Friday, November 28, 2008

What am I doing here again?

Almost three months have passed, and I have yet to post a blog about my research. You are all probably wondering what I am doing here.

Original idea
I thought I would start by stating why I chose to research women with gestational diabetes. First, it is well known that pregnant women with gestational diabetes are instructed to follow a healthy diet with a primary focus on the reduction of the consumption of carbohydrates. They are also advised to exercise 30 minutes a day, five days a week with doctor’s permission. Thus, I hypothesized that if women could look at the disease like a red flag or a teaching point and make those proper lifestyle changes, then they could prevent themselves and their unborn-child from developing type 2 diabetes.

Coincidentally, the word on the street at the hospital’s annual meeting resonated with my objective: the prevention of type 2 diabetes starts in the womb. I guess the idea was not that original after all. However, there are still no studies that have researched gestational diabetes in a Mexican population from a qualitative approach.

Since 2000, diabetes mellitus (DM) has been controversially declared as the number one cause of death for women in Mexico. Nationally, 7.3% of women in Mexico are suffering from DM. The high rates of DM can be attributed to well-known risk factors such as obesity, as well as gestational diabetes mellitus (GDM), or diabetes during pregnancy. More sobering statistics show that for women of child-bearing age, between 20-29 years old, almost 50% are overweight or obese, while the percentage is as high as 70% for women 30-39 years old. Other risk factors include: family members with diabetes, Hispanic ethnicity, history of GDM or glucose intolerance, women 25 years and older, and women with children that weighed more than 4kg at birth. With all of that being said, the prevalence of GDM at the Instituto Nacional de Perinatología was 5.3% in 2007.

Definition of Gestational Diabetes Mellitus
GDM is defined as "carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.” (1) GDM is characterized by insulin resistance and the failure to produce adequate amounts of insulin; the hormone responsible for the up-take of glucose from the blood. While insulin resistance is a normal symptom in pregnancy, the pancreas should be able to compensate and produce more. Those women who can not produce the extra insulin are considered to have GDM.

1. Gabbe S. The gestational diabetes mellitus conference. Diabetes Care 1998; 21 Suppl 2: B1-2.

Objective and Methods
The purpose of my research is two-fold: 1) to evaluate the treatment program provided for women with gestational diabetes (Medical Nutrition Therapy Program) and 2) to help explain the phenomenon of gestational diabetes in a small group of women from a socio-cultural perspective where I will compare participants with good blood glucose control to women with poor control. I have chosen to take a sociological, qualitative approach to study diabetes because the disease is not just a biological manifestation, but psychological and sociological.

I will collect the information with a combination of in-depth interviews, questionnaires and by making observations. Since I cannot follow the patients to their homes to study how and why they do/do not follow their treatment plan, I will capture the data by asking them questions about their perceptions, knowledge and self-care practices surrounding dietary habits, glucose monitoring and physical activity. In addition, I will explore their level of diabetes-related knowledge and their perception of the care that they receive from INPer. Secondly, I will use the questionnaires to describe the demographics of the patients and to take a relatively larger sample (30 women) of how women adhere to their treatment plan. Lastly, I will observe dietitian consultations, patient visits with the endocrinologists and talks on diabetes for women recently diagnosed with the disease.

Evaluation of the Medical Nutrition Therapy Program
The dietitians and rotating-nutrition students base their diet consultations on the Medical Nutrition Therapy program designed for women with gestational diabetes. Due to a lack of resources, it is not the exact same MNT program that is applied in the US. However, all patients are given an individualized diet, as well as educational materials with a diet plan and recommendations for exercise. At the first visit, a nutritional history is taken of the patient. A diet is then constructed using the number of calories assigned by the endocrinologist, based on weeks of gestation and her pregestational weight. The patients are restricted to eating a diet with 42% carbohydrates (people without diabetes are allotted 50-60% of carbohydrates daily). The quantity of carbohydrates is broken up into fourths, where the patients are usually told to eat ¼ of their daily rations with breakfast, 2/4 with lunch (the biggest meal of the day) and ¼ with dinner. Also, they are told to follow a schedule for their meals and snacks. Lastly, women are taught the different food groups, how they should be combined and what portion sizes are.

The latest and greatest
Currently, I am applying the questionnaires with the help of one of the nurses. The process is slow but steady. I plan to have the 30 questionnaires finished before I go home in December. I continue to make observations on a weekly basis; jotting down anything from what I see and hear in the consultation rooms to the waiting areas. With respect to the interviews, we had our first patient this past Thursday. She was a great informant, as she only had to be asked one question and she would provide us with a 20 minute answer. Moreover, the information that she gave us supported the observations that I have been making over the past three months; I was quite excited.

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