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EF: Could you elaborate on your career path and what attracted you to the field of diabetes and its link to Women's Health?

LZ: In 1988, I finished my medical graduation in Rio de Janeiro and decided to study Endocrinology. The physiopathology of the related diseases is very interesting, and with the correct treatment of endocrine disease, it is possible to give patients a good quality of life. My residency, master's degree, and my Ph.D. focused on Endocrinology.  

Due to the high complexity of caring for people with diabetes, especially during pregnancy, multidisciplinary work is crucial. In 1992, at the university, I began to work with women with diabetes and built an interdisciplinary team of endocrinologists, obstetricians, dietitians, nutritionists, psychologists, and psychiatrists, driving improvement in this field.  

The first pregnant woman that I treated in my career had Type 1 diabetes for more than 30 years and was told that motherhood would be impossible for her. Due to this statement, the patient interpreted she was infertile and using any contraceptive method unnecessary. She came to me at 12 weeks of gestation and lost her baby due to severe cardiac malformation. This traumatic experience led me to study the topic more thoroughly. (Fortunately, this patient later achieved a second pregnancy and gave birth to a healthy child.)

Pregnancy is an extraordinary and delicate stage in a woman's life. Caring for pregnant women needs a unique and specialized setting, emphasizing the significance of women treating women during this crucial time.

EF: Could you provide some figures and numbers about diabetes in pregnancy impacting Brazil?

LZ: Diabetes is a prevalent disease in Brazil. Around 9.0% of adults between the ages of 20 and 79 live with this disease. It is estimated that 1 in 6 births occur in women with hyperglycemia in pregnancy.  

Diabetes can manifest before or during pregnancy. When diabetes is diagnosed during pregnancy, it is referred to as Gestational Diabetes Mellitus (GDM). GDM constitutes over 80% of cases, indicating that these women had no prior diabetes diagnosis or were unaware of their diabetic condition before becoming pregnant.  

Gestational Diabetes Mellitus (GDM) poses a significant risk factor for the future onset of Type 2 Diabetes in women. It presents a crucial concern for public health and has individual health implications. GDM increases the likelihood of perinatal complications such as prematurity, cesarean section, traumatic births, neonatal hypoglycemia, and potential future health issues for the mother and her offspring.

The global prevalence of GDM varies significantly, ranging from 1% to 37.7%, with an average of 16.2%. In Brazil, around 18% of women seeking public health services are affected. To ensure effective screening, we recommend that all pregnant women without a pre-gestational diabetes diagnosis undergo testing for GDM. Ideally, an oral glucose tolerance test is preferred. However, due to the country's heterogeneity and limited access to clinical analysis laboratories, a fasting blood glucose measurement alone may suffice for diagnosis, despite limitations.

Regarding cases of pre-gestational diabetes, the number of women with Type 2 diabetes is increasing due to various factors. Especially obesity is a big issue in Brazil, and young women, mostly with low incomes, are greatly affected by it.  
On the other hand, women from higher socio-economic classes are looking to become pregnant, often at an older age, which creates additional risk.

With diagnosed diabetes, preparation before pregnancy is crucial. Without adequate control of blood glucose, gestation involves several risks. Hyperglycemia in early-stage pregnancy is associated with fetal malformations, and eye and kidney complications related to diabetes can worsen during pregnancy. Unfortunately, many women seek healthcare only when they are already pregnant and have difficulty finding specialized care.

Women with Type 2 diabetes often initiate prenatal care even later, and the primary and most concerning issue they face is the concurrent diagnosis of arterial hypertension. Hypertensive pregnancy complications, such as preeclampsia and eclampsia, are significant contributors to maternal mortality in Brazil, making hypertension and bleeding complications the main risk factors for pregnancy-related deaths.

Many women fail to associate hyperglycemia with pregnancy complications, facing challenges in accessing specialized care. Pregnancy-related diabetes extends beyond primary care, requiring access to secondary and emergency care when conditions become severe.

Brazil's healthcare landscape is advancing, yet it remains heterogeneous. Over the years, especially in major cities, medical attention has improved significantly since the 1980s. However, there is still much progress to be made.

The rate of pregnancy planning in Brazil is alarmingly low. Though no official data is available, as a physician in a public university clinic, I have observed that over 90% of the patients I encounter during appointments do not plan their pregnancies. This situation is critical, especially considering that public health services offer free distribution of contraceptives, such as birth control pills. Health illiteracy remains a prevailing issue in our country.

EF: What initiatives are taken to improve the situation of gestational diabetes in Brazil?

LZ: The main focus of our efforts lies in expanding access to GDM screening and enhancing medical education. In 2017, the Minister of Health adopted the GDM diagnosis criteria proposed by the IADPSG (International Association of the Diabetes and Pregnancy Study Groups), supported by the World Health Organization (WHO).  

Collaborating closely with the Ministry, our aim is to disseminate these guidelines nationwide, thereby increasing accessibility and awareness for gestational diabetes screening.

To achieve our objectives, we recognize the need for a more specialized healthcare system and improved health education. Additionally, we are dedicated to promoting self-monitoring of blood glucose and ensuring widespread access to insulin. While Brazil has shown considerable progress in these areas, we must extend these benefits well beyond the major urban centers.

EF: How have treatments been advancing for women with diabetes, and what areas do you believe still hold untapped opportunities for further improvement?

LZ: Postpartum follow-up of women with a history of GDM is still a challenge. The high-risk population needs robust prevention programs. We recently developed a multicenter study in Brazil (LINDA-BRAZIL) evaluating the effectiveness of lifestyle changes in women at high risk for developing Type 2 diabetes. These data sets will help us build realistic programs suitable for our population.  

The main improvement in diabetes treatment for women is the ability to monitor glucose levels, which is crucial, especially for those using insulin. In Brazil, access to self-monitoring tools for blood glucose has been increasing but is still expensive. Continuous glucose monitors, which are particularly effective in pregnant women with Type 1 diabetes, are still scarcely used in the Brazilian population due to their high cost.  

Women with Type 2 diabetes require specialized care due to factors such as advanced age, risk of hypertensive complications, and obesity.

Finally, health literacy remains the main challenge, as some individuals may have access to insulin but struggle to understand how to use it effectively due to the complexity of their treatment.

EF: What steps can be taken to improve education and provide a better patient journey for women with GDM?

LZ: In the future, we must focus on creating multidisciplinary teams to support these women throughout their journey. Educating the population and families has been a significant challenge, but we have achieved positive results by working together in groups with medical professionals, nurses, and pharmacists. The good news is that creating a multidisciplinary team is not an expensive endeavor and can have a profound impact.

Insulin and glucose monitoring are efficient and cost-effective tools for treating hyperglycemia during pregnancy and should be accessible to all pregnant women with diabetes.

Furthermore, we must also address food security in Brazil. Many regions suffer from a lack of access to healthy food, especially after the impact of COVID-19, where unemployment has risen significantly. Lower-income women, particularly single mothers with multiple children, often consume cheaper, ultra-processed foods. Ensuring access to healthy food at reasonable prices is critical.

In 2020, we ran a campaign to provide financial assistance to people with Type 1 diabetes who could not afford nutritious food. Rice, beans, and vegetables are common and healthy staples in Brazil, but unfortunately, many people lack proper cooking facilities-leading them to request processed food. Improving social markers and raising food security in Brazil will directly impact the general population's health.

August 2023