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ORIGINAL ARTICLE
Year : 2022 | Volume
: 8
| Issue : 4 | Page : 205-212
Nutritional assessment of birth outcomes of gestational diabetic mothers in Gaza Strip, Palestine: A retrospective case-control study
Ihab A Naser1, Mona R Shaat2, Mahmmoud H Taleb2, Ahmed A Najim3
1 Department of Clinical Nutrition, Al Azhar University-Gaza, Gaza, Palestine
2 Department of Pharmacology and Medical Sciences, Faculty of Pharmacy, Al Azhar University-Gaza, Palestine
3 Nursing Department, Faculty of Applied Medical Sciences, Al Azhar University-Gaza, Gaza, Palestine
Correspondence Address:
Dr. Ihab A Naser
Department of Clinical Nutrition, Al Azhar University-Gaza, Gaza
Palestine
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijam.ijam_153_21
Introduction: Gestational diabetes mellitus (GDM) is the most prevalent metabolic disorder during pregnancy. Numerous studies have dealt with risk factors of GDM, while others studied the health complications associated with GDM. This study aimed to investigate the association between GDM and nutritional birth outcomes in Gaza Strip, Palestine.
Materials and Methods: The study utilized the case−control design where 44 GDM mothers and 44 non-GDM mothers were recruited. The study was conducted at the obstetric departments at Al-Shifa Maternity Hospital in Gaza and Mubarak Maternity Hospital in Khan Yunis. Data collection included anthropometric measurement and hematological indicators and other pertinent information through a structured questionnaire.
Results: The result reported that the mean age of GDM pregnant women and non-GDM was 31 ± 11.5 and 23 ± 6.75 years, respectively. 13.6% had anemia, 20.5% had previous delivery of macrosomic baby, 15.9% had hypertension, and 11.4% were obese. In addition, 63.6% of GDM mothers had a family history of diabetes and 18.2% had a family history of GDM. 43.2% of GDM mothers delivered by cesarean section (CS) and 13.6% of GDM mothers had a premature delivery. Assessment of dietary intake indicated that 40.9% of GDM mothers have breakfast regularly. The neonatal median birth weight was 3.22 kg for babies of GDM mothers and 3.30 kg for babies of non-GDM mothers, and the median length was 52 cm versus 50 cm; 6.8% of neonates of GDM mothers had low Apgar score. Neonates of GDM mothers expressed significantly lower blood sugar (P = 0.039), lower albumin (P = 0.037), and higher soluble surface receptors – surface transferrin receptor (P = 0.017), but there were no statistically significant differences in the other hematological parameters.
Conclusion: The study reflected a significant association between GDM and lower blood glucose, serum albumin, and iron status. Furthermore, the study reflected a significant association between GDM and CS delivery and neonatal hypoglycemia. The study emphasized the need to integrate clinical nutrition services in maternity departments and antenatal clinics and encourage physical activities during pregnancy.
The following core competencies are addressed in this article: Patient care and procedural skills, Medical knowledge.
Keywords: Gaza, gestational diabetes mellitus, nutritional assessment, pregnancy outcome
Gestational diabetes mellitus (GDM) is the most prevalent metabolic disorder during pregnancy.[1] It occurs in women whose pancreatic β-cell functions are insufficient to overcome insulin resistance due to the secretion of diabetogenic hormones by the placenta.[2] When the level of insulin is low, or the body cannot effectively use insulin (insulin resistance), blood glucose levels rise.[3] Available evidence suggests that β-cell defects in GDM result from the same spectrum of causes that underlie hyperglycemia in general, including autoimmune disease, monogenic causes, and insulin resistance.[4] GDM is a challenging health problem globally as it affects an estimated 15% of pregnant women, and 87.6% of these women are in low- and middle-income countries.[5] In addition, GDM is estimated to be 14%,[6] ranging from 8.4% to 24.5% in the Middle East.[7] In Gaza Strip (GS), the prevalence of GDM is estimated to be 1.8%.[8]
Several studies indicate that different risk factors are associated with GDM, including advanced age of 35 years and more, overweight and obesity, excessive weight gain during pregnancy, excessive central body fat deposition, family history of diabetes, the short stature of <1.50 m, excessive fetal growth, polyhydramnios, hypertension or preeclampsia, history of recurrent miscarriage, offspring malformation, fetal or neonatal death, macrosomia, GDM during prior pregnancies, and polycystic ovary syndrome. In addition to the most common factors, a sedentary lifestyle may also be a risk factor for GDM.[9]
GDM affects the mother and her baby, as both have a risk of developing undesirable outcomes.[10] The associated complications of pregnant women with GDM include preeclampsia, gestational hypertension, urinary tract infection, and cesarean delivery.[11] Regarding newborns, GDM increases the chance of macrosomia, fetal distress, metabolic disorders, and hyperbilirubinemia. These unwanted consequences are related to the onset and duration of glucose intolerance, as well as the severity of GDM.[12] Therefore, to minimize the GDM complications, it is necessary to be diagnosed and treated early. According to the researcher's knowledge, no previous studies assessed the nutritional disorders of neonates of GDM in GS. This study aimed to (1) identify the risk factor for GDM and (2) investigate the association between GDM and nutritional birth outcomes.
MethodsThis case−control study enrolled all mothers diagnosed with GDM, between the ages of 20 and 40, pregnant with a singleton, and who attended the department of obstetrics at Al-Shifa Maternity Hospital in Gaza and Mubarak Maternity Hospital in Khan Yunis, GS, for delivery between March 2020 and August 2020.
Those excluded from the study included mothers who were diagnosed prior to pregnancy with either Type 1 or Type 2 diabetes, twins or multi-pregnancies, mothers who need planned corticosteroid therapy and planned beta-adrenergic therapy, mothers having asthma requiring medication, and chronic medical illnesses such as kidney disease or heart disease, and mothers having hematological and autoimmune disorders such as hemoglobin (Hb) opathies or lupus erythematosus were excluded from the study. The study was approved by the Helsinki Committee (PHRC/HC/463/18), the Deanship of the Faculty of Pharmacy, Graduate Studies at Al Azhar University-Gaza.
In this study, the sample size was calculated by using Power Statistics and sample size software. The number of participants included 44 GDM mothers (case group) selected using the convenience sampling method and 44 non-GDM mothers (control group).
The questionnaire consists of the socioeconomic and demographic characteristics of the participants and their medical history and dietary intake. The dietary intake information of 110 food items was obtained for both cases and controls through a validated food frequency questionnaire (FFQ). The FFQ that has been used in this study was derived from the National Institute of Health in the United States and translated into the Arabic language. [13],[14]
The results of the Apgar score were taken as measured in the first 5 min of birth by a midwife, and measurements were recorded in the questionnaire for each neonate. Anthropometric measurements of neonates include weight, length, and head circumference. A body meter (SECA, Germany) was used for measuring the weight of neonates; recumbent length was measured using an infantometer with a fixed headpiece and horizontal backboard and an adjustable foot piece.[15],[16] Measurements of weight, length, and head circumference were repeated twice and the average was recorded for the subsequent analysis.
The following biochemical tests were done for all neonates of GDM and non-GDM mothers: serum albumin, complete blood count, Vitamin D, surface transferrin receptor (STfR), serum calcium, magnesium, and blood sugar. This was achieved with the assistance of a nursing team specialized in drawing blood samples from newborns within the 1st h of birth; then, these samples were taken immediately to a laboratory specialized in the medical analysis.
The data were entered into the computer using the Statistical Package for the Social Sciences (SPSS version 25). Data analysis was divided into two parts: descriptive statistics and analysis of variance. The categorical data are represented in the form of proportions (%) and of means with standard deviations. All measurements and indicators of the two groups were compared using an independent t-test (for parametric data) or Mann–Whitney U-test for two-independent (for nonparametric data). None of the recruited participants was removed from the entire database and no missing data were observed.
ResultsThe results of this study regarding the socioeconomic and demographic characteristics of respondents presented in [Table 1] showed that there are no significant differences in the proportion between the two groups with respect to the educational level of the spouses. It is worth mentioning that the majority of the mothers in both the groups were unemployed and half of the husbands (50%) of non-GDM were unemployed, while 57% of husbands of the GDM group were unemployed, but these differences were statistically nonsignificant.
Table 1: Comparison of sociodemographic and socioeconomic characteristics between the groupsThe results in [Table 2] show that there are statistically significant associations between the occurrence of GDM and the number of previous pregnancies and previous spontaneous abortions (P = 0.045 and P = 0.014, respectively). However, there is no statistical significance regarding the total number of births, number of previous live births, number of previous fetal deaths, reproduction age, number of cesareans, and history of previous macrosomic babies between the cases and the controls. The majority of GDM mothers (79.5%) and non-GDM mothers (90.9%) have not had a previous cesarean delivery and the difference in proportions between the two groups is nonsignificant. There are no statistically significant differences between the GDM mothers and the non-GDM mothers regarding hemorrhage after delivery, anemia during pregnancy, or previous premature baby. Although there is no statistically significant association between the incidence of delivery of macrosomic babies and the occurrence of GDM, the incidence of premature delivery of macrosomic babies in GDM mothers was higher than in non-GDM mothers. Out of 44 cases, 7 GDM mothers had previous gestational hypertension in their pregnancies while none of the 44 participants in the control groups had previous gestational hypertension in their pregnancies (P = 0.012). In addition, the study indicated that the mean pre-pregnancy weight of the GDM mother was higher than that of the non-GDM (P = 0.001).
Out of 44 GDM mothers, 8 cases had swelling of the legs during pregnancy. In contrast, none of the non-GDM mothers had any leg swelling during their pregnancies (P = 0.006). The results also show that 63.6% of GDM mothers had a family history of diabetes, but only 6.8% of non-GDM mothers had a family history of diabetes (P = 0.001). There are statistically significant associations between the occurrence of GDM in the present pregnancy and the incidence of GDM in previous pregnancies, as illustrated in [Table 2] (P = 0.045). Although the medians of the number of abortions were the same in both the groups, the mean of the number of abortions was in the favor of the GDM group and the difference was statistically significant (P = 0.014).
[Table 3] shows that there were statistical differences between the GDM mothers and the non-GDM mothers regarding the blood sugar at the beginning, mid, and end of pregnancy (P = 0.001, P = 0.001, and P = 0.001, respectively).
Table 3: Differences in blood sugar levels during different periods of pregnancy between groups[Table 4] represents the anthropometric characteristics of child−mother pairs for both the case and control groups. There is a significant difference in means between GDM mothers and non-GDM mothers in their weights before, in the middle, at the end of pregnancy, and in their body mass index (BMI) (P = 0.001, P = 0.001, P = 0.001, and P = 0.001, respectively). There was no statistically significant association between GDM and the mother's height, baby weight, baby length, baby head circumference, and baby chest circumference.
Table 4: Comparison of anthropometric measurements for mother–child pairs between groupsThe results show that the majority of both GDM mothers' babies (93.2%) and non-GDM mothers' babies (100.0%) had a normal Apgar score; the differences in the proportion were not statistically significant. There was no statistically significant association between maternal GDM and the infant's breathing, breathing disorders, and jaundice. [Table 5] shows that there was no statistical difference between the groups regarding the baby's gender and the gestational age (preterm/at term/post-term). The majority of the non-GDM mothers (93.2%) had normal delivery, but only 56.8% of GDM mothers had normal delivery and the remaining deliveries (43.2%) were cesarean, with the difference in proportions between the groups being statistically significant (P = 0.001).
[Table 6] shows that there were significant statistical differences between the two groups regarding blood sugar, albumin, platelet (PLT), and Soluble Transferrin Receptor (sTfR) where the P values were 0.039, 0.037, 0.001, and 0.017, respectively) There were no statistically significant differences between the two groups regarding hematocrit, red blood cells, Hb, white blood cell, Vitamin D, and magnesium.
DiscussionThis study was conducted to investigate the association between GDM and nutritional birth outcomes. Recently, a number of studies discussed the many risks of GDM for both mothers and neonates. The current results showed that GDM adversely affects the birth outcomes and the nutrition status of the baby.
In this study, a significant association between GDM and the age of the mother was observed; this observation does not match the findings of a retrospective case−control study to determine the associated factors of GDM among healthy Chinese pregnant women.[17] However, our finding was consistent with previous classical studies that considered the advanced age of more than 35 years of the mother as one of the major risk factors for developing GDM.[18],[19] Our study reinforced the findings of the previous studies and indicated pregnancy is better planned before the age of 35 years, and the GDM screening strategies should be improved for older pregnant women. Our results indicated no significant associations between maternal educational level, paternal educational level, mother job status, father job status, total family income, and external aid with risk of developing GDM. A case−control study in Turin, Italy, reported that lower levels of education are associated with an increased risk of GDM.[20] Our findings were not congruent with previous reports where the association between the educational level of the mother and the occurrence of GDM was reported.[22],[23] The nonsignificant results are consistent with the previous report from the USA[21] and can be explained by the fact that most Palestinians, and especially females, are higher education degree holders. Family income was not related to the risk of developing GDM, and this can be attributed to the waves of poverty and food insecurity striking the vast majority of the people in the GS.
Regarding the obstetrical history of groups, our study revealed that there were no statistically significant associations between the number of births, live births, deaths, reproduction age, previous number of cesareans, women with a history of macrosomic baby delivery, and the development of GDM. Our findings were not consistent with a study conducted in India which revealed that 40% of patients with GDM had undergone previous cesarean section (CS). The linkage between the number of pregnancies, the stress on beta-cells, and insulin resistance is well established.[24]
In our study, we observed that there was a significant association between developing GDM and these variables: swelling of legs during pregnancy, family history of diabetes, GDM in a previous pregnancy, and presence of chronic diseases. Our finding is congruent with the Korean study that concluded that GDM women in Korea are at high risk of diabetes.[25] Our results show that there is a statistically significant difference between cases and controls regarding family history of diabetes mellitus (P = 0.001). Women with a family history of diabetes make them more susceptible for developing GDM, which suggests that genes play a role. Family history of GDM is also statistically significant (P = 0.03) where the cases have a higher family history of GDM as a risk factor for the development of GDM in cases compared to the controls. The results are consistent with a study performed in Egypt.[26]
Our results showed that the mother's BMI was significantly higher in cases compared to controls (P < 0.001). Several studies reported that the main associated factors for GDM are obesity and increased BMI,[27],[28] and our results agree with these findings. The blood sugar level was higher in GDM mothers than in non-GDM mothers in all periods of pregnancy. Although there are a percentage of mothers with gestational diabetes who used insulin as a hypoglycemic drug, there are differences in mean readings between the two groups. These results were consistent with other studies that indicated similar results. The results obtained by Seabra et al.[29] found that the mean fasting glucose levels of the women who had GDM were higher in the second and third trimesters than for those who had no pregnancy complications. Regarding the mode of delivery, our finding confirmed that the majority of non-GDM mothers (93.2%) had a normal delivery, but around (56.8%) of GDM mothers had a normal delivery and the remained proportion (43.2%) of GDM had CS delivery and this difference between the two groups was significant (P = 0.001). Our result matches the result of an American study which found that CS delivery was more common in GDM (35.3% vs. 22%, P < 0.01).[30] Infants born by CS may have less time for hormonal transitions to occur than infants who are delivered after labor. In addition, postnatal measures to prevent neonatal hypoglycemia such as skin-to-skin and early feeding postbirth are challenging to initiate in the operating room setting.
In our study, babies of GDM mothers were mildly more hypoglycemic than babies of non-GDM mothers, which was consistent with previous studies.[31],[32] The occurrence of neonatal hypoglycemia is explained by the over production of insulin by the fetus in response to the mother's high blood glucose. Insulin lowers the amount of sugar in the blood.[33] It has been noticed that the levels of both albumin and PLT among infants with GDM were statistically less than those of non-GDM (P = 0.037, P = 0.001, respectively).
Measurement of serum STfR concentration is now regarded as a valuable tool in diagnosing iron deficiency and monitoring erythropoiesis. The STfR concentration begins to increase in early iron deficiency with the onset of iron-deficient erythropoiesis before anemia develops. Iron deficiency also may occur earlier in life, during the fetal period, in infants of diabetic mothers (IDMs). When severe, fetal iron deficiency has been associated with a 40% reduction in brain iron concentration in the human IDM.[34]
Limitations
This study has several limitations. First, this was a two-center study, so the number of participants was small. Larger studies are recommended to confirm our results. Second, the lack of local studies and difficulty in identifying and following up on GDM mothers according to eligibility criteria made the sample size more restricted. Finally, financial constraints and expensive costs of biochemical tests hindered the performance of other glycemic markers such as glycated albumin and C-peptide.
ConclusionAssessment of family history reflected that about two-thirds of GDM mothers had a family history of diabetes and 18.2% had a family history of GDM. No differences were noted between the two groups in terms of anthropometric measurements, while 6.8% of neonates of GDM mothers had low Apgar scores. Assessment of biochemical indicators indicated that neonates of GDM mothers had significantly lower blood sugar, lower albumin, and low iron status as indicated by serum transferrin receptor, but no important difference was reported regarding the magnesium and Vitamin D between the two groups.
Acknowledgments
We are using this opportunity to express our gratitude to all of the participants in this study and to the Palestinian Ministry of Health, which gave the permission to conduct this study in the affiliated hospitals.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Research quality and ethics statement
The authors declare that they followed applicable EQUATOR Network (http://www.equator-network.org/) research reporting guidelines. Ethics approval and consent to participate: Written informed consent was obtained from the pregnant mothers before enrollment. The Helsinki Ethics Committee in GS approved the study. Furthermore, an approval letter to conduct the study was obtained from the Palestinian Ministry of Health.
References
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