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PodcastNov | 13 | 2019
Pregnant women have historically been excluded from clinical research due to an abundance of caution for the safety of them and their babies. But consequently, these women are often left out of medical advances. For too long this has been the case for pregnant women with diabetes, and endocrinologist Dr. Camille Powe is passionate about changing that. In this episode, she discusses her work to better understand diabetes and pregnancy, as well as how she hopes to develop more personalized treatments for these patients.
Camille Powe, MD, is an endocrinologist who specializes in treating endocrine disorders, such as diabetes, in pregnancy. She helped found the Diabetes in Pregnancy Program at Massachusetts General Hospital, a collaboration between the Diabetes Unit and the Maternal-Fetal Medicine Division in the Department of Obstetrics & Gynecology, and serves as one of the program’s co-directors. Her clinical research focuses on the genetics and physiology of metabolic disease in pregnancy.
Dr. Powe received an AB degree from Harvard College and her MD from Harvard Medical School. She completed a residency in internal medicine at Brigham and Women's Hospital, where she also served as chief medical resident. Dr. Powe completed her endocrinology fellowship at Mass General.
November is Diabetes Awareness Month. In honor of the month, we are bringing you this episode with Dr. Camille Powe.
Today, any woman with diabetes who gets pregnant or who develops gestational diabetes is given the same advice—track your food, check your blood multiple times each day, and use trial and error to determine the best combination of foods for your body. But the truth is, there’s still very little we know about treating pregnant women, since they are largely excluded from clinical trials and research studies.
Endocrinologist Dr. Camille Powe, who co-leads the Diabetes in Pregnancy Program at Mass General, envisions a better future for these patients. She has devoted her career to better understanding how a growing baby affects the mother’s biology, and she is committed to applying that knowledge to help pregnant women benefit from these medical advances.
Through her research and important collaborations, Camille hopes to enable doctors to offer more personalized treatments to women with diabetes of any kind during their pregnancies.
Q: So welcome Camille.
A: Thanks. It’s great to be here.
Q: So to start can you talk to me a little bit about how you got interested in diabetes in the first place?
A: In college I was a biological anthropology major, which is human evolutionary biology, and I got really excited and captivated by this idea of maternal-fetal conflict.People think of motherhood as this beautiful and loving relationship, which of course it is, but during human evolutionary history, we think that fetuses’ and mothers’ interests were not always aligned. And so we think that babies’ genes have been selected to extract resources from their mother, whereas a mother’s genes will have been selected to in some ways limit some of that resource extraction.
And we can see this playing out in a variety of diseases. And so I got really interested in that idea. I did some projects on breastfeeding, which you can think about as energy transfer from mother to baby, but perhaps the most classic example of this is preeclampsia. Preeclampsia is basically a pretty dangerous syndrome of high blood pressure and protein in the urine that we see in pregnant women, and in that disease we think basically that the fetus is making something, the placenta is making something to raise the mother’s blood pressure, and what ends up causing disease.
And so I was fortunate enough to meet some mentors who were studying preeclampsia, but they pointed out to me that more work needed to be done in gestational diabetes and that gestational diabetes is sort of part of the same paradigm where the baby or the placenta is making something that is raising the mother’s blood sugars to get more resources from the mother.
Q: So, this problem that you’re describing, in essence it’s that the needs of the mother and the needs of the child are in conflict?
A: They could be that’s the theory behind why we think some of these diseases in pregnancy occur. It’s not necessarily true now that these things are good for the baby and bad for the mother, but that may be a driving force for why we see so many of these diseases popping up in the population.
Q: Are there other diseases that fit within this paradigm?
A: Well, I think those are the two most classic diseases. Another disease that I’m fascinated by in pregnancy which is really awful is hyperemesis. So, many pregnant women experience a mild form of hyperemesis, nausea, vomiting in pregnancy, or morning sickness, don’t know why women get morning sickness and presumably there was something advantageous to babies making mothers have morning sickness.
Q: That’s wild. That this thing that at least culturally is so essential to pregnancy, we don’t know why it happens.
A: Yeah, and that is a knowledge gap that I am really passionate about bringing attention to with my own research.
Q: Do you think having a background in anthropology changes how you approach medicine or how you practice medicine?
A: Yeah. I think in biological anthropology we’re taught to ask why on many different levels, not just why something is happening, like how does this molecule collide with that molecule to create some biological phenomenon but really why did this evolve over human history, what were the evolutionary mechanisms leading to it, how does that interact with our society and culture to lead to some of the observations that we’re making.
When I’m treating pregnant women with diabetes, I have become very interested in understanding each individual’s unique complement of hormonal, sociocultural, genetic factors that lead to their blood sugars being high. Each pregnancy is different, it’s driven by a different placenta, it’s driven by a different fetus, each mother and her baby have a unique set of genes that interact in a different way. Each woman brings into her pregnancy certain dietary habits that may relate to her culture where she was born, and has a different daily schedule.
And so when I am seeing a pregnant woman with diabetes, I am not only thinking about how to treat her blood sugars, but why is this happening. And I try to listen very carefully to my patients when they tell me something is happening that is different from what I expected, and this really informs both their individual treatment plan and also the research that I plan to do.
Q: Can you talk a little bit more about that sociocultural piece?
A: In diabetes I think we have to think a lot about people’s dietary habits and their lives and those things are just so intertwined with sociocultural factors. What you eat for breakfast every day heavily depends on your cultural context. I have patients from all over. And each place and each person have certain things that they eat and what we eat affects our blood sugars. I need to work with each, woman in that context to see how we can manage their blood sugar while still respecting all of those things.
Q: Is there a difference between the way you would approach someone who had preexisting diabetes and someone who has developed gestational diabetes?
A: Part of the problem that I see with how we currently treat diabetes in pregnancy is we sort of take a one size fits all approach, and women are generally put on the same treatment plan regardless of what type of diabetes they have. So, all women with diabetes during pregnancy are asked to check four to seven finger stick blood sugars a day. They’re asked to count and limit the amount of carbohydrates they eat, but not too much because we think baby needs some carbohydrates, so imagine what position that puts the women in. And they’re asked to log their food.
While I do think there are some differences between how we would treat someone who came into pregnancy with type one diabetes and someone who developed gestational diabetes for their pregnancy, I think that our approach is far too similar for those conditions, and even among women with gestational diabetes I think our approach is too crude, too rote, and treats every woman as if she is the same.
Q: Do you have any hunches about how we might tease out differences or where you think we’re headed?
A: So, because there is universal screening for diabetes in pregnancy I get to see the full spectrum of blood sugars across a population of women of childbearing age, and because of that, the patient population I see is actually enriched for rarer types of diabetes. And so I think the low hanging fruit is taking what we know about diabetes outside of pregnancy and what types there are and what the physiology is and not just assuming that every pregnant woman with high blood sugar has gestational diabetes.
I have several patients who have come to me with an atypical story, and they say, “Hey, Dr. Powe, I don’t understand why I have gestational diabetes. I have no risk factors for this. But what I noticed is that I have all these family members and they also have no risk factors and they all have diabetes.” And because of cases like that I have diagnosed rare genetic forms of diabetes in this population of women with high blood sugars during pregnancy.
So first let’s just take those women out of the general pool that we’re treating as gestational diabetes and diagnose them with the condition that they actually have.
What I am interested in from a research perspective is taking the more common form of gestational diabetes and really understanding all of the heterogeneity and diversity among women with that condition and dividing people into subgroups and seeing if we can come up with better, less burdensome, and easier treatment plans that apply specifically to those smaller groups of women, rather than treating everybody the same.
Q: So, it sounds like some of the work you’re doing is to reframe the way we understand what is now one disorder.
A: Yes definitely. And I think I have been inspired by that work that is going on with diabetes outside of pregnancy. We’ve seen a huge explosion of what is called precision medicine for all sorts of conditions, including cancer and including diabetes, and I want to make sure that pregnant women aren’t left out of that movement.
Q: Can you explain what precision medicine is?
A: Rather than studying population averages what drug works in this group of people who have this same condition.
Precision medicine aims to take the latest advances in genetics and molecular biology to subgroup people or individualize treatment, and so we don’t just say, “What is the best drug on average, so we’re going to try that one first” but we look at an individual’s or their cancer’s genetic profile and we say, “Oh you have this genetic change. We have a specific drug that targets that genetic change and we’re going to use that.”
So it’s really about reframing how we learn about new drugs and technologies and apply them to individual patients.
Q: So if a woman is diagnosed with some form of gestational diabetes is that a concern just within her pregnancy or are there longer term consequences to think about?
A: We know that having gestational diabetes is a huge risk factor for getting type 2 diabetes later in life, and so in some studies the risk of getting type 2 diabetes after gestational diabetes has been as high as 50 to 70%. I think that there is a lot more that we can do once we identify women with this risk factor, to prevent them from getting diabetes, and some work that was done here at Mass General in the Diabetes Prevention Program, which was a large medical study, showed that doing intensive lifestyle modification, meaning diet and exercise, weight loss, or prescribing Metformin decreases the risk of getting type 2 diabetes in all people, but in women with gestational diabetes included.
And so I also think what is interesting to study is why do some women progress to type 2 diabetes and why do some women not. Can we predict who you are at the time of your gestational diabetes diagnosis?
And so in trying to describe subtypes of gestational diabetes, one of the things we’re really interested in is figuring out whether all women with gestational diabetes do have this elevated risk of type 2 diabetes.
Q: Can you talk a little more about that research and how are you trying to answer that question?
A: Working with one of my mentors and collaborators who was in the Diabetes Unit here, Dr. Maria Franzivar, we have looked at women with gestational diabetes and divided them into subgroups depending on their underlying physiology, whether it looked like their high blood sugar was due more to a problem with their body making insulin, or whether it was more due to their body not responding to the high levels of insulin that their body was making. In that study, we saw differences between those two types of women and what the complications of gestational diabetes were in their pregnancies.
Moving forward we are doing studies here at Mass General trying to see if we see these same groups of gestational diabetes in our patient population and also following women over time and exploring whether the women from the original study have a different risk of type 2 diabetes depending on what subgroup they’re in. And now we’re even launching a study to see whether people with different types of gestational diabetes respond differently to different diets.
Q: And through the course of the research you’ve been doing are there things that you have already learned that have helped adjust your practice or the practice of the field?
A: Because I’m a scientist and I want to prove something before I take it to my patients, I am very careful about taking my hypotheses that haven’t been tested and applying them to my patients. But I do think my research has shown that people with diabetes in pregnancy in general are not the same, and so I like to meet each individual and focus on what is unique about them and pay attention to those differences, rather than ignoring them, because I think that is what is most interesting, that is what is most fun, and that is how we get the best outcomes for our patients by treating them as individuals and listening.
Q: I wanted to zoom out a little bit and go back to something you talked about previously, which is this whole question of pregnant women and research. So can you talk about pregnant women and the research canon and what that’s all about?
A: I think no one would want to expose a pregnant woman or their fetus to an experimental protocol or procedure that has considerable risk associated with it, because mothers and babies are so precious. And I think that has been the motivation behind excluding pregnant women from research. And so when a pharmaceutical company or a device company or even most investigators are designing studies, one of the first exclusion criteria that they always put is pregnancy. And in fact, researchers go to great lengths to make sure that their research participants are not pregnant.
And I think the intentions are good, but the consequence is that when you’re a pregnant woman, there is less that we can offer you from the latest advances in medicine. And so I am interested in designing research studies specifically for pregnant women that are ethically sound, don’t have excess risk that is disproportionate to the benefit that the participants can be expected to receive so that we can make sure that we don’t leave pregnant women behind from all of the advances that we’re making in medicine.
Q: How do you design those studies that help push knowledge forward but also protect the participants?
A: I think one misconception about research is that if you participate in a research study you’re a guinea pig, you’re going to have all these interventions done to you. Most of the research I do is actually what is called “observational.” And so that means we just take some measurements and we observe you. And the risks are not greater than what you would experience in medical care, but we’re collecting data that is going to tell us about associations between certain hormones or genes and outcomes for a woman and her baby.
And so I don’t think there is any reason to exclude a pregnant woman from a research study like that, because, any risk that there is is acceptable, it’s similar to the risk you would encounter just going to your doctor.
Q: It’s interesting to me to think about the fact that we have excluded women because we want to protect them, but then ultimately in some ways they are less protected on the whole.
A: Yeah, this standard exclusion for pregnancy in research studies started from that idea that we want to protect women and their fetuses, but I don’t think we have revisited it enough as medicine. I think sometimes people just put that exclusion in their studies because it’s easier and they don’t even want to think about how they could feasibly do their study in pregnant women or how they could account for it.
Q: Is it part too, there has been discussions more generally about a need for a more diverse patient population in general when it comes to medical studies.
A: Yeah. So, pregnancy is complex, right, it’s not enough to just know whether a woman is pregnant, you need to know how pregnant she is, is she carrying twins, and so it introduces a lot of what I think is very interesting complexity into research studies, but if your primary goal isn’t to study that, that could become noise or something that you have to just sort of deal with in an analytical scenario, and it can be complicated and more work.
There has been a big movement recently to make sure that females and not just women but also female animals are included in experiments, because people have said, “Oh, women are too complicated, females are too complicated. They have all these cycles and things and all these hormones.” Men have hormones too, everyone. And so there has been a huge push in the medical research world that uses animals as models for human disease to stop excluding female animals.
I think the work I’m doing in pregnancy is just one piece of a larger picture of needing to include the full dimension and complexity of the human experience and human diversity in our research.
Q: I know you started a program, the Diabetes in Pregnancy Program, to have more specialized care for this patient population. Can you talk a little bit more about why you started it?
A: The Diabetes in Pregnancy Program is an interdisciplinary collaboration between my unit, the Diabetes Unit, and the Endocrine Division, and the Maternal-Fetal Medicine Division in the Obstetrics and Gynecology Department. And we came together to start the program because we thought by working together that we could deliver much better care for women with diabetes in pregnancy.
When you have diabetes you are considered to have a high risk pregnancy and you are followed very closely by usually a maternal-fetal medicine doctor, and if you came into pregnancy with an endocrinologist you’re often followed by an endocrinologist.
And just on the logistical side having that many appointments with that many different specialists is extremely burdensome for women who may need to work, may need to care for their other children, may need to have a life outside their medical care. And so we thought why don’t we see patients together in the same place at the same time, but really it’s so much more than that.
I have friends who have type 1 diabetes and colleagues who have described to me how difficult it was to even get their endocrinologist and their obstetrician to talk to each other, let alone get them on the same page about what they should be doing for their blood sugars.
So, it’s totally different in our program. I am right there. The maternal-fetal medicine specialist is right there. We have meetings where we talk about all our patients, we review the ultrasounds together of all the babies. We make sure that the advice we’re giving doesn’t conflict, and I think as a result, we’re able to really have great outcomes for our moms and babies, no matter what type of diabetes they have.
Q: Are there other ways that technology is changing the way that we either treat or understand diabetes?
A: Technology has totally transformed the care of type 1 diabetes over the past couple decades. And so type 1 diabetes technology is getting more and more advances are happening each day. But in large part that has not been translated to pregnant women.
Anyone with type 1 diabetes needs to monitor their diabetes frequently. And now instead of pricking their finger multiple times a day, many people with type 1 diabetes are using continuous glucose monitoring technology, which is a device that is placed on the body and takes your blood sugar every five minutes, and it often connects to your smartphone. And now we’re even moving more towards the ability to automate insulin delivery. Meanwhile, over here with diabetes in pregnancy people haven’t benefited from that technology at all unless they happen to have Type One and have one of these devices.
But we have two populations of people who have the same problem, which is that they need intensive monitoring of their blood sugar, and one is having all technology thrown at the problem and one population is left behind. I am very interested in being part of bringing that type of technology to women diabetes in pregnancy, and we just initiated a collaboration with the National Institutes of Health, to do that as part of a national consortium here at Mass General.
Q: Is there a reason they couldn’t be directly translated to gestational diabetes?
A: So that is happening a little bit, and pregnant women with Type One we have actually a study that came out about two years ago that suggests using these monitors in pregnancy decreased the risk of having a baby with a negative outcome.
But there is a few problems with just taking that and applying it to women with gestational diabetes. One is that there are very few studies of these devices in gestational diabetes, like I can count them on my hand, and the blood sugars in someone with gestational diabetes are actually often in a different range than the blood sugars of someone with type 1 diabetes.
The second reason is we actually don’t have enough data in normal pregnancy with these devices. And so we have based our recommendations for gestational diabetes on knowing what the blood sugar is one to two hours after the meal. Well, now we know what it is five minutes after the meal, 30 minutes after the meal, 45 minutes after the meal. And what is it supposed to be? We don’t actually know. So that is what this big study that I am involved in planning with the National Institutes of Health will address.
Q: When you think to the future, you think forward with all of this research that you’re involved in, how do you envision it changing the field?
A: So, the main goal of my research program is to change how we approach diabetes in pregnancy to make it less burdensome, simpler and get better outcomes for mothers and their babies.
I envision a time when at the time of diagnosis of gestational diabetes instead of telling women to prick their fingers four to seven times a day and change their diet by trial and error, that we can tell something about that woman when she is diagnosed.
Maybe some people don’t need to monitor that much their blood sugar, because we can put them on a certain diet and they’ll be on autopilot. Maybe some other women are extremely high risk and they need a personal continuous glucose monitoring device to target their blood sugar in a certain range. Maybe some people need a different blood sugar target range than other people. Maybe some people need a certain medication and some people need another medication.
So, I want to move our care so that at diagnosis we can figure out what you need instead of doing trial and error and putting all the burden on the woman to figure out what works.
Q: It sounds like a great future.
A: I hope so.
Q: Well thank you so much for talking with me today. Before you go, Camille, I have my final five questions.
What is the best advice you have ever gotten?
A: I think the best advice I’ve gotten is to not let people put you in a box. One of my mentors told me, “Don’t let people tell you you can’t study pregnant women.” I’ve had a lot of people tell me, “Oh you want a career in research. Why are you focusing on this problem? There are so many limitations and complications with studying pregnancy.” And I haven’t listened to them, and I think that studying pregnancy is one of my favorite things that I do every day.
Q: If you weren’t a doctor what would you be?
A: If I wasn’t a doctor I think that I would be an engineer. I have always liked solving puzzles and problems and I think I am doing that now through research and clinical practice, but I think doing that from an engineering perspective has always been something that has interested me since I was a little kid.
Q: What advice would you give your younger self?
A: I would tell my younger self not to worry so much about what I would be able to do in the future, and I spent a lot of time worrying about whether I was making the right decisions about what specialty to go into or what kind of training I would get, and now the job that I have is really my dream job, I am doing exactly what I always wanted to do, and I wish I hadn’t worried about getting there so much.
Q: What is the best decision you have ever made?
A: The best decision I have ever made is marrying my husband, because he is a great supportive partner that has allowed me to have my career and we have a beautiful two year old son that I am really grateful for.
Q: What was your first job?
A: My first job was being a camp counselor. I was a regular day camp counselor and then I became the music and drama counselor, and I wrote plays for little kids to perform for their parents.
Q: That sounds like a fun job.
Perfect. Alright. Thank you so much, Camille. It’s been such a pleasure talking with you today.
A: Thanks, Amy. It’s great to be here.
Charged is a podcast devoted to uncovering the stories of the women at Mass General who break boundaries and provide exceptional care.
For pediatric neurosurgeon Dr. Tina Duhaime, it’s not hard to explain our struggle with climate change when you consider how the human brain works.
Episode #22 of the Charged podcast