ReviewA systematic review of interventions for Hispanic women with or at risk of Gestational diabetes mellitus (GDM)
Introduction
Gestational diabetes mellitus (GDM) is a serious health challenge for pregnant women [1] with increased risk for caesarean birth and hypertensive disorders [2]. For infants, GDM is linked to increased mortality and morbidity including respiratory distress, macrosomia and special care admission [3]. Longer term, GDM increases women’s risk for type 2 diabetes, and their infants’ risk for obesity, type 2 diabetes and cardiovascular disease [2]. Recent research indicates that high glucose levels or over nutrition during pregnancy can result in a ‘metabolic programming’ effect on the fetus, predisposing the child to early onset diabetes and obesity [4].
Rates of GDM are increasing dramatically in the United States [1], [5] with a 10–100% increase in some ethnic groups in the past 2 decades [5]. Hispanic women are at particularly high risk [6] and in a recent US study, Hispanics had considerably higher rates of GDM (12.1%) compared to non-Hispanic whites (6.8%) [7]. The risk for recurrence of GDM in subsequent pregnancies is also significantly higher amongst Hispanic women [8]. This is of particular concern as Hispanics are the largest minority group in the US, representing approximately 17% of the total population [9] and have higher than average birthrates [9].
Hispanic women incur a disproportionate risk for GDM as they possess additional risk factors that are associated with poor pregnancy outcomes, including; birth outside the US [10]; and overweight/obesity [11]. Cavicchi et al. [11], for example, found that a BMI (Body Mass Index) of 25–29 kg/m2 was associated with 14.4% of GDM cases among Hispanic women, compared to White (8.8%) and Black (7.8%) women while Hedderson et al. [12] suggested that BMI > 25 kg/m2 was attributable to 61.2% of GDM cases among Hispanics. Low levels of education and low socio-economic factors, which are associated with a calorie dense diet and minimal fruit/vegetables [13], may also contribute to this problem [14].
Although GDM poses serious health risks, careful management, which aims to maintain blood glucose levels (BGLs) within normal ranges, mitigates some of these risks. Recommended approaches include: gestational weight gain counselling, nutrition and exercise intervention and pharmacological approaches (oral hypoglycemics or insulin). Most studies evaluating interventions consider their approach to be successful: at reducing insulin requirements; macrosomia and hypertensive disorders, and improving knowledge and pregnancy outcomes [15]. Studies evaluating interventions for GDM that are specifically tailored to cultural groups have shown significant improvements in GDM management behaviours and health outcomes [16], [17]. Nonetheless, a systematic review of nutrition interventions tailored to Asian women with GDM found limited effects on glycemic control and overall pregnancy outcome, however diet changes made in early pregnancy were associated with reduced neonatal birthweight [18]. These findings demonstrate the inconsistencies in this area of research, and it is not clear how existing interventions address the needs of Hispanic women with GDM.
Thus, the aim of this systematic review was to critically examine existing gestational diabetes mellitus (GDM) programs for Hispanic women of Mexican origin. It was intended that the insights gained would inform the development of a GDM intervention for Hispanic Mexican women in US Border regions.
Section snippets
Methods
A systematic review approach was chosen for this project, using Uman’s guidelines [19], p. 57–5919:
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Formulating the review question/s
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Data searching using key search terms
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Study selection using defined inclusion/exclusion criteria
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Data extraction and quality assessment
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Results (Analysis and interpretation of findings)
Results of the search
The literature search took place in Melbourne, Australia and El Paso Texas and was conducted by (MCO, MDG, JL) in January-May 2015. A total of 189 citations were retrieved from electronic databases and hand searches (Fig. 1). After reviewing abstracts and full articles, 22 unique publications related to interventions for the management or prevention of GDM were located. A further four articles were identified when the search criteria was broadened to include studies located in Mexico. After
Discussion
Our goal was to evaluate interventions to assist Hispanic women manage their GDM. However, there is a dearth of studies aimed at this population, and limited consensus as to which approach is most likely to be successful at reducing GDM rates or improving perinatal outcomes. This is concerning as Hispanic populations incur high rates of GDM [30] and they and their infants are at greater risk of adverse perinatal outcomes.
Overall, findings suggest that: (1) intensive nutritional counselling over
Limitations
Limited available literature resulted in a broadening of the original search to include GDM interventions in Mexican settings. Other limitations include the quality of the studies, heterogeneity of study methods, sample size, intervention approaches, all of which limit possible comparison between studies. Variability in GDM diagnosis is a further limitation and three studies that tested for GDM did not describe GDM diagnostic criteria (22, 25, 26). Efforts were made to contact these authors to
Implications and conclusion
Our understanding that Spanish language approaches produce the best results is consistent with the literature [31], [40] and research suggests that language and culturally adapted interventions are more effective for ethnic minorities [41]. Our review indicates not only a dearth of research on GDM interventions for Hispanic women but also few culturally adapted interventions. This is an area that requires much greater attention in the future.
Overall, this review has highlighted a lack of
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