests. These approaches minimise the number of women who have to spend two hours at a collection centre doing a glucose tolerance test. It is important to note that these are temporary changes due to the risks posed by COVID-19. There is no new evidence to say that these alternative screening methods are as effective in the long term as the usual screening recommendations.
Do the COVID-19 guidelines have different criteria for diagnosis of GDM?
The ‘gold standard’ for diagnosing gestational diabetes is the oral glucose tolerance test (OGTT). The diagnostic criteria associated with the OGTT are consistent across Australia. Due to COVID-19, some locations are using alternatives to the OGTT such as HbA1c and random blood glucose levels. These tests are quicker and easier to perform but not as good at detecting GDM. Women with borderline results will still be asked to do an OGTT. In the Top End of the NT, we are fortunate to have had no community transmission of COVID-19 and the plan is for GDM screening to go ahead as normal for now.
Our Diabetes Across the Lifecourse website will continue to keep you updated on the latest diabetes and COVID-19 guidelines nationally.
For a lot of people, isolation impacts greatly on mental health. Is there a link between changes to diabetes management and poor mental health?
Many people with diabetes experience additional stress related to their condition. This can have an impact on mental health.
For some people with mental health conditions, the added load of looking after diabetes can be challenging. It is really important in these times of physical distancing that we all look out for each other. We encourage all people with diabetes to ensure they keep in touch with friends and family regularly and reach out to their diabetes team and other supports as needed. There are numerous phone-based support services available for those who are feeling the impact of the COVID-19 pandemic on their mental health such as Lifeline, who are available 24/7 via 13 11 14.
How has COVID-19 affected you personally?
Both my research and clinical roles have been heavily impacted by COVID-19. The impact was greatest on my clinical role at RDH, due to the need for service re-design, roster changes and preparing for changes in clinical roles due to COVID-19. The burden on many of my clinical colleagues has been even greater and it is thanks to them that we have had great outcomes thus far from our NT public health strategies.
What are you doing to relax?
I love to exercise outdoors, particularly along our beautiful Darwin foreshore, thus have been enjoying plenty of bike-riding and walking the dog. I’ve also been reading more novels recently – thanks to a good friend in my book club who has leant me a few from her shelves.