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Diabetes is one of the most prevalent diseases worldwide with an increasing mortality and morbidity rates globally which imposes a major public health concern. With the onset of heavy urbanisation associated with unhealthy lifestyles, maternal and foetal malnutrition, high-caloric and fat diets and limited exercise the prevalence of diabetes is increasing alarming (Ali & Hussain, 2016). According to the Australian Institute of Health and Welfare (2018) an estimated 1.2 million Australian adults had some form of diabetes. There are three major types of diabetes mellitus, type 1, type 2 and gestational (GDM). GDM is a defined as a glucose intolerance during pregnancy that affects 14% of women in Australia (Diabetes Australia, 2015; Damm et al., 2016). The development of GDM in pregnancy is associated with infant birth weight and long-term risks of type two diabetes in the mother (Wahlberg et al., 2016). The importance of screening and diagnoses of GDM along with regular treatment such as healthy eating and regular exercise can improve mother and infant’s health outcomes. The aim of this report is to give the background information to propose a brochure for women whom are at risk or have GDM to inform and educate about GDM and the management of GDM to empower pregnant women to have autonomy over their own health.
The prevalence of GDM has increased significantly by 30% globally in the last two decades and is due to increase as the epidemic of obesity continues (Zhu & Zhang, 2016; Ulla et al., 2015). In 2017, 21.3 million live births had some form of hyperglycaemia in pregnancy where an estimated 85.1% were due to GDM (Monir, Rahman & Monir, 2018). Due to the ethnicity and development of country all pregnancies that are affected by GDM can range from <1.0% in Germany to 28.0% in Nepal (Monir, Rahman & Monir, 2018; Jiwani et al., 2011). The introduction of urbanisation in developing countries that has led to increase in unhealthy eating behaviours and sedentary lifestyles the prevalence of GDM has increased globally with the prevalence of type two diabetes and obesity (Ali & Hussain, 2016; Erem et al., 2015).
GDM has become the highest rising type of diabetes diagnosed in Australia. In Australia, GDM affects around 10% of pregnancies however can occur up to 30% in high-risk populations. The increase prevalence of diabetes in Australia is due to women entering pregnancy at an older age and are more likely to be overweight or obese or from a high-risk ethnic background such as Aboriginal and Torres Strait Islander women (Nankervis, Price & Conn, 2018). Aboriginal and Torres Strait Islanders are 2.5 times higher than of non-Aboriginal Australians to be diagnosed with GDM women (Nankervis, Price & Conn, 2018).
Understanding Gestational Diabetes Mellitus
GDM is a form of diabetes that is a glucose intolerance resulting in hyperglycaemia onset or first recognition during pregnancy. GDM is often not diagnosed til the second or third trimester of pregnancy. GDM develops around the 24th to the 28th week of gestation, however some women may develop it earlier. Women whom are diagnosed in the first trimester are classified of having pre-existing diabetes (Buchanan et al., 2007; Jeffery et al., 2018). There is clinical detection of GDM; clinical risk assessment, formal glucose testing and glucose tolerance screening. After diagnosis women to adopt lifestyle changes or may need medication to control GDM (Buchanan et al., 2007).
Who is at risk?
There are many factors that can increase a women’s risk of developing GDM during pregnancy. Women that are older than thirty years of age are four times more likely to develop GDM than women of a younger age (Shirazian et al., 2009; Zhu & Zhang, 2016). Another major risk factor is ethnicity, women from Aboriginal and Torres Strait Islander, Melanesian, Chinese, Southeast Asia and Middle East background are more likely to develop GDM. Pregnancy is a major stressor that can cause increased insulin resistance, lipoprotein changes and fluid retention which can lead to an increased risk of GDM that are genetically susceptible (Catov & Kuller, 2017). Other strong risk factors include, pregnancy adiposity, family history of diabetes unhealthy and sedentary lifestyle, obesity, excessive weight gain during pregnancy and socioeconomic determinants (Ning & Zhang 2011; Zhang & Zhu, 2016).
Consequences of Gestational Diabetes
GDM affects both the mother and baby during pregnancy and in the long-term. If GDM is left untreated and diagnosis, there can be lifelong consequences for mother and foetus. Women with GDM are at increased risk of pre-eclampsia, hypertension, macrosomia, induction of labour, premature delivery and caesarean section (Nankervis, Price & Conn, 2018; Kampmann, 2015). In the long term, women with GDM have a greater increased risk of developing type 2 diabetes mellitus. The cumulative risk of type two diabetes mellitus is 25.8% at fifteen years post pregnancy in moderate to risk population and 70% in elevated risk population, which is the strongest predicator of type two diabetes (Nankervis, Price & Conn, 2018; Kampmann, 2015). If left untreated women with GDM also have a long-term risk of developing metabolic syndrome, cardiovascular morbidly, ophthalmic, malignancies and renal disease (Farahvar, Sheiner & Walfisch, 2018). The potential adverse effects of GDM on a foetus can include macrosomia, foetal death, nerve palsy, respiratory distress, hypoglycaemia and shoulder dystocia (Nankervis, Price & Conn, 2018). Exposure to hypoglycaemia and mediated by epigenetic mechanisms in the womb, the foetus’s long-term effects can relate to an inclination to being overweight or obesity, type 2 diabetes, insulin sensitivity, dysglyceamia, hypertension and dyslipidaemia. The metabolic changes can occur in the pre-school years and are well recognized in adolescence in more than 50% of whose mothers had GDM (Nankervis, Price & Conn, 2018). However, with treatment and diagnosis can prevent long-term metabolic changes in offspring (Damm et al., 2016).
Impacts of Gestational Diabetes on the Wider Community
There are social, financial and health impacts on the health and vitality among the community that is impacted by GDM. GDM causes great costs to the health system with the total cost to manage GDM with medical costs, pharmaceuticals, and allied health services with an estimated $163.9 million in Queensland respectively (Cardona, Coyne, McClintock & Mulle, 2002). Persons with diabetes are 38.4% more likely to visit a general partitioner in the past two weeks than those without diabetes (21.4%). Thus, GDM and diabetes on the whole is a great burden to Australian health care systems. In addition to health costs, diabetes contributes to loss of life and loss of productivity in the community. In Queensland adults aged 20-29 years were four times more likely to reported days of reduced activity than those without diabetes (Cardona, Coyne, McClintock & Mulle, 2002).
For the management of GDM lifestyle management such as dietary and physical activity interventions are the most effective to help prevent or reduce GDM. Other management interventions can include pharmacologic therapy, Sulfonylureas, insulin, metformin and managing appropriate weight gain during pregnancy (American Diabetes Association, 2017; Brown et al., 2015).
The primary management of GDM is changing dietary behaviours. A diet that is carbohydrate-controlled that provides adequate nutrition alongside with glycaemic control and avoids ketonuria is the optimal diet to reduce complications associated with GDM. Other elements such as fibre and fat are also important to be controlled to regulate glucose concentration (Brown et al., 2015; Dornhorst, 2002). Therefore, women whom have or at risk of GDM should spread carbohydrate foods over three small meals and into two to three snacks each day to manage glucose levels and maintain weight gain. Women whom are at elevated risk of GDM should also have foods that are high in fibre and avoid food and drinks that contain substantial amounts of sugar (Brown et al. 2015; Diabetes Australia, 2015). Dietary advice in second trimester can help reduce the risk of adverse health outcomes for women and foetus (Brown et al., 2015; Dornhorst 2002).
Lastly, another primary management of GDM is increase physical activity in women with GDM. The role of physical activity interventions may help improve the insulin sensitivity and glucose control in persons with GDM (Asano 2014; Brown et al., 2015).
The primary intervention strategy implemented in the brochure is to improve and educate women whom are at risk or have GDM to change or modify their diet in order to improve health outcomes. The intervention includes carbohydrate, fat and sugar control and ways women can do this. Also implemented in the brochure is the importance of women to maintain or increase by a little their physical activity to improve insulin resistance. Therefore, lifestyle changes are the most effective way to improve health outcomes for mother and foetus that are associated with GDM.
Gestational Diabetes Mellitus can have major long-term and adverse health outcomes for mother and infant. GDM can lead to the progression of type 2 diabetes for the mother and obesity, overweight and type 2 diabetes in the infant that progresses later on in life. GDM also has major health impacts on the wider community with high cost of health care, production and production lost to diabetes. Therefore, the need for lifestyle management in the prevention and management of GDM is important to alleviated adverse and long-term health outcomes for women and infants affected by GDM.
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