Gestational diabetes mellitus: A “kitchen table” approach

Gestational diabetes mellitus: A “kitchen table” approach

Vogel, Ellen

CASE STUDY

Abstract/Resume

The issue of gestational diabetes mellitus within disadvantaged communities is being addressed by Healthy Start for Mom & Me, a highly collaborative and multi-faceted prenatal nutrition program targeting at-risk women and teens in Winnipeg, Manitoba. The program’s “kitchen table” approach focuses on the core concepts of education, community participation, and capacity-building to develop effective methods for community-based practice in this population. A qualitative case study of the program was conducted in 1999. This study showed that health education practices in the program are sensitive to marginalized women’s needs and enhance service providers’ understanding of the context of participants’ lives. Community dietitians’ roles in this prenatal program are evolving, and are significant for other dietitians charting a new course of community-based practice.

(Can J Diet Prac Res 2001; 62:169-173)

Healthy Start for Mom & Me, un programme de nutrition prenatale caracterise par une grande concertation et comportant de multiples volets, s’attaque au probleme du diabete gestationnel dans des communautes defavorisees. II s’adresse aux femmes et aux adolescentes a risque eleve de Winnipeg, Manitoba. L’approche – table de cuisine , du programme met l’accent sur les concepts de base en education, la participation communautaire et le renforcement des capacites a elaborer des methodes efficaces d’action communautaire dans cette population. Une etude de cas qualitative du programme menee en 1999 a montre que les pratiques d’education en matiere de same dans le programme sont sensibles aux besoins des femmes marginalisees et am6liorent la comprehension du contexte de vie des participantes par les prestateurs de services. Les roles des dietetistes communautaires dans ce programme prenatal sont en evolution et peuvent inspirer d’autres dietetistes qui con*oivent un nouveau modele d’action communautaire.

(Rev can prat rech dietet 2001; 62:169-173)

INTRODUCTION

The prevention and management of gestational diabetes mellitus (GDM) are being addressed by Healthy Start for Mom & Me (HSMM), a community-based prenatal nutrition program targeting low-income, socially isolated women and teens living in Winnipeg’s inner city. The program’s practical and informal “kitchen table” approach uses food and nutrition “as a springboard to build access, skills, confidence, and social support” among participating women (1). The approach has also been described as a method of “facing food challenges with participant women” (2).

The Canada Prenatal Nutrition Program (CPNP) funds HSMM, and CPNP partner organizations and agencies contribute staff and in-kind resources. Dietitians of Canada is the program sponsor.

Primary prevention and health promotion

Diabetes prevention initiatives may be described, in general terms, as primary (before disease onset), secondary (early detection of disease), or tertiary (reduction of adverse disease consequences) (3). This terminology can be confusing, because diabetes is a risk factor for many other diseases (e.g., cardiovascular disease). Diabetes treatment regimens should therefore include heart-health strategies with a primary prevention focus.

Health promotion and/or population health approaches are broader than primary prevention initiatives because they focus on identifying and eliminating the economic, social, and physical barriers to a healthy, active lifestyle (4). Both health promotion and primary prevention are critical to diabetes prevention, especially for people in environments that present risk conditions.

Saskatchewan Health (4) reviewed the literature about successful national and international diabetes prevention programs using a population health approach. The findings suggested that successful health promotion interventions also addressed key issues in diabetes management (i.e., reducing fat intake, increasing fibre consumption, increasing physical activity, and maintaining a healthy body weight). Saskatchewan Health identified strategies common to exemplary programs with a population health focus (Table 1).

Secondary prevention: GDM screening and prevention

The diagnosis of GDM has short- and long-term implications

for both mother and infant. GDM may be associated with an increased risk of fetal malformation and perinatal mortality in a subset of patients whose diabetes was present, but unrecognized, before pregnancy (5). More frequent and significant morbidity for the infant includes macrosomia (birth weight > 4,500 g) with a risk of fetal and maternal trauma during birth.

Even with contemporary medical care, GDM has a wide range of effects on child health and development. According to Silverman et al. (6), many of these effects, including “childhood obesity, higher levels of blood pressure and glucose intolerance, and lower than expected intellectual and psychomotor development,” appeared linked with the extent of the disturbances in maternal glucose metabolism.

In the long term, women with a history of GDM are at increased risk for the development of type 2 diabetes after pregnancy. Kjos and Buchanan (7) estimated that women with GDM have a 17-63% chance of developing nongestational diabetes within five to 16 years after the index pregnancy.

Diagnostic criteria used to define GDM

Simply defined, GDM is glucose intolerance first detected during pregnancy (8). The definition applies whether the treatment is insulin therapy or diet modification, and whether or not the condition persists after pregnancy (9). The simplicity of the definition, unfortunately, has not assisted the medical community in reaching consensus on the detection and clinical management of GDM. A recent study on primary care providers’ attitudes toward diabetes highlighted their frustrations in managing the condition; these frustrations were partly due to unclear diagnosis and treatment protocols (10). Providers perceived that many controversies existed within the academic medical community about how to manage diabetes effectively.

Screening for GDM

Controversy also exists about GDM screening. The Canadian Task Force on the Periodic Health Examination (11) concluded that available evidence did not support a recommendation either for or against universal GDM screening. Health Canada states that:

“while the 1998 CDA Clinical Practice Guidelines for the Management of Diabetes in Canada recognizes the lack of evidence for universal screening, it recommends, based on consensus, that all women be screened for GDM between 24 and 28 weeks of gestation, with the exception of those at very low risk (lean Caucasian women under the age of 25, with no personal history orfamily history of diabetes and no history of large babies).” (12)

The authors of both documents agree that screening should occur when GDM risk factors are present (Table 2).

A CASE STUDY

Background

The process of developing HSMM began with extensive community consultations over six months. The process used a community development approach, and actively involved members of the target population. Existing community-based services were reviewed, gaps were documented, and the following issues were identified:

* Many women living in the inner city of Winnipeg and adjacent districts experienced poverty and social isolation daily.

* Pregnant teens and women living in poverty typically did not receive prenatal check-ups at recommended intervals and did not attend prenatal classes. Fear, denial, and distrust of the traditional health care system, as well as a lack of transportation, bus fare, and/or childcare arrangements, were frequently cited as barriers.

* Economically disadvantaged pregnant women were often unable to afford either the optimal amount or the variety of food necessary to support a healthy pregnancy.

Many marginalized women were unaware of the type and amount of food they should be eating, and they lacked knowledge of simple recipes and basic food preparation techniques. Mainstream nutrition education resources and health education information did not meet their needs.

The HSMM program was designed to address these issues and “to encourage healthy pregnancies and healthier babies through the provision of social support, basic food and vitamins, promotion and support of breast-feeding, and related informal health education” (13). The founding premise of HSMM was that culturally appropriate social support, coupled with community resources and information, enables high-risk pregnant women to overcome barriers to early prenatal care.

Program description

Eight prenatal drop-in programs operated from community facilities that were selected by the community and perceived as nonthreatening. The neighbourhoods were chosen on the basis of their low-income demographics and associated low birth-weight rates. Program statistics indicated that approximately 800 women participated in HSMM from 1999 to 2000. The number of Aboriginal women and teens attending HSMM has increased and they now represent approximately 50% of participants (14).

The key ingredients of an HSMM drop-in session are illustrated in Figure 1. Because women told staff what would work and what would not, a friendly, informal, and practical approach was taken; this approach does not resemble traditional prenatal classes. Each neighbourhood site has a team consisting of a dietitian, a peer outreach worker, and a public health nurse. Many dedicated volunteers, including University of Manitoba Foods and Nutrition students, donate services. The prenatal drop-in sessions are offered once every two weeks.

METHODS

A qualitative case study of HSMM was initiated in 1999, after ethical approval was obtained from the University of Alberta Faculty of Agriculture, Forestry, and Home Economics Review Committee and the Winnipeg Community Long-term Care Authority (WCA) Research Review Committee. Two of the eight HSMM neighbourhood drop-in programs served as primary sites for data collection. In addition, data were collected at the HSMM central office in Winnipeg. A combination of participant observation; in-depth individual interviews (n=21) with program staff, community partners, and key informants; and two focus group interviews with participants (n=23) were used to gather information on the HSMM program and its functions. This approach permitted multiple perspectives on the program. Interviews were audiotaped and respondents were asked to review typed transcripts for accuracy. Only findings relevant to GDM in the HSMM population are reported here.

RESULTS

Gestational diabetes mellitus within the HSMM environment was explored using the observational and interview data.

During one interview, an HSMM peer outreach worker recalled her past personal experience with GDM. Alice (a pseudonym, as are all participants’ names) reflected on her lack of understanding about the implications of GDM and the ineffectiveness of the dietary counselling she received:

“Your doctor doesn’t sit and talk to you about how you’re eating, and the impact of the food you eat on your baby later on. They told me that my blood sugars were too high, that I didn’t have to go onto insulin or anything, I just had to have a diet. So, I went to a dietitian at the hospital. I talked to her and she told me, `This is sort of what you have to eat,’ and whatever. But it was sort of like, okay, I’ll try that, but I really didn’t stick to it like I should have. From what I know now, it would be different. It was just like, `Go on this diet, and try not to eat sweets.’ She didn’t tell me how important it was to follow this diet. To me, it was no big deal. She made it sound like you eat small meals, and eat this and this. And a lot of the food on there [the diet instruction sheet] I didn’t really like, and I didn’t feel comfortable telling her that. ”

In talking to a participant with recently diagnosed GDM, Alice contrasted the HSMM approach to her own experience:

“Girls that are coming to our program with gestational [diabetes], it’s just explained to them a lot differently and in more depth, and you have time to meet with the dietitian and really talk about any questions you may have. Beth [an HSMM dietitian] has even done home visits, which I think is really, really neat. She could actually go right in the home and talk to this mom if she wants her to. I think it’s more personal. Beth sort of knows what situations they’re in and what they can afford and what they can’t.”

Beth, a community dietitian and an HSMM core staff member, explained that her busy schedule, competing pressures, and HSMM’s overwhelming success in attracting participants to neighbourhood sites resulted in her doing home visits on an as-needed basis. She described her role at a drop-in session, acknowledging that it may be very difficult for someone unfamiliar with HSMM’s collaborative “kitchen table” approach to grasp the basic concepts:

“You physically almost have to see it to understand and really get a sense of what it feels like to be there. It’s not formal teaching. I don’t use an overhead [projector]. I don’t lecture.

I don’t do one-on-one clinical work with every single person that comes in every single time. It’s really women sitting down, talking, sharing the things that I’ve learned and the experience that I’ve had with pregnancy, nutrition and pregnancy, and also having the team members share their experiences.”

Judy, a community dietitian and an HSMM team member, spoke at length about GDM. She described many participants’ initial fear and ongoing challenges as their contact with health care professionals increased. Judy stressed the important role that HSMM plays in supporting women with GDM and encouraging them to seek appropriate treatment:

“We’ve had some moms, for example, with gestational diabetes, that have had to go on insulin, where it’s very difficult for those moms because of the time they have to spend with health professionals. It’s just been a real exercise for us at Healthy Start to talk as much as we can with those women about what’s happening in the health care system and encouraging them to be persistent about attending their appointments, and their doctor visits, to have their insulin increased, to have the ultrasound and stress tests and all of the things that we sort of accept are necessary that are really difficult for women; as they get towards the end of their pregnancy, almost every day they need to be doing something different.”

Judy described an HSMM participant’s progress in dealing with GDM in her second pregnancy, and compared this pregnancy with the woman’s first:

“We had one gal who really struggled with that [insulin injections] a great deal in her first pregnancy that she was with us. But, by the second time around, she was living closer to the hospital intentionally so that she would be able to get care more easily. She really did make a lot of changes so that she could adjust. So, we did see where the program really helped her to have better contact and better health care – and earlier. ”

Beth recalled an HSMM participant’s escalating frustration with the prescribed dietary management of GDM. Beth reflected on the lessons learned in working collaboratively with this HSMM participant:

“I worked with one woman who had gestational diabetes with her first pregnancy. After the baby was born she [mother] developed type 2 diabetes, and then went on insulin. Now she’s pregnant again but does not want to talk to me about it at all. Her physician is following her, but she’s not really on any type of diet plan. Her blood sugar is all over the place right now. She told me, ‘I know what I have to do. I’ve done this before, but I’m just frustrated. I want to be like everyone else. I want to eat like everyone else.”

Beth explained that in working with this HSMM mom, she had learned that it was necessary to “back off” and respect what the woman wanted to know, and, in fact, already knew about GDM:

“She knows I’m there for her if she ever needs me. It’s hard though, because you want to say, `Okay, I’m going to tell you everything you need to know about GDM. “‘

Judy stressed that the counselling approach involved the whole HSMM team. The lines between professionals , staff members , and community partners’ roles were often blurred, and a willingness to be flexible and less bound to traditional roles was important:

“We all work together. I don’t mean to say that I do this myself, because we’re very much a team. We talk about this at our team meeting; we try and share as much as we can of our perceptions of how people are managing with things and how can we support them as a team. We all feel very strongly about teamwork and share as much as we can.”

She shared her perspective on the importance of first creating an atmosphere of safety and security at the drop-in sites:

“A lot of it is not necessarily the detail of the messages you’re trying to get across, but the caring. It’s not access to food only, and it’s not only having food at the site, but it’s that feeling of security that we have at the site, the feeling of being very safe. And food is a part of that, and getting the messages across about food in a way that feels good to people, and in a way that feels like they’re learning about things that they can do, that are possible for them, and that’s a good feeling – it’s a safe feeling.”

Judy discussed the significance of the HSMM milk coupons at length. She added her perspective as a community dietitian:

“It takes a lot of pressure off me as a dietitian. As soon as I give women the milk coupons, it says, `Milk is so important for you to drink.’ And it makes it very accessible for them. I see a lot of women, not everyone, automatically starting to drink milk without me having to say to them, `You need to have it.’

DISCUSSION

Strategies to prevent or delay the development of type 2 diabetes in women with a history of GDM have the potential to save millions of health care dollars and to prevent substantial suffering caused by the disease (15). Current findings (15) suggest that the burden of GDM will continue to increase, and that we must move beyond the traditional approach to diabetes management. There is a need for innovative programs using a population health approach to address diabetes prevention, education, care, research, and support.

The shift in emphasis from acute treatment to communitybased care necessitates a search for factors that will predict positive outcomes. In Walker’s view (16), service providers need to consider the following key questions in designing effective, culturally appropriate diabetes prevention and treatment programs:

How can educators perform individualized assessment and education in a group setting?

Who is the optimal provider of self-management education to meet adult learners’ needs?…

What are the predictors of readiness for self-management, autonomy, and empowerment?…

How can we communicate risk to adult learners in a way that informs, motivates, and activates behaviour change and does not paralyze them with fear?

What types of social support are optimal for assisting the adult learner with diabetes self-management?…

RELEVANCE TO PRACTICE

The research described in this article can increase our understanding of community-based health education about GDM. The HSMM program has an alternative orientation based on education, community participation, and capacity building. In addition, by helping service providers understand the context of participants’ lives, the program encourages health education practices that are more sensitive to high-risk women’s and teens’ needs. According to Travers (17), “without an appreciation of the everyday experiences of the disadvantaged, there remains a temptation to take on the traditional expert role.”

The research has significance for dietitians who are charting a new course of community-based practice. The findings call for a reorientation of nutrition services from hospitals to communities, and from the dominant individual emphasis to a more social one. From a health educator’s perspective, the community-based dietetic practice associated with HSMM is a “radically re-oriented one, requiring a role change from expert to facilitator and advocate” (17).

Acknowledgments

We wish to express our gratitude to HSMM team members for their interest in the research and their generous willingness to share their experiences. We also appreciate the assistance of Ruth Diamant and Lauranne Matheson, RD, in reviewing the article. Funding support from Dr. Kim Raine and the Alberta Heritage Foundation for Medical Research (Health Scholar Award) is gratefully acknowledged.

References

1. Matheson L, Wylie G. The Canada Prenatal Nutrition Program – a healthy start. Presented at the International Congress of Dietetics, Edinburgh, Scotland, Aug 2000.

2. Healthy Start for Mom & Me. Working with food and nutrition as a springboard at Healthy Start for Mom & Me. [handout]. Prepared for Dietitians of Canada National Conference, Acadia University, Wolfville, Nova Scotia, Jun 1998.

3. Health Canada. Canadian diabetes strategy: expert meeting. [meeting report]. Ottawa, ON: Feb 2000.

4. Saskatchewan Health. Population health promotion practice in the primary prevention of type 2 diabetes. Population Health Promotion: From Issues to Action: “Getting Started.” Echo Valley Centre, Fort Qu’Appelle, SK, 1999.

5. Persson B, Hanson U. Neonatal morbidities in gestational diabetes mellitus. Diabetes Care 1998;21(suppl 2):B79-84.

6. Silverman BL, Rizzo TA, Cho NH, et al. Long-term effects of the intrauterine environment. Diabetes Care 1998;21(suppl 2):B142-9. 7. Kjos SL, Buchanan TA. Gestational diabetes mellitus. N Engl J Med 1999;341 (23):1749-56.

8. Metzger BE, Coustan DM, Organizing Committee. Summary and recommendations of the fourth international workshop-conference on gestational diabetes mellitus. Diabetes Care 1998;21 (suppl 2):B1 61-7.

9. American Diabetes Association. Gestational diabetes mellitus. Diabetes Care 1999;22 (suppl 2):574-7.

10. Larme AC, Pugh JA. Attitudes of primary care providers toward diabetes. Diabetes Care 1998;21(9):1391-6.

11. Beaulieu MD. Screening for gestational diabetes mellitus. In: Canadian Task Force on the Periodic Health Examination, ed. The Canadian guide to clinical preventative health care. Ottawa, ON: Minister of Supply and Services Canada,1994;16-23.

12. Health Canada. Nutrition for a healthy pregnancy: national guidelines for the childbearing years. Ottawa, ON: Minister of Public Works and Government Services Canada, 1999.

13. Winnipeg Prenatal Nutrition Initiative Steering Committee. Healthy Start for Mom & Me program proposal. Prepared for Health Canada (Canada Prenatal Nutrition Program). Winnipeg, MB:1996.

14. G. Wylie, personal communication, Jul 12, 2000.

15. Gregory KD, Kjos SL, Peters RK Cost of non-insulin-dependent diabetes in women with a history of gestational diabetes: implications for prevention. Obstet Gynecol 1993;81(5):782-6.

16. Walker EA. Characteristics of the adult learner. Diabetes Educator 1999;25(6):16-23.

17. Travers KD. Reducing inequities through participatory research and community empowerment. Health Educ Behav 1997;24:344-56.

ELLEN VOGEL, PhD, RD, Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, AB;

KRISTIN ANDERSON, RD, CDE, Diabetes and Chronic Diseases Unit, Public Health Branch, Manitoba Health, Winnipeg, MB;

KIM RAINE, PhD, RD, Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, AB;

TOM CLANDININ, PhD, Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, AB

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