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ORIGINAL ARTICLES
Year : 2022 | Volume
: 13
| Issue : 3 | Page : 270-276
Medical nutrition therapy in gestational diabetes mellitus: A survey among dietitians
Sindhu S, S Uma Mageshwari
Department of Food Service Management and Dietetics, Avinashilingam Institute for Home Science and Higher Education for Women University, Coimbatore, Tamil Nadu, India
Correspondence Address:
Ms. Sindhu S
Department of Food Service Management and Dietetics, Avinashilingam Institute for Home Science and Higher Education for Women University, Coimbatore, Tamil Nadu
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jod.jod_37_22
Aim: The aim of this study was to elicit information on the perception of dietitians about gestational diabetes mellitus (GDM) and their dietetic practices. Materials and Methods: A survey was conducted among dietitians working in hospitals, maternity centers, and other clinics using the purposive sampling criterion. A validated questionnaire was used to obtain details about the perception of GDM, guidelines used, dietetic screening, assessment, interventions and follow-up. Descriptive statistics were reported as frequency of total number of responses for each question. Fisher’s exact test on perception of GDM, operating guidelines and topics discussed in diet consultations with respect to the years of clinical experience, age group and educational qualification of the participants were performed. Results: Perception of dietitians on family history of type2 DM as an associated risk factor of GDM had significant association with their clinical experience. Majorly discussed topic in diet consultation was carbohydrate distribution followed by protein requirement, fiber and small frequent meal pattern. On the basis of clinical experience of dietitians, difference was observed in discussed topics such as hypoglycemia, food groups, post-natal diet, and breast feeding. A major inconsistency observed was the nonavailability or lack in the use of pregnancy specific screening tool. Conclusion: Specific screening tools for pregnancy should be brought into practice. There is also the need for sustainable protocols in hospitals for uniformity in management of GDM.
Keywords: Dietitians, gestational diabetes mellitus, MNT, perception
Gestational diabetes mellitus (GDM) is one of the common problems in pregnancy, posing a considerable risk on maternal and fetal health. The International Diabetes Federation (IDF) Atlas More Details 2019 described 223 million women (20–79 years) living with diabetes globally. IDF also projected the number to increase to 343 million by 2045. According to IDF, 20 million or 16% of live births were associated with some form of hyperglycemia in pregnancy and one in six births were affected by GDM.[1] A recent study on the prevalence of GDM found significant variations in the prevalence of GDM across the different states, the socioeconomic environment, and demographic parameters. The study reported the age-adjusted prevalence of GDM to be highest in Telangana and Kerala.[2] Unlike the usual belief that GDM is only a temporary problem for the expectant woman, which reverts to normal after delivery, there is now substantial evidence of it being a risk factor for future metabolic problems such as type 2 DM, hypertension, obesity, ischemic heart disease, and other cardiovascular diseases in both mother and the baby.[3],[4],[5] In 1979, the First International Workshop on GDM held in Chicago proposed nutritional counseling and diet therapy in the guidelines for the management of GDM.[6] Medical nutrition therapy (MNT) became the cornerstone of GDM management. Recommendations suggested that dietary management should be individualized to meet the calorie requirements for maternal and fetal health while reducing the risks of hyperglycemia and ketonemia.[7] Intensive nutrition therapy based on the total amount, type, and distribution of carbohydrates consumed and self-monitoring of blood glucose are essential aspects in the management of GDM.[8] Even when most cases could be managed with diet therapy alone, evidence-based practice guidelines for GDM were not available.[8] In 2001, Diabetes Care and Education and the Women and Reproductive Nutrition practice groups of the American Dietetic Association collaborated and framed the practice guidelines for GDM to overcome the inconsistencies in the nutrition care of women with GDM. The field test studies based on the implementation of guidelines at prenatal care and other provider centers showed improvement of glucose control in women with GDM.[9] MNT still is a mainstay in the treatment of GDM[10] and dietetic interventions in the form of individualized diet consultations with a registered dietitian have been effective in improving blood glucose control, and reducing the need for insulin and also the occurrence of adverse maternal fetal outcomes in women with GDM.[11] However, diet consultation for women with GDM still exists as a major concern in many low-income settings due to the scarcity of dietitians.[12] Also, evidence lacks whether a systematic, evidence-based dietetic care of women with GDM is followed in many states across India. This study was conducted to obtain information on the perception of dietitians about GDM and the dietetic practices in the management of GDM.
Materials and MethodsA survey was conducted among dietitians working in hospitals, maternity centers, and private clinics in Kochi, Kerala, India using a purposive sampling criterion from March 2019 to January 2020. Institutional Human Ethics Committee approval was obtained for the study. Consenting dietitians who were willing to fill and submit a questionnaire were included in the study. The questionnaire was directly handed over or mailed to the dietitians according to their preference. The questionnaire was designed based on the structured survey tools used in Women in India with Gestational Diabetes Mellitus Strategy (WINGS-5) project[13] as well as the Gestational Diabetes Dietetic Practice Survey developed by Morrison et al.[14] Additional questions were incorporated based on the Diagnosis and Management of Gestational Diabetes Mellitus: Technical and Operating Guidelines developed by Ministry of Health and Family Welfare, Government of India.[15] The 47-item questionnaire included both multiple-choice and open-ended questions. Open-ended questions were used to record demographic details (6 questions), nutrition screening and assessment (6 questions), guidelines and dietetic interventions (9 questions), follow-up, and evaluation practices (10 questions). Likert scale responses were used to report perception of GDM (8 questions) and the need for protocol-based management strategies and dietetic interventions (8 questions). The developed questionnaire was pilot tested by two dietitians, two obstetricians, two academicians and one statistician for content validation and then used as the survey tool. Statistical analysis was done using SPSS version 21. Descriptive statistics were expressed as the frequency of the total number of responses for each question in the questionnaire (%). Fisher’s exact test was performed to understand the association between age group, years of clinical experience and educational qualification of the respondents with perception of GDM, operating guidelines used and topics discussed in diet consultations for GDM women.
ResultsDemographic details
A total of 55 dietitians participated in the survey, out of which 85.5% worked in multispeciality hospitals with a mean age of 33.87 (standard deviation = 7.63) years. Out of the surveyed respondents, all were full-time dietitians except one respondent who worked as a consultant clinical nutritionist. Majority of the dietitians were postgraduates, and almost half of the surveyed respondents had 5–10 years of clinical experience.
Perception about GDM
A 5-point Likert scale on the perception of dietitians about GDM demonstrated 34.5% strongly agreeing, 63.6% agreeing, and 1.8% not knowing that GDM is on the rise. When the participants were asked about the prevalence of GDM being considered more in urban than rural areas, 20% strongly agreed, 58.2% agreed, 18.2% had a neutral opinion, and 3.6% disagreed. Half of the respondents (50.8%) strongly agreed on GDM as a risk factor for future type 2 diabetes mellitus in expectant mothers. Out of the total participants, 43.6% suggested evidence-based treatment strategies, 54.5% early diagnosis and detection of GDM, 70.9% health and nutrition education and 61.8% regular follow-up and evaluation as preventive measures to reduce the incidence of GDM at a national level. Twenty-two (40%) of the respondents also demonstrated strong agreement with the perception that normoglycemia in GDM women can be achieved through proper MNT and exercise. Fisher’s exact test was performed to find the relation between associated risk factors of GDM and years of clinical experience, educational qualification and age group of the respondents. The results in [Table 1] describe a significant association only between the perception of family history of diabetes mellitus as an associated risk factor for GDM and the clinical experience of respondents.
Table 1: Perception of respondents on associated risk factors of GDM and years of clinical experienceThe study also assessed the confidence level among dietitians in providing dietetic advice to GDM women. The respondents were asked to rate on a scale of 1 to 4, where 1 represented very confident and 4 as not confident. More than half of the dietitians, 29 of 55 (52.7%), expressed their confidence level as very confident. Their level of understanding of current evidence-based guidelines in the management of GDM was also asked to be rated on a scale of 1 to 4, where 1 indicated excellent understanding and four as needing improvement. The results revealed that out of the total respondents, 8 (14.5%) confirmed they have excellent understanding, 29 (50.9%) a good understanding, 17 (30.9%) fair understanding, and 2 (3.6%) needing improvement.
Screening and assessment of gestational diabetes mellitus
More than three-fourths of the respondents (78.2%) reported that screening of GDM was done for all pregnant women during their first visit to the hospital, whereas 16.4% confirmed screening as not being done and 5.5% expressed that they do not know if such screening was being done during the first visit. Forty-six (83.6%) dietitians stated single step blood glucose test with 75 g oral glucose (Diabetes in Pregnancy Study Group of India – DIPSI guideline) as the screening test used for GDM, but only 23 (41.8%) of the respondents were able to describe the threshold value taken as cutoff for diagnosis of GDM (PPBS ≥140 mg/dL). Majority of dietitians (90.9%) also reported doing maternal nutrition assessment for all GDM women visiting their respective hospitals, whereas 5.5% reported not doing and 3.6% were not responsive. However, no screening/ assessment tools specific for pregnancy were used or available in any hospitals.
The average number of GDM women seen per month was reported to be five or less by half of the surveyed dietitians, suggesting a lack of regular dietetic referrals. Only 10 out of 55 (18.2%) dietitians reported that the department of obstetrics and gynecology in their respective hospitals had specifically assigned dietitians to provide MNT for pregnant women.
Guidelines and dietetic interventions for gestational diabetes mellitus
Use of an operating guideline in the MNT for GDM was indicated by 49.1% of the respondents. However, 38.2% reported not using any operating guideline, 9.1% did not respond, and 3.6% expressed a lack of knowledge. When the dietitians were asked to specify the reference guideline used, only 20 out of 55 (36%) could do so, while more than half (63.6%) did not indicate any response, suggesting the low usage of specific reference guidelines.
Only 20 out of 55 (36.4%) dietitians described obstetricians, diabetologists and dietitians as the significant healthcare workers directly involved in managing GDM women. Information provided by the surveyed dietitians on the planning and implementation of MNT for GDM showed differences which may be due to many factors like lack of awareness among dietitians, non-availability of adequate resources for implementing evidence-based guidelines and lack of awareness and support from the management of the respective hospitals and also from other healthcare professionals involved in the treatment of GDM women. Only 9 out of 55 (16.4%) respondents specifically described a national or international guideline-based stepwise dietetic intervention. This included nutrition screening during the first visit, estimating body mass index based on pre-pregnancy weight, calculation of energy, protein and other nutrient requirements using the guidelines of Institute of Medicine, American Dietetic Association or Indian Dietetic Association, personalized diet counseling and regular follow-up of GDM women. More than half (67.3%) could only generalize the dietetic interventions practiced by them.
Forty-nine (89.1%) dietitians confirmed receiving a majority of diet consultations for GDM as referrals from doctors within their respective hospitals, and nearly the same number, 48 (85.7%) also reported individual diet consultation as the type of consultation done by them. Approximately 44% of the total respondents reported that they could provide two diet consultations per GDM woman throughout the entire period of gestation, as shown in [Figure 1]. More than three-fourths of dietitians (78.2%) also described taking 30 min to 1 h for diet consultations per GDM client.
Figure 1: Number of diet consultations per GDM woman throughout the period of pregnancyThe surveyed dietitians were also asked to specify ten major topics from a group of twenty possible topics discussed while providing diet consultations to GDM women [Figure 2]. The topics found to be less discussed were food groups (45.5%), self-monitoring of blood glucose (45.5%), review visit requirement (43.6%), salt and fluid intake (36.4%), diet during lactation (30.9%), breastfeeding (29.1%), low-calorie foods (29.1%), food label reading (27.3%) food safety (25.5%), postprandial blood glucose target level (23.6%), and use of artificial sweeteners (10.9%).
Figure 2: Major topics discussed during diet consultations for GDM womenFisher’s exact test on major topics discussed during diet consultation for GDM women based on years of clinical experience, educational qualification, and age group of the respondents showed that there was a significant association with respect to years of clinical experience and the inclusion of topics such as hypoglycemia, food groups, postnatal diet, and breastfeeding in their consultations [Table 2]. No association was observed between the other groups.
Table 2: Major topics discussed during diet consultation for GDM women and years of clinical experienceOutcomes, follow-up and evaluation for gestational diabetes mellitus
Of the total surveyed respondents, 70.9% stated assisted labor, 61.8% miscarriage or stillbirth, 49.1% polyhydramnios or oligohydramnios, and 40% prolonged labor as the commonly seen maternal problems in GDM. The fetal problems reported by more than half (87.3%) of the respondents were excessive weight gain followed by neonatal hypoglycemia (63.6%) and spontaneous abortion (50.9%). Obesity was described as the major future risk for children born to GDM mothers by 39 of 55 (70.9%) respondents. The other prominent risks suggested by the respondents were type 2 diabetes mellitus in childhood or adolescence and glucose intolerance.
Just above half (50.9%) of the surveyed dietitians reported that full compliance to dietetic advice was observed among GDM women who consulted them. Partial compliance was reported by around 40% of the participants. The possible reasons for this according to their shared experience were lack of awareness among GDM women regarding the importance of MNT in the management of GDM, inability to follow diet restrictions due to increased food cravings and appetite and lack of time management, especially among working women with GDM. Out of the total surveyed participants, 40% also reported partial compliance among GDM women for regular dietetic follow-up and evaluation after delivery. The reason for this was attributed to the blood sugar levels reverting to normal in most GDM women after delivery. Thirty (54.5%) dietitians reported nutrition evaluation being done for all children born to GDM women. The other 25 (45.45%) dietitians reported not doing nutrition evaluation. Eight dietitians also reported that nutrition evaluation of children born to GDM women was performed only upon receiving referrals from doctors or in conditions such as preterm birth, small for gestational age, large for gestational age, and hyperglycemia in the newborn.
Perception of protocol-based dietetic management
There was strong agreement among respondents for protocol-based management strategies such as multidisciplinary approach (72.7%), use of evidence-based guidelines (58.2%), development of standard operating protocols (40%), continuous training of healthcare professionals (58.2%), interdisciplinary rounds and clinical audits (38.2%), and proper documentation (78.2%) conforming to set quality standards. Almost half of the respondents (49.1%) agreed, and 32.7% strongly agreed to a protocol-based flowchart for effective planning of MNT for GDM women. When the surveyed dietitians were asked to describe the factors that influenced the need for diet consultations, 78.2% reported glycemic control as the primary factor. Their responses to other factors are illustrated in [Figure 3].
Figure 3: Factors influencing the need for diet consultations for GDM women Discussion The study attempted at understanding the perception of GDM and its dietetic interventions among dietitians. The study results reveal that more than half of the surveyed dietitians agreed that GDM is on the rise and that the incidence is more in urban than rural areas. Half of the participants strongly agreed that GDM is a risk factor for future type 2 diabetes among GDM women. They were also in strong agreement for improved management strategies like multidisciplinary approach (72.7%), use of evidence-based guidelines (58.2%), development of standard operating protocols (40%), continuous training of healthcare professionals (58.2%), interdisciplinary rounds and clinical audits (38.2%), and proper documentation (78.2%) conforming to set quality standards.
The study also helped identify some inconsistencies in the management of GDM across the surveyed hospitals. Almost one-third of dietitians were unsure of screening techniques used at their place of work. The dietitians who reported the screening as being done confirmed that a general nutrition screening tool was used for this purpose instead of a pregnancy-specific screening tool. The current screening tool used in the surveyed hospitals was also found to be inconsistent in identifying pregnant women who are at risk of developing GDM.
More than half (63.6%) of the surveyed dietitians did not specify the operating guideline used in MNT, suggesting the low usage of specific reference guidelines. The number of dietetic consultations done by a dietitian per month and the number of dietetic consultations given per client indicated the lack of regular referrals to dietitians. This is contrary to the national and international guidelines, which emphasize MNT as one of the primary interventions required in the treatment and management of GDM.[16],[17] This implies that not all pregnant women visiting the surveyed hospitals get access to proper dietetic advice on GDM. Proper MNT for GDM has proved in many studies as being beneficial in improving maternal and fetal outcomes.[18],[19],[20]
The diet consultations done by dietitians were found to be covering a large number of topics, but topics like gestational weight gain pattern, self-monitoring of blood glucose, setting target levels for postprandial blood glucose, and the need for review visits were found to be less discussed. These interventions have been reported to serve as effective strategies in attaining good glycemic control in GDM women, thereby maintaining maternal and fetal health.[21],[22]
Limitations
The study had a small sample size and it was conducted in one geographical region of the country. Results cannot be thus generalized for the entire county. Further large multicentric countrywide research may be taken up to understand the existing dietetic practices for GDM all over India. This would help to arrive at more concrete conclusions and facilitate the development of sustainable protocols for improved dietetic management of GDM.
ConclusionThe study strongly recommends the need for a pregnancy-specific nutrition screening tool to identify those at risk of GDM. It also suggests ensuring systematic referrals to the dietitian for MNT of GDM women and educating and training dietitians in adopting evidence-based national or international guidelines for providing uniform, optimal and consistent care for all pregnant women for the prevention and management of GDM.
Acknowledgement
The authors express their gratitude toward the hospitals and private clinics in Kochi city, Kerala for granting the permission to conduct the study. The authors wish to thank all the dietitians whose participation made this study possible. The authors would also like to thank Dr. V. Mohan, Dr. I. Ranjit Unnikrishnan, and Dr. B. Bhavadharini of Madras Diabetes Research Foundation, Chennai for providing the resources for survey tool development.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest
References
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