RESEARCH ARTICLES

Implications of diet restrictions in the daily lives of women with gestational Diabetes Mellitus

Joice Moreira Schmalfuss^I; Ana Lucia de Lourenzi Bonilha^II

^I Master in Nursing. Specialist in Obstetric Nursing. Assistant Professor of Graduate Program in Nursing at the Federal University of Fronteira do Sul. Chapecó, Santa Catarina, Brazil. E-mail: joicemschmalfuss@gmail.com
^II PhD in Nursing. Professor of the School of Nursing and the Graduate Program in Nursing of the Federal University of Rio Grande do Sul. Porto Alegre, Rio Grande do Sul, Brazil. E-mail: bonilha.ana@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.5712

ABSTRACT

Diet is one of the main focuses of treatment for diabetic pregnant women, and constitutes a recommended strategy for appropriate gestational monitoring and healthy childbirth. This qualitative, descriptive study examined the implications of diet restrictions in the daily lives of women with gestational diabetes mellitus. The study was performed between July and November 2010 at a university hospital in the city of Porto Alegre, Rio Grande do Sul, by means of interviews of 25 diabetic pregnant women in outpatient care. Data assessment was thematic. The women had difficulty sticking to the prescribed diet plan, which has adverse implications for their daily lives. Nutritional counseling should be flexible and contemplate the social condition of each pregnant woman. Care strategies and proposals should be developed to help these women surmount diet-related obstacles.

Keywords: Gestational diabetes; high-risk pregnancy; antenatal care; diet for diabetics.

INTRODUCTION

Gestational diabetes mellitus (GDM) is one of the classifications¹ of diabetes mellitus (DM), which is defined as a group of metabolic diseases of multiple etiology characterized by hyperglycemia due to effects on insulin secretion and/or action^1,2 that most frequently coincides with pregnancy ³.

Approximately 7% of all pregnancies in the world are complicated by GDM, resulting in more than 200,000 cases per year and representing 90% of cases of this disease. The prevalence may range from 1 to 14% depending on the population studied and the diagnostic tests employed⁴. In Spain, the prevalence of GDM in women attending endocrinology and nutrition services and in high-risk obstetric consultations was 4.2%³.

In Brazil, in 2010, the prevalence of GDM in women over 20 years of age attended at the Health System was 7.6%⁵. Study to determine the prevalence of GDM in pregnant women attended at Basic Health Units of the city of Vitoria/ES concluded that this rate was 5.8% in a sample of 396 pregnant women⁶. In another study conducted in Pelotas/RS, which investigated the factors associated with GDM in 4,243 mothers, the prevalence of the disease was 2.95%⁷.

Rates quoted above demonstrate the relevance of GDM, both as a complication acquired in the course of pregnancy, and as a public health problem. This finding is aggravated when the disease is not controlled, which may result in serious consequences for the mother-infant dyad.

Because of this and in order to avoid losses that may affect the dyad, it is essential that women with GDM adopt care, such as: glycemic control, physical activity, outpatient follow-up with qualified professionals to meet high-risk pregnancies, along the accomplishment of diet. This latter item, in particular, has great importance for the successful treatment of GDM, in addition to be a recommended strategy for an appropriate gestational monitoring and for the birth of a healthy baby.

Given the above, the following question arises: what are the implications caused by dietary restrictions in the daily lives of women with GDM? Thus, the aim of this research was to understand the implications of dietary restrictions in the daily lives of women with GDM.

LITERATURE REVIEW

During pregnancy, metabolic changes occur in the woman's body in order to support the baby for it to grow and develop in a healthy way⁸. These changes include fasting hypoglycemia, excessive catabolism of lipids with consequent formation of ketone bodies and increased insulin resistance ².

Insulin resistance increases as the placenta grows and the production of progesterone, cortisol, human placental lactogen, prolactin, growth hormone, and somatotropin hormones increases ^2,8.

Increase in placental hormone production occurs around the 20th week of gestation and progresses until the end of it. It is the most responsible for the resistance of the maternal organism to the production of insulin. As a result, more insulin is secreted to overcome this resistance, which ultimately causes a glycemic decompensation that can affect the mother and the baby^2,8. For this reason, DMG is often diagnosed in the late second or early third trimester of pregnancy, when, due to hormonal action, insulin resistance becomes increased.

Diabetes in pregnancy is often associated with complications such as hypoglycemia, hyperglycemia, ketoacidosis, retinopathy, nephropathy, hypertensive disorders of pregnancy, polyhydramnios, preterm labor, cesarean section by shoulders dystocia, congenital anomalies (cardiac, renal, neurological and gastrointestinal), decreased brain growth, fetal macrosomia, clavicle fracture, brachial plexus injury, hypoglycemia, and neonatal hyperbilirubinemia, hyaline membrane disease and antenatal corticosteroid therapy^2,9-11.

Given these complications, care for pregnant women with GDM should start from the first prenatal consultation, and screening for the detection of this disease must be mandatory. Frequent and rigorous evaluations performed by the prenatal care professional aim at the identification of any change and should extend throughout the pregnancy, only ending six weeks after the birth.

Regarding the management of GDM, it is noteworthy that 60% of pregnant women can keep euglycemic only with diet and physical activity, without carrying higher risks for pregnancy⁵ and maternal hyperglycemia should be carefully controlled only with diet ¹².

In this perspective, study using the educational intervention as implementation of self-care and treatment adherence concluded that after the development of this intervention with a group of diabetics, it produced better results regarding treatment adherence, knowledge about the disease, strategies to conserve their well-being and responsibility for their health, generating a new nutritional concept when compared to a control group (that received no intervention)¹³.

This shows the importance of health professionals advise pregnant women about their nutritional diet, valuing their complaints and difficulties, as well as facilitating their dietary adjustments to the prescribed food, so that they are successful in their treatment and avoid the need for supplementation with insulin.

In this context, study that aimed to identify the nursing care provided to women with GDM during antenatal care found that all items included in the sample showed conformity with the decisive role played by nurses in the care provided to diabetic pregnant women, stressing the importance that this professional has with regard to the practice of health education in their daily work in order to enhance self-care of women with GDM¹⁴.

Corroborando com o exposto, outro estudo que objetivou analisar as estratégias educativas utilizadas junto às pessoas com hipertensão e DM, constatou que os profissionais mais envolvidos com o enfoque educativo são os enfermeiros e que as estratégias emancipatórias foram as mais frequentes entre os estudos publicados¹⁵.

METHODOLOGY

This is a qualitative descriptive research conducted in a university hospital in the city of Porto Alegre/RS, considered a reference for the care of high-risk pregnancies, which also performs diabetic women groups weekly.

Study participants were 25 women with GDM in outpatient follow-up. Inclusion criteria were: pregnant women with 18 years of age or older; with diagnosis of GDM and gestational age over 20 weeks. Exclusion criteria were: pregnant women diagnosed with pre-gestational diabetes and who had the pregnancy interrupted or fetal loss.

We decided to only include in the research pregnant women with GDM, because contrary to what happens to women who have diabetes prior to pregnancy (DM type 1 or 2), those that found themselves diabetic during pregnancy have the addition of a risk condition that extrapolate peculiarities inherent in any low-risk pregnancy. Gestational age over 20 weeks was also considered an inclusion criterion because GDM is typically diagnosed from the 20th week, when insulin resistance becomes increased due to hormones produced by the placenta. In order to preserve the identity of the participants included in the study, they were identified with the letter P for pregnant, followed by numbers from 1 to 25.

Data collection was carried out from July to November 2010, on Mondays (the day in which the group occurs), when pregnant women who met the inclusion criteria were identified and selected. Approaches and invitations were made by the researcher at the place of care for pregnant women, through verbal contact with potential participants. Upon acceptance of women and signing the Informed Consent Form, a search was conducted in their electronic medical record and in their prenatal card to collect necessary data and, then, we proceeded to the semi-structured interview. Interviews had an average duration of 30 minutes, were conducted on the facilities of roomin-in care, in an environment that ensured the privacy of women interviewed, and recorded on a digital recorder MP3 Player type.

Data from this study were analyzed according to content analysis of thematic type proposed by Bardin¹⁶. The legal provisions of Resolution of National Health Council number 466/2012 have been respected in this research¹⁷, and it was conducted in accordance with the required ethical standards, having its project approved by the Scientific Committee and Committee on Research Ethics in Health of Porto Alegre Clinical Hospital (HCPA) under number 100230/2010.

RESULTS AND DISCUSSION

Characterization of pregnant women

The average age of the 25 women interviewed was 29.8 years old, with ages ranging between 21 and 39 years old. The findings of this research are close to the data from a study conducted in a university hospital in Rio de Janeiro/RJ, which revealed the average age of 29.6 years old of 21 pregnant women with gestational diabetes mellitus who were in outpatient follow-up¹⁸.

In relation to the profession of pregnant women, it was found that 12 of them are housewives, 12 work with service provision activities, such as housemaid, cook, manicure, hairdresser, secretary, among others, and one is self-employed. Similar data were found in a study conducted in Porto Alegre/RS, in the same hospital object of this research in 2001, which found that of 105 pregnant women in the sample, 51.4% were engaged in household activities and only 1.9% developed autonomously activities¹⁹.

As for education of participants, 10 had incomplete primary education; two had complete primary education; three did not complete high school, six completed it, and four attended technical courses, and none of the participants had attended higher education. These data indicate that approximately one third of pregnant women interviewed did not complete primary education.

Regarding marital status, 21 respondents live with a partner, while four have no partner, characterized as single or separated. There were similarity to the findings of another study in the same research site, in which most participants (70.5%, or 74 pregnant women) were married and/or had a partner ¹⁹.

Implications of food restrictions in the daily lives of women with GDM

Diet is a major focus of the treatment of diabetic pregnant women, and nutritional guidance should be provided by a nutritionist to indicate the appropriate caloric values for food intake of a pregnant woman. In general, the estimated caloric need is between 1,800 and 2,220 total daily calories ²⁰, while that the caloric values ingested by the study participants ranged from 1,600 for the minimum consumption and 2,300 for maximum consumption, with an average of 2,000 total daily calories.

When asked about the type of diet followed, there were those who were following the diet prescribed by the nutritionist that performs the outpatient follow-up treatment of high risk prenatal, in the hospital of the present study. This statement was observed in reports:

[...] I follow that diet she (nutritionist) gave to me. I eat what is marked there... The amount. (P5)

I have completely cut sugar and reduced the food portions, because I used to eat much more than that. (P16)

I simply follow the diet, I do not eat anything at the wrong time. (P21)

I have cut the sugar, I have cut the carbs. (P6)

But even if some participants have stated performing the diet as directed in the high risk prenatal clinic, many stated having difficulties in strictly obeying the nutritional guidelines:

[...] I do not do correctly six meals a day, I don't. (P4)

[...] to me, the major difficult is having six meals a day, because I do not have the habit of eating six meals a day. (P8)

Considering that the food plan should be divided into fractions with lower volume, previously stipulated time, and controlled intervals and five to six meals a day²¹, the nurse plays an important role when it is noticed non-compliance with the prescribed diet plan. The nurse should plan, negotiate and accommodate food preferences of women in order to facilitate the adaptation and adherence to the diet that was proposed by professionals who follow the nutritional aspect of their high-risk pregnancy^22-24.

Other difficulties with food restriction were also related to the working environment of pregnant women:

[...] the problem is when I'm working, and I stay there almost all day long. So, there isn't whole meal bread, there isn't whole grain cookies, no milk, there is almost nothing like that. (P2)

[...] I am forced to stick out on the diet because of the working hours. If you are serving someone, you cannot stop at that time, or if you are doing something else. (P3)

It's difficult at my workplace. At home I even have a better control, but at my workplace there is no way. (P6)

Difficulties experienced by pregnant women in relation to diet were present in many different ways, and we observed negative feelings towards the impossibility to eat something they would like, as acknowledged in the following statements:

[...] I cannot eat what I want to eat. It's torture when you cannot eat what you want to eat. I have always been used to eat and now I cannot eat. It's too bad. (P10)

I'm finding it very bad because before I didn't deprive myself from eating anything and now I have to go there, look on the refrigerator door whether in such a time I can eat that. I cannot eat candy... (P18)

Before I was used to eat everything, I had no limits to anything [...]. And now it's different... Some days I feel a discomfort, a desire to eat something. And I can't. This is the hardest part. (P24)

With regard to food reeducation, it is noted that, for many individuals, the act of eating is one of the greatest joys of life, a way to balance something or even a way to dismiss a problem or disappointment^{10,12,14,15,20-24}.

In addition to that exposed above, the deprivation of eating certain foods can sometimes cause feelings of discontent among pregnant²⁴. This fact, not only generated frustration but can also result in difficulties in dealing with GDM and anger with the disease, so it is recommended that the professionals who follow these women ask for psychological counseling in order to help them understand the need for food planning for a good maternal and fetal prognosis^20-24.

The possibility for pregnant women to fail in adjusting to the eating plan is also another common fear expressed by them²², and the desire to eat a forbidden food was reported by participants as very difficult to control, especially because it was not common before pregnancy.

[...] it is more complicated because now we feel like eating things that we looked at before or didn't care. (P6)

[...] I know I'm with diabetes. So I know I can't eat, but that makes me want to eat. It's something that keeps calling you [laughs]. (P9)

It is noteworthy that in addition to the strong desire to eat food not recommended in the nutritional treatment, the possibility of failure can also occur due to financial difficulties and/or anxiety ²³, external factors that should be checked by professionals who follow the prenatal diabetic women.

Closely related to anxiety factor, some participants stated they could not stop eating some desired food, disregarding the prescribed nutritional guidance:

[...] I like a little chocolate from time to time. When I am with a strong desire, I eat. (P1)

I will not deny that I ate. We always fail in a little something. (G6)

Sometimes I have that crazy desire to eat something sweet. So I sit down with a pot of milk jam, pick up the spoon and eat it. (P9)

Converging on the findings of this research, study performed with 12 diabetic pregnant women, followed up by a Health Institution of Fortaleza/Ceara, found that pregnant women had self-care deficit related to diet²³.

However, even with some participants having expressed difficulties in following the prescribed diet, others said they did not eat anything but the diet, as the statements show:

[...] I feel like eating, but I don't. (P13)

Sometimes I can eat a little something more, but I can't eat. I wish I ate a cookie, but I can't, I get stymied. So the way I'm taking care of myself is by strictly following the diet. (P17)

In order to achieve success in nutritional therapy of pregnant women, the ideal is that it is approached in an inter and multidisciplinary way in order to allow an appropriate weight gain, glucose levels control and the absence of ketone bodies, factors that will result in benefits for maternal and fetal health^21-23.

In addressing the social interaction, special attention should be given to diabetic pregnant women, as one of the factors that can cause them to move away from social activities is the forbiddance of the consumption of certain foods. Thus, the loss in leisure time was another important implication reported by participants, which was strongly associated with food restriction:

[...] these days I went to a party. [...] I left before they cut the cake. (P4)

[...] at the parties, we have to go and we have to look, we can't eat. (P11)

I avoid going to certain places, because I know that if I go there I'll be in the mood to eat. [...] Then I already avoid it, you know, I stay home [...] (P13)

[...] if we go out, to have dinner out or at someone else's house ... Our food is complicated, it's harder. (P15)

Party, for example, I go to birthday parties, I only look. I don't eat [laughs]. (P16)

There are several factors that can influence following the prescribed diet. It is noteworthy that in order to facilitate the adherence to diet by pregnant women, it is recommended that health professionals prioritize the quality of information communicated to each woman and try to facilitate their adherence to the diet, through negotiation and accommodation of their food preferences.

In addition, it is necessary that the diet indicated by the nutritionist is flexible and respect the social condition of each pregnant woman²⁰. Such cares, together with others, are designed to facilitate their adherence to the nutritional guidance, whether by the understanding of the information, by the proper consumption of food or by the more affordable type of food, according to their financial condition.

CONCLUSION

This study has helped understanding the implications of food restrictions in the daily lives of women with GDM. Regarding adherence to the prescribed diet plan, during monitoring high-risk prenatal, participants reported to follow the advice given by the nutritionist. However, although there are participants who reported following the diet, others expressed it difficult to strictly follow the nutritional guidelines, presenting negative feelings and dissatisfaction with the deprivation of some food preferences. Other pregnant women even said to consume foods that are not included in the diet, indicating the lack of adaptation to nutritional plan.

Due to the food restriction, there are participants who also reported losses related to leisure time and habits of attending public places like shopping malls, parties, friends' houses, among others, since they favor the access to food not recommended in the diet.

Thus, it was noticed that there are several consequences caused by food restrictions in the daily lives of women with GDM, and these consequences range from difficulties in adapting to the new diet to major hardships in daily life, especially those related to leisure time.

Allied to these findings, the scarcity of publications on the subject makes it difficult to direct actions for diabetic pregnant women, which is a confirmed limitation in this study. In this context, in order to develop strategies and care proposals to help these women to face the obstacles encountered in high-risk pregnancies, especially those related to difficulties with diet, it is recommended to carry out studies directed to this important part of population.

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