Annotated Bibliography

Karina Almanza karina.almanza.249@my.csun.edu

1. Houshmand, A., Jensen, D., Mathiesen, E., & Damm, P. (2013). Evolution of diagnostic criteria
for gestational diabetes mellitus. Acta Obstetricia Et Gynecologica Scandinavica, 92(7), 739-745.

This study consists of randomized control trials that analyze different procedures taken when

diagnosing gestational diabetes including different dosages of glucose tolerance testing, different

definitions and classifications. It was discovered that when gestational diabetes is managed properly,

there is an overall lower birth weight when compared to infants with uncontrolled gestational diabetes.

Proper management is dependent on the facility of which the patient is being served. There were benefits

for each individual with gestational diabetes in the usage of O’Sullivan and Mahan’s cut-off values, WHO

criteria, Australia's version of WHO and some components of IADSPG, which will be the first

international guidelines testing, diagnosing and treating hyperglycemia.

This relates to our topic in further analyzing different approaches in appropriate gestational

diabetes management outside the general responsibilities of the Registered Dietitian and Physician. This

article was found within the official international journal of the Nordic Federation of Societies of

Obstetrics and Gynecology, which is published monthly. Furthermore, this series is dedicated to

providing the very latest information on the results of both clinical and research work from around the

globe. A possible weakness for this study could be that the article itself does not specify the particular

importance and role of the Registered Dietitian and the Physician when providing proper gestational

diabetes education and management although it does propose alternative options to coping with

gestational diabetes, outside the scope of a Registered Dietitian or Physician.

- http://onlinelibrary.wiley.com.libproxy.csun.edu/doi/10.1111/aogs.12152/epdf
 A C TA Obstetricia et Gynecologica

AOGS A CT A C O M M EN T A RY

Evolution of diagnostic criteria for gestational diabetes

mellitus
AZADEH HOUSHMAND1,2, DORTE MØLLER JENSEN3,4, ELISABETH R. MATHIESEN1,5,6 &
PETER DAMM1,2,6
1
Center for Pregnant Women with Diabetes, Rigshospitalet University Hospital, Copenhagen, 2Department of Obstetrics,
Rigshospitalet University Hospital, Copenhagen, 3Department of Endocrinology, Odense University Hospital, Odense,
4
Faculty of Health Science, University of Southern Denmark, Odense, 5Department of Endocrinology, Rigshospitalet
University Hospital, Copenhagen, and 6Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark

Key words Abstract

Gestational diabetes mellitus, diagnostic
criteria, perinatal morbidity, perinatal
mortality, oral glucose tolerance test
Correspondence
Peter Damm, Center for Pregnant Women
with Diabetes, Department of Obstetrics
4031, Rigshospitalet, Blegdamsvej 9, 2100
Copenhagen Ø, Denmark.
E-mail: pdamm@dadlnet.dk
Conflict of interest
All the authors have stated explicitly that
there are no conflicts of interest in
connection with this article.
Please cite this article as: Houshmand A,
Jensen DM, Mathiesen ER, Damm P.
Evolution of diagnostic criteria for gestational
diabetes mellitus. Acta Obstet Gynecol Scand
2013; 92:739–745.
Received: 28 January 2013
Accepted: 12 April 2013
The establishment of universal diagnostic guidelines for gestational diabetes
mellitus has been a long time coming. The lack of consensus and uniformity in
procedures for diagnosing this disease has been a problem ever since its exis-
tence was recognized. The USA, European countries, and Australia have each
developed their own guidelines through the years, all based either on the
maternal risk of subsequent diabetes, on arbitrary statistics, or on studies con-
ducted on non-pregnant women. None of these guidelines have been based on
risk for perinatal complications. Recently, the Hyperglycemia and Adverse
Pregnancy Outcomes study demonstrated that maternal hyperglycemia is asso-
ciated with perinatal risk in a linear way with no obvious threshold. The Inter-
national Association of Diabetes and Pregnancy Study Group has translated
these results into clinical practice by proposing new diagnostic criteria for ges-
tational diabetes mellitus, based for the first time on perinatal outcome.
Abbreviations: EASD, European Association for the Study of Diabetes; GDM,
gestational diabetes mellitus; HAPO, Hyperglycemia and Adverse Pregnancy
Outcomes; IADPSG, International Association of Diabetes and Pregnancy
Study Groups; IGT, impaired glucose tolerance; NDDG, National Diabetes
Data Group; OGTT, oral glucose tolerance test; SD, standard deviations;
WHO, World Health Organization.

DOI: 10.1111/aogs.12152

Lack of consensus and uniformity for the diagnosis of

GDM has been a problem ever since the existence of
GDM was recognized. The purpose of this article is to
Introduction
give an overview of the most commonly used diagnostic
Gestational diabetes mellitus (GDM) is defined as carbo-
hydrate intolerance resulting in hyperglycemia, with onset
or first recognition during pregnancy (1). This definition
includes women with undiagnosed pregestational diabetes, Key Message
and those who develop glucose intolerance/diabetes dur- The backgrounds for the most commonly used crite-
ing their pregnancy. The definition applies regardless of ria for gestational diabetes are described thoroughly
whether or not insulin is used for treatment or if the together with the new, outcome-based criteria pro-
condition persists after pregnancy. It includes the possi- posed by the International Association of Diabetes
bility that unrecognized glucose intolerance may have and Pregnancy Study Group.
antedated pregnancy (2).

ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 92 (2013) 739–745 739
 2. Lega, Mclaughlin, Coroneos, Handley-Derry, Donovan, & Lipscombe. (2012). A physician
reminder to improve postpartum diabetes screening in women with gestational diabetes mellitus.
Diabetes Research and Clinical Practice, 95(3), 352-357.

This article focuses on evaluating the role of the physician as a reminder system. The Physician is

then assessed in effectiveness in improvement of postpartum screening rates of mothers diagnosed with

gestational diabetes. This article is unique in the sense that the physician takes the role of a reminder

system in this experiment rather than another clinical staff doing so.

Author, Iliana C.Lega currently works at the Women's College Research Institute in Toronto,

Ontario, Canada focusing her research on women’s health and wellness. In further supporting our

research and proposed in identifying the role of the physician in a clinical setting with gestational diabetes

management, a possible weakness from this article is the perception of the physician in a clinical setting

might vary from what is perceived my local hospitals (not as a reminder system). This article furthermore

concludes that physicians play an effective role when dealing with blood glucose management in

gestational diabetes. It is concluded that a multilevel approach targeting both mothers and physicians

should be incorporated for best results. This article weakens the role of the registered dietitian for our

hypothesis, although there was no mention of the role a dietitian can provide in this scenario as efficiently

or better.

- http://www.sciencedirect.com.libproxy.csun.edu/science/article/pii/S0168822711005663
 diabetes research and clinical practice 95 (2012) 352–357

Contents available at Sciverse ScienceDirect

Diabetes Research
and Clinical Practice
jou rnal hom ep ag e: w ww.e l s e v i er . c om/ loca te / d i ab r es

A physician reminder to improve postpartum diabetes

screening in women with gestational diabetes mellitus

Iliana C. Lega a,*, Heather McLaughlin a,b, Marie Coroneos a,c,

Frances Handley-Derry a,d, Nicola Donovan a, Lorraine L. Lipscombe a,e
a
Women’s College Hospital, Women’s College Research Institute, Toronto, Ontario, Canada
b
University of Western Ontario, London, Ontario, Canada
c
McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
d
McGill University, Faculty of Arts and Sciences, Montreal, Quebec, Canada
e
University of Toronto, Department of Medicine, Toronto, Ontario, Canada

article info abstract

Article history: Aims: Women with gestational diabetes (GDM) have a 20% risk of developing diabetes in
Received 10 June 2011 the 10 years following pregnancy, but the risk may be as high as 70% in higher risk
Received in revised form populations. Guidelines recommend screening for diabetes postpartum, but screening
29 September 2011 rates are low. We evaluated the effect of a physician reminder on postpartum screening
Accepted 17 October 2011 and in women with GDM.
Published on line 17 November 2011 Methods: We conducted a retrospective chart review among women with GDM seen at our
urban, academic endocrine clinic in Toronto, Canada between 2006 and 2010. Our primary
Keywords: outcome was to evaluate the effect of a reminder checklist on postpartum diabetes
Gestational diabetes screening rates.
Reminder system Results: We included 314 women in our study, 173 had a checklist on their chart. Women had a
Prevention mean age of 34.9 years, 45% were Caucasian and 23% had a previous GDM. The checklist was
Screening associated with a 3 fold increase in odds of being screened postpartum, and nearly 4 fold
increase in postpartum follow up visits (OR 2.99, 95% CI 1.84–4.85 and OR 3.71, 95% CI 2.26–6.11).
Conclusion: A physician based reminder system is an effective way to improve postpartum
screening rates. To further increase screening rates, a multilevel approach targeting both
patients and physicians is required.
# 2011 Elsevier Ireland Ltd. All rights reserved.

diabetes can be prevented in this population through lifestyle

1. Introduction
Gestational diabetes mellitus (GDM), glucose intolerance first
diagnosed in pregnancy, is a strong predictor of future type 2
diabetes in women. Women with GDM have a 20% chance of
developing type 2 diabetes in the first decade following
pregnancy though the risk can be as high as 70% in higher
risk populations [1,2]. There is increasing evidence that
and pharmacologic interventions, making it critical to identify
women with ongoing glucose abnormalities postpartum [3].
Many national and international societies have instituted
guidelines for postpartum diabetes screening for women with
GDM. In Canada, both the Society of Obstetrics and Gynecol-
ogists of Canada (SOGC) and the Canadian Diabetes Associa-
tion (CDA) recommend a 75 g oral glucose tolerance test
(OGTT) between 6 weeks and 6 months postpartum [4,5].

* Corresponding author at: 790 Bay St, Rm 704, Toronto, Ontario M5G1N8, Canada. Tel.: +1 416 351 3732x2532; fax: +1 416 351 4746.
E-mail address: iliana.lega@wchospital.ca (I.C. Lega).
0168-8227/$ – see front matter # 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.diabres.2011.10.023
 3. Juan Gui, Qing Liu, & Ling Feng. (2013). Metformin vs insulin in the management of gestational
diabetes: A meta-analysis. PLoS ONE, 8(5), E64585.

This experiment investigated the use of insulin and metformin when coping with gestational

diabetes. This article could further show the correlation of absence of Registered Dietitian in

supplementation of nutrition education and preferences with medication usage such as insulin or

metformin during pregnancy. This article provides the unique position that while the role of the Physician

or Registered Dietitian can be beneficial in diabetes management, there are still outside factors that can

contribute to the conclusive findings of our research.

Juan Gui locates his work of practice at the Department of Obstetrics and Gynecology in Tongji

Hospital, Tongji Medical College, Huazhong University of Science and Technology, China. His work

focuses on women’s health, obstetrics and gynecology. The conclusive findings of this article were that

when metformin is used as a form of gestational diabetes management, birth weights of infants were born

lower than usual. Recognizing that lower birth weights are seen in metformin usage, this article could

support the position of outside factors hindering both roles of the Physician and the Registered Dietitian;

weakening our proposed hypothesis and acting as an outside factor.

- http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC3664585&blobtype=pdf
Metformin vs Insulin in the Management of Gestational
Diabetes: A Meta-Analysis
Juan Gui, Qing Liu, Ling Feng*
Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China

Abstract
Background: Nowadays, there have been increasing studies comparing metformin with insulin. But the use of metformin in
pregnant women is still controversial, therefore, we aim to examine the efficiency and safety of metformin by conducting a
meta-analysis of randomized controlled trials (RCTs) comparing the effects of metformin with insulin on glycemic control,
maternal and neonatal outcomes in gestational diabetes mellitus (GDM).

Methods: We used the key words ‘‘gestational diabetes’’ in combination with ‘‘metformin’’ and searched the databases
including Pubmed, the Cochrane Library, Web of knowledge, and Clinical Trial Registries. A random-effects model was used
to compute the summary risk estimates.

Results: Meta-analysis of 5 RCTs involving 1270 participants detected that average weight gains after enrollment were
much lower in the metformin group (n = 1006, P = 0.003, SMD = 20.47, 95%CI [20.77 to 20.16]); average gestational ages at
delivery were significantly lower in the metformin group (n = 1270, P = 0.02, SMD = 20.14, 95%CI [20.25 to 20.03]);
incidence of preterm birth was significantly more in metformin group (n = 1110, P = 0.01, OR = 1.74, 95%CI [1.13 to 2.68]); the
incidence of pregnancy induced hypertension was significantly less in the metformin group (n = 1110, P = 0.02, OR = 0.52,
95%CI [0.30 to 0.90]). The fasting blood sugar levels of OGTT were significantly lower in the metformin only group than in
the supplemental insulin group (n = 478, P = 0.0006, SMD = 20.83, 95%CI [21.31 to 20.36]).

Conclusions: Metformin is comparable with insulin in glycemic control and neonatal outcomes. It might be more suitable
for women with mild GDM. This meta-analysis also provides some significant benefits and risks of the use of metformin in
GDM and help to inform further development of management guidelines.

Citation: Gui J, Liu Q, Feng L (2013) Metformin vs Insulin in the Management of Gestational Diabetes: A Meta-Analysis. PLoS ONE 8(5): e64585. doi:10.1371/
journal.pone.0064585
Editor: Raffaella Buzzetti, Sapienza, University, Italy
Received December 28, 2012; Accepted April 16, 2013; Published May 27, 2013
Copyright: ! 2013 Gui et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors have no support or funding to report.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: fltj007@163.com

Introduction incidence of adverse pregnancy outcomes. The previous study has

In recent years, the morbidity of gestational diabetes mellitus
(GDM) is increasing. Approximately 1–14% of all pregnancies are
complicated by GDM, depending on the population studied and
the diagnostic tests employed [1]. It has been defined as any
degree of glucose intolerance with onset or first recognition during
pregnancy [1]. GDM, the most frequent medical complication of
pregnancy, is associated with several adverse outcomes over the
short- and long-term for both mother and offspring [2]. First, the
presence of GDM always accompanies an increased maternal risk
for preeclampsia, cesarean section, and with an increased risk for
developing type 2 diabetes (T2D) after pregnancy [3], [4]. In
addition, there is an increased risk for neonatal death, still birth
and congenital defects [5] resulting from excessive mother-to-fetus
glucose transfer [6], [7]. Another major complication is macro-
somia, which is a risk factor for instrumental delivery, cesarean
section and shoulder dystocia during delivery and neonatal
hypoglycemia directly after birth [8]. Furthermore, the influence
of the intrauterine hyperglycemia environment might go with the
children in later life [3], [9]. So the management of GDM is
primarily aimed at controlling glycemic level to reduce the
demonstrated that intensive treatment in women with GDM
reduced birth weight and incidence of macrosomia in infants born
to mothers who had participated in the intervention compared
with women who had received routine care [10]. Therefore, active
treatments - such as dietary therapy, exercise, oral hypoglycemic
agents, insulin - are necessary to reduce the complications [11].
When an appropriate diet, alone or associated with physical
exercise, does not suffice to control blood glucose levels in
pregnant women, subcutaneous insulin therapy has been consid-
ered the standard for management of GDM [12-14]. However,
insulin has several disadvantages including multiple daily injec-
tions, the risk of hypoglycemia and maternal weight gain [15]. It
requires modification based on the patient’s body mass index,
glucose levels and lifestyle [16]. Therefore, detailed guidance for
dose change of insulin is necessary to ensure the safe self-
administration of insulin. Meanwhile, substantial costs of health
education on the safe use of insulin as well as the cost of the drug
itself are followed. Naturally, safe and effective oral therapy would
be more acceptable even highly desired for women with GDM [2],
[17]. However, it is essential to comprehend the effects of oral

PLOS ONE | www.plosone.org 1 May 2013 | Volume 8 | Issue 5 | e64585

 4. Funnell, Martha M., Brown, Tammy L., Childs, Belinda P., Haas, Linda B., Hosey, Gwen M.,
Jensen, Brian, . . . Weiss, Michael A. (2012). National standards for diabetes self-management
education.(STANDARDS AND REVIEW CRITERIA). Diabetes Care, 35(1), S101-S108.

This article reviews in detail the inclusion of different aspects of diabetes education and self-

management. Acknowledging the collaboration of the health care team including the Registered Dietitian

and the Physician, and how it can support effectiveness of both positions of our proposed hypothesis.

What is unique to this article when compared to the other articles supporting our proposed hypothesis is

that the education itself is evaluated rather than the individual who is supplying it. Furthermore,

encouraging the possibility that an education rubric or guidelines can ultimately have a greater

effectiveness in the outcomes of gestational diabetes.

This article was published through Gale online expanded academic ASAP library. Gale has been

working with libraries for over 60 years, making research articles and other scientific-based findings

available to each associated library. Evaluating the effectiveness of the education courses provided to

each patient for our hypothesis, it was concluded that the patient will be able to efficiently practice

decision-making, self-care behaviors, problem-solving and active collaboration with the health care team.

Although this article focused on education supplemented to each patient, the article also evaluated the

needs, goals, and life experiences that are anticipated for the diagnosed patient, there was an absence of

focus in the roles the physician or the registered dietitian played.

- http://go.galegroup.com.libproxy.csun.edu/ps/i.do?&id=GALE%7CA280004193&v=2.1&u=csun
orthridge&it=r&p=EAIM&sw=w
 5. Powers, M., Bardsley, J., Cypress, M., Duker, P., Funnell, M., Fischl, A., . . . Vivian, E. (2017).
Diabetes Self-management Education and Support in Type 2 Diabetes. The Diabetes Educator,
43(1), 40-53.

This publication focuses on creating a position statement to improve the patient experience of

care and education, to improve the health of patients, and can ultimately reduce diabetes-associated

healthcare costs. This publication focuses on evaluating the needs of individuals with diabetes, focusing

on type 2 diabetes with consideration of similar needs needed for women with gestational diabetes. This

publication takes the position of evaluating diabetes self-management and support (DSME/S) with

consideration of the Academy of Nutrition and Dietetics, giving greater information and background to

the practices of a Registered Dietitian with diabetes.

The AADE position statements set goals and missions for different topics when discussing

diabetes; this position statement in particular would be diabetes self management. Each position statement

is reviewed by a multidisciplinary group of diabetes educators, are peer-reviewed and are submitted for

review and final approval to AADE’s Board of Directors. It was concluded by this position statement that

providing DSME/S reduces hospital admissions, readmissions, lifetime health-care costs and places the

patient in lower risk for complications. The weakness to this article is that is does not support a particular

position or experiment to support our hypothesis but can play a critical role in understanding the thought-

process and importance of the role of the Registered Dietitian.

- http://journals.sagepub.com.libproxy.csun.edu/doi/pdf/10.1177/0145721716689694
689694TDEXXX10.1177/0145721716689694DSME Support in DiabetesPowers et al
research-article2015

The Diabetes EDUCATOR

40

Diabetes Self-management
Education and Support in
Type 2 Diabetes
A Joint Position Statement of the American
Diabetes Association, the American
Association of Diabetes Educators, and
the Academy of Nutrition and Dietetics

D
Margaret A. Powers, PhD, RD iabetes is a chronic disease that requires a
Joan Bardsley, MBA, RN person with diabetes to make a multitude
Marjorie Cypress, PhD, RN, CNP of daily self-management decisions and
perform complex care activities. Diabetes
Paulina Duker, MPN, RN
self-management education and support
Martha M. Funnell, MS, RN
(DSME/S) provides the foundation to help people with
AADE position

Amy Hess Fischl, MS, RD diabetes to navigate these decisions and activities and has
Melinda D. Maryniuk, MEd, RD been shown to improve health outcomes.1-7 Diabetes self-
Linda Siminerio, RN, PhD management education (DSME) is the process of facilitat-
Eva Vivian, PharmD, MS ing the knowledge, skill, and ability necessary for diabetes
statement

American Association of Diabetes Educators position statement self-care. Diabetes self-management support (DSMS)
From International Diabetes Center at Park Nicollet, Minneapolis, Minnesota (Dr Powers); MedStar
refers to the support that is required for implementing and
Health Research Institute and MedStar Nursing, Hyattsville, Maryland (Ms Bardsley); ABQ Health sustaining coping skills and behaviors needed to self-
Partners, Albuquerque, New Mexico (Dr Cypress); LifeScan, a Johnson & Johnson Diabetes
Solutions Company, Dubai, United Arab Emirates (Ms Duker); University of Michigan Medical School, manage on an ongoing basis (see further definitions in
Ann Arbor, Michigan (Ms Funnell); University of Chicago, Chicago, Illinois (Ms Fischl); Joslin Diabetes
Center, Boston, Massachusetts (Ms Maryniuk); School of Medicine, University of Pittsburgh, Table 1). Although different members of the health care
Pittsburgh, Pennsylvania (Dr Siminerio); and University of Wisconsin–Madison, Madison, Wisconsin
(Dr Vivian).
team and community can contribute to this process, it is
important for health care providers and their practice set-
Correspondence to Margaret A. Powers, International Diabetes Center at Park Nicollet,
Minneapolis, MN 55416-2699, USA. (margaret.powers@parknicollet.com). tings to have the resources and a systematic referral pro-
Acknowledgments: The authors gratefully acknowledge the commitment and support of the collaborat-
cess to ensure that patients with type 2 diabetes receive
ing organizations—the American Association of Diabetes Educators, the American Diabetes both DSME and DSMS in a consistent manner. The initial
Association, and the Academy of Nutrition and Dietetics; their colleagues, including members of the
Executive Committee of the National Diabetes Education Program, who participated in discussions and DSME is typically provided by a health professional,
reviews about this inaugural position statement; and patients who teach and inspire them. The authors
also thank Erika Gebel Berg (American Diabetes Association) for her invaluable editorial contribution. whereas ongoing support can be provided by personnel
The position statement was reviewed and approved by the Professional Practice Committee of the
within a practice and a variety of community-based
American Association of Diabetes Educators, the Professional Practice Committee of the American resources. DSME/S programs are designed to address the
Diabetes Association, and the House Leadership Team, the Academy Positions Committee, and the
Evidence-Based Practice Committee of the Academy of Nutrition and Dietetics. patient’s health beliefs, cultural needs, current knowledge,
This article is being simultaneously published in The Diabetes Educator, Diabetes Care, and the
physical limitations, emotional concerns, family support,
Journal of the Academy of Nutrition and Dietetics. financial status, medical history, health literacy, numeracy,
Duality of Interest. No potential conflicts of interest relevant to this article were reported. and other factors that influence each person’s ability to
DOI: 10.1177/0145721716689694
meet the challenges of self-management.
© 2015 by the American Association of Diabetes Educators, the American Diabetes Association,
and the Academy of Nutrition and Dietetics. Readers may use this article as long as the work is
properly cited, the use is educational and not for profit, and the work is not altered.

Volume 43, Number 1, February 2017

 6. Mathiesen, E., Andersen, H., Kring, S., & Damm, P. (2017). Design and rationale of a large,
international, prospective cohort study to evaluate the occurrence of malformations and
perinatal/neonatal death using insulin detemir in pregnant women with diabetes in comparison
with other long-acting insulins. BMC Pregnancy and Childbirth, 17(1), BMC Pregnancy and
Childbirth, Jan 18, 2017, Vol.17(1).

The main purpose of the publication is to investigate the long-term effects of insulin usage during

gestational diabetes considering malformations and mortality. This article relates to our proposed

hypothesis but further investigated the external factors that could interfere with the accuracy and

collection of our data when investigating the role of the Registered Dietitian and Physician. This article

further supports the research of another article I had investigated, “Metformin vs insulin in the

management of gestational diabetes: A meta-analysis,” where insulin is investigated as a remedy for

gestational diabetes, rather than making nutrition education a primary form of management.

This article was located in the NCBI-PMC, National Library of Medicine website. Elisabeth R.

Mathiensen has 20 different publications, focusing primarily on gestational diabetes, pre-pregnancy

diabetes, insulin resistance and overall women’s health and well-being. The conclusive findings of this

article provides opportunity for the team investigating this ongoing project in different types of

comparisons for insulin efficiency. It was noted that insulin dosage during pregnancy reduces blood

glucose but there is still speculation as to whether the medication could cause long-term effects. Possible

indicators of weakness in using this article to provide information for our hypothesis is that the study is

based in Europe, encompassing a different culture and lifestyle than what may be seen in Southern

California. Furthermore, this article does not support the position of Registered Dietitian or Physician but

provides substantial information on usage of insulin and the anticipated comparison of different insulin

types.

- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241954/
Mathiesen et al. BMC Pregnancy and Childbirth (2017) 17:38
DOI 10.1186/s12884-016-1177-4

STUDY PROTOCOL Open Access

Design and rationale of a large,

international, prospective cohort study to
evaluate the occurrence of malformations
and perinatal/neonatal death using insulin
detemir in pregnant women with diabetes
in comparison with other long-acting
insulins
Elisabeth R. Mathiesen1,4*, Henning Andersen2, Sofia I. I. Kring3 and Peter Damm1,4

Abstract
Background: There are a lack of data regarding the effect of basal insulin analogues on rates of events like
congenital malformation and perinatal mortality in diabetic pregnancy.
Methods: The present study is a prospective, non-interventional, multicentre cohort study conducted in seven
countries, designed to assess the safety of insulin detemir during pregnancy, and to monitor the health status of
resulting infants (exposed in utero) up to 1 year of age. The study population includes women with type 1 or type
2 diabetes, who are pregnant and being treated with insulin. Data will be collected in the context of routine
practice. The primary endpoint is the proportion of pregnancies in women treated with insulin detemir, compared
with other basal insulin regimens, which do not result in any of the following events: major congenital
malformations, perinatal death or neonatal death. A sample size of 3075 pregnancies was calculated to provide an
80% power to detect a difference of 3.5% between groups in the primary endpoint at a 5% level.
Discussion: The study will also examine other important maternal endpoints (e.g., incidences of severe
hypoglycaemia and pre-eclampsia) and perinatal outcomes such as overweight neonates, as well as infant
outcomes at 1 year of age. It has a fixed recruitment period from 2013 to 2018, enrolling all eligible patients, and is
expected to inform future prescribing with basal insulins in diabetic pregnancy.
Trial registration: ClinicalTrials.gov: NCT01892319 (date registered: 27.06.2013).
Keywords: Diabetes, Pregnancy, Insulin detemir, Cohort study

* Correspondence: elisabeth.mathiesen@rh.regionh.dk
1
Department of Endocrinology, Center for Pregnant Women with Diabetes,
Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical
Sciences, University of Copenhagen, DK-2100 Copenhagen, Denmark
4
Department of Obstetrics, Center for Pregnant Women with Diabetes,
Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical
Sciences, University of Copenhagen, Copenhagen, Denmark
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
 7. Jelsma, J., Simmons, D., Gobat, N., Rollnick, S., Blumska, K., Jans, G., . . . Van Poppel, J.
(2017). Is a motivational interviewing based lifestyle intervention for obese pregnant women
across Europe implemented as planned? Process evaluation of the DALI study. Bmc Pregnancy
And Childbirth, 17(1), 293.
The focus of this publication is to investigate the effectiveness of motivational interviewing when

counseling obese pregnant women, with the ultimate goal of preventing gestational diabetes. Although

this article is constructed in terms of a preventative care process for gestational diabetes, it allows insight

into motivational interviewing that is commonly practiced by Registered Dietitians and the effectiveness

it would have on a very similar type of population that would practice gestational diabetes management.

While the publication itself does not specify the role of the Registered Dietitians or the physicians in

providing this type of counseling, the publication provides insightful information on the importance of the

practices that a Registered Dietitian exhibit.

Author, Jelsma JGM has 3 other publications, all focused on different concerns pertaining to

gestational diabetes, including the history and epidemiology of gestational diabetes. This article was

found on PubMed, the US National Library of Medicine which plays a role within the branches of the

NCBI and the Board of Scientific Counselors. PubMed holds the mission of discovering new knowledge.

Conclusively, it was found by the authors of this publication that there was a substantial amount of

variability when assessing the quality of the motivational interviewing supplemented by the practitioners.

Although there was no association seen between the delivery process of the nutrition education

and the gestation weight gain, it was observed that individuals who were counselled by individuals who

used motivational interviewing were more successful in educating their participants, when compared to

individuals who did not practice motivational interviewing. A possible complication for this experiment is

that it was based in Europe and not in the U.S., where culture and beliefs may vary when compared to the

population in Southern California.

- https://www.ncbi.nlm.nih.gov/pubmed/28882133
Jelsma et al. BMC Pregnancy and Childbirth (2017) 17:293
DOI 10.1186/s12884-017-1471-9

RESEARCH ARTICLE Open Access

Is a motivational interviewing based

lifestyle intervention for obese pregnant
women across Europe implemented
as planned? Process evaluation of the
DALI study
Judith G. M. Jelsma1, David Simmons2,3, Nina Gobat4, Stephen Rollnick4, Kinga Blumska5, Goele Jans6,
Sander Galjaard6,7, Gernot Desoye8, Rosa Corcoy9,10, Fabiola Juarez9, Alexandra Kautzky-Willer11, Jürgen Harreiter11,
Andre van Assche6, Roland Devlieger6, Dirk Timmerman6, David Hill12, Peter Damm13, Elisabeth R. Mathiesen13,
Ewa Wender-Ożegowska5, Agnieszka Zawiejska5, Annunziata Lapolla14, Maria G. Dalfrà14, Stefano del Prato15,
Alessandra Bertolotto15, Fidelma Dunne16, Dorte M. Jensen17, Liselotte Andersen17, Frank J. Snoek18,19
and Mireille N. M. van Poppel1,20*

Abstract
Background: Process evaluation is an essential part of designing and assessing complex interventions. The vitamin
D and lifestyle intervention study (DALI) study is testing different strategies to prevent development of gestational
diabetes mellitus among European obese pregnant women with a body mass index ≥29 kg/m2. The intervention
includes guidance on physical activity and/or healthy eating by a lifestyle coach trained in motivational
interviewing (MI). The aim of this study was to assess the process elements: reach, dose delivered, fidelity and
satisfaction and to investigate whether these process elements were associated with changes in gestational weight
gain (GWG).
Methods: Data on reach, dose delivered, fidelity, and satisfaction among 144 participants were collected. Weekly
recruitment reports, notes from meetings, coach logs and evaluation questionnaires (n = 110) were consulted.
Fidelity of eight (out of twelve) lifestyle coach practitioners was assessed by analysing audio recorded counselling
sessions using the MI treatment integrity scale. Furthermore, associations between process elements and GWG were
assessed with linear regression analyses.
Results: A total of 20% of the possible study population (reach) was included in this analysis. On average 4.0
(of the intended 5) face-to-face sessions were delivered. Mean MI fidelity almost reached ‘expert opinion’ threshold
for the global scores, but was below ‘beginning proficiency’ for the behavioural counts. High variability in quality of
MI between practitioners was identified. Participants were highly satisfied with the intervention, the lifestyle coach
and the intervention materials. No significant associations were found between process elements and GWG.
(Continued on next page)

* Correspondence: mnm.vanpoppel@vumc.nl
1
Department of Public and Occupational Health and, Amsterdam Public
Health research institute, VU University Medical Centre, Van der
Boechorststraat 7, 1081BT Amsterdam, Amsterdam, The Netherlands
20
Institute of Sport Science, University of Graz, Graz, Austria
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
 8. Morrison, M., Collins, C., & Lowe, J. (2011). Dietetic practice in the management of gestational
diabetes mellitus: A survey of Australian dietitians. Nutrition & Dietetics, 68(3), 189-194.
The main purpose of this experiment is to examine the current practice used amongst dietitians

when responding to gestational diabetes. This article takes into consideration nation evidence-based

guidelines used amongst Registered Dietitians. This article will be useful for our hypothesis in further

reviewing the current practices of Registered Dietitians in the U.S.. Furthermore, identifying the

components of gestational diabetes education, management and counseling through the role of a

Registered Dietitian. What makes this study unique is that instead of observing and studying the

Registered Dietitian practice counseling for gestational diabetes management, Registered Dietitians are

asked to complete a survey about their role as a dietitian.

Corresponding author, Melinda K. Morrison works in the Education and Prevention Division and

is part of the Australian Diabetes Council in Sydney. Morrison has worked on 3 other publications,

entailing gestational diabetes and diabetes in children younger than 15. It was concluded that the services

that are offered by a Registered Dietitian are utilized when managing gestational diabetes, women

diagnosed with gestational diabetes at each facility preferred in one-on-one (93%) counseling, rather than

group counseling (33%). While there are several other significant findings in this article, what this one

finding suggests to our hypothesis is that nearly all individuals that are diagnosed with gestational

diabetes hold some form of communication with a Registered Dietitian to consult with management. For

our study, the objective would be to compare the 93% mentioned in this study against the 7% that are not

attending individual services or group sessions. Possible weakness for this article could be that there is an

abundance of information, knowing how to apply all of its finding to our research might require further

research on it’s validity.

- http://onlinelibrary.wiley.com.libproxy.csun.edu/doi/10.1111/j.1747-0080.2011.01537.x/full
Nutrition & Dietetics 2011; 68: 189–194 DOI: 10.1111/j.1747-0080.2011.01537.x

ORIGINAL RESEARCH

Dietetic practice in the management of gestational

diabetes mellitus: A survey of Australian dietitians ndi_1537 189..194

Melinda K. MORRISON,1 Clare E. COLLINS2 and Julia M. LOWE3

1
Education and Prevention Division, Australian Diabetes Council, Sydney, and 2School of Health Sciences,
University of Newcastle, Newcastle, New South Wales, Australia; and 3University of Toronto, Sunnybrook Health
Sciences Centre, Toronto, Ontario, Canada

Abstract
Aim: To examine current Australian dietetic practice in the management of gestational diabetes, to identify models
of dietetic care and to determine the need for national evidence-based dietetic practice guidelines for gestational
diabetes.
Methods: A 55-item cross-sectional survey of Australian dietitians practicing in the area of gestational diabetes was
undertaken. Participants were recruited via Dietitians Association of Australia interest group membership, public and
private hospital maternity and diabetes services across Australia. The survey examined dietetic service provision,
interventions, management recommendations, postnatal care, current guideline use and the perceived need for
Australian evidence-based dietetic management guidelines.
Results: A total of 220 eligible dietitians participated in the survey. The majority (77%) reported that all women with
gestational diabetes attending their service were referred to a dietitian. Group (33%) and individual consults (93%)
were provided and 67% provided one to two dietetic consults per client. Fifty-four per cent (54%) believed that their
service currently offered adequate antenatal dietetic interventions and 8% adequate postnatal follow up for women
with gestational diabetes. There were differences in the implementation of medical nutrition therapy by Australian
dietitians in regards to nutrient recommendations. However, consistency was seen in key components of nutrition
education. Dietitians perceived that there was a need for evidence-based gestational diabetes dietetic practice
guidelines (86%) and nutrition recommendations (87%).
Conclusion: The survey results strongly indicate there is a need for evidence-based gestational diabetes practice
guidelines and nutritional recommendations and provide baseline data for future practice of Australian dietitians
working in gestational diabetes.

Key words: dietetic practice, dietitian, gestational diabetes mellitus, nutrition guideline.

Introduction Medical nutrition therapy (MNT) is the primary therapeu-

Gestational diabetes mellitus (GDM) is a form of diabetes
with onset or first recognition during pregnancy.1 In Austra-
lia, GDM affects approximately 5% of pregnancies, increas-
ing up to 14% in some high-risk groups2 and is usually
diagnosed through selective or universal antenatal screening
between 26 and 28 weeks of pregnancy.1 GDM has been
demonstrated to pose significant peri-natal risks3 as well as
adverse maternal health consequences including future type
2 diabetes.4
M.K. Morrison, MSc, Grad Cert Diabetes Ed, APD, CDE, Senior Dietitian
C.E. Collins, PhD, AdvAPD, FDAA, Professor in Nutrition and Dietetics,
NHMRC CDA Research Fellow
J.M. Lowe, MBChB, FRCP, M.MedSci(Clin.Epi), Associate Professor
Correspondence: M.K. Morrison, Australian Diabetes Council,
26 Arundel St Glebe, Sydney, NSW 2037, Australia.
Email: melindam@australiandiabetescouncil.com
Accepted December 2010
tic strategy for the management of GDM with the goal of
ensuring that a pregnancy affected by GDM results in the
delivery of a healthy infant without related complications.5,6
Studies evaluating the implementation of the American
Dietetic Association (ADA) evidence-based GDM guidelines
have demonstrated the benefit of MNT when implemented
as intended.7 In a randomised controlled trial of 215 women
receiving either standard care or guideline-based MNT, fewer
subjects in the MNT group required insulin (24.6% vs 31.7%
P = 0.05) and there was a trend towards improved blood
glucose management during the treatment period in those
receiving MNT.7 Likewise, studies with type 1 and type 2
diabetes have demonstrated beneficial outcomes as a result
of systematic and consistent care when MNT practice
guidelines are implemented.8,9 Kulkarni et al. in 1998
demonstrated that the implementation of dietetic practice
guidelines in type 1 diabetes significantly increased time
spent with patients and the frequency of visits, but also

© 2011 The Authors 189

Nutrition & Dietetics © 2011 Dietitians Association of Australia
 9. Akinci, Tosun, Bekci, Yener, Demir, & Yesil. (2010). Management of gestational diabetes by
physicians in Turkey. Primary Care Diabetes, 4(3), 173-180.
The main focus of this article is to identify the process that clinicians in Turkey practice when

screening, diagnosing, and managing gestational diabetes. This article is useful in providing further

information on the position and role of a physician when working with a patient diagnosed with

gestational diabetes. This article helps shed light on effectiveness of physicians and different practices

that are used and can be comparable to Registered Dietitians. This article is unique amongst the other

articles collected because it goes into detail of different patterns, characteristics, precautions and actions

taken specifically taken by the physician when meeting with an individual with gestational diabetes.

Author, Baris Akinci work in the Division of Endocrinology and Metabolism as part of the

Department of Internal Medicine at Dokuz Eylul University Medical School in Turkey. Baris has 82 other

published articles, encompassing a focus on general diabetes and endocrinology. It was concluded that

despite there being regulations or rules of conduct, the practice and services offered by physicians when

assessing gestational diabetes varied. Additionally, there was acknowledgement that very few women that

were diagnosed with gestational diabetes seeked services or assistance from a registered dietitian; this was

particularly true if the women was already assisted by a general family physician. When compared to

similar studies conducted in the U.S., patients diagnosed with gestational diabetes were more likely to

review their diagnosis and management with a Registered Dietitian. Whereas in Turkey, it seemed more

common for women to seek the help of a family physician more than a Registered Dietitian. A possible

weakness in using this article for our hypothesis would be that the study was conducted and emphasized

on the population of Turkey rather than population on the U.S.; demonstrating different beliefs, cultures

and practices.

- http://www.sciencedirect.com.libproxy.csun.edu/science/article/pii/S1751991810000732
 p r i m a r y c a r e d i a b e t e s 4 ( 2 0 1 0 ) 173–180

Contents lists available at ScienceDirect

Primary Care Diabetes

journal homepage: http://www.elsevier.com/locate/pcd

Original research

Management of gestational diabetes by physicians in Turkey

Baris Akinci a,∗ , Pinar Tosun b , Emine Bekci b , Serkan Yener a ,

Tevfik Demir a , Sena Yesil a
a Division of Endocrinology and Metabolism, Department of Internal Medicine, Dokuz Eylul University Medical School, Inciralti, Izmir
35340, Turkey
b Department of Internal Medicine, Dokuz Eylul University Medical School, Izmir, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Aims: We sought to investigate the practice patterns of clinicians (family physicians,
Received 31 May 2009 internists and obstetricians) in Turkey in screening for gestational diabetes mellitus (GDM),
Received in revised form management and monitoring of hyperglycaemia in pregnant women with GDM, and assess-
9 April 2010 ment of glucose tolerance in the postpartum state.
Accepted 21 May 2010 Methods: Between January and December 2007, current practices of Turkish physicians
Available online 16 June 2010 (n = 434) were assessed by a questionnaire which was concerned with physician demograph-
ics and clinical practice including screening and diagnostic methods for GDM, management
Keywords: of GDM during pregnancy and postpartum assessment of glucose tolerance. The ques-
Diabetes tionnaire was developed in respect to the recommendation of the Fifth International
Physicians Workshop-Conference on GDM and the standards of the American Diabetes Association
Pregnancy (ADA).
Practice patterns Results: Although most of the physicians stated that they performed screening for GDM
and postpartum screening for glucose intolerance in women with GDM, their screening
practices vary. The proportion of women who were provided with a nutrition counselling
by a registered dietician and a patient education by a trained nurse was low, especially in
women treated by the family physicians. Home glucose monitoring was widely used in the
management of GDM, however, postprandial glucose assays were used occasionally. Regular
and NPH insulin preparations were the most preferred drugs to treat GDM. Internists were
more likely to use insulin analogues. On the other hand, a significant number of physicians
stated that they used oral antidiabetics (OADs). A considerable number of family physicians
used OADs which have not been proved to be safe in pregnancy.
Conclusions: Our results suggest that there is considerable variation in the clinical practice
patterns of physicians. An education program to enhance the clinical aptitude of physicians,
particularly family physicians, in the medical management of GDM should be designed
throughout the country.
© 2010 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Corresponding author. Tel.: +90 232 4123744; fax: +90 232 2792267.
∗

E-mail address: baris.akinci@deu.edu.tr (B. Akinci).

1751-9918/$ – see front matter © 2010 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.pcd.2010.05.004
 10. Kalyandurgmath, K., & Mohanty, R. (2015). Health Management: The Role of Primary Care
Physician in Nutrition and Functional Food Counselling. ASBM Journal of Management, 8(2),
93-107.
This study was conducted in Mumbai, India where the role of the physician in nutrition and

functional foods counseling is further assessed. This experiment is unique in the sense that is

accomplished our proposed hypothesis in taking a closer look in the overall effectiveness of a physician

when providing nutrition education.

Other articles worked on by Kavita Kalyandurgmath include “Health Management: The Role of

Primary Care Physician in Nutrition” and “Functional Food Counselling and Determinants of Buying

Intention for Genetically Modified Food,” demonstrating interest in the nutritional scope of research. It

was found that of the physicians that participated in study, 91% thought that functional foods could have

beneficial effects to help prevent disease, 77% through functional foods would improve performance and

53% thought that functional foods could repair damage of unhealthy food habits. It was found that

majority of the physicians that participated believed that functional food and nutrition counseling is a

foundation for improvement of several diseases and conditions in India (diabetes, hypertension, cancer,

etc).

The weakness of this article is that the research was conducted and emphasized in rural areas of

India. Although there was no specification to our hypothesis taking place in Southern California, there is

less of a possibility for correlation when the study takes place in a different country and a different type of

population than one we would see or work with. Additionally, the nutrition education that is provided to

these patients does not emphasis the individuals diagnosed with gestational diabetes.

- https://search-proquest-
com.libproxy.csun.edu/docview/1773921006?accountid=7285&rfr_id=info%3Axri%2Fsid%3Ap
rimo