Article​ ​2​:​ ​Dietetic​ ​practice​ ​in​ ​the​ ​management​ ​of​ ​gestational​ ​diabetes​ ​mellitus:​ ​A​ ​survey​ ​of​ ​Australian

dietitians.

- 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.

- http://onlinelibrary.wiley.com.libproxy.csun.edu/doi/10.1111/j.1747-0080.2011.01537.x/full

Method

The​ ​hypothesis​ ​of​ ​this​ ​article​ ​is​ ​that​ ​there​ ​is​ ​a​ ​difference​ ​between​ ​current​ ​Australian​ ​dietetic

practice​ ​in​ ​the​ ​management​ ​of​ ​gestational​ ​diabetes​ ​and​ ​the​ ​national​ ​evidence-based​ ​dietetic​ ​practice

guidelines​ ​for​ ​gestational​ ​diabetes.​ ​The​ ​study​ ​population​ ​was​ ​focused​ ​on​ ​Australian​ ​dietitians​ ​practicing

in​ ​the​ ​area​ ​of​ ​gestational​ ​diabetes​ ​who​ ​were​ ​recruited​ ​through​ ​the​ ​dietitians​ ​association​ ​of​ ​Australia.

About​ ​3295​ ​electronic​ ​surveys​ ​were​ ​emailed​ ​out​ ​and​ ​295​ ​written​ ​invitation​ ​were​ ​mailed​ ​out;​ ​220​ ​eligible

dietitians​ ​participated​ ​in​ ​the​ ​survey.​ ​The​ ​statistical​ ​power​ ​could​ ​be​ ​the​ ​lack​ ​of​ ​responsiveness​ ​from​ ​the

total​ ​emails​ ​and​ ​letters​ ​mailed​ ​out​ ​compared​ ​to​ ​the​ ​total​ ​responses.​ ​Of​ ​the​ ​total​ ​220​ ​responses,​ ​77%​ ​said

that​ ​their​ ​services​ ​for​ ​GDM​ ​were​ ​based​ ​upon​ ​references​ ​to​ ​a​ ​dietitian,​ ​54%​ ​felt​ ​they​ ​met​ ​adequate​ ​services

to​ ​their​ ​patients,​ ​and​ ​8%​ ​had​ ​a​ ​follow-up​ ​visit​ ​post-pregnancy.​ ​What​ ​was​ ​the​ ​most​ ​significant​ ​was​ ​that

86%​ ​of​ ​the​ ​participants​ ​said​ ​they​ ​felt​ ​there​ ​was​ ​a​ ​need​ ​for​ ​GDM​ ​dietetic​ ​practice​ ​guidelines​ ​and​ ​87%

expressed​ ​the​ ​need​ ​for​ ​nutrition​ ​recommendations.

Assignment

The​ ​appropriateness​ ​in​ ​this​ ​study​ ​was​ ​noted​ ​in​ ​the​ ​elevated​ ​rates​ ​of​ ​prognosis​ ​of​ ​expecting

mothers.​ ​In​ ​Australia,​ ​5%​ ​of​ ​pregnancies​ ​are​ ​GDM​ ​and​ ​14%​ ​are​ ​placed​ ​in​ ​a​ ​high-risk​ ​category,​ ​suffer

from​ ​adverse​ ​effects​ ​after​ ​pregnancy​ ​such​ ​as​ ​type​ ​2​ ​diabetes​ ​and​ ​perinatal​ ​risks.​6,7​​ ​The​ ​precision​ ​of​ ​this

assignment​ ​is​ ​seen​ ​in​ ​the​ ​complete​ ​and​ ​concise​ ​answers​ ​provided​ ​from​ ​the​ ​surveys.​ ​There​ ​was​ ​fault​ ​in

precision​ ​when​ ​assessing​ ​the​ ​open-ended​ ​questions​ ​that​ ​provided​ ​an​ ​array​ ​of​ ​responses.​ ​The​ ​measurement

of​ ​this​ ​assignment​ ​was​ ​executed​ ​as​ ​a​ ​cross-sectional​ ​survey​ ​between​ ​March​ ​and​ ​June​ ​of​ ​2009.​ ​The
surveys​ ​were​ ​reviewed​ ​once​ ​completed​ ​and​ ​reviewed​ ​in​ ​its​ ​entirety​ ​for​ ​answers​ ​recorded​ ​on​ ​the​ ​multiple

choice​ ​section​ ​and​ ​the​ ​open-ended​ ​responses​ ​that​ ​allowed​ ​for​ ​thoughts,​ ​opinions​ ​and​ ​feedback​ ​form​ ​each

of​ ​the​ ​220​ ​dietitians​ ​that​ ​participated.​ ​The​ ​observational​ ​effect​ ​of​ ​the​ ​outcomes​ ​was​ ​that​ ​despite​ ​having

reached​ ​out​ ​to​ ​several​ ​services,​ ​only​ ​an​ ​estimated​ ​6%​ ​of​ ​the​ ​individuals​ ​reached​ ​out​ ​to,​ ​responded.​ ​What

was​ ​consistently​ ​noted​ ​from​ ​the​ ​220​ ​responses​ ​was​ ​that​ ​majority​ ​of​ ​the​ ​dietitians​ ​(87%)​ ​were​ ​working

within​ ​a​ ​multidisciplinary​ ​service​ ​and​ ​could​ ​be​ ​classified​ ​as​ ​diabetes​ ​educator​ ​(92%),​ ​endocrinologist/

diabetes​ ​specialist​ ​(38%)​ ​and​ ​obstetrician​ ​(38%).

Assessment

With​ ​the​ ​motive​ ​of​ ​evaluating​ ​the​ ​dietitian's​ ​practices​ ​with​ ​a​ ​rise​ ​in​ ​GDM​ ​prognosis​ ​in​ ​Australia,

the​ ​appropriateness​ ​of​ ​this​ ​cross-sectional​ ​study​ ​is​ ​supported​ ​by​ ​the​ ​conclusive​ ​evidence​ ​that​ ​surfaced​ ​and

new​ ​knowledge​ ​that​ ​has​ ​been​ ​provided​ ​from​ ​the​ ​220​ ​participants.​ ​When​ ​taking​ ​a​ ​look​ ​at​ ​the​ ​precision​ ​of

this​ ​study,​ ​the​ ​assessment​ ​of​ ​each​ ​multiple​ ​choice​ ​answer​ ​was​ ​precise​ ​because​ ​there​ ​was​ ​no​ ​other​ ​options

made​ ​available​ ​for​ ​participants​ ​outside​ ​of​ ​the​ ​ones​ ​made​ ​available​ ​for​ ​them.​ ​Precision​ ​of​ ​each​ ​assessment

becomes​ ​confusing​ ​when​ ​reviewed​ ​the​ ​open-ended​ ​questions​ ​proposed​ ​because​ ​each​ ​participant​ ​yields

their​ ​own​ ​unique​ ​thoughts​ ​and​ ​opinions​ ​that​ ​can​ ​make​ ​it​ ​challenging​ ​to​ ​categorize​ ​into​ ​precise​ ​responses

or​ ​categories.​ ​Completion​ ​of​ ​the​ ​online​ ​survey​ ​or​ ​return​ ​of​ ​the​ ​paper​ ​questionnaire​ ​was​ ​considered

implied​ ​consent​ ​from​ ​each​ ​participant.​ ​These​ ​participants​ ​were​ ​from​ ​states​ ​all​ ​around​ ​Australia,​ ​further

hindering​ ​precision.​ ​Measurement​ ​of​ ​each​ ​assessment​ ​was​ ​reviewed​ ​in​ ​order​ ​of​ ​the​ ​questions​ ​proposed​ ​in

the​ ​survey​ ​which​ ​were​ ​as​ ​follows,​ ​“multiple-choice,​ ​open-ended​ ​questions​ ​or​ ​used​ ​Likert​ ​scale​ ​responses

to​ ​report​ ​demographics​ ​(12​ ​questions),​ ​GDM​ ​service​ ​provision​ ​(12​ ​questions),​ ​dietetic​ ​assessment​ ​and

interventions​ ​(11​ ​questions),​ ​screening​ ​and​ ​management​ ​guidelines​ ​(5​ ​questions),​ ​postnatal​ ​management

practices​ ​(8​ ​questions),​ ​as​ ​well​ ​as​ ​information​ ​on​ ​current​ ​guideline​ ​use​ ​and​ ​perceived​ ​need​ ​for​ ​Australian

evidence-based​ ​guidelines.”​​ ​9​​ ​The​ ​observational​ ​effect​ ​of​ ​outcomes​ ​for​ ​the​ ​assessment​ ​in​ ​this​ ​study​ ​was

seen​ ​through​ ​the​ ​honest​ ​responses​ ​that​ ​these​ ​dietitians​ ​completed​ ​the​ ​survey​ ​with.​ ​Dietitians​ ​who
responded​ ​yielded​ ​a​ ​variety​ ​of​ ​positions​ ​such​ ​as​ ​full-time,​ ​DAA​ ​membership​ ​and​ ​DAA​ ​interest​ ​groups

and​ ​were​ ​from​ ​states​ ​representing​ ​NSW,​ ​VIC​ ​and​ ​QLD​ ​responded;​ ​allowing​ ​an​ ​array​ ​of​ ​opinions​ ​from

Australian​ ​states.

Results

Estimation​ ​during​ ​this​ ​study​ ​was​ ​precise​ ​and​ ​uniform,with​ ​little​ ​ambiguity​ ​with​ ​the​ ​multiple

choice​ ​responses​ ​and​ ​higher​ ​variability​ ​in​ ​the​ ​open-ended​ ​responses.​ ​On​ ​the​ ​end​ ​of​ ​the​ ​observers,​ ​there

was​ ​a​ ​high​ ​amount​ ​of​ ​estimation​ ​needed​ ​when​ ​categorizes​ ​the​ ​written​ ​responses​ ​from​ ​each​ ​participant.

The​ ​inference​ ​from​ ​this​ ​study​ ​is​ ​that​ ​while​ ​54%​ ​of​ ​participants​ ​expressed​ ​their​ ​services​ ​to​ ​the​ ​GDM

patients​ ​being​ ​adequate,​ ​86-87%​ ​of​ ​participants​ ​also​ ​felt​ ​a​ ​strong​ ​need​ ​for​ ​GDM​ ​dietetic​ ​guidelines​ ​and

nutrition​ ​recommendations.​ ​“When​ ​asked​ ​to​ ​describe​ ​their​ ​level​ ​of​ ​confidence​ ​in​ ​GDM​ ​management,​ ​33%

were​ ​very​ ​confident,​ ​50%​ ​confident,​ ​16%​ ​somewhat​ ​confident​ ​and​ ​1%​ ​not​ ​confident.​9​ ​”​ ​While​ ​the​ ​goal​ ​of

this​ ​study​ ​to​ ​to​ ​further​ ​understand​ ​the​ ​role​ ​of​ ​a​ ​dietitian​ ​in​ ​GDM​ ​prognosis​ ​and​ ​management,​ ​what​ ​is

noted​ ​in​ ​this​ ​study​ ​is​ ​that​ ​there​ ​are​ ​a​ ​variety​ ​of​ ​dietitians​ ​that​ ​feel​ ​on​ ​different​ ​scales​ ​on​ ​confidents.​ ​With

that​ ​in​ ​mind,​ ​the​ ​observer​ ​should​ ​take​ ​into​ ​consideration​ ​this​ ​variability​ ​between​ ​participants​ ​and​ ​the

conclusive​ ​findings​ ​of​ ​on​ ​effectiveness​ ​of​ ​current​ ​dietetic​ ​guidelines.

Interpretation

What​ ​is​ ​included​ ​in​ ​this​ ​study​ ​is​ ​that​ ​there​ ​are​ ​differences​ ​in​ ​the​ ​implementation​ ​of​ ​MNT

practices​ ​and​ ​guidelines​ ​for​ ​GDM​ ​management.​ ​Two-thirds​ ​of​ ​participants​ ​reported​ ​that​ ​only​ ​one​ ​to​ ​two

consults​ ​per​ ​client​ ​were​ ​provided​ ​per​ ​week,​ ​a​ ​value​ ​lower​ ​than​ ​what​ ​is​ ​recommended​ ​in​ ​ADA​ ​guidelines

(which​ ​recommends​ ​a​ ​minimum​ ​of​ ​3​ ​consultations).​ ​Additionality,​ ​less​ ​than​ ​half​ ​of​ ​the​ ​participants​ ​were

able​ ​to​ ​provide​ ​a​ ​consultation​ ​within​ ​a​ ​week’s​ ​time,​ ​also​ ​a​ ​standard​ ​recommendation​ ​in​ ​the​ ​ADA

guidelines.​ ​The​ ​efficacy​ ​of​ ​this​ ​study​ ​is​ ​addressed​ ​in​ ​gaining​ ​a​ ​better​ ​understanding​ ​a​ ​dietitian’s​ ​role​ ​in

GDM.​ ​The​ ​main​ ​difference​ ​noted​ ​through​ ​this​ ​study​ ​is​ ​that​ ​there​ ​are​ ​inconsistencies​ ​with​ ​the​ ​guidelines

that​ ​are​ ​currently​ ​available​ ​and​ ​the​ ​practices​ ​that​ ​are​ ​currently​ ​being​ ​executed​ ​by​ ​dietitians.​ ​The​ ​absence
of​ ​specific​ ​guidelines​ ​hinders​ ​efficacy​ ​in​ ​glycemic​ ​control,​ ​clinical​ ​judgement,​ ​staffing​ ​levels,​ ​specific

issues​ ​related​ ​to​ ​literacy,​ ​language​ ​spoken​ ​and​ ​health​ ​care​ ​services.​9​ ​The​ ​survey​ ​concluded​ ​a​ ​variability​ ​in

reported​ ​glycemic​ ​targets,​ ​as​ ​noted​ ​in​ ​the​ ​efficacy​ ​section.​ ​This​ ​places​ ​the​ ​patients​ ​and​ ​participants​ ​of​ ​this

study​ ​in​ ​a​ ​varied​ ​range​ ​of​ ​harm,​ ​as​ ​some​ ​are​ ​receiving​ ​care​ ​and​ ​services​ ​that​ ​might​ ​be​ ​missed​ ​by​ ​another.

The​ ​interactions​ ​of​ ​this​ ​study​ ​are​ ​seen​ ​in​ ​the​ ​role​ ​of​ ​the​ ​dietitian​ ​with​ ​GDM​ ​and​ ​GDM​ ​management​ ​for

each​ ​patient;​ ​providing​ ​greater​ ​emphasis​ ​in​ ​nutrition​ ​education,​ ​consultation​ ​and​ ​meeting​ ​ADA

guidelines.

Extrapolation

From​ ​this​ ​survey,​ ​it​ ​could​ ​be​ ​said​ ​that​ ​future​ ​patients​ ​of​ ​these​ ​registered​ ​dietitians​ ​will​ ​be

receiving​ ​services​ ​that​ ​range​ ​in​ ​terms​ ​of​ ​MNT​ ​confidence,​ ​assessing​ ​glycemic​ ​values​ ​and​ ​overall​ ​success.

What​ ​can​ ​be​ ​drawn​ ​from​ ​this​ ​study​ ​is​ ​that​ ​there​ ​is​ ​a​ ​demand​ ​for​ ​specific​ ​guidelines​ ​for​ ​proper​ ​gestational

diabetes​ ​care.​ ​It​ ​is​ ​suggested​ ​by​ ​the​ ​majority​ ​of​ ​the​ ​220​ ​participants​ ​that​ ​these​ ​guidelines​ ​should​ ​be​ ​met​ ​by

the​ ​national​ ​DAA​ ​endorsed​ ​dietetic​ ​practice​ ​guidelines​ ​and​ ​nutrition.​ ​The​ ​services​ ​that​ ​will​ ​be​ ​provided​ ​to

future​ ​patients​ ​depend​ ​on​ ​the​ ​MNT​ ​quality​ ​and​ ​personal​ ​efforts​ ​exerted​ ​by​ ​the​ ​RD.​ ​While​ ​there​ ​has​ ​been

limited​ ​research​ ​for​ ​dietetic​ ​interventions​ ​specific​ ​for​ ​patients​ ​diagnosed​ ​with​ ​gestational​ ​diabetes,​ ​there

have​ ​been​ ​larger​ ​prevention​ ​trials​ ​that​ ​confirm​ ​benefits​ ​for​ ​the​ ​patient’s​ ​lifestyle​ ​and​ ​wellbeing.​11​​ ​There

have​ ​also​ ​been​ ​other​ ​studies​ ​that​ ​have​ ​suggest​ ​the​ ​need​ ​for​ ​additional​ ​resources​ ​in​ ​addressing​ ​gestational

diabetes​ ​and​ ​a​ ​guideline​ ​for​ ​proper​ ​management.​12​​ ​The​ ​previous​ ​studies​ ​mentioned​ ​are​ ​similar​ ​to​ ​this

study​ ​in​ ​the​ ​sense​ ​of​ ​addressing​ ​an​ ​absence​ ​in​ ​quality​ ​and​ ​efficiency​ ​for​ ​GDM​ ​management​ ​and​ ​care.

Rather​ ​than​ ​having​ ​studies​ ​that​ ​have​ ​shown​ ​similarities,​ ​the​ ​studies​ ​mentioned​ ​previously​ ​further​ ​validate

the​ ​need​ ​for​ ​more​ ​investigation​ ​of​ ​the​ ​implementation​ ​of​ ​specific​ ​guidelines​ ​for​ ​GDM​ ​nutrition

management.​ ​This​ ​relates​ ​to​ ​our​ ​research​ ​in​ ​allowing​ ​further​ ​insight​ ​into​ ​the​ ​role​ ​of​ ​the​ ​RD​ ​with​ ​GDM

care,​ ​considering​ ​areas​ ​needing​ ​improvement​ ​and​ ​areas​ ​that​ ​favor​ ​the​ ​role​ ​over​ ​the​ ​primary​ ​physician.
Citations

1. 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.

2. M.A.​ ​Russell,​ ​M.G.​ ​Phipps,​ ​C.L.​ ​Olson,​ ​H.G.​ ​Welch,​ ​M.W.​ ​(2006)​ ​Carpenter​ ​Rates​ ​of
postpartum​ ​glucose​ ​testing​ ​after​ ​gestational​ ​diabetes​ ​mellitus.​ ​Obstet​ ​Gynecol​,​ ​108,​ ​pp.
1456-1462

3. C.​ ​Kim,​ ​B.P.​ ​Tabaei,​ ​R.​ ​Burke,​ ​L.N.​ ​McEwen,​ ​R.W.​ ​Lash,​ ​S.L.​ ​Johnson,​ ​et​ ​al.​ ​(2006)​ ​Missed
opportunities​ ​for​ ​type​ ​2​ ​diabetes​ ​mellitus​ ​screening​ ​among​ ​women​ ​with​ ​a​ ​history​ ​of​ ​gestational
diabetes​ ​mellitus.​ ​Am​ ​J​ ​Public​ ​Health​,​ ​96​ ​,​ ​pp.​ ​1643-1648

4. L.R.​ ​Greenberg,​ ​T.R.​ ​Moore,​ ​H.​ ​Murphy.​ ​(1995)​ ​Gestational​ ​diabetes​ ​mellitus:​ ​antenatal
variables​ ​as​ ​predictors​ ​of​ ​postpartum​ ​glucose​ ​intolerance.​ ​Obstet​ ​Gynecol​,​ ​86,​ ​pp.​ ​97-101

5. K.J.​ ​Hunt,​ ​S.L.​ ​Logan,​ ​D.L.​ ​Conway,​ ​J.E.​ ​Korte​ ​(2010).​ ​Postpartum​ ​screening​ ​following​ ​GDM:
how​ ​well​ ​are​ ​we​ ​doing?​ ​Curr​ ​Diab​ ​Rep​,​ ​10,​ ​pp.​ ​235-241

6. Templeton​ ​M​,​ ​Pieris-Caldwell​ ​I​.​ ​Gestational​ ​Diabetes​ ​Mellitus​ ​in​ ​Australia,​ ​2008​.​ ​Canberra:
Australian​ ​Institute​ ​of​ ​Health​ ​and​ ​Welfare​.

7. Anderson​ ​K,​ ​Barbeau​ ​M-C,​ ​Blagrave​ ​P​ ​et​ ​al.​ ​(2006)​ ​Recommendations​ ​for​ ​nutrition​ ​best​ ​practice
in​ ​the​ ​management​ ​of​ ​gestational​ ​diabetes​ ​mellitus.​ ​Can​ ​J​ ​Diet​ ​Pract​ ​Res,​ ​67:​ ​206–8.

8. Weintrob​ ​N,​ ​Karp​ ​M,​ ​Hod​ ​M.​ ​(1996)​ ​Short-​ ​and​ ​long-range​ ​complications​ ​in​ ​offspring​ ​of​ ​diabetic
mothers.​ ​J​ ​Diabetes​ ​Complications​.​ ​10:​ ​294–301.

9. 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.

10. Reader​ ​D,​ ​Splett​ ​P,​ ​Gunderson​ ​EP.​ ​(2006)​ ​For​ ​the​ ​Diabetes​ ​Care​ ​and​ ​Education​ ​Dietetic​ ​Practice
Group.​ ​Impact​ ​of​ ​gestational​ ​diabetes​ ​mellitus​ ​nutrition​ ​practice​ ​guidelines​ ​implemented​ ​by
registered​ ​dietitians​ ​on​ ​pregnancy​ ​outcomes.​ ​J​ ​Am​ ​Diet​ ​Assoc​,​ ​106:​ ​1426–33.

11. The​ ​Diabetes​ ​Prevention​ ​Program​ ​Research​ ​Group​ ​(2002).​ ​Reduction​ ​in​ ​the​ ​incidence​ ​of​ ​type​ ​2
diabetes​ ​with​ ​lifestyle​ ​intervention​ ​or​ ​metformin.​ ​N​ ​Engl​ ​J​ ​Med​,​ ​346:​ ​393–403.
12. Hoffman​ ​L,​ ​Nolan​ ​C,​ ​Wilson​ ​JD,​ ​Oats​ ​JN,​ ​Simmons​ ​D.​ ​(1998).​ ​Gestational​ ​diabetes
mellitus—management​ ​guidelines.​ ​Med​ ​J​ ​Aust​,​ ​169:​ ​93–7.