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GESTATIONAL​ ​DIABETES​ ​INTERVENTION:

PHYSICIAN​ ​VS.​ ​REGISTERED​ ​DIETITIAN

Karina​ ​Almanza
Itzel​ ​Dzul-Hernandez
Alejandra​ ​Perez

Dr.​ ​Dena​ ​Herman


FCS​ ​681:​ ​FALL​ ​2017
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​1

TABLE​ ​OF​ ​CONTENTS

ABSTRACT……………………………………………………………………………..………..​ ​2

CHAPTER​ ​1:​ ​INTRODUCTION………………………………………………………...………​ ​3

CHAPTER​ ​2:​ ​REVIEW​ ​OF​ ​LITERATURE……………………………………………….…….​ ​6

CHAPTER​ ​3:​ ​METHODOLOGY…………………………………………..…………………..​ ​28

APPENDIX​ ​A:​ ​SOCIO-ECOLOGICAL​ ​MODEL​ ​THEORY​……………….……………….…​...​ ​38

APPENDIX​ ​B:​ ​EMAIL​ ​SHARED​ ​TO​ ​HOSPITALS​………………..……….….………………​...​ ​39

APPENDIX​ ​C:​ ​EXCEL​ ​DOCUMENTS…………..………………………………..………......​ ​40

APPENDIX​ ​D:​ ​NUTRITION​ ​QUESTIONNAIRE…………………………………….……….​ ​42

APPENDIX​ ​E:​ ​CONSENT​ ​FORM………………………...………………….……………..…​ ​46

APPENDIX​ ​F:​ ​TIMELINE………………………………………………..…………………….​ ​48

REFERENCES…………………………………………….…………………....………………​ ​49
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​2

ABSTRACT

Background​:​ ​Gestational​ ​diabetes​ ​mellitus​ ​(GDM)​ ​is​ ​a​ ​condition​ ​that​ ​impacts​ ​about​ ​12.4%​ ​of

women​ ​in​ ​Los​ ​Angeles​ ​alone​ ​every​ ​year​ ​as​ ​a​ ​result​ ​of​ ​elevated​ ​hormonal​ ​activity​ ​during

pregnancy​ ​(Los​ ​Angeles​ ​County​ ​Department​ ​of​ ​Public​ ​Health,​ ​2010).​ ​To​ ​diagnose​ ​women​ ​with

GDM,​ ​an​ ​oral​ ​glucose​ ​tolerance​ ​test​ ​is​ ​done.​ ​Individuals​ ​qualify​ ​as​ ​having​ ​diabetes​ ​if​ ​their​ ​blood

value​ ​is​ ​140​ ​mg/dL​ ​or​ ​higher​ ​an​ ​hour​ ​after​ ​taking​ ​the​ ​test.

Methods​:​ ​This​ ​study​ ​is​ ​an​ ​observational​ ​study​ ​conducted​ ​in​ ​hospitals​ ​affiliated​ ​with​ ​the​ ​Sweet

Success​ ​Program​ ​in​ ​the​ ​greater​ ​Los​ ​Angeles​ ​area.​ ​Hospitals​ ​include​ ​Providence​ ​Holy​ ​Cross

Medical​ ​Center​ ​in​ ​Mission​ ​Hills,​ ​Kaiser​ ​Permanente​ ​in​ ​Woodland​ ​Hills,​ ​Memorial​ ​Hospital​ ​in

Glendale,​ ​Adventist​ ​Health​ ​White​ ​Memorial​ ​in​ ​Los​ ​Angeles,​ ​and​ ​Huntington​ ​Memorial​ ​Hospital

in​ ​Pasadena.​ ​This​ ​study​ ​will​ ​recruit​ ​as​ ​many​ ​as​ ​1,200​ ​pregnant​ ​women​ ​with​ ​gestational​ ​diabetes

with​ ​the​ ​goal​ ​of​ ​obtaining​ ​500​ ​participants​ ​after​ ​assessing​ ​for​ ​eligibility.​ ​Measured​ ​variables

include​ ​(1)​ ​the​ ​number​ ​of​ ​times​ ​a​ ​patient​ ​meets​ ​with​ ​a​ ​physician​ ​after​ ​GDM​ ​diagnosis,​ ​(2)​ ​the

number​ ​of​ ​times​ ​a​ ​patient​ ​meets​ ​with​ ​an​ ​RD​ ​after​ ​GDM​ ​diagnosis,​ ​(4)​ ​the​ ​forms​ ​of​ ​GDM

education​ ​received,​ ​(5)​ ​the​ ​average​ ​carbohydrate​ ​intake,​ ​and​ ​(6)​ ​blood​ ​glucose​ ​values.

Hypothesis​:​ ​Women​ ​with​ ​gestational​ ​diabetes​ ​who​ ​receive​ ​nutrition​ ​education​ ​from​ ​an

interdisciplinary​ ​team​ ​that​ ​includes​ ​meeting​ ​with​ ​a​ ​physician​ ​and​ ​individual​ ​counseling​ ​sessions

with​ ​a​ ​registered​ ​dietitian​ ​will​ ​have​ ​lower​ ​fasting​ ​blood​ ​glucose​ ​levels​ ​and​ ​demonstrate​ ​better

nutrition​ ​knowledge​ ​retention.

Keywords​:​ ​Gestational​ ​Diabetes​ ​(GDM),​ ​pregnancy,​ ​registered​ ​dietitian​ ​(RDN),​ ​primary

physician​ ​(MD),​ ​blood​ ​glucose​ ​management,​ ​nutrition,​ ​health,​ ​education,​ ​survey,​ ​interview
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​3

CHAPTER​ ​I
INTRODUCTION

Gestational​ ​diabetes​ ​mellitus​ ​(GDM)​ ​is​ ​a​ ​disorder​ ​of​ ​insulin​ ​resistance​ ​that​ ​arises​ ​during

pregnancy​ ​in​ ​women​ ​who​ ​were​ ​not​ ​previously​ ​diagnosed​ ​with​ ​diabetes.​ ​This​ ​is​ ​caused​ ​by

pregnancy​ ​hormones​ ​interfering​ ​with​ ​the​ ​actions​ ​of​ ​insulin,​ ​a​ ​hormone​ ​that​ ​signals​ ​to​ ​cells​ ​to

take​ ​in​ ​glucose​ ​from​ ​the​ ​bloodstream​ ​after​ ​meal​ ​consumption​ ​(Diabetes​ ​in​ ​Pregnancy).​ ​Pregnant

women​ ​are​ ​screened​ ​for​ ​gestational​ ​diabetes​ ​between​ ​24​ ​and​ ​28​ ​weeks​ ​of​ ​pregnancy​ ​through​ ​a

glucose​ ​tolerance​ ​test,​ ​in​ ​which​ ​they​ ​drink​ ​a​ ​glucose​ ​solution​ ​and​ ​have​ ​their​ ​blood​ ​glucose

measured.​ ​An​ ​abnormally​ ​high​ ​value,​ ​typically​ ​higher​ ​than​ ​140​ ​mg/dL​ ​an​ ​hour​ ​after​ ​drinking​ ​the

solution,​ ​indicates​ ​gestational​ ​diabetes​ ​(U.S.​ ​National​ ​Library​ ​of​ ​Medicine,​ ​2016).​ ​It​ ​was

estimated​ ​that​ ​12.4%​ ​of​ ​pregnant​ ​women​ ​in​ ​the​ ​greater​ ​Los​ ​Angeles​ ​area​ ​were​ ​diagnosed​ ​with

gestational​ ​diabetes​ ​in​ ​2010​ ​(Los​ ​Angeles​ ​Department​ ​of​ ​Public​ ​Health,​ ​2010).

While​ ​some​ ​cases​ ​of​ ​gestational​ ​diabetes​ ​mellitus​ ​(GDM)​ ​require​ ​insulin​ ​medications​ ​as

part​ ​of​ ​treatment,​ ​other​ ​cases​ ​can​ ​be​ ​controlled​ ​with​ ​diet​ ​and​ ​exercise​ ​(U.S.​ ​Department​ ​of

Health​ ​and​ ​Human​ ​Services,​ ​2017).​ ​When​ ​gestational​ ​diabetes​ ​is​ ​not​ ​managed​ ​properly​ ​and

blood​ ​glucose​ ​remains​ ​high​ ​throughout​ ​a​ ​pregnancy,​ ​negative​ ​complications​ ​can​ ​include

pre-eclampsia​ ​(high​ ​blood​ ​pressure),​ ​needing​ ​a​ ​C-section,​ ​complications​ ​during​ ​childbirth,

having​ ​a​ ​very​ ​large​ ​infant​ ​and​ ​increased​ ​risk​ ​of​ ​developing​ ​type​ ​II​ ​diabetes​ ​mellitus​ ​postpartum

(U.S.​ ​Department​ ​of​ ​Health​ ​and​ ​Human​ ​Services,​ ​2017).​ ​ ​A​ ​GDM​ ​care​ ​team​ ​should​ ​ideally​ ​be

composed​ ​of​ ​physicians​ ​(MD),​ ​diabetes​ ​educators,​ ​and​ ​registered​ ​dietitian​ ​nutritionists​ ​(RDN),

and​ ​a​ ​nurse.​ ​As​ ​students​ ​in​ ​the​ ​nutrition​ ​field,​ ​we​ ​care​ ​about​ ​medical​ ​nutrition​ ​therapy​ ​being

effectively​ ​applied​ ​to​ ​cases​ ​of​ ​gestational​ ​diabetes​ ​to​ ​avoid​ ​future​ ​health​ ​complications.
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​4

Even​ ​after​ ​an​ ​individual​ ​is​ ​diagnosed​ ​with​ ​GDM,​ ​barriers​ ​in​ ​communication,​ ​a​ ​lack​ ​of

education​ ​and​ ​other​ ​unknown​ ​factors​ ​can​ ​impede​ ​individuals​ ​from​ ​following​ ​precautions​ ​and

properly​ ​managing​ ​their​ ​high​ ​blood​ ​glucose.​ ​Medical​ ​consultations​ ​with​ ​a​ ​physician​ ​or

obstetrician​ ​(OB)​ ​are​ ​often​ ​brief​ ​and​ ​individuals​ ​may​ ​not​ ​be​ ​able​ ​to​ ​properly​ ​go​ ​over​ ​gestational

diabetes​ ​condition​ ​or​ ​management.​ ​Although​ ​an​ ​RDN​ ​is​ ​the​ ​key​ ​provider​ ​of​ ​nutrition​ ​education,

the​ ​importance​ ​of​ ​their​ ​role​ ​is​ ​often​ ​not​ ​understood​ ​by​ ​pregnant​ ​women,​ ​is​ ​underemphasized​ ​by

physicians,​ ​and​ ​does​ ​not​ ​entail​ ​significant​ ​research​ ​in​ ​justifying​ ​their​ ​role​ ​in​ ​GDM​ ​management.

This​ ​can​ ​lead​ ​to​ ​pregnant​ ​women​ ​skipping​ ​appointments​ ​with​ ​RDNs​ ​or​ ​not​ ​considering​ ​to

schedule​ ​them​ ​at​ ​all.​ ​The​ ​purpose​ ​of​ ​our​ ​research​ ​project​ ​is​ ​to​ ​investigate​ ​if​ ​pregnant​ ​women

with​ ​gestational​ ​diabetes​ ​are​ ​more​ ​likely​ ​to​ ​improve​ ​blood​ ​glucose​ ​management​ ​if​ ​they​ ​are

counseled​ ​by​ ​an​ ​RDN​ ​compared​ ​to​ ​an​ ​MD.​ ​Our​ ​research​ ​question​ ​is,​ ​“Are​ ​women​ ​with

gestational​ ​diabetes​ ​more​ ​likely​ ​to​​ ​improve​ ​blood​ ​glucose​ ​management​,​ ​if​ ​they​ ​are​ ​counseled​ ​by

a​ ​Registered​ ​Dietitian​ ​compared​ ​to​ ​a​ ​Physician?”​ ​Our​ ​proposed​ ​hypothesis​ ​is​ ​that​ ​women​ ​with

GDM​ ​who​ ​receive​ ​nutrition​ ​education​ ​from​ ​an​ ​RDN​ ​in​ ​individual​ ​counseling​ ​sessions​ ​will​ ​have

lower​ ​fasting​ ​blood​ ​glucose​ ​levels​ ​and​ ​make​ ​healthier​ ​food​ ​choices.

In​ ​theory,​ ​there​ ​are​ ​many​ ​factors​ ​that​ ​influence​ ​a​ ​person's​ ​behavior​ ​and​ ​decision​ ​making

when​ ​it​ ​comes​ ​to​ ​nutrition​ ​and​ ​health.​ ​Using​ ​the​ ​social​ ​ecological​ ​model​ ​theory​ ​as​ ​a​ ​tool,​ ​can

help​ ​understand​ ​and​ ​identify​ ​important​ ​factors​ ​that​ ​impede​ ​or​ ​influence​ ​changes​ ​in​ ​behavior​ ​for

better​ ​health​ ​outcomes​ ​for​ ​mother​ ​and​ ​baby.​ ​​ ​This​ ​theoretical​ ​framework​ ​entails​ ​5​ ​different

factors​ ​that​ ​includes​ ​the​ ​individual​ ​factor,​ ​interpersonal​ ​factor,​ ​community​ ​factor,​ ​organizational

factor,​ ​and​ ​the​ ​policy/environmental​ ​factor.​ ​The​ ​social​ ​ecological​ ​model​ ​emphasizes​ ​interactions

between​ ​all​ ​factors​ ​as​ ​they​ ​ultimately​ ​influence​ ​the​ ​health​ ​behaviors​ ​of​ ​the​ ​person​ ​(Boyle,​ ​2013).
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​5

The​ ​individual​ ​factors​ ​for​ ​this​ ​study​ ​includes​ ​women​ ​with​ ​little​ ​to​ ​no​ ​knowledge​ ​in​ ​nutrition​ ​or

gestational​ ​diabetes.​ ​At​ ​the​ ​interpersonal​ ​level,​ ​it​ ​entails​ ​healthcare​ ​teams,​ ​encompassing​ ​a​ ​heavy

focus​ ​on​ ​the​ ​role​ ​of​ ​the​ ​physician​ ​and​ ​registered​ ​dietitian.​ ​At​ ​the​ ​community​ ​level,​ ​women​ ​in​ ​this

study​ ​will​ ​have​ ​access​ ​to​ ​an​ ​organization​ ​that​ ​provides​ ​health​ ​education​ ​and​ ​support​ ​for​ ​the

management​ ​of​ ​GDM​ ​known​ ​as​ ​the​ ​Sweet​ ​Success​ ​Program.​ ​The​ ​organizational​ ​level​ ​includes

hospitals​ ​that​ ​are​ ​affiliated​ ​with​ ​the​ ​Sweet​ ​Success​ ​Program.​ ​Finally,​ ​at​ ​the​ ​policy​ ​and

environmental​ ​level,​ ​would​ ​be​ ​their​ ​accessibility​ ​to​ ​a​ ​Sweet​ ​Success​ ​affiliated​ ​hospital/clinic​ ​and

whether​ ​the​ ​environment​ ​they​ ​live​ ​in​ ​supports​ ​their​ ​goal​ ​of​ ​managing​ ​their​ ​GDM.​ ​Find​ ​Social

Ecological​ ​Model​ ​Theory​ ​in​ ​Appendix:​ ​I.


Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​6

CHAPTER​ ​II
REVIEW​ ​OF​ ​LITERATURE

Different​ ​Management​ ​Techniques​ ​and​ ​Risks​ ​of​ ​GDM

​ ​Analyzing​ ​studies​ ​focused​ ​on​ ​other​ ​different​ ​types​ ​of​ ​management​ ​techniques​ ​for​ ​GDM

can​ ​help​ ​capture​ ​a​ ​more​ ​understanding​ ​on​ ​what​ ​needs​ ​to​ ​be​ ​done​ ​to​ ​help​ ​this​ ​population​ ​more

efficiently.​ ​While​ ​different​ ​management​ ​techniques​ ​are​ ​being​ ​practiced​ ​and​ ​suggested​ ​for​ ​women

with​ ​GDM,​ ​multiple​ ​studies​ ​have​ ​shown​ ​that​ ​adherence​ ​to​ ​glucose​ ​management​ ​that​ ​includes

taking​ ​medications,​ ​special​ ​diet,​ ​and​ ​exercise​ ​is​ ​not​ ​always​ ​the​ ​case.​ ​Therefore,​ ​studies​ ​focused

on​ ​management​ ​for​ ​GDM​ ​strongly​ ​emphasize​ ​the​ ​importance​ ​of​ ​educating​ ​women​ ​on​ ​GDM​ ​and

what​ ​it​ ​really​ ​entails.

Teng​ ​et​ ​al.​ ​(2017)​ ​and​ ​Rossouw​ ​et​ ​al.​ ​(2017)​ ​focused​ ​on​ ​outcomes​ ​that​ ​women​ ​and​ ​their

children​ ​could​ ​be​ ​potentially​ ​be​ ​at​ ​risk​ ​for​ ​as​ ​a​ ​result​ ​of​ ​GDM.​ ​Both​ ​studies​ ​were​ ​conducted​ ​in

China,​ ​therefore,​ ​it​ ​is​ ​important​ ​to​ ​note​ ​that​ ​their​ ​environment​ ​and​ ​lifestyles​ ​are​ ​much​ ​different

than​ ​those​ ​in​ ​the​ ​U.S.​ ​Teng’s​ ​study​ ​investigated​ ​the​ ​long-term​ ​risk​ ​of​ ​metabolic​ ​disorders​ ​in

GDM​ ​mothers​ ​and​ ​their​ ​children.​ ​Mothers​ ​who​ ​gave​ ​birth​ ​between​ ​February​ ​1998​ ​and​ ​July​ ​2005

were​ ​invited​ ​to​ ​be​ ​part​ ​of​ ​the​ ​study,​ ​ultimately​ ​consisting​ ​of​ ​467​ ​mothers​ ​with​ ​gestational

diabetes​ ​and​ ​560​ ​mothers​ ​without​ ​gestational​ ​diabetes.​ ​Of​ ​these​ ​two​ ​groups,​ ​123​ ​mothers​ ​with

gestational​ ​diabetes​ ​were​ ​followed​ ​up​ ​and​ ​only​ ​80​ ​mothers​ ​without​ ​gestational​ ​diabetes​ ​were

followed​ ​up.​ ​Data​ ​analyzed​ ​included​ ​blood​ ​pressure,​ ​height,​ ​body​ ​weight,​ ​weight​ ​circumference,

oral​ ​glucose​ ​tolerance​ ​test​ ​(OGTT),​ ​and​ ​blood​ ​tests​ ​such​ ​as​ ​fasting​ ​blood​ ​glucose,​ ​insulin,

triglycerides,​ ​and​ ​cholesterol.​ ​To​ ​obtain​ ​information,​ ​participants​ ​were​ ​followed-up​ ​by​ ​telephone

and​ ​at​ ​their​ ​outpatient​ ​clinic.​ ​After​ ​conducting​ ​a​ ​statistical​ ​analysis​ ​using​ ​a​ ​t-test​ ​on​ ​the​ ​different

data​ ​obtained,​ ​it​ ​was​ ​concluded​ ​that​ ​GDM​ ​mothers​ ​and​ ​their​ ​offspring​ ​could​ ​have​ ​higher​ ​risk​ ​for
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​7

glucose​ ​and​ ​lipid​ ​metabolism​ ​disorders​ ​as​ ​well​ ​a​ ​hypertension​ ​and​ ​overweight​ ​or​ ​obesity​ ​(Teng

et​ ​al.,​ ​2017).​ ​However,​ ​the​ ​small​ ​number​ ​of​ ​participants​ ​that​ ​agreed​ ​to​ ​continue​ ​to​ ​participate​ ​in

the​ ​follow-up​ ​sessions​ ​created​ ​a​ ​limitation​ ​to​ ​the​ ​study​ ​as​ ​well​ ​as​ ​the​ ​unfavorable​ ​ratio​ ​between

GDM​ ​and​ ​non-GDM​ ​mothers​ ​and​ ​children.​ ​Rossouw’s​ ​study​ ​on​ ​the​ ​other​ ​hand,​ ​was​ ​conducted

in​ ​South​ ​Africa,​ ​and​ ​studied​ ​the​ ​prevalence​ ​of​ ​stillborn​ ​babies​ ​in​ ​pregnant​ ​mothers​ ​with​ ​GDM.

Researchers​ ​were​ ​able​ ​to​ ​obtain​ ​records​ ​from​ ​Tygerberg​ ​Hospital​ ​of​ ​all​ ​of​ ​the

diabetes-associated​ ​stillbirths​ ​from​ ​2010-2015,​ ​and​ ​found​ ​56​ ​patients​ ​that​ ​fit​ ​their​ ​criteria.When

looking​ ​at​ ​patients​ ​records,​ ​data​ ​obtained​ ​included​ ​gestational​ ​age,​ ​comorbidities,​ ​treatment

regimens,​ ​appointments​ ​attended​ ​and​ ​abnormalities.​ ​Descriptive​ ​statistics​ ​was​ ​the​ ​method​ ​used

by​ ​researchers​ ​to​ ​analyze​ ​data.​ ​Treatment​ ​regimens​ ​for​ ​these​ ​mothers​ ​included​ ​a​ ​lifestyle

modification​ ​only,​ ​lifestyle​ ​modification​ ​and​ ​metformin,​ ​lifestyle​ ​modification,​ ​metformin,​ ​and

glibenclamide,​ ​ ​lifestyle​ ​modification​ ​and​ ​insulin,​ ​and​ ​any​ ​home​ ​monitoring.​ ​ ​Of​ ​those,​ ​the​ ​most

common​ ​form​ ​of​ ​treatment​ ​or​ ​management​ ​was​ ​lifestyle​ ​modification​ ​plus​ ​insulin​ ​and

self-monitoring​ ​at​ ​home​ ​(Rossouw​ ​et​ ​al.,​ ​2017).​ ​Records​ ​also​ ​showed​ ​that​ ​7%​ ​of​ ​stillbirth​ ​deaths

was​ ​associated​ ​with​ ​GDM,​ ​and​ ​28%​ ​were​ ​detected​ ​to​ ​have​ ​macrossomia​ ​(Rossouw​ ​et​ ​al.,​ ​2017).

Although​ ​multiple​ ​factors​ ​could​ ​have​ ​increased​ ​the​ ​risk​ ​of​ ​ ​stillbirths,​ ​the​ ​strength​ ​to​ ​this​ ​study

was​ ​that​ ​researchers​ ​were​ ​able​ ​to​ ​analyze​ ​patients​ ​records​ ​themselves,​ ​one​ ​of​ ​the​ ​most​ ​accurate

method​ ​of​ ​collecting​ ​data.​ ​Rossouw​ ​et​ ​al.,​ ​came​ ​to​ ​the​ ​conclusion​ ​that​ ​prenatal​ ​care​ ​and

increased​ ​surveillance​ ​from​ ​36​ ​weeks​ ​gestation​ ​may​ ​lower​ ​number​ ​of​ ​stillbirths​ ​(Rossouw​ ​et​ ​al.,

2017).

Other​ ​studies​ ​have​ ​aimed​ ​to​ ​research​ ​different​ ​forms​ ​of​ ​GDM​ ​management.​ ​Gui​ ​at​ ​el.

(2013)​ ​for​ ​example,​ ​further​ ​investigated​ ​the​ ​effects​ ​of​ ​metformin​ ​versus​ ​insulin​ ​in​ ​treating​ ​GDM
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​8

by​ ​looking​ ​into​ ​existing​ ​literature.​ ​Upon​ ​researching,​ ​this​ ​article​ ​grouped​ ​5​ ​different​ ​articles​ ​that

met​ ​specific​ ​criteria​ ​such​ ​as,​ ​patients​ ​with​ ​GDM,​ ​randomized​ ​studies,​ ​compared​ ​insulin​ ​and

metformin,​ ​maternal​ ​outcomes,​ ​and​ ​glycemic​ ​control.​ ​The​ ​grouping​ ​of​ ​articles​ ​compiled​ ​1,270

participants​ ​as​ ​part​ ​of​ ​the​ ​study.​ ​Major​ ​variables​ ​used​ ​to​ ​determine​ ​the​ ​efficiency​ ​of​ ​these

treatments​ ​were​ ​glycemic​ ​control,​ ​maternal​ ​risk,​ ​and​ ​neonatal​ ​outcomes.​ ​The​ ​instrument​ ​used​ ​to

measure​ ​out​ ​theses​ ​specific​ ​variables​ ​was​ ​the​ ​chi-squared​ ​test.​ ​Furthermore,​ ​it​ ​is​ ​inevitable​ ​to

ignore​ ​the​ ​adverse​ ​events​ ​reported​ ​in​ ​this​ ​article​ ​including​ ​the​ ​incident​ ​of​ ​fetal​ ​death​ ​as​ ​a​ ​result

of​ ​insulin​ ​and​ ​an​ ​intrauterine​ ​fetal​ ​death​ ​related​ ​to​ ​use​ ​of​ ​metformin​ ​(Gui​ ​at​ ​el.,​ ​2013).​ ​Still,

researchers​ ​data​ ​showed​ ​that​ ​the​ ​use​ ​of​ ​metformin​ ​on​ ​its​ ​own​ ​could​ ​help​ ​women​ ​with​ ​GDM.

Using​ ​metformin​ ​resulted​ ​with​ ​lower​ ​glycemic​ ​levels​ ​than​ ​insulin,​ ​lower​ ​weight​ ​gain​ ​compared

to​ ​insulin,​ ​and​ ​average​ ​birth​ ​weight​ ​was​ ​lower​ ​(Gui​ ​at​ ​el.​ ​2013).​ ​A​ ​limitation​ ​to​ ​this​ ​study​ ​is​ ​that

they​ ​were​ ​only​ ​able​ ​to​ ​find​ ​5​ ​articles​ ​that​ ​pertained​ ​to​ ​the​ ​focus​ ​of​ ​this​ ​subject​ ​and​ ​the​ ​fact​ ​that​ ​a

meta-analysis​ ​could​ ​have​ ​the​ ​potential​ ​to​ ​be​ ​biased.

Most​ ​recently,​ ​Mathiesen​ ​et​ ​al.​ ​(2017),​ ​planned​ ​a​ ​study​ ​that​ ​explored​ ​the​ ​effects​ ​of

different​ ​types​ ​of​ ​insulin​ ​treatments​ ​on​ ​pregnant​ ​women​ ​with​ ​GDM.​ ​The​ ​gap​ ​in​ ​literature​ ​they

found​ ​was​ ​the​ ​lack​ ​of​ ​large​ ​international​ ​studies.​ ​Therefore,​ ​this​ ​5​ ​year​ ​planned​ ​study​ ​would

include​ ​pregnant​ ​women​ ​with​ ​T1DM​ ​and​ ​T2DM​ ​from​ ​14​ ​different​ ​countries.​ ​In​ ​total,​ ​they​ ​would

expect​ ​3,055​ ​participants​ ​to​ ​start​ ​with​ ​the​ ​anticipation​ ​that​ ​numerous​ ​people​ ​would​ ​drop​ ​out

within​ ​that​ ​long​ ​period​ ​of​ ​time.​ ​Planned​ ​data​ ​collection​ ​methods​ ​consists​ ​of​ ​frequent​ ​follow-ups

for​ ​mother​ ​during​ ​gestation​ ​and​ ​follow-ups​ ​for​ ​infants​ ​at​ ​1​ ​month​ ​and​ ​1​ ​year​ ​of​ ​age​ ​to​ ​analyze

the​ ​outcomes​ ​of​ ​long-term​ ​use.​ ​Ultimately​ ​they​ ​plan​ ​to​ ​collect​ ​height,​ ​weight,​ ​neonatal​ ​deaths,

congenital​ ​malformations,​ ​and​ ​lactation​ ​and​ ​then​ ​analyze​ ​their​ ​data​ ​using​ ​t-test.​ ​The​ ​t-test​ ​will
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​9

allow​ ​them​ ​to​ ​highlight​ ​significant​ ​differences​ ​in​ ​their​ ​data.​ ​Limitation​ ​to​ ​this​ ​study​ ​is​ ​that​ ​it​ ​fails

to​ ​explain​ ​their​ ​research​ ​design​ ​with​ ​more​ ​detail.​ ​Fortunately,​ ​it​ ​will​ ​help​ ​to​ ​determine​ ​behaviors

on​ ​adherence​ ​and​ ​nonadherence​ ​reasons​ ​from​ ​around​ ​the​ ​world,​ ​making​ ​trends​ ​in​ ​barriers​ ​for

GDM​ ​management​ ​more​ ​visible​ ​to​ ​plan​ ​for​ ​action.

The​ ​practice​ ​of​ ​self-monitoring​ ​of​ ​blood​ ​glucose​ ​as​ ​the​ ​only​ ​management​ ​and​ ​educational

tool​ ​for​ ​GDM​ ​has​ ​also​ ​been​ ​studied.​ ​Alfadhli​ ​at​ ​el.​ ​(2016)​ ​carried​ ​out​ ​a​ ​study​ ​that​ ​compared

blood​ ​glucose​ ​self-monitor​ ​alone​ ​to​ ​those​ ​that​ ​practiced​ ​wearing​ ​the​ ​Guardian​ ​Real-Time

Continuous​ ​Glucose​ ​Monitoring​ ​System​ ​along​ ​with​ ​self-monitoring​ ​their​ ​glucose.​ ​130​ ​patients

with​ ​GDM​ ​that​ ​were​ ​seeking​ ​antenatal​ ​care​ ​at​ ​a​ ​hospital​ ​in​ ​Saudi​ ​Arabia​ ​from​ ​2011-2014​ ​were

randomly​ ​placed​ ​in​ ​either​ ​the​ ​control​ ​or​ ​RT-CGMS​ ​group,​ ​leaving​ ​62​ ​patients​ ​in​ ​the​ ​control

group​ ​and​ ​68​ ​patients​ ​in​ ​the​ ​RT-CGMS​ ​group.​ ​Patients​ ​were​ ​instructed​ ​to​ ​record​ ​their​ ​glucose

monitoring​ ​values​ ​for​ ​fasting​ ​and​ ​2​ ​hours​ ​after​ ​every​ ​meal,​ ​a​ ​total​ ​of​ ​4​ ​times​ ​per​ ​day.​ ​HbA1c,

mean​ ​fasting​ ​and​ ​postprandial​ ​glucose​ ​levels,​ ​real​ ​time​ ​continuous​ ​glucose​ ​monitoring,​ ​glycemic

control​ ​and​ ​lastly,​ ​pregnancy​ ​outcomes​ ​were​ ​major​ ​variables​ ​collected​ ​every​ ​week.​ ​Outcomes

were​ ​measured​ ​using​ ​statistical​ ​analysis​ ​software,​ ​to​ ​analyze​ ​statistical​ ​differences​ ​between

treatment​ ​methods.​ ​Strength​ ​to​ ​this​ ​study​ ​is​ ​that​ ​it​ ​is​ ​randomized​ ​controlled​ ​study​ ​in​ ​which​ ​bias

is​ ​limited.​ ​Also​ ​not​ ​only​ ​patients​ ​were​ ​encouraged​ ​to​ ​self-monitor​ ​their​ ​glucose,​ ​but​ ​they​ ​were

also​ ​able​ ​to​ ​learn​ ​how​ ​different​ ​factors​ ​affect​ ​their​ ​blood​ ​results.​ ​Weaknesses​ ​to​ ​this​ ​study

involves​ ​the​ ​fact​ ​that​ ​patients​ ​encountered​ ​difficulties​ ​with​ ​the​ ​self-monitoring​ ​device​ ​including

calibration,​ ​skin​ ​reactions,​ ​disparities​ ​in​ ​readings,​ ​frustration​ ​with​ ​the​ ​alarm,​ ​and​ ​anxiety​ ​from

being​ ​able​ ​to​ ​see​ ​the​ ​their​ ​own​ ​bloor​ ​results​ ​(Alfadhli​ ​at​ ​el.​ ​2016).​ ​The​ ​small​ ​number​ ​of

participants​ ​also​ ​serves​ ​as​ ​one​ ​of​ ​the​ ​studies​ ​weaknesses.​ ​Nonetheless,​ ​the​ ​study​ ​found​ ​that
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​10

self-monitoring​ ​glucose​ ​monitoring​ ​and​ ​using​ ​the​ ​RT-CGMS​ ​proved​ ​that​ ​it​ ​helped​ ​to​ ​educate

and​ ​motivate​ ​women​ ​with​ ​GDM​ ​to​ ​monitor​ ​their​ ​blood​ ​glucose.​ ​However,​ ​using​ ​those​ ​methods

of​ ​management​ ​was​ ​not​ ​associated​ ​with​ ​improvement​ ​in​ ​glycemic​ ​control​ ​or​ ​pregnancy

outcomes​ ​as​ ​there​ ​was​ ​no​ ​significant​ ​differences​ ​in​ ​data​ ​collected​ ​(Alfadhli​ ​at​ ​el.​ ​2016).

Relationship​ ​of​ ​MD​ ​and​ ​GDM

The​ ​importance​ ​of​ ​reviewing​ ​the​ ​role​ ​of​ ​the​ ​physician​ ​with​ ​patients​ ​diagnosed​ ​with

gestational​ ​diabetes​ ​is​ ​crucial​ ​for​ ​our​ ​study.​ ​Physicians​ ​are​ ​generally​ ​well​ ​respected​ ​in​ ​the

medical​ ​field​ ​for​ ​the​ ​prestige​ ​in​ ​completion​ ​of​ ​medical​ ​school​ ​and​ ​accreditation​ ​as​ ​a​ ​practicing

doctor.​ ​Yet,​ ​it​ ​is​ ​not​ ​uncommon​ ​that​ ​physicians​ ​are​ ​also​ ​associated​ ​for​ ​lacking​ ​empathy​ ​or

patience​ ​for​ ​individualized​ ​care​ ​for​ ​each​ ​patient.​ ​One​ ​of​ ​the​ ​common​ ​diagnoses​ ​that​ ​can​ ​be

dismissed​ ​by​ ​a​ ​physician​ ​for​ ​being​ ​the​ ​responsibility​ ​of​ ​the​ ​nurse,​ ​registered​ ​dietitian​ ​or​ ​other

supporting​ ​medical​ ​staff,​ ​is​ ​gestational​ ​diabetes.​ ​In​ ​addressing​ ​the​ ​role​ ​and​ ​characteristics​ ​of​ ​the

registered​ ​dietitian​ ​and​ ​the​ ​physician​ ​in​ ​gestational​ ​diabetes​ ​management,​ ​our​ ​study​ ​can​ ​address

different​ ​methods​ ​of​ ​better​ ​GDM​ ​management.

In​ ​a​ ​study​ ​conducted​ ​by​ ​Hunsburger​ ​et​ ​al.​ ​(2012)​ ​titled,​ ​“Physician​ ​Care​ ​Patterns​ ​and

Adherence​ ​to​ ​Postpartum​ ​Glucose​ ​Testing​ ​after​ ​Gestational​ ​Diabetes​ ​Mellitus​ ​in​ ​Oregon,”​ ​the

reader​ ​is​ ​able​ ​to​ ​learn​ ​about​ ​the​ ​medical​ ​practices​ ​of​ ​physicians​ ​in​ ​response​ ​to​ ​GDM​ ​in​ ​Oregon.

The​ ​285​ ​participants​ ​that​ ​participated​ ​in​ ​this​ ​study​ ​were​ ​selected​ ​if​ ​the​ ​physician​ ​held​ ​active

licenses​ ​with​ ​the​ ​Oregon​ ​Board​ ​of​ ​Medical​ ​Examiners​ ​in​ ​Family​ ​Medicine​ ​and​ ​Obstetrics/

Gynecology.​ ​Each​ ​physician​ ​completed​ ​a​ ​study​ ​as​ ​part​ ​of​ ​the​ ​cross-sectional​ ​study​ ​that​ ​assessed

the​ ​physician’s​ ​knowledge,​ ​attitudes,​ ​beliefs​ ​and​ ​practice​ ​patterns​ ​regarding​ ​the​ ​care​ ​of​ ​women

with​ ​GDM.​ ​What​ ​was​ ​found​ ​was​ ​that​ ​physicians​ ​showed​ ​more​ ​attention​ ​to​ ​detail​ ​for​ ​patients
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​11

with​ ​GDM​ ​after​ ​they​ ​have​ ​given​ ​birth,​ ​warning​ ​a​ ​higher​ ​percentage​ ​of​ ​patients​ ​of​ ​the​ ​increased

risk​ ​for​ ​type​ ​2​ ​diabetes​ ​after​ ​birth​ ​and​ ​following​ ​a​ ​consistent​ ​routine​ ​check-up.​ ​There​ ​were

differences​ ​found​ ​between​ ​the​ ​practices​ ​and​ ​beliefs​ ​of​ ​Ob/Gyn​ ​and​ ​FM​ ​(family​ ​medicine)

physicians,​ ​with​ ​36%​ ​(Ob/Gyn)​ ​to​ ​18.7%​ ​(FM)​ ​agreeing​ ​that​ ​GDM​ ​was​ ​transient.​ ​The​ ​main

success​ ​attributed​ ​to​ ​this​ ​study​ ​is​ ​the​ ​evaluation​ ​of​ ​the​ ​role​ ​of​ ​the​ ​MD​ ​with​ ​GDM​ ​in​ ​the​ ​U.S.,​ ​to

which​ ​limited​ ​studies​ ​have​ ​been​ ​completed.​ ​When​ ​looking​ ​at​ ​weaknesses​ ​in​ ​this​ ​study,​ ​there​ ​was

a​ ​lack​ ​of​ ​responses​ ​from​ ​the​ ​initially​ ​anticipated​ ​sample​ ​size​ ​of​ ​683​ ​physicians.​ ​The​ ​survey​ ​relied

on​ ​self-reported​ ​patterns​ ​and​ ​habits​ ​that​ ​could​ ​represent​ ​false​ ​or​ ​biased​ ​information​ ​in​ ​responses.

Lastly,​ ​while​ ​it​ ​is​ ​a​ ​success​ ​to​ ​see​ ​the​ ​practices​ ​of​ ​physicians​ ​that​ ​are​ ​done​ ​by​ ​a​ ​state​ ​within​ ​our

country,​ ​the​ ​conclusive​ ​findings​ ​from​ ​this​ ​study​ ​only​ ​speak​ ​in​ ​regards​ ​to​ ​the​ ​state​ ​of​ ​Oregon​ ​and

not​ ​the​ ​country​ ​as​ ​a​ ​whole.​ ​With​ ​the​ ​findings​ ​showing​ ​that​ ​physicians​ ​in​ ​Oregon​ ​show​ ​more

support​ ​for​ ​GDM​ ​postpartum​ ​and​ ​that​ ​different​ ​beliefs​ ​are​ ​held​ ​with​ ​different​ ​specialties

(Ob/Gyn​ ​and​ ​FM),​ ​this​ ​could​ ​propose​ ​the​ ​possibility​ ​of​ ​physicians​ ​currently​ ​playing​ ​a​ ​more

active​ ​role​ ​postpartum​ ​with​ ​diabetes​ ​management​ ​rather​ ​than​ ​during​ ​pregnancy.

With​ ​limited​ ​availability​ ​to​ ​recent​ ​studies​ ​conducted​ ​in​ ​the​ ​U.S.,​ ​Lucas​ ​et​ ​al.​ ​(2014)

conducted​ ​a​ ​Systematic​ ​Literature​ ​Review​ ​titled,​ ​“Nutrition​ ​Advice​ ​During​ ​Pregnancy.”​ ​The

review​ ​directly​ ​compares​ ​the​ ​differences​ ​in​ ​physician​ ​services​ ​between​ ​different​ ​countries

including​ ​A​ustralia,​ ​New​ ​Zealand,​ ​United​ ​States​ ​of​ ​America,​ ​Canada,​ ​the​ ​United​ ​Kingdom​ ​and

European​ ​countries.​ ​With​ ​2​ ​out​ ​of​ ​the​ ​31​ ​articles​ ​being​ ​conducted​ ​in​ ​the​ ​U.S.,​ ​different

measurement​ ​tools​ ​included​ ​randomized​ ​control​ ​trials,​ ​pseudo-randomized​ ​control​ ​trial​ ​as​ ​a

cross-sectional​ ​study​ ​and​ ​case​ ​series.​ ​Studies​ ​that​ ​were​ ​selected​ ​addressed​ ​the​ ​following​ ​three

topics,​ ​“​What​ ​nutrition​ ​information​ ​women​ ​received​ ​during​ ​pregnancy,​”​ ​“​Women's​ ​perceptions
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​12

on​ ​nutrition​ ​information​ ​received​ ​during​ ​pregnancy,​”​ ​and​ ​“​Healthcare​ ​providers​ ​perceptions​ ​on

nutrition​ ​information​ ​required​ ​during​ ​pregnancy.​”​ ​The​ ​two​ ​studies​ ​that​ ​will​ ​be​ ​closely​ ​examined

will​ ​me​ ​a​ ​study​ ​by​ ​DeStephano​ ​et​ ​al.​ ​and​ ​Oken​ ​et​ ​al..

In​ ​the​ ​study​ ​conducted​ ​by​ ​DeStephano​ ​et​ ​al.​ ​(2008),​ ​prenatal​ ​educational​ ​videos​ ​were

presented​ ​to​ ​pregnant​ ​Somali​ ​refugees​ ​that​ ​were​ ​randomly​ ​selected​ ​and​ ​then​ ​completed​ ​an​ ​8-item

survey​ ​in​ ​the​ ​effectiveness​ ​of​ ​education.​ ​What​ ​was​ ​found​ ​was​ ​that​ ​all​ ​women​ ​agreed​ ​that​ ​the

survey​ ​was​ ​appropriate​ ​and​ ​96%​ ​of​ ​participants​ ​preferred​ ​educational​ ​videos​ ​to​ ​be​ ​their​ ​main

medium​ ​of​ ​nutrition​ ​education.​ ​In​ ​a​ ​separate​ ​study​ ​conducted​ ​by​ ​Oken​ ​et​ ​al.​ ​(2013),

supplementary​ ​antenatal​ ​care​ ​was​ ​evaluated​ ​to​ ​see​ ​if​ ​there​ ​could​ ​be​ ​an​ ​improvement​ ​in​ ​nutrition

during​ ​pregnancy.​ ​It​ ​was​ ​found​ ​that​ ​food​ ​provision​ ​paired​ ​with​ ​dietary​ ​counseling,​ ​rather​ ​than

counseling​ ​alone,​ ​could​ ​improve​ ​desired​ ​dietary​ ​habits.​ ​The​ ​conclusive​ ​findings​ ​of​ ​which

suggested​ ​that​ ​increased​ ​counseling​ ​could​ ​improve​ ​nutrition​ ​knowledge,​ ​interest​ ​in​ ​accessing

additional​ ​nutrition​ ​education​ ​and​ ​compliance​ ​with​ ​supplementation.​ ​The​ ​success​ ​of​ ​this

literature​ ​review​ ​was​ ​that​ ​a​ ​variety​ ​of​ ​articles​ ​were​ ​brought​ ​together​ ​and​ ​reviewed,​ ​furthermore

addressing​ ​that​ ​pregnant​ ​women​ ​in​ ​developed​ ​countries​ ​are​ ​not​ ​receiving​ ​sufficient​ ​nutrition

advice​ ​from​ ​reputable​ ​sources​ ​and​ ​healthcare​ ​professionals.​ ​A​ ​weakness​ ​from​ ​this​ ​review​ ​was

that​ ​majority​ ​of​ ​the​ ​31​ ​articles​ ​were​ ​of​ ​low​ ​quality​ ​in​ ​sample​ ​size,​ ​and​ ​the​ ​articles​ ​were

cross-sectional​ ​by​ ​nature,​ ​utilizing​ ​both​ ​the​ ​quantitative​ ​and​ ​qualitative​ ​methods.​ ​ ​This​ ​review

conclusively​ ​shows​ ​that​ ​different​ ​educational​ ​tactics​ ​work​ ​more​ ​efficiently​ ​in​ ​different​ ​cultures

and​ ​countries,​ ​such​ ​as​ ​educational​ ​videos​ ​shared​ ​with​ ​Somali​ ​refugees.​ ​It​ ​was​ ​also​ ​indicated​ ​that

despite​ ​the​ ​immediate​ ​treatment​ ​or​ ​consistent​ ​consultation​ ​with​ ​a​ ​physician,​ ​the​ ​support​ ​of​ ​a
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​13

nutrition​ ​educator​ ​could​ ​improve​ ​the​ ​overall​ ​results​ ​of​ ​GDM​ ​management​ ​and​ ​the​ ​nutrition

knowledge​ ​that​ ​is​ ​supplemented.

When​ ​reviewing​ ​a​ ​study​ ​conducted​ ​by​ ​Oza-Frank​ ​et​ ​al.​ ​(2014)​ ​titled,​ ​“Improving​ ​Care

for​ ​Women​ ​with​ ​a​ ​History​ ​of​ ​Gestational​ ​Diabetes,”​ ​the​ ​study​ ​takes​ ​a​ ​closer​ ​look​ ​in​ ​the

knowledge,​ ​attitudes​ ​and​ ​postpartum​ ​practices​ ​toward​ ​diabetes​ ​prevention​ ​for​ ​women​ ​that​ ​have

had​ ​gestational​ ​diabetes.​ ​The​ ​study​ ​was​ ​conducted​ ​by​ ​the​ ​Ohio​ ​Department​ ​of​ ​Health​ ​in​ ​the​ ​form

of​ ​a​ ​37-questionnaire​ ​survey​ ​that​ ​held​ ​a​ ​random​ ​sample​ ​of​ ​obstetricians,​ ​gynecologist,​ ​certified

nurse​ ​midwives​ ​and​ ​family​ ​practitioners.​ ​The​ ​sample​ ​size​ ​consisted​ ​of​ ​904​ ​participants​ ​out​ ​of​ ​the

initial​ ​2,375​ ​that​ ​were​ ​contacted.​ ​The​ ​questionnaire​ ​took​ ​an​ ​estimated​ ​15​ ​minutes​ ​to​ ​complete

and​ ​was​ ​reviewed​ ​by​ ​experts​ ​for​ ​validity,​ ​having​ ​initially​ ​conducted​ ​a​ ​pilot​ ​survey​ ​with​ ​5

obstetricians/​ ​gynecologist,​ ​5​ ​certified​ ​nurse​ ​midwives​ ​and​ ​4​ ​family​ ​practitioners.​ ​What​ ​was

found​ ​from​ ​this​ ​study​ ​was​ ​that​ ​majority​ ​of​ ​the​ ​providers​ ​felt​ ​that​ ​reimbursement​ ​for​ ​lifestyle

modification​ ​programs​ ​acted​ ​as​ ​a​ ​barrier.​ ​Out​ ​of​ ​all​ ​the​ ​participants,​ ​Ob/Gyn​ ​felt​ ​less​ ​likely​ ​to

agree​ ​that​ ​improvement​ ​of​ ​diet​ ​and​ ​exercise​ ​for​ ​women​ ​with​ ​GDM​ ​was​ ​a​ ​responsibility​ ​that

pertained​ ​to​ ​their​ ​job.​ ​On​ ​the​ ​other​ ​hand,​ ​about​ ​70%​ ​of​ ​certified​ ​nurse​ ​midwives​ ​that​ ​participated

in​ ​the​ ​study,​ ​felt​ ​it​ ​was​ ​part​ ​of​ ​their​ ​job​ ​description​ ​to​ ​help​ ​women​ ​with​ ​GDM​ ​in​ ​management​ ​of

diet​ ​and​ ​exercise.​ ​Family​ ​practitioners​ ​followed​ ​in​ ​decreasing​ ​percentages​ ​of​ ​supporting​ ​GDM

through​ ​means​ ​of​ ​promoting​ ​diet​ ​and​ ​exercise​ ​after​ ​certified​ ​nurse​ ​midwives.​ ​There​ ​was​ ​an

identified​ ​needs​ ​for​ ​more​ ​nutrition​ ​experts​ ​and​ ​specialists​ ​in​ ​demand​ ​for​ ​GDM​ ​management​ ​by

Ob/Gyns​ ​and​ ​certified​ ​nurse​ ​midwives.​ ​There​ ​was​ ​advocation​ ​of​ ​lifestyle​ ​modification​ ​programs

and​ ​corresponding​ ​reimbursements​ ​by​ ​about​ ​60​ ​to​ ​70%​ ​of​ ​Ob/Gyn​ ​and​ ​certified​ ​nurse​ ​midwives.

Oza-Frank​ ​et​ ​al.​ ​were​ ​most​ ​successful​ ​in​ ​the​ ​direct​ ​identification​ ​of​ ​the​ ​importance​ ​and​ ​role​ ​of
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​14

each​ ​practitioner​ ​in​ ​the​ ​medical​ ​team​ ​with​ ​gestational​ ​diabetes​ ​management.​ ​Furthermore,​ ​this

study​ ​allowed​ ​for​ ​the​ ​interdisciplinary​ ​team​ ​to​ ​voice​ ​their​ ​opinions​ ​and​ ​suggest​ ​an​ ​importance

and​ ​higher​ ​demand​ ​on​ ​nutrition​ ​education​ ​during​ ​GDM.​ ​What​ ​this​ ​study​ ​lacked​ ​was​ ​support​ ​in

reliability​ ​of​ ​responses,​ ​that​ ​might​ ​be​ ​biased;​ ​actual​ ​practices​ ​may​ ​differ​ ​from​ ​documented

responses.​ ​There​ ​is​ ​also​ ​the​ ​possibility​ ​that​ ​the​ ​responses​ ​are​ ​biased​ ​because​ ​the​ ​individuals​ ​that

responded,​ ​most​ ​likely​ ​had​ ​a​ ​stronger​ ​interest​ ​in​ ​gestational​ ​diabetes.​ ​Overall,​ ​this​ ​study​ ​helped

review​ ​the​ ​effectiveness​ ​and​ ​perspective​ ​of​ ​a​ ​state​ ​within​ ​the​ ​United​ ​States,​ ​suggesting​ ​a​ ​greater

emphasis​ ​on​ ​nutrition​ ​expertise​ ​to​ ​assist​ ​in​ ​the​ ​management​ ​of​ ​GDM.

Relationship​ ​of​ ​RD​ ​and​ ​GDM

With​ ​very​ ​limited​ ​research​ ​done,​ ​there​ ​were​ ​no​ ​studies​ ​found​ ​that​ ​directly​ ​evaluated​ ​the

role​ ​of​ ​the​ ​registered​ ​dietitian​ ​and​ ​gestational​ ​diabetes​ ​in​ ​the​ ​United​ ​States.​ ​This​ ​further​ ​validates

the​ ​importance​ ​of​ ​evaluating​ ​the​ ​role​ ​of​ ​the​ ​RD​ ​in​ ​the​ ​clinical​ ​settings​ ​and​ ​in​ ​response​ ​to​ ​medical

conditions​ ​that​ ​demand​ ​nutrition​ ​therapy​ ​such​ ​as​ ​gestational​ ​diabetes.​ ​While​ ​our​ ​proposed​ ​study

would​ ​implicate​ ​a​ ​study​ ​that​ ​would​ ​shed​ ​more​ ​light​ ​on​ ​the​ ​topic,​ ​the​ ​closest​ ​study​ ​that​ ​has​ ​been

conducted​ ​in​ ​encompass​ ​the​ ​role​ ​of​ ​the​ ​RD​ ​was​ ​a​ ​study​ ​conducted​ ​by​ ​Morrison​ ​et​ ​al.​ ​(2011)​ ​in

Australia,​ ​titled,​ ​“Dietetic​ ​Practice​ ​in​ ​the​ ​Management​ ​of​ ​Gestational​ ​Diabetes​ ​Mellitus:​ ​A

survey​ ​of​ ​Australian​ ​Dietitians.”

In​ ​the​ ​study​ ​conducted​ ​by​ ​Morrison​ ​et​ ​al.,​ ​a​ ​conclusive​ ​220​ ​eligible​ ​registered​ ​dietitians

participated​ ​in​ ​the​ ​study​ ​and​ ​were​ ​recruited​ ​through​ ​the​ ​Dietitians​ ​Association​ ​of​ ​Australia

interest​ ​group​ ​membership,​ ​public​ ​and​ ​private​ ​hospital​ ​maternity​ ​and​ ​diabetes​ ​services

throughout​ ​Australia.​ ​Each​ ​participant​ ​took​ ​a​ ​55-item​ ​cross-sectional​ ​survey​ ​that​ ​addressed​ ​the

role​ ​and​ ​responsibilities​ ​of​ ​the​ ​RD​ ​that​ ​are​ ​seen​ ​in​ ​Australia.​ ​What​ ​was​ ​found​ ​from​ ​this​ ​study
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​15

was​ ​that​ ​a​ ​significantly​ ​higher​ ​proportion​ ​of​ ​dietitians​ ​(93%)​ ​provide​ ​individual​ ​consults​ ​while​ ​a

small​ ​proportion​ ​(33%)​ ​provide​ ​group​ ​consults​ ​regarding​ ​gestational​ ​diabetes,​ ​where​ ​a​ ​little

more​ ​than​ ​half​ ​(67%)​ ​would​ ​have​ ​an​ ​additional​ ​follow-up​ ​consult​ ​after​ ​the​ ​initial.​ ​The​ ​role​ ​of​ ​the

registered​ ​dietitian​ ​was​ ​praised​ ​in​ ​this​ ​study,​ ​reporting​ ​that​ ​77%​ ​of​ ​women​ ​with​ ​diagnosed​ ​with

GDM​ ​were​ ​referred​ ​to​ ​an​ ​RD​ ​for​ ​consultation.​ ​Although​ ​it​ ​might​ ​be​ ​biased,​ ​it​ ​was​ ​also

mentioned​ ​that​ ​54%​ ​of​ ​RDs​ ​that​ ​participated​ ​in​ ​this​ ​study​ ​believed​ ​that​ ​their​ ​services​ ​were

adequate​ ​dietetic​ ​interventions​ ​and​ ​that​ ​8%​ ​had​ ​adequate​ ​follow-up​ ​appointments.​ ​A​ ​major

strength​ ​for​ ​our​ ​study​ ​that​ ​was​ ​evident​ ​through​ ​Morrison’s​ ​study​ ​was​ ​that​ ​is​ ​addressed​ ​a

significant​ ​question​ ​that​ ​our​ ​study​ ​asks,​ ​“what​ ​is​ ​the​ ​role​ ​of​ ​the​ ​RD​ ​in​ ​GDM​ ​management?”

Another​ ​strength​ ​was​ ​that​ ​this​ ​study​ ​allowed​ ​88%​ ​of​ ​RDs​ ​that​ ​were​ ​in​ ​the​ ​study,​ ​to​ ​voice​ ​the

important​ ​opinion​ ​that​ ​there​ ​is​ ​a​ ​need​ ​for​ ​evidence-based​ ​gestational​ ​diabetes​ ​dietetic​ ​practice

guidelines​ ​(Morrison,​ ​2011).​ ​The​ ​weakness​ ​of​ ​this​ ​study​ ​was​ ​that​ ​the​ ​role​ ​of​ ​the​ ​physician​ ​was

not​ ​evaluated,​ ​compared​ ​or​ ​used​ ​as​ ​a​ ​reference,​ ​it​ ​was​ ​done​ ​in​ ​Australia​ ​rather​ ​than​ ​within​ ​the

U.S.,​ ​and​ ​as​ ​predicted,​ ​there​ ​was​ ​variation​ ​between​ ​the​ ​practices​ ​and​ ​beliefs​ ​of​ ​each​ ​individual

dietitian​ ​particularly​ ​with​ ​nutrition​ ​assessment​ ​and​ ​macronutrient​ ​targets.

Role​ ​of​ ​RD​ ​and​ ​MD​ ​Around​ ​the​ ​World

While​ ​there​ ​is​ ​a​ ​scarce​ ​amount​ ​of​ ​recent​ ​studies​ ​examining​ ​the​ ​relationship​ ​between

gestational​ ​diabetes​ ​and​ ​physicians​ ​or​ ​registered​ ​dietitians​ ​in​ ​the​ ​United​ ​States,​ ​the​ ​literature​ ​is

rich​ ​in​ ​research​ ​conducted​ ​in​ ​other​ ​regions​ ​of​ ​the​ ​world.​ ​Studies​ ​from​ ​Turkey,​ ​China,​ ​Brazil,

Australia,​ ​and​ ​different​ ​cities​ ​in​ ​Canada​ ​have​ ​assessed​ ​how​ ​physicians’​ ​practices​ ​and​ ​dietitians’

interventions​ ​have​ ​an​ ​effect​ ​on​ ​health​ ​outcomes.​ ​Although​ ​diabetes​ ​care​ ​guidelines​ ​may​ ​vary​ ​in

each​ ​country,​ ​analyzing​ ​the​ ​success​ ​of​ ​medical​ ​care​ ​approaches​ ​can​ ​support​ ​our​ ​argument​ ​that​ ​an
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​16

interdisciplinary​ ​team​ ​addressing​ ​lifestyle​ ​changes​ ​is​ ​advantageous​ ​for​ ​gestational​ ​diabetes

management.

In​ ​Morisset​ ​et​ ​al.​ ​(2014)​ ​and​ ​Shi​ ​et​ ​al.​ ​(2016),​ ​groups​ ​who​ ​received​ ​medical​ ​nutrition

therapy​ ​(MNT)​ ​by​ ​a​ ​registered​ ​dietitian​ ​were​ ​compared​ ​to​ ​groups​ ​that​ ​did​ ​not.​ ​Morisset’s

research​ ​was​ ​a​ ​quantitative​ ​quasi-experimental​ ​study.​ ​Seventeen​ ​pregnant​ ​women​ ​with​ ​GDM​ ​and

27​ ​pregnant​ ​women​ ​without​ ​GDM​ ​were​ ​recruited​ ​at​ ​the​ ​Centre​ ​Hospitalier​ ​Universitaire​ ​in

Quebec,​ ​Canada​ ​after​ ​a​ ​75-g​ ​oral​ ​glucose​ ​tolerance​ ​test​ ​in​ ​their​ ​2nd​
​ ​ ​trimester.​ ​The​ ​women​ ​with

GDM​ ​formed​ ​part​ ​of​ ​the​ ​experimental​ ​group​ ​and​ ​received​ ​a​ ​90-minute​ ​group​ ​session​ ​covering

basic​ ​nutrition​ ​information,​ ​a​ ​75-minute​ ​individual​ ​session​ ​with​ ​a​ ​dietitian,​ ​and​ ​follow-up​ ​visits

as​ ​needed.​ ​An​ ​endocrinologist​ ​formed​ ​part​ ​of​ ​the​ ​care​ ​team​ ​and​ ​handled​ ​medication​ ​management

if​ ​needed.​ ​The​ ​healthy​ ​pregnant​ ​women​ ​were​ ​the​ ​control​ ​group​ ​and​ ​had​ ​one​ ​30-minute​ ​visit​ ​with

a​ ​dietitian.​ ​Gestational​ ​diabetes​ ​management​ ​was​ ​measured​ ​through​ ​gestational​ ​weight​ ​gain​ ​and

dietary​ ​intakes.​ ​Nutrient​ ​analyses​ ​were​ ​performed​ ​on​ ​the​ ​food​ ​frequency​ ​questionnaire​ ​that

measured​ ​dietary​ ​intakes​ ​and​ ​then​ ​paired​ ​t-tests​ ​compared​ ​macronutrient​ ​intakes​ ​between​ ​the​ ​two

groups.​ ​Results​ ​demonstrated​ ​that​ ​the​ ​GDM​ ​group​ ​significantly​ ​lowered​ ​their​ ​carbohydrate,​ ​fat,

and​ ​total​ ​caloric​ ​intake​ ​after​ ​the​ ​intervention​ ​and​ ​gained​ ​weight​ ​at​ ​a​ ​lower​ ​rate​ ​compared​ ​to​ ​the

control​ ​group​ ​(Mosisset​ ​et​ ​al.,​ ​2014).​ ​While​ ​this​ ​study’s​ ​strength​ ​was​ ​using​ ​validated​ ​tools​ ​to

collect​ ​dietary​ ​information,​ ​limitations​ ​were​ ​using​ ​small​ ​groups​ ​and​ ​using​ ​self-reported

pre-gestational​ ​weight​ ​to​ ​calculate​ ​weight​ ​gain​ ​since​ ​the​ ​participants​ ​could​ ​have​ ​given​ ​inaccurate

data.​ ​Shi’s​ ​study​ ​was​ ​a​ ​quantitative​ ​retrospective​ ​cohort​ ​study​ ​conducted​ ​in​ ​Beijing,​ ​China.​ ​The

researchers​ ​reviewed​ ​high​ ​risk​ ​pregnancy​ ​medical​ ​records​ ​from​ ​the​ ​China-Japan​ ​Friendship

Hospital​ ​dating​ ​from​ ​2008​ ​to​ ​2012.​ ​They​ ​were​ ​able​ ​to​ ​identify​ ​488​ ​cases​ ​of​ ​gestational​ ​diabetes,
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​17

of​ ​which​ ​only​ ​62.9%​ ​received​ ​MNT.​ ​Most​ ​information​ ​was​ ​gathered​ ​from​ ​the​ ​medical​ ​records

and​ ​compared.​ ​Rate​ ​of​ ​delivery​ ​by​ ​cesarean​ ​section,​ ​insulin​ ​usage,​ ​gestational​ ​weight​ ​gain,

fasting​ ​blood​ ​glucose​ ​from​ ​the​ ​32​nd​​ ​week​ ​of​ ​pregnancy​ ​to​ ​time​ ​of​ ​delivery,​ ​and​ ​frequency​ ​of​ ​fetal

macrosomia​ ​were​ ​all​ ​found​ ​to​ ​be​ ​lower​ ​in​ ​the​ ​group​ ​of​ ​women​ ​receiving​ ​MNT​ ​(Shi​ ​et​ ​al.,​ ​2016).

The​ ​strength​ ​of​ ​this​ ​study​ ​is​ ​the​ ​large​ ​sample​ ​size.​ ​Limitations​ ​are​ ​that​ ​the​ ​results​ ​may​ ​only​ ​be

generalizable​ ​to​ ​this​ ​hospital​ ​and​ ​that​ ​some​ ​medical​ ​records​ ​were​ ​incomplete,​ ​in​ ​which​ ​case​ ​the

patient​ ​had​ ​to​ ​be​ ​contacted​ ​to​ ​give​ ​missing​ ​information​ ​leading​ ​to​ ​potential​ ​research​ ​bias.​ ​Both

Morisset​ ​and​ ​Shi​ ​effectively​ ​demonstrated​ ​the​ ​relevance​ ​of​ ​a​ ​dietitian​ ​in​ ​a​ ​prenatal​ ​care​ ​team.

Akinci​ ​et​ ​al.​ ​(2010)​ ​and​ ​Malta​ ​et​ ​al.​ ​(2016)​ ​focused​ ​on​ ​clinical​ ​practices​ ​and

recommendations​ ​made​ ​by​ ​physicians​ ​during​ ​prenatal​ ​care.​ ​Their​ ​studies​ ​used​ ​qualitative

information​ ​gathered​ ​from​ ​questionnaires.​ ​Akinci​ ​et​ ​al.​ ​recruited​ ​Turkish​ ​physicians​ ​at​ ​the

annual​ ​meetings​ ​for​ ​each​ ​specialty​ ​in​ ​2010.​ ​Four-hundred​ ​thirty-four​ ​physicians​ ​agreed​ ​to

respond​ ​a​ ​questionnaire​ ​that​ ​was​ ​administered​ ​through​ ​a​ ​face-to​ ​face​ ​interview.​ ​The​ ​questions

asked​ ​about​ ​their​ ​clinical​ ​practices​ ​such​ ​as​ ​how​ ​they​ ​screen​ ​and​ ​treat​ ​GDM.​ ​ ​Notable​ ​findings

were​ ​that​ ​97.9%​ ​of​ ​physicians​ ​stated​ ​screening​ ​women​ ​for​ ​GDM,​ ​48.4%​ ​used​ ​the​ ​assistance​ ​of

an​ ​RD,​ ​40.3%​ ​used​ ​the​ ​help​ ​of​ ​a​ ​trained​ ​diabetes​ ​nurse​ ​educator,​ ​25.6%​ ​of​ ​all​ ​physicians

provided​ ​MNT​ ​themselves.​ ​Strengths​ ​of​ ​the​ ​study​ ​are​ ​the​ ​inclusion​ ​of​ ​a​ ​large​ ​number​ ​of​ ​family

physicians,​ ​internists,​ ​and​ ​obstetricians.​ ​A​ ​weakness​ ​is​ ​that​ ​through​ ​a​ ​questionnaire,​ ​the

respondent​ ​can​ ​give​ ​an​ ​answer​ ​that​ ​differs​ ​from​ ​what​ ​they​ ​actually​ ​do​ ​in​ ​clinical​ ​practice.​ ​Since

the​ ​interviews​ ​were​ ​conducted​ ​in​ ​person,​ ​the​ ​physicians​ ​may​ ​have​ ​felt​ ​obligated​ ​to​ ​give​ ​a​ ​more

honest​ ​response.
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​18

Malta’s​ ​study​ ​differed​ ​in​ ​that​ ​it​ ​was​ ​a​ ​controlled,​ ​quasi-experimental​ ​study​ ​rather​ ​an

observational​ ​study.​ ​All​ ​nurses​ ​and​ ​physicians​ ​performing​ ​prenatal​ ​care​ ​in​ ​the​ ​Botacatu

municipal​ ​in​ ​Brazil​ ​were​ ​invited​ ​to​ ​participate.​ ​Twenty-two​ ​healthcare​ ​professionals​ ​working​ ​in

family​ ​health​ ​units​ ​were​ ​part​ ​of​ ​the​ ​intervention​ ​group​ ​that​ ​received​ ​16-hours​ ​of​ ​training​ ​on

exercise​ ​and​ ​dietary​ ​recommendations​ ​for​ ​pregnant​ ​women​ ​while​ ​20​ ​healthcare​ ​professionals

practicing​ ​basic​ ​health​ ​served​ ​as​ ​the​ ​control.​ ​Both​ ​groups​ ​answered​ ​a​ ​questionnaire​ ​that​ ​assessed

their​ ​walking​ ​recommendations​ ​for​ ​pregnant​ ​women​ ​and​ ​dietary​ ​guideline​ ​knowledge​ ​1​ ​month

before​ ​and​ ​12​ ​months​ ​after​ ​the​ ​intervention.​ ​One​ ​hundred​ ​forty​ ​pregnant​ ​women​ ​being​ ​seen​ ​by

the​ ​intervention​ ​group​ ​and​ ​141​ ​pregnant​ ​women​ ​being​ ​seen​ ​by​ ​the​ ​control​ ​group​ ​completed​ ​a

take-home​ ​questionnaire​ ​that​ ​asked​ ​if​ ​their​ ​physician​ ​or​ ​nurse​ ​had​ ​discussed​ ​walking​ ​or​ ​diet​ ​with

them.​ ​The​ ​findings​ ​were​ ​that​ ​professionals​ ​that​ ​received​ ​the​ ​intervention​ ​training​ ​had​ ​more

knowledge​ ​regarding​ ​walking​ ​and​ ​diet​ ​recommendations​ ​and​ ​were​ ​more​ ​likely​ ​to​ ​discuss​ ​these

topics​ ​with​ ​patients​ ​compared​ ​to​ ​the​ ​control​ ​group.​ ​The​ ​strengths​ ​of​ ​this​ ​study​ ​are​ ​that​ ​the

patient's’​ ​perspective​ ​was​ ​taken​ ​into​ ​consideration​ ​and​ ​used​ ​to​ ​verify​ ​if​ ​healthcare​ ​providers​ ​were

in​ ​fact​ ​implementing​ ​recommendations​ ​into​ ​their​ ​practice.​ ​One​ ​of​ ​the​ ​limitations​ ​is​ ​that​ ​the

pregnant​ ​women​ ​treated​ ​were​ ​not​ ​diagnosed​ ​with​ ​GDM,​ ​which​ ​reduces​ ​its​ ​application​ ​to​ ​our

proposed​ ​study.​ ​The​ ​role​ ​of​ ​a​ ​registered​ ​dietitian​ ​was​ ​not​ ​discussed​ ​in​ ​the​ ​Malta​ ​study,​ ​which

strengthens​ ​our​ ​assumption​ ​that​ ​registered​ ​dietitians​ ​are​ ​not​ ​always​ ​regarded​ ​as​ ​a​ ​critical

component​ ​of​ ​prenatal​ ​care​ ​by​ ​the​ ​physician​ ​even​ ​when​ ​proper​ ​nutrition​ ​education​ ​is​ ​seems​ ​as

fundamental.

Lega​ ​et​ ​al.​ ​(2012)​ ​and​ ​Russell​ ​et​ ​al.​ ​(2013)​ ​studied​ ​improvements​ ​in​ ​health​ ​care​ ​services

that​ ​can​ ​enhance​ ​diabetic​ ​care.​ ​Lega’s​ ​study​ ​was​ ​a​ ​retrospective​ ​observational​ ​study​ ​conducted​ ​in
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​19

Toronto,​ ​Canada​ ​that​ ​looked​ ​at​ ​how​ ​the​ ​inclusion​ ​of​ ​a​ ​checklist​ ​reminding​ ​physicians​ ​to​ ​schedule

a​ ​postpartum​ ​check-up​ ​for​ ​patients​ ​with​ ​GDM​ ​increased​ ​postpartum​ ​diabetes​ ​screening.​ ​The

medical​ ​charts​ ​of​ ​all​ ​women​ ​with​ ​GDM​ ​attending​ ​Women’s​ ​College​ ​Hospital​ ​were​ ​examined.​ ​A

total​ ​of​ ​314​ ​medical​ ​files​ ​belonged​ ​to​ ​women​ ​with​ ​GDM​ ​and​ ​only​ ​143​ ​of​ ​those​ ​medical​ ​files

included​ ​the​ ​diabetes​ ​screening​ ​checklist.​ ​The​ ​study​ ​found​ ​that​ ​58%​ ​of​ ​women​ ​with​ ​a​ ​checklist

attached​ ​to​ ​their​ ​chart​ ​attended​ ​a​ ​postpartum​ ​checkup​ ​compared​ ​to​ ​30%​ ​without​ ​a​ ​checklist

(Lega​ ​et​ ​al.,​ ​2012).​ ​A​ ​possible​ ​explanation​ ​as​ ​to​ ​why​ ​postpartum​ ​checkups​ ​are​ ​so​ ​low​ ​when​ ​a

checklist​ ​is​ ​not​ ​used​ ​is​ ​that​ ​the​ ​primary​ ​physician​ ​might​ ​believe​ ​that​ ​the​ ​responsibility​ ​of

discussing​ ​postpartum​ ​diabetes​ ​screening​ ​belongs​ ​to​ ​the​ ​endocrinologist​ ​or​ ​obstetrician.

Strengths​ ​of​ ​the​ ​study​ ​are​ ​strong​ ​internal​ ​validity​ ​since​ ​all​ ​the​ ​subjects​ ​attended​ ​the​ ​same​ ​clinic

and​ ​data​ ​gathered​ ​could​ ​have​ ​not​ ​been​ ​manipulated​ ​by​ ​researchers’​ ​biases.​ ​Limitations​ ​are​ ​that

the​ ​role​ ​of​ ​the​ ​RD​ ​is​ ​not​ ​discussed​ ​and​ ​the​ ​checklist​ ​alone​ ​cannot​ ​determine​ ​causation.​ ​There

could​ ​have​ ​been​ ​external​ ​factors​ ​that​ ​influence​ ​women’s​ ​decision​ ​to​ ​attend​ ​a​ ​postpartum​ ​diabetes

screening.

Similarly,​ ​Russell’s​ ​prospective​ ​controlled​ ​trial​ ​investigated​ ​if​ ​a​ ​community​ ​based

diabetes​ ​clinic​ ​opened​ ​in​ ​a​ ​low-income​ ​area​ ​in​ ​Australia​ ​with​ ​an​ ​interdisciplinary​ ​team​ ​could

improve​ ​follow-up​ ​visits​ ​and​ ​diabetes​ ​management.​ ​Patients​ ​were​ ​referred​ ​to​ ​the​ ​community

based​ ​clinic​ ​by​ ​Princess​ ​Alexandra​ ​Hospital​ ​staff.​ ​One​ ​hundred​ ​eighty-three​ ​patients​ ​attended​ ​the

community​ ​based​ ​clinic​ ​while​ ​145​ ​patients​ ​were​ ​referred​ ​to​ ​the​ ​usual​ ​specialist​ ​diabetes​ ​clinic.

Variables​ ​measured​ ​at​ ​baseline,​ ​at​ ​6​ ​months,​ ​and​ ​12​ ​months​ ​post​ ​start​ ​of​ ​intervention​ ​for

comparison​ ​were​ ​attendance,​ ​HbA1c,​ ​and​ ​blood​ ​pressure.​ ​Community​ ​clinic​ ​physicians​ ​saw​ ​2.7

times​ ​more​ ​patients​ ​than​ ​the​ ​physicians​ ​in​ ​usual​ ​care​ ​and​ ​76.8%​ ​of​ ​patients​ ​in​ ​the​ ​intervention
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​20

met​ ​with​ ​an​ ​RD​ ​(Russell​ ​et​ ​al.,​ ​2013).​ ​At​ ​12-months,​ ​average​ ​HbA1c​ ​and​ ​blood​ ​pressure

significantly​ ​decreased​ ​in​ ​the​ ​intervention​ ​groups​ ​and​ ​less​ ​significantly​ ​in​ ​the​ ​usual​ ​care​ ​group.

Limitations​ ​of​ ​the​ ​study​ ​are​ ​exclusion​ ​of​ ​pregnant​ ​women​ ​and​ ​possible​ ​selection​ ​bias.​ ​Perhaps

those​ ​who​ ​were​ ​willing​ ​to​ ​participate​ ​in​ ​the​ ​study​ ​and​ ​visit​ ​the​ ​community​ ​clinic​ ​had​ ​a​ ​greater

interest​ ​in​ ​the​ ​health.​ ​In​ ​addition,​ ​the​ ​study​ ​does​ ​not​ ​discuss​ ​how​ ​many​ ​patients​ ​in​ ​the​ ​usual​ ​care

group​ ​met​ ​with​ ​a​ ​dietitian.​ ​Notable​ ​strengths​ ​are​ ​the​ ​sample​ ​size​ ​and​ ​length​ ​of​ ​study.​ ​Both​ ​of

these​ ​studies​ ​emphasize​ ​how​ ​increased​ ​interactions​ ​between​ ​patients​ ​and​ ​healthcare​ ​practitioners

enhance​ ​the​ ​management​ ​of​ ​diabetes.​ ​Our​ ​study​ ​also​ ​wants​ ​to​ ​measure​ ​how​ ​increased​ ​meetings

with​ ​a​ ​dietitian​ ​would​ ​affect​ ​GDM​ ​management​ ​but,​ ​in​ ​an​ ​American​ ​setting.

Impact​ ​of​ ​Nutrition​ ​Education

Another​ ​recurring​ ​theme​ ​in​ ​literature​ ​concerning​ ​gestational​ ​diabetes​ ​management​ ​was

the​ ​impact​ ​of​ ​nutrition​ ​education.​ ​Making​ ​dietary​ ​changes​ ​and​ ​limiting​ ​carbohydrate​ ​intake​ ​is

crucial​ ​in​ ​order​ ​to​ ​keep​ ​blood​ ​glucose​ ​levels​ ​under​ ​control​ ​(Ali​ ​et​ ​al.,​ ​2013,​ ​Perichart-Perera​ ​et

al.,​ ​2009).​ ​For​ ​this​ ​reason,​ ​registered​ ​dietitians​ ​and​ ​diabetes​ ​educators​ ​are​ ​an​ ​essential​ ​component

of​ ​a​ ​diabetes​ ​care​ ​team.​ ​While​ ​some​ ​recent​ ​studies​ ​investigate​ ​the​ ​effect​ ​of​ ​new​ ​educational

interventions​ ​on​ ​eating​ ​patterns,​ ​others​ ​explore​ ​knowledge​ ​retention​ ​or​ ​physicians’​ ​attitudes

towards​ ​providing​ ​nutrition​ ​information.​ ​It​ ​is​ ​worth​ ​noting​ ​that​ ​the​ ​studies​ ​found​ ​belonging​ ​to

this​ ​theme​ ​were​ ​conducting​ ​in​ ​other​ ​countries​ ​using​ ​very​ ​specific​ ​populations,​ ​which​ ​limits​ ​the

generalizability​ ​of​ ​the​ ​results.

Tawfik​ ​(2017)​ ​and​ ​Perichart-Perera​ ​et​ ​al.,​ ​(2009)​ ​studied​ ​the​ ​impact​ ​of​ ​innovative

nutrition​ ​education​ ​approaches.​ ​Tawfik’s​ ​cluster-randomized​ ​controlled​ ​trial​ ​in​ ​Egypt​ ​is​ ​the​ ​first
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​21

study​ ​to​ ​investigate​ ​the​ ​influence​ ​of​ ​a​ ​Health​ ​Belief​ ​Model-based​ ​educational​ ​intervention​ ​on

women​ ​with​ ​GDM.​ ​Pregnant​ ​women​ ​in​ ​their​ ​24​th​​ ​week​ ​of​ ​gestation​ ​attending​ ​1​ ​of​ ​12​ ​primary

health​ ​care​ ​centers​ ​were​ ​invited​ ​to​ ​participate​ ​in​ ​the​ ​study​ ​after​ ​being​ ​diagnosed​ ​with​ ​GDM.​ ​Six

sites​ ​were​ ​selected​ ​to​ ​be​ ​the​ ​control​ ​and​ ​continue​ ​providing​ ​their​ ​usual​ ​routine​ ​care​ ​while​ ​the

other​ ​6​ ​sites​ ​offered​ ​nutrition​ ​education​ ​that​ ​emphasized​ ​the​ ​risks​ ​of​ ​developing​ ​type​ ​2​ ​diabetes

postpartum​ ​and​ ​the​ ​severity​ ​of​ ​the​ ​disease.​ ​A​ ​questionnaire​ ​was​ ​developed​ ​by​ ​the​ ​researcher​ ​to

assess​ ​qualitative​ ​data​ ​such​ ​medical​ ​history,​ ​knowledge,​ ​self-reported​ ​practices,​ ​and​ ​beliefs

among​ ​the​ ​103​ ​women​ ​in​ ​the​ ​intervention​ ​group​ ​and​ ​the​ ​98​ ​in​ ​the​ ​control​ ​group.​ ​Quantitative

variables​ ​such​ ​as​ ​gestational​ ​weight​ ​gain​ ​and​ ​postpartum​ ​weight​ ​retention​ ​were​ ​also​ ​measured.

Nurses​ ​recorded​ ​weight​ ​and​ ​trained​ ​personnel​ ​administered​ ​the​ ​questionnaire.​ ​McNemar’s​ ​and

paired​ ​t-tests​ ​were​ ​used​ ​to​ ​analyze​ ​pre-​ ​and​ ​post-intervention​ ​differences.​ ​The​ ​intervention​ ​group

showed​ ​marked​ ​improvement​ ​in​ ​their​ ​knowledge​ ​regarding​ ​nutrition​ ​and​ ​diabetes,​ ​had​ ​lower

average​ ​gestational​ ​weight​ ​gain,​ ​and​ ​lower​ ​postpartum​ ​weight​ ​gain​ ​compared​ ​to​ ​the​ ​control

group.​ ​A​ ​strength​ ​of​ ​the​ ​study​ ​is​ ​that​ ​the​ ​groups​ ​were​ ​large​ ​enough​ ​to​ ​demonstrate​ ​clinical

significance​ ​since​ ​a​ ​power​ ​calculation​ ​showed​ ​that​ ​only​ ​92​ ​subjects​ ​in​ ​each​ ​group​ ​were​ ​needed.

A​ ​weakness​ ​was​ ​that​ ​the​ ​education​ ​the​ ​control​ ​group​ ​received​ ​was​ ​not​ ​described.

In​ ​Perichart-Pereras’s​ ​study,​ ​medical​ ​nutrition​ ​therapy​ ​was​ ​introduced​ ​for​ ​the​ ​first​ ​time​ ​at

the​ ​National​ ​Institute​ ​of​ ​Perinatology​ ​in​ ​Mexico​ ​City.​ ​Eighty-nine​ ​women​ ​with​ ​GDM​ ​were

recruited​ ​for​ ​the​ ​study​ ​from​ ​the​ ​National​ ​Institute​ ​of​ ​Perinatology​ ​while​ ​the​ ​control​ ​group​ ​was

composed​ ​of​ ​86​ ​previous​ ​patients,​ ​whose​ ​medical​ ​records​ ​included​ ​enough​ ​information​ ​to​ ​be

used​ ​in​ ​the​ ​study.​ ​The​ ​intervention​ ​group​ ​received​ ​individual​ ​nutrition​ ​counseling​ ​with​ ​an​ ​RD,​ ​a

monthly​ ​nutrition​ ​assessment,​ ​and​ ​self-monitored​ ​their​ ​glucose​ ​while​ ​the​ ​usual​ ​routine​ ​care
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​22

group​ ​received​ ​one​ ​nutrition​ ​education​ ​group​ ​session​ ​and​ ​monthly​ ​visits​ ​with​ ​the

endocrinologist.​ ​Any​ ​complications​ ​or​ ​laboratory​ ​values​ ​was​ ​included​ ​in​ ​the​ ​patient’s​ ​medical

record.​ ​Post-intervention,​ ​it​ ​was​ ​found​ ​that​ ​women​ ​in​ ​the​ ​MNT​ ​group​ ​were​ ​less​ ​likely​ ​to​ ​develop

preeclampsia,​ ​be​ ​hospitalized,​ ​or​ ​have​ ​their​ ​infants​ ​admitted​ ​to​ ​the​ ​NICU​ ​(neonatal​ ​intensive

care​ ​unit).​ ​A​ ​strength​ ​of​ ​the​ ​study​ ​is​ ​the​ ​detail​ ​with​ ​which​ ​the​ ​methods​ ​are​ ​described,​ ​making​ ​the

study​ ​easily​ ​reproducible.​ ​A​ ​weakness​ ​is​ ​that​ ​the​ ​medical​ ​charts​ ​used​ ​for​ ​the​ ​control​ ​lacked

measurements​ ​the​ ​researchers​ ​wanted​ ​to​ ​compare​ ​such​ ​as​ ​BMI​ ​and​ ​dietary​ ​habits.​ ​Although

using​ ​different​ ​interventions,​ ​results​ ​from​ ​Tawfik​ ​(2017)​ ​and​ ​Perichart-Perera​ ​et​ ​al​ ​(2009)

indicate​ ​that​ ​women​ ​with​ ​GDM​ ​benefit​ ​from​ ​treatments​ ​in​ ​which​ ​they​ ​are​ ​made​ ​more​ ​aware​ ​of

the​ ​consequences​ ​of​ ​their​ ​diet​ ​choices.

Ali​ ​et​ ​al.​ ​(2013)​ ​compared​ ​the​ ​nutrition​ ​knowledge​ ​of​ ​pregnant​ ​women​ ​with​ ​GDM​ ​to

pregnant​ ​women​ ​without​ ​GDM​ ​in​ ​United​ ​Arab​ ​Emirates,​ ​a​ ​country​ ​with​ ​a​ ​high​ ​prevalence​ ​of

diabetes​ ​mellitus,​ ​in​ ​an​ ​observational​ ​study.​ ​Ninety-four​ ​women​ ​formed​ ​part​ ​of​ ​the​ ​GDM​ ​group

while​ ​90​ ​women​ ​formed​ ​part​ ​of​ ​the​ ​control​ ​group​ ​after​ ​being​ ​referred​ ​by​ ​a​ ​doctor​ ​in​ ​1​ ​of​ ​3​ ​major

hospitals​ ​to​ ​the​ ​study.​ ​Nutrition​ ​knowledge​ ​and​ ​dietary​ ​practices​ ​were​ ​evaluated​ ​through​ ​a

questionnaire​ ​designed​ ​by​ ​the​ ​researchers​ ​and​ ​a​ ​single​ ​24-hour​ ​dietary​ ​recall​ ​collected​ ​during​ ​the

women’s​ ​3rd​​ ​ ​trimester.​ ​Associations​ ​between​ ​variables​ ​were​ ​found​ ​using​ ​Chi-square​ ​tests,

Fisher’s​ ​exact​ ​test,​ ​and​ ​independent​ ​t-tests.​ ​Interesting​ ​findings​ ​were​ ​that​ ​22%​ ​of​ ​women​ ​with

GDM​ ​reported​ ​never​ ​meeting​ ​with​ ​a​ ​dietitian​ ​and​ ​65%​ ​reported​ ​meeting​ ​with​ ​a​ ​dietitian​ ​once​ ​or

twice.​ ​The​ ​GDM​ ​group​ ​also​ ​reported​ ​a​ ​lower​ ​intake​ ​of​ ​fruits​ ​and​ ​fruit​ ​juice​ ​but​ ​their

carbohydrate​ ​knowledge​ ​was​ ​not​ ​significantly​ ​better​ ​compared​ ​to​ ​the​ ​control​ ​group​ ​after

adjusting​ ​scores​ ​for​ ​educational​ ​level​ ​and​ ​the​ ​number​ ​of​ ​visits​ ​to​ ​a​ ​dietitian.​ ​A​ ​strength​ ​of​ ​the
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​23

study​ ​was​ ​that​ ​food​ ​models​ ​and​ ​measuring​ ​cups​ ​were​ ​available​ ​during​ ​the​ ​nutrition​ ​questionnaire

and​ ​dietary​ ​recall​ ​to​ ​help​ ​subjects​ ​correctly​ ​estimate​ ​their​ ​intake.​ ​In​ ​our​ ​study,​ ​we​ ​will​ ​also

consider​ ​using​ ​measuring​ ​cups​ ​along​ ​with​ ​a​ ​questionnaire​ ​so​ ​study​ ​participants​ ​can​ ​estimate​ ​their

carbohydrate​ ​intake.​ ​Ali​ ​et​ ​al.​ ​concluded​ ​that​ ​United​ ​Arab​ ​Emirates​ ​is​ ​one​ ​of​ ​many​ ​countries​ ​in

which​ ​the​ ​nutrition​ ​education​ ​offered​ ​to​ ​pregnant​ ​women​ ​with​ ​GDM​ ​can​ ​be​ ​improved​ ​(2013).

Like​ ​the​ ​Tawfik​ ​(2017)​ ​and​ ​Perichart-Perera​ ​et​ ​al.​ ​(2009)​ ​articles,​ ​a​ ​strong​ ​limitation​ ​in​ ​the​ ​study

is​ ​the​ ​lack​ ​of​ ​generalizability​ ​in​ ​the​ ​results​ ​since​ ​a​ ​very​ ​specific​ ​geographical​ ​area​ ​was​ ​used.

Kalyandurgmath​ ​and​ ​Mohanty​ ​(2015)​ ​differed​ ​from​ ​Tawfik​ ​(2017),​ ​Perichart-Perera​ ​et

al.​ ​(2009),​ ​and​ ​Ali​ ​et​ ​al.​ ​(2013)​ ​by​ ​gathering​ ​quantitative​ ​information​ ​regarding​ ​nutrition

education​ ​from​ ​the​ ​physicians​ ​and​ ​not​ ​patients.​ ​This​ ​one-group​ ​observational​ ​study​ ​was

conducted​ ​in​ ​India​ ​and​ ​consisted​ ​of​ ​50​ ​physicians​ ​recruited​ ​through​ ​convenience​ ​sampling.

Researchers​ ​selected​ ​physicians​ ​for​ ​the​ ​study​ ​and​ ​not​ ​dietitians​ ​since​ ​families​ ​often​ ​approach

their​ ​family​ ​physician​ ​first​ ​for​ ​information​ ​on​ ​diets​ ​and​ ​treatment​ ​(Kalyandurgmath​ ​and​ ​Mohanty

2015).​ ​The​ ​physicians​ ​completed​ ​a​ ​structured​ ​questionnaire​ ​written​ ​specifically​ ​for​ ​the​ ​study​ ​that

asked​ ​about​ ​everyday​ ​practices​ ​involving​ ​nutrition​ ​counseling.​ ​Significant​ ​findings​ ​were​ ​that

82%​ ​of​ ​physicians​ ​were​ ​willing​ ​to​ ​recommend​ ​functional​ ​foods​ ​for​ ​chronic​ ​disease​ ​management,

66%​ ​of​ ​physicians​ ​see​ ​more​ ​1000​ ​patients​ ​per​ ​month,​ ​and​ ​94%​ ​of​ ​physicians​ ​agreed​ ​that

nutrition​ ​information​ ​is​ ​sought​ ​from​ ​them.​ ​The​ ​large​ ​number​ ​of​ ​patients​ ​seen​ ​by​ ​each​ ​physicians

likely​ ​reduces​ ​the​ ​time​ ​physicians​ ​can​ ​spend​ ​with​ ​them,​ ​therefore​ ​limiting​ ​how​ ​much​ ​information

can​ ​be​ ​shared.​ ​Selecting​ ​a​ ​small​ ​sample​ ​size​ ​was​ ​a​ ​weakness​ ​as​ ​well​ ​as​ ​a​ ​strength​ ​because​ ​very

detailed​ ​information​ ​was​ ​collected​ ​from​ ​the​ ​group​ ​but,​ ​the​ ​results​ ​cannot​ ​be​ ​generalized​ ​to​ ​all

physicians.​ ​This​ ​study​ ​supports​ ​our​ ​assumption​ ​that​ ​nutrition​ ​education​ ​is​ ​often​ ​provided​ ​by
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​24

physicians​ ​although​ ​dietitians​ ​are​ ​the​ ​nutrition​ ​experts.​ ​Overall,​ ​the​ ​authors​ ​of​ ​the​ ​studies

included​ ​in​ ​this​ ​section​ ​advocated​ ​increasing​ ​the​ ​nutrition​ ​education​ ​patients​ ​receive​ ​or​ ​using

teaching​ ​styles​ ​that​ ​resonate​ ​with​ ​the​ ​patient.

Knowledge​ ​and​ ​Barriers

Furthermore,​ ​existing​ ​barriers​ ​and​ ​perceived​ ​knowledge​ ​in​ ​adhering​ ​to​ ​healthier​ ​lifestyle

behaviors​ ​among​ ​pregnant​ ​women​ ​with​ ​GDM​ ​or​ ​at​ ​risk​ ​have​ ​also​ ​been​ ​studied.​ ​Although​ ​this

study​ ​focuses​ ​on​ ​the​ ​management​ ​of​ ​GDM​ ​through​ ​either​ ​a​ ​MD​ ​or​ ​RD,​ ​it​ ​is​ ​important​ ​to​ ​analyze

other​ ​factors​ ​that​ ​affect​ ​or​ ​influence​ ​their​ ​ability​ ​to​ ​maintain​ ​healthy​ ​blood​ ​glucose​ ​levels​ ​and​ ​a

healthy​ ​pregnancy.

Banerjee​ ​et​ ​al.​ ​(2016)​ ​and​ ​Poth​ ​et​ ​al.​ ​(2013)​ ​analyzed​ ​the​ ​knowledge​ ​and​ ​behavioral

changes​ ​among​ ​pregnant​ ​women​ ​with​ ​gestational​ ​diabetes.​ ​Based​ ​on​ ​the​ ​results,​ ​both​ ​studies

suggested​ ​that​ ​pregnant​ ​women​ ​need​ ​to​ ​be​ ​offered​ ​more​ ​education​ ​on​ ​GDM​ ​and​ ​lifestyle

changes​ ​to​ ​improve​ ​their​ ​health​ ​and​ ​the​ ​health​ ​of​ ​their​ ​baby.​ ​Banerjee​ ​et​ ​al.​ ​(2016)​ ​came​ ​this

conclusion​ ​from​ ​conducting​ ​a​ ​cross-sectional​ ​study​ ​in​ ​Canada​ ​that​ ​compared​ ​behavioral​ ​changes

between​ ​caucasian​ ​and​ ​non-caucasian/minority​ ​women​ ​after​ ​finding​ ​out​ ​they​ ​had​ ​GDM.​ ​For​ ​the

purpose​ ​of​ ​this​ ​study,​ ​women​ ​from​ ​ages​ ​18​ ​and​ ​over​ ​with​ ​GDM​ ​were​ ​invited​ ​to​ ​be​ ​a​ ​part​ ​of​ ​the

study.​ ​Women​ ​that​ ​were​ ​recruited​ ​attended​ ​one​ ​of​ ​five​ ​different​ ​prenatal​ ​diabetes​ ​clinics​ ​in

Ontario​ ​between​ ​June​ ​2009​ ​and​ ​June​ ​2013.​ ​This​ ​study​ ​was​ ​able​ ​to​ ​recruit​ ​1358​ ​participants,​ ​but

only​ ​898​ ​participants​ ​completed​ ​what​ ​was​ ​required​ ​of​ ​them​ ​as​ ​part​ ​of​ ​the​ ​study.​ ​To​ ​investigate

the​ ​differences​ ​in​ ​health​ ​behavior​ ​changes​ ​during​ ​pregnancy​ ​between​ ​the​ ​two​ ​cultures,

participants​ ​were​ ​required​ ​to​ ​complete​ ​a​ ​questionnaire​ ​either​ ​in​ ​paper,​ ​telephone,​ ​or​ ​online.

Then,​ ​to​ ​further​ ​analyze​ ​the​ ​differences​ ​in​ ​behaviour​ ​between​ ​Caucasian​ ​and​ ​minorities,​ ​a
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​25

Pearson​ ​Chi-square​ ​analysis​ ​was​ ​conducted.​ ​Given​ ​the​ ​results,​ ​they​ ​concluded​ ​that​ ​ethnic

minority​ ​women​ ​with​ ​GDM​ ​were​ ​significantly​ ​more​ ​likely​ ​that​ ​Caucasian​ ​women​ ​to​ ​increase

their​ ​physical​ ​activity​ ​and​ ​reduce​ ​meal​ ​portion​ ​sizes​ ​in​ ​response​ ​to​ ​their​ ​diagnosis,​ ​indicating​ ​that

majority​ ​of​ ​ethnic​ ​minority​ ​women​ ​are​ ​taking​ ​the​ ​initiative​ ​to​ ​make​ ​lifestyle​ ​changes​ ​after​ ​being

diagnosed​ ​(Banerjee​ ​et​ ​al.​ ​2016).​ ​A​ ​few​ ​limitations​ ​mentioned​ ​in​ ​the​ ​study​ ​is​ ​that​ ​they​ ​failed​ ​to

include​ ​information​ ​such​ ​as​ ​their​ ​severity​ ​of​ ​GDM,​ ​glucose​ ​control,​ ​and​ ​pre-pregnancy​ ​dietary

patterns​ ​that​ ​could​ ​ultimately​ ​have​ ​had​ ​an​ ​impact​ ​on​ ​their​ ​behavioral​ ​changes.​ ​They​ ​also​ ​missed

to​ ​mention​ ​why​ ​Caucasian​ ​mothers​ ​were​ ​less​ ​likely​ ​to​ ​make​ ​lifestyle​ ​changes​ ​after​ ​their

diagnosis.​ ​Still,​ ​strengths​ ​to​ ​this​ ​study​ ​include​ ​the​ ​large​ ​number​ ​of​ ​participants​ ​that​ ​they​ ​were

able​ ​to​ ​include​ ​in​ ​their​ ​study​ ​and​ ​the​ ​focus​ ​in​ ​different​ ​cultural​ ​behaviors.​ ​It​ ​can​ ​be​ ​noted​ ​that

management​ ​for​ ​GDM​ ​is​ ​more​ ​than​ ​just​ ​physical​ ​activity​ ​and​ ​portion​ ​control,​ ​therefore​ ​it​ ​is

agreeable​ ​that​ ​more​ ​education​ ​in​ ​nutrition​ ​can​ ​be​ ​beneficial​ ​for​ ​both​ ​ethnic​ ​minorities​ ​and

Caucasian​ ​population.

​ ​ ​ ​Poth​ ​et​ ​al.​ ​(2013)​ ​study​ ​included​ ​6​ ​pregnant​ ​women​ ​who​ ​were​ ​at​ ​risk​ ​of​ ​GDM​ ​in​ ​their

study,​ ​and​ ​tested​ ​their​ ​knowledge​ ​on​ ​GDM.​ ​30​ ​participants​ ​were​ ​recruited​ ​by​ ​midwifery​ ​staff​ ​at

a​ ​hospital​ ​located​ ​in​ ​a​ ​low​ ​income​ ​area,​ ​and​ ​were​ ​further​ ​assessed​ ​according​ ​to​ ​the​ ​inclusion

criteria,​ ​leaving​ ​only​ ​6​ ​eligible​ ​participants.​ ​They​ ​measured​ ​their​ ​knowledge​ ​of​ ​GDM,​ ​their

knowledge​ ​of​ ​the​ ​effect​ ​of​ ​GDM​ ​on​ ​mother​ ​and​ ​baby,​ ​their​ ​knowledge​ ​on​ ​a​ ​healthy​ ​lifestyle,​ ​and

their​ ​knowledge​ ​on​ ​the​ ​prevention​ ​of​ ​GDM​ ​by​ ​conducting​ ​a​ ​6​ ​question​ ​one-on-one​ ​interview.​ ​To

analyze​ ​and​ ​interpret​ ​the​ ​results,​ ​they​ ​grouped​ ​similarities​ ​and​ ​patterns​ ​in​ ​their​ ​answers,​ ​using​ ​a

thematic​ ​analysis.​ ​Their​ ​results​ ​showed​ ​that​ ​most​ ​pregnant​ ​women​ ​at​ ​risk​ ​for​ ​gestational​ ​diabetes

were​ ​not​ ​knowledgeable​ ​on​ ​GDM​ ​and​ ​therefore​ ​recommended​ ​the​ ​need​ ​for​ ​maternity​ ​care
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​26

providers​ ​and​ ​health​ ​care​ ​providers​ ​to​ ​give​ ​clear​ ​and​ ​consistent​ ​diet​ ​and​ ​exercise​ ​advice​ ​early​ ​in

pregnancy​ ​(Poth​ ​et​ ​al.​ ​2013).​ ​A​ ​definite​ ​limitation​ ​to​ ​this​ ​study​ ​is​ ​the​ ​relatively​ ​small​ ​cohort​ ​of

participants.

Bookari​ ​et​ ​al.​ ​(2017)​ ​and​ ​Mukona​ ​et​ ​al.​ ​(2017),​ ​focused​ ​on​ ​investigating​ ​barriers​ ​that

have​ ​an​ ​impact​ ​on​ ​pregnant​ ​women​ ​when​ ​it​ ​comes​ ​to​ ​managing​ ​their​ ​GDM.​ ​Both​ ​studies

implemented​ ​a​ ​in-person​ ​questionnaire​ ​as​ ​part​ ​of​ ​their​ ​study​ ​to​ ​encourage​ ​women​ ​to​ ​answer​ ​open

ended​ ​questions​ ​and​ ​ultimately​ ​get​ ​more​ ​information​ ​that​ ​what​ ​was​ ​asked.​ ​Using​ ​the​ ​cluster

sampling​ ​method,​ ​Bookari​ ​et​ ​al.​ ​(2017)​ ​gathered​ ​17​ ​pregnant​ ​women​ ​and​ ​9​ ​post-partum​ ​women.

The​ ​questions​ ​asked​ ​were​ ​closely​ ​related​ ​to​ ​their​ ​experiences​ ​with​ ​their​ ​healthcare​ ​providers​ ​and

eating​ ​practices.​ ​For​ ​example,​ ​what​ ​barriers​ ​prevent​ ​you​ ​from​ ​translating​ ​knowledge​ ​into​ ​eating

practices?​ ​Are​ ​you​ ​satisfied​ ​with​ ​the​ ​information​ ​provided​ ​by​ ​your​ ​healthcare​ ​provider?​ ​(Bookari

et​ ​al.​ ​2017).​ ​Results​ ​from​ ​a​ ​thematic​ ​analysis​ ​concluded​ ​that​ ​women​ ​wanted​ ​more​ ​constructive

and​ ​interactive​ ​engagement​ ​with​ ​health​ ​care​ ​providers​ ​and​ ​a​ ​respectful​ ​environment​ ​where​ ​they

feel​ ​comfortable​ ​to​ ​raise​ ​issues​ ​when​ ​needed​ ​(Bookari​ ​et​ ​al.​ ​2017).​ ​Strength​ ​to​ ​this​ ​study​ ​was

their​ ​ability​ ​to​ ​obtain​ ​women's​ ​perception​ ​on​ ​the​ ​guidance​ ​they​ ​felt​ ​they​ ​needed​ ​for​ ​a​ ​healthy

pregnancy​ ​outcome.​ ​Mukona​ ​et​ ​al.​ ​(2017)​ ​on​ ​the​ ​other​ ​hand,​ ​also​ ​used​ ​the​ ​cluster​ ​sampling

method​ ​to​ ​gather​ ​pregnant​ ​women​ ​with​ ​GDM​ ​until​ ​4​ ​groups​ ​of​ ​7​ ​participants​ ​were​ ​formed.​ ​This

qualitative​ ​study​ ​formed​ ​group​ ​discussions​ ​in​ ​a​ ​private​ ​room​ ​where​ ​answers​ ​were​ ​analyzed​ ​using

thematic​ ​analysis.​ ​Questions​ ​included​ ​in​ ​discussions​ ​pertained​ ​to​ ​topics​ ​that​ ​would​ ​create​ ​a

barrier​ ​in​ ​adherence​ ​to​ ​antidiabetic​ ​therapy​ ​such​ ​as​ ​socioeconomic​ ​status,​ ​support,​ ​therapeutic

regimen​ ​difficulty,​ ​problems​ ​in​ ​pregnancy,​ ​religious​ ​or​ ​cultural​ ​beliefs,​ ​and​ ​hospital​ ​services.

According​ ​to​ ​responses​ ​across​ ​all​ ​four​ ​groups,​ ​financial​ ​barriers​ ​and​ ​lack​ ​of​ ​support​ ​created
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​27

challenges​ ​in​ ​adherence​ ​to​ ​diet,​ ​physical​ ​activity,​ ​and​ ​medications​ ​(Mukona​ ​et​ ​al.​ ​2017).

Although​ ​group​ ​discussions​ ​are​ ​not​ ​always​ ​comfortable​ ​for​ ​some,​ ​an​ ​advantage​ ​to​ ​this​ ​study​ ​was

their​ ​ability​ ​to​ ​express​ ​the​ ​challenges​ ​they​ ​face​ ​with​ ​their​ ​diagnosis​ ​of​ ​GDM​ ​and​ ​the​ ​room​ ​for​ ​the

assumption​ ​that​ ​an​ ​interdisciplinary​ ​team​ ​of​ ​healthcare​ ​providers​ ​could​ ​potentially​ ​provide​ ​them

that​ ​support​ ​they​ ​need​ ​to​ ​adhere​ ​to​ ​diet,​ ​physical​ ​activity,​ ​and​ ​medications​ ​recommended​ ​for

GDM.

Limitations​ ​in​ ​Available​ ​Research

After​ ​analyzing​ ​existing​ ​literature,​ ​we​ ​identified​ ​various​ ​gaps​ ​that​ ​makes​ ​our​ ​study

unique​ ​from​ ​others.​ ​It​ ​can​ ​be​ ​easily​ ​noted​ ​that​ ​the​ ​majority​ ​of​ ​the​ ​studies​ ​were​ ​conducted​ ​in

Australia,​ ​China,​ ​Canada,​ ​India,​ ​and​ ​other​ ​parts​ ​of​ ​the​ ​world​ ​besides​ ​the​ ​US.​ ​Therefore,​ ​this

would​ ​be​ ​the​ ​most​ ​recent​ ​study​ ​to​ ​be​ ​conducted​ ​in​ ​the​ ​United​ ​States​ ​that​ ​further​ ​investigates

GDM​ ​management.​ ​Second,​ ​there​ ​were​ ​no​ ​existing​ ​studies​ ​that​ ​compared​ ​physicians​ ​and

registered​ ​dietitians​ ​side-by-side​ ​to​ ​determine​ ​the​ ​type​ ​of​ ​intervention​ ​that​ ​is​ ​most​ ​efficient​ ​for

this​ ​population.​ ​Most​ ​of​ ​the​ ​studies​ ​found,​ ​only​ ​studied​ ​the​ ​delivery​ ​of​ ​ ​healthcare​ ​from​ ​either​ ​a

physician​ ​or​ ​a​ ​registered​ ​dietitian​ ​for​ ​the​ ​management​ ​of​ ​GDM.​ ​Last,​ ​our​ ​study​ ​would​ ​be​ ​the​ ​first

to​ ​include​ ​various​ ​hospitals​ ​that​ ​are​ ​affiliated​ ​with​ ​the​ ​Sweet​ ​Success​ ​Program,​ ​whereas​ ​most​ ​of

the​ ​existing​ ​studies​ ​only​ ​focused​ ​in​ ​recruiting​ ​from​ ​one​ ​hospital​ ​and​ ​none​ ​of​ ​the​ ​studies​ ​were

affiliated​ ​with​ ​the​ ​Sweet​ ​Success​ ​Program​ ​or​ ​similar​ ​programs.


Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​28

CHAPTER​ ​III
METHODOLOGY

Research​ ​Design

The​ ​goal​ ​of​ ​this​ ​research​ ​study​ ​is​ ​to​ ​investigate​ ​the​ ​overall​ ​impact​ ​of​ ​healthcare​ ​providers

in​ ​the​ ​management​ ​of​ ​GDM​ ​in​ ​the​ ​greater​ ​Los​ ​Angeles​ ​area.​ ​The​ ​question​ ​at​ ​hand​ ​is,​ ​“Are

women​ ​with​ ​gestational​ ​diabetes​ ​more​ ​likely​ ​to​ ​improve​ ​blood​ ​glucose​ ​management,​ ​if​ ​they​ ​are

counseled​ ​by​ ​a​ ​Registered​ ​Dietitian​ ​compared​ ​to​ ​a​ ​Physician?”​ ​To​ ​address​ ​this​ ​question,​ ​our

study​ ​design​ ​will​ ​be​ ​an​ ​observational​ ​study.​ ​Thus,​ ​observing​ ​behavioral​ ​changes​ ​after​ ​seeing​ ​a

physician​ ​and​ ​after​ ​seeing​ ​a​ ​registered​ ​dietitian.​ ​All​ ​participants​ ​will​ ​be​ ​observed​ ​as​ ​one​ ​group.

After​ ​data​ ​has​ ​been​ ​collected,​ ​we​ ​will​ ​separate​ ​participants​ ​into​ ​two​ ​groups;​ ​the​ ​group​ ​that

frequently​ ​saw​ ​a​ ​physician​ ​and​ ​the​ ​group​ ​the​ ​frequently​ ​saw​ ​the​ ​registered​ ​dietitian.​ ​Once

grouped,​ ​we​ ​will​ ​compare​ ​both​ ​groups​ ​to​ ​find​ ​significant​ ​differences​ ​in​ ​behaviors​ ​and​ ​their​ ​blood

glucose​ ​tests.​ ​Our​ ​proposed​ ​hypothesis​ ​is​ ​that​ ​women​ ​with​ ​gestational​ ​diabetes​ ​who​ ​receive

nutrition​ ​education​ ​from​ ​an​ ​interdisciplinary​ ​team,​ ​including​ ​meeting​ ​with​ ​a​ ​physician​ ​and​ ​a

registered​ ​dietitian​ ​in​ ​individual​ ​counseling​ ​sessions,​ ​will​ ​have​ ​lower​ ​fasting​ ​blood​ ​glucose

levels​ ​and​ ​demonstrate​ ​better​ ​nutrition​ ​knowledge​ ​retention.

There​ ​will​ ​be​ ​specific​ ​criteria​ ​when​ ​selecting​ ​the​ ​study​ ​participants.​ ​Women​ ​eligible​ ​to

participate​ ​in​ ​the​ ​study​ ​must​ ​be​ ​ages​ ​18​ ​and​ ​over,​ ​be​ ​diagnosed​ ​with​ ​gestational​ ​diabetes​ ​through

an​ ​oral​ ​glucose​ ​tolerance​ ​test,​ ​be​ ​expecting​ ​a​ ​singleton​ ​baby,​ ​and​ ​must​ ​be​ ​receiving​ ​prenatal​ ​care

(in​ ​one​ ​of​ ​the​ ​hospitals​ ​we​ ​selected)​ ​until​ ​time​ ​of​ ​delivery.​ ​In​ ​addition,​ ​women​ ​will​ ​be​ ​excluded

from​ ​the​ ​study​ ​if​ ​they​ ​had​ ​type​ ​1​ ​or​ ​type​ ​2​ ​diabetes​ ​before​ ​pregnancy,​ ​and​ ​if​ ​they​ ​are​ ​using​ ​drugs

that​ ​could​ ​affect​ ​pregnancy​ ​outcomes.​ ​Participants​ ​will​ ​also​ ​be​ ​excluded​ ​if​ ​they​ ​speak​ ​other

languages​ ​besides​ ​English​ ​and​ ​Spanish.


Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​29

The​ ​hospitals​ ​that​ ​will​ ​be​ ​contacted​ ​for​ ​this​ ​study​ ​include​ ​Kaiser​ ​Permanente​ ​(Woodland

Hills),​ ​Providence​ ​Holy​ ​Cross​ ​Medical​ ​Center​ ​(Mission​ ​Hills),​ ​Dignity​ ​Health-​ ​Glendale

Memorial​ ​Hospitals​ ​(Glendale),​ ​Adventist​ ​Health​ ​White​ ​Memorial​ ​(Los​ ​Angeles),​ ​and

Huntington​ ​Memorial​ ​Hospital​ ​(Pasadena).​ ​These​ ​hospitals​ ​were​ ​selected​ ​because​ ​of​ ​their

affiliation​ ​with​ ​the​ ​Sweet​ ​Success​ ​program​ ​and​ ​the​ ​25​ ​miles​ ​radius​ ​from​ ​Northridge​ ​where​ ​the

researchers​ ​and​ ​research​ ​assistants​ ​are​ ​centered.​ ​We​ ​found​ ​hospitals​ ​affiliated​ ​with​ ​Sweet

Success​ ​through​ ​the​ ​program’s​ ​Sweet​ ​Success​ ​Affiliate​ ​Locator

(​http://www.cdappsweetsuccess.org/Consumers/AffiliateLocator.aspx​).​ ​In​ ​summary,​ ​the​ ​Sweet

Success​ ​program​ ​was​ ​initiated​ ​by​ ​the​ ​California​ ​Diabetes​ ​and​ ​Pregnancy​ ​Program​ ​(CDAPP)​ ​in

1982​ ​to​ ​provide​ ​a​ ​comprehensive​ ​technical​ ​support​ ​system​ ​to​ ​women​ ​with​ ​gestational​ ​diabetes

and​ ​education​ ​to​ ​medical​ ​personnel​ ​and​ ​community.​ ​Some​ ​of​ ​the​ ​main​ ​goals​ ​for​ ​Sweet​ ​Success

is​ ​to​ ​improve​ ​fetal​ ​birth​ ​outcomes,​ ​prevent​ ​complications​ ​during​ ​pregnancy​ ​and​ ​at​ ​childbirth,

promotion​ ​of​ ​healthy​ ​lifestyle​ ​changes​ ​and​ ​ensuring​ ​quality​ ​medical​ ​management​ ​by​ ​addressing

health​ ​education​ ​and​ ​disease​ ​prevention.​ ​Addressing​ ​the​ ​goals​ ​that​ ​the​ ​Sweet​ ​Success​ ​program

envisions​ ​and​ ​how​ ​they​ ​align​ ​with​ ​the​ ​intentions​ ​and​ ​purpose​ ​of​ ​this​ ​study,​ ​we​ ​felt​ ​it​ ​furthermore

validated​ ​the​ ​necessity​ ​to​ ​connect​ ​with​ ​hospitals​ ​that​ ​are​ ​affiliated​ ​with​ ​Sweet​ ​Success.​ ​Hospitals

affiliated​ ​with​ ​the​ ​Sweet​ ​Success​ ​program​ ​requires​ ​staff​ ​to​ ​receive​ ​special​ ​training​ ​on​ ​GDM

management.​ ​The​ ​Resource​ ​and​ ​Training​ ​Center​ ​at​ ​Sweet​ ​Success​ ​created​ ​a​ ​guideline​ ​manual

called​ ​“CDAPP​ ​Sweet​ ​Success​ ​Guidelines​ ​for​ ​Care”​ ​to​ ​ensure​ ​consistent​ ​and​ ​quality​ ​care​ ​when

addressing​ ​gestational​ ​diabetes.​ ​It​ ​is​ ​believed​ ​that​ ​for​ ​this​ ​study,​ ​women​ ​treated​ ​at​ ​hospitals

affiliated​ ​with​ ​Sweet​ ​Success​ ​are​ ​be​ ​more​ ​likely​ ​to​ ​be​ ​referred​ ​by​ ​their​ ​primary​ ​physician​ ​to​ ​see​ ​a
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​30

registered​ ​dietitian.​ ​Therefore,​ ​facilitating​ ​the​ ​ability​ ​to​ ​compare​ ​the​ ​delivery​ ​of​ ​healthcare

between​ ​the​ ​physician​ ​and​ ​registered​ ​dietitian.

Recruitment​ ​of​ ​participants​ ​for​ ​this​ ​study​ ​begins​ ​with​ ​promoting​ ​our​ ​research​ ​at​ ​the

hospitals​ ​we​ ​selected.​ ​The​ ​hospitals​ ​will​ ​be​ ​contacted​ ​and​ ​asked​ ​for​ ​permission​ ​to​ ​post​ ​flyers

from​ ​the​ ​research​ ​division.​ ​If​ ​allowed,​ ​the​ ​flyers​ ​will​ ​be​ ​distributed​ ​to​ ​the​ ​office​ ​of​ ​the​ ​doctors,

endocrinologists,​ ​obstetricians,​ ​and​ ​nurses​ ​that​ ​assist​ ​in​ ​GDM​ ​management.​ ​Additionally,​ ​upon

receiving​ ​support​ ​from​ ​health​ ​education​ ​department​ ​and​ ​the​ ​research​ ​department​ ​of​ ​the​ ​hospital,

announcements​ ​will​ ​be​ ​made​ ​in​ ​scheduled​ ​group​ ​classes​ ​and​ ​support​ ​groups​ ​pertaining​ ​to​ ​GDM

that​ ​are​ ​listed​ ​on​ ​calendars​ ​posted​ ​on​ ​the​ ​hospital’s​ ​website.​ ​To​ ​ensure​ ​that​ ​we​ ​reach​ ​as​ ​many

eligible​ ​participants,​ ​we​ ​hope​ ​that​ ​the​ ​health​ ​education​ ​department​ ​and​ ​research​ ​department

within​ ​the​ ​hospital​ ​will​ ​share​ ​a​ ​template​ ​email​ ​detailing​ ​our​ ​research​ ​and​ ​the​ ​intention​ ​of

pursuing​ ​the​ ​research.​ ​The​ ​email​ ​itself​ ​will​ ​be​ ​written​ ​in​ ​a​ ​vague​ ​manner​ ​with​ ​the​ ​intention​ ​of​ ​it

to​ ​be​ ​shared​ ​with​ ​a​ ​variety​ ​of​ ​individuals,​ ​including​ ​internal​ ​medicine​ ​staff​ ​such​ ​as​ ​physicians

and​ ​registered​ ​dietitians.​ ​Using​ ​vague​ ​information​ ​might​ ​be​ ​misleading​ ​in​ ​not​ ​providing​ ​further

detailed​ ​information​ ​about​ ​the​ ​research.​ ​However,​ ​it​ ​is​ ​strongly​ ​presumed​ ​that​ ​physicians​ ​and

registered​ ​dietitians​ ​will​ ​change​ ​their​ ​delivery​ ​of​ ​healthcare​ ​if​ ​they​ ​knew​ ​the​ ​research​ ​was

examining​ ​their​ ​quality​ ​of​ ​work.​ ​With​ ​that​ ​in​ ​note,​ ​all​ ​eligible​ ​participants​ ​that​ ​express​ ​interest​ ​to

their​ ​physician,​ ​health​ ​education​ ​director,​ ​or​ ​call​ ​and/or​ ​email​ ​will​ ​be​ ​reached​ ​out​ ​to​ ​by​ ​the

research​ ​team​ ​and​ ​will​ ​be​ ​provided​ ​with​ ​a​ ​detailed​ ​informed​ ​consent.

During​ ​this​ ​progress,​ ​the​ ​role​ ​of​ ​the​ ​researcher​ ​is​ ​key​ ​in​ ​recruiting​ ​participants,​ ​hiring​ ​and

training​ ​volunteers​ ​that​ ​will​ ​be​ ​staffed​ ​from​ ​the​ ​MMC​ ​and​ ​meet​ ​the​ ​desired​ ​qualifications,

monitoring​ ​consistency​ ​during​ ​the​ ​interview​ ​process,​ ​compiling​ ​collected​ ​data​ ​into​ ​the​ ​2​ ​separate
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​31

excel​ ​documents.​ ​When​ ​looking​ ​at​ ​the​ ​research​ ​team​ ​as​ ​a​ ​whole,​ ​the​ ​team​ ​consists​ ​of​ ​the​ ​3​ ​main

researchers​ ​(Almanza,​ ​Dzul​ ​and​ ​Perez),​ ​and​ ​volunteer-staff​ ​that​ ​will​ ​be​ ​recruited​ ​through​ ​our

affiliation​ ​with​ ​Dr.​ ​Besnilian,​ ​who​ ​is​ ​incharge​ ​of​ ​most​ ​of​ ​the​ ​opportunities​ ​and​ ​programs

availables​ ​at​ ​the​ ​MMC.​ ​Given​ ​their​ ​heavy​ ​background​ ​in​ ​Human​ ​Nutrition​ ​Almanza,​ ​Dzul,​ ​and

Perez​ ​are​ ​qualified​ ​to​ ​conduct​ ​this​ ​study​ ​as​ ​the​ ​primary​ ​researchers.​ ​When​ ​looking​ ​at

qualifications​ ​for​ ​the​ ​volunteers​ ​that​ ​will​ ​be​ ​staffed​ ​for​ ​this​ ​research​ ​study,​ ​the​ ​following

qualifications​ ​will​ ​be​ ​anticipated:​ ​a​ ​junior​ ​or​ ​senior​ ​standing​ ​if​ ​they​ ​are​ ​undergraduate​ ​students​ ​or

any​ ​master’s​ ​students,​ ​a​ ​GPA​ ​of​ ​3.0​ ​to​ ​show​ ​they​ ​are​ ​in​ ​good​ ​academic​ ​standing,​ ​a​ ​flexible

schedule​ ​that​ ​will​ ​adhere​ ​to​ ​interview​ ​process​ ​of​ ​the​ ​study,​ ​HIPAA​ ​certification,​ ​updated​ ​resume,

letter​ ​of​ ​recommendation​ ​from​ ​professor​ ​or​ ​colleague​ ​that​ ​supports​ ​the​ ​volunteers​ ​potential​ ​in

professionalism​ ​and​ ​research.​ ​Training​ ​of​ ​the​ ​staff​ ​will​ ​include​ ​HIPAA​ ​certification​ ​if​ ​not

completed,​ ​cultural​ ​sensitivity,​ ​and​ ​specialized​ ​training​ ​in​ ​interviewing,​ ​emphasizing​ ​a​ ​heavy

focus​ ​on​ ​practice​ ​and​ ​usage​ ​of​ ​motivational​ ​interviewing.​ ​Since​ ​we​ ​anticipate​ ​the​ ​graduation​ ​of

our​ ​volunteers​ ​over​ ​the​ ​length​ ​of​ ​the​ ​study,​ ​we​ ​will​ ​repeat​ ​recruiting​ ​and​ ​training​ ​of​ ​volunteers

each​ ​summer.

Participants

Newly​ ​diagnosed​ ​pregnant​ ​women​ ​with​ ​GDM​ ​will​ ​be​ ​recruited​ ​from​ ​Summer​ ​2018​ ​to

Summer​ ​2021,​ ​and​ ​will​ ​be​ ​followed​ ​until​ ​time​ ​of​ ​delivery.​ ​According​ ​to​ ​the​ ​Los​ ​Angeles​ ​County

Department​ ​of​ ​Public​ ​Health​ ​(LACDPH),​ ​in​ ​2013​ ​there​ ​was​ ​a​ ​total​ ​average​ ​of​ ​11,597​ ​live​ ​births

per​ ​year​ ​after​ ​taking​ ​the​ ​sum​ ​of​ ​the​ ​five​ ​hospitals​ ​our​ ​study​ ​will​ ​be​ ​focusing​ ​on​ ​(LACDPH,

2013).​ ​Of​ ​the​ ​total​ ​live​ ​births,​ ​1,438​ ​of​ ​them​ ​are​ ​predicted​ ​to​ ​be​ ​born​ ​from​ ​mothers​ ​with​ ​GDM,

with​ ​a​ ​12.4%​ ​prevalence​ ​(LACDPH,​ ​2010).​ ​Therefore,​ ​the​ ​convenient​ ​sample​ ​size​ ​of​ ​pregnant
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​32

women​ ​with​ ​GDM​ ​that​ ​will​ ​be​ ​contacted​ ​to​ ​participate​ ​in​ ​this​ ​study​ ​will​ ​be​ ​at​ ​least​ ​1,200

individuals,​ ​as​ ​this​ ​study​ ​anticipates​ ​the​ ​possibility​ ​of​ ​there​ ​being​ ​dropouts​ ​and​ ​individuals​ ​that

might​ ​not​ ​be​ ​able​ ​participate​ ​to​ ​be​ ​removed.There​ ​are​ ​a​ ​number​ ​of​ ​reasons​ ​for​ ​individuals​ ​to​ ​not

qualify​ ​or​ ​participate​ ​in​ ​the​ ​study​ ​including​ ​not​ ​meeting​ ​the​ ​necessary​ ​inclusion​ ​criteria

mentioned,​ ​not​ ​being​ ​available​ ​to​ ​participate​ ​for​ ​all​ ​scheduled​ ​appointments,​ ​lack​ ​of​ ​interest,

forgetting​ ​about​ ​scheduled​ ​appointments,​ ​or​ ​being​ ​unable​ ​to​ ​attend​ ​appointments.​ ​Aspiring​ ​for​ ​a

minimum​ ​of​ ​500​ ​individuals​ ​to​ ​attend​ ​all​ ​MD​ ​consultations​ ​and​ ​RD​ ​appointments,​ ​we​ ​believe

that​ ​the​ ​study​ ​will​ ​be​ ​able​ ​to​ ​reflect​ ​results​ ​that​ ​favor​ ​or​ ​disprove​ ​our​ ​proposed​ ​hypothesis.​ ​The

margin​ ​of​ ​error​ ​of​ ​potential​ ​dropouts​ ​and​ ​margin​ ​of​ ​error​ ​for​ ​a​ ​study​ ​conducted​ ​with​ ​a​ ​sample

size​ ​of​ ​500​ ​individuals​ ​is​ ​anticipated​ ​to​ ​be​ ​4%​ ​(Margin​ ​of​ ​Error,​ ​2017).​ ​While​ ​this​ ​is​ ​a​ ​higher

percentage​ ​of​ ​error,​ ​we​ ​realistically​ ​think​ ​this​ ​study​ ​would​ ​work​ ​best​ ​with​ ​a​ ​smaller​ ​team​ ​of

participants​ ​that​ ​follow​ ​the​ ​rules​ ​our​ ​research​ ​would​ ​apply,​ ​allowing​ ​for​ ​more​ ​consistent​ ​results.

Ensuring​ ​confidentiality​ ​is​ ​an​ ​important​ ​component​ ​to​ ​our​ ​study​ ​as​ ​it​ ​encourages

participation.​ ​To​ ​ensure​ ​the​ ​privacy​ ​of​ ​our​ ​participants,​ ​we​ ​will​ ​assign​ ​a​ ​unique​ ​5​ ​digit​ ​code

number​ ​to​ ​each​ ​participant​ ​that​ ​will​ ​be​ ​used​ ​as​ ​their​ ​file​ ​name.​ ​Only​ ​participants​ ​themselves​ ​and

primary​ ​researchers​ ​will​ ​know​ ​who​ ​the​ ​identifying​ ​number​ ​belongs​ ​to.​ ​Hospital​ ​staff​ ​will​ ​provide

information​ ​needed​ ​using​ ​the​ ​patient’s​ ​code​ ​number​ ​for​ ​discretion.​ ​The​ ​5​ ​digit​ ​code​ ​number​ ​will

be​ ​randomly​ ​generated​ ​using​ ​a​ ​true​ ​random​ ​number​ ​generator​ ​and​ ​this​ ​number​ ​will​ ​replace​ ​their

name​ ​on​ ​documents​ ​that​ ​show​ ​their​ ​diagnosis,​ ​lab​ ​results,​ ​and​ ​other​ ​identifiable​ ​and​ ​sensitive

information.​ ​Given​ ​the​ ​considerable​ ​amount​ ​of​ ​sensitive​ ​information,​ ​it​ ​is​ ​crucial​ ​that​ ​the

research​ ​team​ ​is​ ​HIPPA​ ​compliant​ ​to​ ​further​ ​enforce​ ​participants​ ​privacy.​ ​Study​ ​records​ ​will​ ​be

stored​ ​in​ ​a​ ​protected​ ​digital​ ​file​ ​that​ ​is​ ​protected​ ​by​ ​a​ ​security​ ​program​ ​and​ ​will​ ​require​ ​a
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​33

password​ ​to​ ​access​ ​information.​ ​Only​ ​primary​ ​researchers​ ​will​ ​have​ ​access​ ​to​ ​these​ ​files.​ ​Upon

completion​ ​of​ ​the​ ​study,​ ​all​ ​hard​ ​copies​ ​with​ ​information​ ​that​ ​pertained​ ​to​ ​the​ ​study​ ​will​ ​be

destroyed.​ ​However,​ ​files​ ​will​ ​be​ ​saved​ ​for​ ​three​ ​years​ ​and​ ​then​ ​destroyed.

It​ ​is​ ​also​ ​important​ ​to​ ​note​ ​that​ ​this​ ​study​ ​focuses​ ​on​ ​a​ ​population​ ​that​ ​is​ ​considered​ ​to​ ​be

vulnerable.​ ​Therefore,​ ​it​ ​is​ ​critical​ ​that​ ​this​ ​study​ ​be​ ​approved​ ​by​ ​the​ ​Institutional​ ​Review​ ​Board

(IRB).​ ​A​ ​Human​ ​Subject​ ​Protocol​ ​Form​ ​will​ ​be​ ​sent​ ​to​ ​California​ ​State​ ​University,​ ​Northridge

for​ ​approval​ ​of​ ​the​ ​study.

Measurements

The​ ​variables​ ​we​ ​will​ ​be​ ​measuring​ ​are​ ​as​ ​follows:​ ​(1)​ ​the​ ​number​ ​of​ ​times​ ​a​ ​patient

meets​ ​with​ ​a​ ​physician​ ​after​ ​GDM​ ​diagnosis,​ ​(2)​ ​the​ ​number​ ​of​ ​times​ ​a​ ​patient​ ​meets​ ​with​ ​an​ ​RD

after​ ​GDM​ ​diagnosis,​ ​(4)​ ​the​ ​forms​ ​of​ ​GDM​ ​education​ ​received,​ ​(5)​ ​the​ ​average​ ​carbohydrate

intake,​ ​and​ ​(6)​ ​blood​ ​glucose​ ​values.​ ​Most​ ​of​ ​our​ ​variables​ ​will​ ​be​ ​collected​ ​through​ ​an​ ​in-person

interview​ ​(see​ ​appendix​ ​A)​ ​that​ ​will​ ​be​ ​administered​ ​immediately​ ​after​ ​GDM​ ​diagnosis​ ​and​ ​in

the​ ​last​ ​week​ ​of​ ​gestation​ ​or​ ​soon​ ​after​ ​patient​ ​gives​ ​birth.​ ​Independent​ ​variables​ ​include,

physicians​ ​and​ ​the​ ​registered​ ​dietitians.

During​ ​the​ ​in-person​ ​interview,​ ​the​ ​participant​ ​will​ ​hold​ ​a​ ​paper​ ​copy​ ​of​ ​the​ ​4-page,

28-question​ ​questionnaire​ ​while​ ​one​ ​of​ ​the​ ​research​ ​assistants​ ​goes​ ​over​ ​each​ ​question​ ​one​ ​by

one​ ​to​ ​clarify​ ​any​ ​misunderstandings.​ ​Part​ ​I​ ​of​ ​the​ ​questionnaire​ ​has​ ​basic​ ​health​ ​questions​ ​such

as​ ​age​ ​of​ ​the​ ​participant,​ ​number​ ​of​ ​times​ ​participant​ ​has​ ​been​ ​pregnant,​ ​and​ ​if​ ​she​ ​is

self-monitoring​ ​her​ ​blood​ ​glucose.​ ​These​ ​questions​ ​were​ ​created​ ​by​ ​the​ ​main​ ​researchers

Almanza,​ ​Dzul,​ ​and​ ​Perez.​ ​Part​ ​II​ ​of​ ​the​ ​questionnaire​ ​assesses​ ​carbohydrate​ ​intake​ ​by​ ​asking

how​ ​often​ ​the​ ​participant​ ​has​ ​consumed​ ​grains,​ ​fruit,​ ​and​ ​sugary​ ​drinks​ ​in​ ​the​ ​week​ ​preceding​ ​the
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​34

interview.​ ​These​ ​questions​ ​were​ ​selected​ ​from​ ​the​ ​National​ ​Institutes​ ​of​ ​Health​ ​Diet​ ​History

Questionnaire​ ​(DHQ)​ ​II.​ ​The​ ​DHQ​ ​II​ ​has​ ​not​ ​been​ ​validated​ ​since​ ​it​ ​only​ ​has​ ​a​ ​few​ ​changes​ ​from

the​ ​DHQ​ ​I,​ ​which​ ​was​ ​shown​ ​to​ ​be​ ​a​ ​validated​ ​tool​ ​by​ ​3​ ​separate​ ​studies​ ​(Epidemiology​ ​and

Genomics​ ​Research​ ​Program,​ ​n.d.).​ ​Part​ ​III​ ​of​ ​the​ ​questionnaire​ ​has​ ​4​ ​simple​ ​questions​ ​that​ ​asks

the​ ​participant​ ​which​ ​member​ ​of​ ​the​ ​medical​ ​team​ ​has​ ​discussed​ ​certain​ ​topics​ ​with​ ​her.​ ​To​ ​assist

in​ ​this​ ​process​ ​of​ ​individualization​ ​and​ ​searching​ ​for​ ​specific​ ​answers​ ​and​ ​traits,​ ​recruitment​ ​and

thorough​ ​training​ ​of​ ​volunteers​ ​from​ ​the​ ​Marilyn​ ​Magaram​ ​Center​ ​(MMC)​ ​will​ ​be​ ​needed.

Before​ ​conducting​ ​the​ ​first​ ​interviews,​ ​training​ ​for​ ​the​ ​volunteers​ ​will​ ​need​ ​to​ ​be​ ​completed​ ​and

a​ ​pilot​ ​test​ ​of​ ​the​ ​interview​ ​process​ ​will​ ​be​ ​done​ ​with​ ​each​ ​volunteer​ ​staffed.​ ​While​ ​volunteers

are​ ​conducting​ ​the​ ​interviews,​ ​they​ ​will​ ​have​ ​measuring​ ​cups​ ​and​ ​food​ ​models​ ​obtained​ ​from

CSUN’s​ ​Marilyn​ ​Magaram​ ​Center​ ​so​ ​participants​ ​can​ ​provide​ ​accurate​ ​estimates​ ​of​ ​their

carbohydrate​ ​intake.​ ​Once​ ​the​ ​interviews​ ​commence​ ​with​ ​the​ ​participants,​ ​it​ ​will​ ​be​ ​required​ ​that

at​ ​least​ ​one​ ​of​ ​the​ ​three​ ​lead​ ​researchers​ ​in​ ​this​ ​be​ ​present​ ​with​ ​the​ ​volunteers.

Blood​ ​glucose​ ​information​ ​will​ ​be​ ​collected​ ​by​ ​hospital​ ​staff​ ​or​ ​by​ ​participants

themselves.​ ​Results​ ​from​ ​a​ ​2-hour​ ​oral​ ​glucose​ ​tolerance​ ​test​ ​will​ ​be​ ​collected​ ​and​ ​assessed​ ​after

initial​ ​diagnosis​ ​from​ ​the​ ​participants’​ ​medical​ ​files.​ ​Fasting​ ​blood​ ​glucose​ ​levels​ ​and​ ​2-hour

postprandial​ ​glucose​ ​scores​ ​will​ ​be​ ​evaluated​ ​weekly.​ ​We​ ​will​ ​receive​ ​blood​ ​glucose

measurements​ ​for​ ​3​ ​weekdays​ ​(Monday,​ ​Wednesday,​ ​and​ ​Friday)​ ​from​ ​medical​ ​files​ ​or​ ​from

participants​ ​themselves,​ ​average​ ​the​ ​fasting​ ​and​ ​postprandial​ ​blood​ ​glucose​ ​levels,​ ​and​ ​evaluate

progress.​ ​If​ ​there​ ​is​ ​the​ ​scenario​ ​where​ ​participants​ ​are​ ​not​ ​self-monitoring,​ ​these​ ​individuals​ ​will

be​ ​asked​ ​to​ ​come​ ​into​ ​their​ ​hospital’s​ ​laboratory​ ​and​ ​have​ ​their​ ​blood​ ​glucose​ ​values​ ​checked​ ​by

a​ ​Registered​ ​Dietitian​ ​or​ ​a​ ​nurse,​ ​using​ ​glucose​ ​meters​ ​at​ ​the​ ​30th​ ​week,​ ​36th​ ​week,​ ​and​ ​right
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​35

before​ ​delivery.​ ​The​ ​primary​ ​system​ ​that​ ​will​ ​be​ ​used​ ​to​ ​document​ ​and​ ​record​ ​this​ ​data​ ​will​ ​be

Microsoft​ ​Excel​ ​Sheets.​ ​There​ ​will​ ​be​ ​two​ ​different​ ​excel​ ​sheets,​ ​the​ ​first​ ​will​ ​be​ ​a​ ​document

used​ ​and​ ​added​ ​to​ ​during​ ​the​ ​conduction​ ​of​ ​interviews,​ ​the​ ​second​ ​will​ ​be​ ​a​ ​result​ ​of​ ​the

conclusive​ ​findings​ ​from​ ​each​ ​interview​ ​and​ ​what​ ​the​ ​findings​ ​indicate.

Data​ ​analysis​ ​will​ ​be​ ​performed​ ​using​ ​the​ ​Statistical​ ​Analysis​ ​System,​ ​SPSS.​ ​A

statistician​ ​will​ ​be​ ​hired​ ​from​ ​California​ ​State​ ​University,​ ​Northridge​ ​Statistics​ ​Department​ ​to

assist​ ​with​ ​data​ ​interpretation.​ ​All​ ​participants​ ​will​ ​be​ ​observed​ ​as​ ​one​ ​group.​ ​Once​ ​all​ ​data​ ​is

collected,​ ​we​ ​will​ ​divide​ ​the​ ​participants​ ​into​ ​two​ ​groups:​ ​those​ ​who​ ​frequently​ ​met​ ​with​ ​an

RD/RDN​ ​and​ ​those​ ​rarely​ ​had​ ​a​ ​consultation​ ​with​ ​an​ ​RD/RDN.​ ​Since​ ​we​ ​are​ ​comparing​ ​two

independent​ ​variables​ ​(mostly​ ​registered​ ​dietitian​ ​education​ ​and​ ​mostly​ ​physician​ ​education)​ ​to

discover​ ​which​ ​leads​ ​to​ ​improvement​ ​in​ ​participants​ ​knowledge​ ​and​ ​adherence​ ​to​ ​blood​ ​glucose

management,​ ​we​ ​felt​ ​a​ ​paired​ ​t-test​ ​was​ ​the​ ​most​ ​appropriate.​ ​Ultimately,​ ​the​ ​paired​ ​t-test​ ​will​ ​be

used​ ​to​ ​test​ ​the​ ​significant​ ​differences​ ​in​ ​blood​ ​glucose​ ​lab​ ​results​ ​and​ ​the​ ​results​ ​of​ ​the

questionnaire​ ​after​ ​seeing​ ​both​ ​the​ ​physician​ ​and​ ​the​ ​registered​ ​dietitian.

Future​ ​Implications

Once​ ​our​ ​study​ ​is​ ​concluded,​ ​we​ ​hope​ ​that​ ​our​ ​results​ ​support​ ​our​ ​hypothesis,​ ​which

states​ ​that​ ​an​ ​interdisciplinary​ ​team​ ​that​ ​includes​ ​a​ ​physician​ ​and​ ​a​ ​Registered​ ​Dietitian​ ​will

result​ ​in​ ​better​ ​blood​ ​glucose​ ​management​ ​and​ ​healthier​ ​dietary​ ​practices​ ​for​ ​the​ ​management​ ​of

GDM.​ ​Benefits​ ​of​ ​our​ ​study​ ​include​ ​reproducibility​ ​of​ ​the​ ​methods,​ ​comparison​ ​of​ ​the​ ​role​ ​of​ ​the

RD​ ​and​ ​MD​ ​in​ ​GDM,​ ​and​ ​limited​ ​finances​ ​required​ ​for​ ​the​ ​execution​ ​of​ ​the​ ​study.​ ​Although​ ​we

can​ ​only​ ​draw​ ​associations​ ​from​ ​our​ ​data,​ ​our​ ​results​ ​can​ ​be​ ​used​ ​to​ ​advocate​ ​for​ ​more
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​36

individualized​ ​nutrition​ ​education​ ​in​ ​hospitals.​ ​This​ ​is​ ​particularly​ ​true​ ​for​ ​scenarios​ ​where

participants​ ​who​ ​receive​ ​more​ ​one-on-one​ ​consultations​ ​demonstrate​ ​better​ ​GDM​ ​management.

Hospitals​ ​may​ ​be​ ​interested​ ​in​ ​reviewing​ ​and​ ​assessing​ ​the​ ​findings​ ​of​ ​this​ ​study​ ​to

furthermore,​ ​identify​ ​appropriate​ ​GDM​ ​management​ ​and​ ​funding​ ​allocations,​ ​where​ ​the​ ​money

is​ ​going​ ​to​ ​support​ ​the​ ​hired​ ​staff​ ​like​ ​RDs​ ​and​ ​MDs.​ ​In​ ​addition,​ ​our​ ​findings​ ​will​ ​allow​ ​for

further​ ​evidence​ ​to​ ​support​ ​the​ ​importance​ ​in​ ​the​ ​support​ ​of​ ​an​ ​interdisciplinary​ ​team​ ​when

addressing​ ​GDM.​ ​Furthermore,​ ​it​ ​can​ ​encourage​ ​for​ ​nutrition​ ​education​ ​and​ ​health​ ​promotion.

Most​ ​importantly,​ ​this​ ​study​ ​correlates​ ​with​ ​the​ ​ ​socio-ecological​ ​model​ ​theory​ ​in​ ​that​ ​the

interpersonal​ ​level​ ​has​ ​an​ ​influence​ ​on​ ​the​ ​health​ ​behaviors​ ​of​ ​the​ ​individual.

This​ ​new​ ​study​ ​could​ ​potentially​ ​inspire​ ​research​ ​on​ ​the​ ​role​ ​of​ ​the​ ​nurses​ ​amongst​ ​the

interdisciplinary​ ​team.​ ​Ultimately,​ ​it​ ​would​ ​be​ ​ideal​ ​to​ ​follow-up​ ​on​ ​the​ ​live​ ​births​ ​completes

from​ ​mothers​ ​that​ ​pertains​ ​to​ ​this​ ​study.​ ​This​ ​will​ ​allow​ ​us​ ​to​ ​evaluate​ ​the​ ​impact​ ​of​ ​health

education​ ​and​ ​the​ ​long-term​ ​effects​ ​GDM​ ​management​ ​and​ ​care​ ​when​ ​comparing​ ​the​ ​role​ ​of​ ​an

RD​ ​and​ ​MD.


Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​37

APPENDIX:​ ​TABLE​ ​OF​ ​CONTENTS

APPENDIX​ ​A:​ ​Socio-Ecological​ ​Model​ ​Theory………………………………………....…..38

APPENDIX​ ​B:​ ​Email​ ​Shared​ ​to​ ​Hospitals………………………………………………..…..39

APPENDIX​ ​C:​ ​Excel​ ​Documents…………………………..………….………………….40-41


I. 1st​ ​Interview:​ ​Part​ ​1​ ​and​ ​3…………………………………....……………….40
II. 1st​ ​Interview:​ ​Part​ ​2…………………………………………………………...40
III. 2nd​ ​Interview:​ ​Part​ ​1​ ​and​ ​3…………………………………………………....40
IV. 2nd​ ​Interview:​ ​Part​ ​2……………………………………………….………….41
V. Blood​ ​Glucose​ ​Tracking……………………………………….………………41

APPENDIX​ ​D:​ ​Nutrition​ ​Questionnaire…………………………………………...……...42-46

APPENDIX​ ​E:​ ​Informed​ ​Consent​ ​Form………………………………………………......47-48

APPENDIX​ ​F:​ ​Timeline……………………………………………………………………....52


Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​38

APPENDIX​ ​A:​ ​Socio-Ecological​ ​Model​ ​Theory


Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​39

APPENDIX​ ​B:​ ​EMAIL

Email​ ​to​ ​Hospitals

Dear​ ​__________,

My​ ​name​ ​is​ ​Karina​ ​Almanza,​ ​I​ ​am​ ​a​ ​Dietetic​ ​Intern​ ​completing​ ​my​ ​master’s​ ​degree​ ​in​ ​Human​ ​Nutrition​ ​at
California​ ​State​ ​University,​ ​Northridge.​ ​The​ ​reason​ ​I​ ​am​ ​reaching​ ​out​ ​is​ ​because​ ​I​ ​am​ ​currently​ ​in​ ​the​ ​process​ ​of
conducting​ ​a​ ​research​ ​study​ ​that​ ​will​ ​emphasize​ ​its​ ​focus​ ​on​ ​gestational​ ​diabetes.​ ​Our​ ​study​ ​is​ ​aimed​ ​to​ ​observe
different​ ​methods​ ​and​ ​techniques​ ​that​ ​are​ ​currently​ ​being​ ​implemented​ ​in​ ​today’s​ ​medical​ ​practices​ ​and​ ​their
influence​ ​in​ ​gestational​ ​diabetes​ ​management.​ ​The​ ​goal​ ​of​ ​this​ ​study​ ​would​ ​be​ ​to​ ​address​ ​key​ ​tactics​ ​that​ ​will​ ​assist
in​ ​gestational​ ​diabetes​ ​management.

The​ ​table​ ​below​ ​demonstrates​ ​the​ ​total​ ​amount​ ​of​ ​patients​ ​that​ ​are​ ​received​ ​by​ ​the​ ​five​ ​hospitals​ ​that​ ​we​ ​are​ ​hoping
to​ ​be​ ​affiliated​ ​with,​ ​including​ ​your​ ​own:

Women​ ​Annually​ ​Diagnosed​ ​with​ ​Gestational​ ​Diabetes

Total​ ​Live​ ​Births​ ​(2013)

Kaiser​ ​Permanente,​ ​Woodland​ ​Hills 1,221

Providence​ ​Holy​ ​Cross,​ ​Mission​ ​Hills 2,961

Dignity​ ​Health-​ ​Glendale​ ​Memorial​ ​Hospital,​ ​Glendale 1,810

Adventist​ ​Health​ ​White​ ​Memorial,​ ​Los​ ​Angeles 2,359

Huntington​ ​Memorial,​ ​Pasadena 3,246

TOTAL 11,597

Multiplied​ ​by​ ​Statistic​ ​of​ ​Women​ ​with​ ​GDM 1,438​ ​women​ ​with​ ​GDM
(12.4%)

An​ ​average​ ​of​ ​1,428​ ​women​ ​are​ ​diagnosed​ ​with​ ​gestational​ ​diabetes​ ​each​ ​year.​ ​This​ ​number​ ​is​ ​only​ ​taking​ ​into
consideration​ ​the​ ​number​ ​of​ ​live​ ​births​ ​that​ ​are​ ​delivered​ ​in​ ​the​ ​5​ ​hospitals​ ​mentioned​ ​above.

What​ ​we​ ​will​ ​need​ ​help​ ​on​ ​for​ ​the​ ​progress​ ​of​ ​our​ ​study​ ​would​ ​be​ ​the​ ​recruitment​ ​of​ ​participants​ ​of​ ​women
diagnosed​ ​with​ ​gestational​ ​diabetes​ ​within​ ​a​ ​25​ ​mile​ ​radius​ ​of​ ​the​ ​Northridge​ ​area.​ ​The​ ​reason​ ​we​ ​are​ ​contacting
your​ ​assistance​ ​in​ ​recruitment​ ​of​ ​an​ ​anticipated​ ​300​ ​participants​ ​for​ ​our​ ​study​ ​is​ ​because​ ​of​ ​the​ ​professionalism​ ​of
your​ ​facility​ ​and​ ​your​ ​affiliation​ ​with​ ​Sweet​ ​Success,​ ​A​ ​relationship​ ​of​ ​which​ ​plays​ ​a​ ​critical​ ​role​ ​in​ ​study.

Any​ ​help​ ​for​ ​this​ ​research​ ​would​ ​be​ ​greatly​ ​appreciated.​ ​Please​ ​feel​ ​free​ ​to​ ​forward​ ​this​ ​email​ ​and​ ​information​ ​with
anyone​ ​you​ ​feel​ ​might​ ​be​ ​interested​ ​in​ ​participating​ ​or​ ​promoting.

Thank​ ​you,
Karina

karina.almanza.249@my.csun.edu
CC:​ ​itzel.dzulhernandez.56@my.csun.edu
alejandra.perez.479@my.csun.edu
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​40

APPENDIX​ ​C:​ ​EXCEL​ ​DOCUMENTS

Part​ ​I​ ​and​ ​III​ ​of​ ​Questionnaire​ ​at​ ​Time​ ​of​ ​GDM​ ​Diagnosis

Part​ ​II​ ​of​ ​Questionnaire​ ​at​ ​Time​ ​of​ ​GDM​ ​Diagnosis

Part​ ​I​ ​and​ ​III​ ​of​ ​Questionnaire​ ​Near​ ​Time​ ​of​ ​Delivery
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​41

Part​ ​II​ ​of​ ​Questionnaire​ ​Near​ ​Time​ ​of​ ​Delivery

Fasting​ ​and​ ​Postprandial​ ​Blood​ ​Glucose​ ​Tracking


Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​42

Appendix​ ​D:​ ​Nutrition​ ​Questionnaire​ ​For​ ​Women​ ​with​ ​GDM

Part​ ​I:​​ ​Please​ ​answer​ ​each​ ​question​ ​to​ ​the​ ​best​ ​of​ ​your​ ​knowledge.​ ​Your​ ​answers​ ​are​ ​very​ ​valuable​ ​to
our​ ​research​ ​and​ ​will​ ​be​ ​used​ ​to​ ​have​ ​a​ ​better​ ​understanding​ ​of​ ​women​ ​with​ ​gestational​ ​diabetes.​ ​Your
participation​ ​in​ ​this​ ​survey​ ​is​ ​voluntary,​ ​and​ ​you​ ​may​ ​stop​ ​at​ ​any​ ​point.​ ​Thank​ ​you!

1. What​ ​is​ ​your​ ​date​ ​of​ ​birth?​ ​ ​ ​ ​ ​Month​ ​____​ ​Day​ ​____​ ​Year​ ​____

2. What​ ​is​ ​your​ ​ethnicity?


​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Hispanic​ ​ ​ ​ ​▢​ ​White​ ​ ​ ​ ​▢​ ​African-American​ ​ ​ ​ ​▢​ ​Asian​ ​ ​ ​ ​▢​ ​Other​ ​(please​ ​describe)​ ​_____________

3. How​ ​many​ ​times​ ​have​ ​you​ ​been​ ​pregnant​ ​(including​ ​this​ ​pregnancy)​?​ ​ ​__________

4. How​ ​many​ ​weeks​ ​of​ ​gestation​ ​(pregnancy)​ ​are​ ​you​ ​at?​ ​If​ ​you​ ​are​ ​not​ ​sure,​ ​write​ ​the​ ​date​ ​of
your​ ​last​ ​menstrual​ ​period?​ ​ ​___________

5. At​ ​how​ ​many​ ​weeks​ ​of​ ​gestation​ ​did​ ​you​ ​start​ ​prenatal​ ​care?​ ​ ​ ​___________​ ​weeks

6. Have​ ​you​ ​been​ ​diagnosed​ ​with​ ​gestational​ ​diabetes​ ​during​ ​previous​ ​pregnancies?
​ ​ ​ ​▢​ ​Yes ▢​ ​No ​ ​ ​ ​ ​ ​ ​ ​▢​ ​This​ ​is​ ​my​ ​first​ ​pregnancy

7. How​ ​often​ ​have​ ​you​ ​met​ ​with​ ​your​ ​physician​ ​(or​ ​gynecologist)​ ​this​ ​past​ ​month?
​ ​ ​ ​▢​ ​ ​0​ ​times ▢​ ​Once​ ​ ​ ​ ​ ​ ​ ​▢​ ​Twice ▢​ ​3​ ​times​ ​or​ ​more

8. Have​ ​you​ ​met​ ​with​ ​a​ ​RD/​ ​Nutritionist​ ​for​ ​your​ ​gestational​ ​diabetes​ ​management?
​ ​ ​ ​▢​ ​Yes ▢​ ​No ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​I’m​ ​not​ ​sure

9. If​ ​yes,​ ​how​ ​often​ ​within​ ​the​ ​past​ ​month​ ​on​ ​the​ ​have​ ​you​ ​met​ ​with​ ​the​ ​RD/​ ​Nutritionist?
​ ​ ​ ​▢​ ​Once​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Twice​ ​ ​ ​ ​ ​ ​▢​ ​3​ ​times​ ​or​ ​more

10. Through​ ​which​ ​of​ ​the​ ​following​ ​have​ ​you​ ​received​ ​gestational​ ​diabetes/blood​ ​glucose
education?​ ​Select​ ​all​ ​that​ ​apply.
​ ​ ​ ​▢​ ​One-On-One​ ​consultation​ ​with​ ​Physician/Doctor
​ ​ ​ ​▢​ ​One-On-One​ ​consultation​ ​with​ ​Registered​ ​Dietitian/​ ​Nutritionist
​ ​ ​ ​▢​ ​One-On-One​ ​consultation​ ​with​​ ​a​ ​Nurse​ ​Practitioner
​ ​ ​ ​▢​ ​Group​ ​class
​ ​ ​ ​▢​ ​Pamphlets/​ ​Handouts
​ ​ ​ ​▢​ ​Other​ ​(​please​ ​describe​):​ ​________________________________________
​ ​ ​ ​▢​ ​None​ ​of​ ​the​ ​above

11. Have​ ​you​ ​self​ ​monitored​ ​your​ ​blood​ ​glucose​ ​(​sugar​)?​ ​ ​ ​ ​▢​ ​Yes ​ ​ ​ ​▢​ ​No

12. If​ ​you​ ​are​ ​self-monitoring​ ​your​ ​blood​ ​glucose,​ ​how​ ​often​ ​do​ ​you​ ​do​ ​it?
​ ​ ​▢​ ​In​ ​the​ ​morning,​ ​after​ ​breakfast,​ ​after​ ​lunch,​ ​and​ ​after​ ​dinner/before​ ​bed​ ​everyday
​ ​ ​▢​ ​Once​ ​per​ ​day
​ ​ ​▢​ ​2-3​ ​times​ ​per​ ​week
​ ​ ​▢​ ​Less​ ​than​ ​once​ ​per​ ​week ​ ​ ​ ​Write​ ​down​ ​5-digit​ ​patient​ ​code:___________
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​43

Part​ ​II:​​ ​ ​The​ ​following​ ​questions​ ​are​ ​to​ ​have​ ​a​ ​better​ ​understanding​ ​of​ ​what​ ​you​ ​typically​ ​eat​ ​now​ ​that
you​ ​are​ ​pregnant.​ ​Answer​ ​each​ ​question​ ​to​ ​the​ ​best​ ​of​ ​your​ ​knowledge.​ ​Honest​ ​answers​ ​will​ ​be​ ​the
most​ ​helpful​ ​to​ ​our​ ​research.
13.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​eat​ ​cold 15.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​drink
​ ​ ​ ​ ​ ​ ​cereal? ​ ​ ​ ​ ​ ​ ​100%​ ​fruit​ ​juice​ ​or​ ​100%​ ​fruit​ ​juice​ ​mixtures?
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​14) ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​16)
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​day ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1-2​ ​times​ ​per​ ​week​ ​ ​ ​ ​▢​ ​2-3​ ​times​ ​per​ ​day
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​ ​2​ ​times​ ​per​ ​day ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​▢​ ​4-5​ ​times​ ​per​ ​day
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week​ ​ ​ ​ ​▢​ ​6+​ ​times​ ​per​ ​day
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​day

13a.​ ​Each​ ​time​ ​you​ ​ate​ ​cold​ ​cereal,​ ​how​ ​much​ ​did 15a.​ ​Each​ ​time​ ​you​ ​drank​ ​other​ ​100%​ ​fruit​ ​juice
​ ​ ​ ​ ​ ​ ​ ​ ​you​ ​usually​ ​eat? ​ ​ ​ ​ ​ ​ ​ ​ ​or​ ​100%​ ​fruit​ ​juice​ ​mixtures,​ ​how​ ​much​ ​did
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Less​ ​than​ ​1​ ​cup ​ ​ ​ ​ ​ ​ ​ ​ ​you​ ​usually​ ​drink?
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​cup​ ​to​ ​2​ ​½​ ​cups ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Less​ ​than​ ​¾​ ​cup​ ​(6​ ​ounces)
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​More​ ​than​ ​2​ ​½​ ​cups ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​¾​ ​to​ ​1½​ ​cups​ ​(6​ ​to​ ​12​ ​ounces)
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​More​ ​than​ ​1½​ ​cups​ ​(12​ ​ounces)

13b.​ ​How​ ​often​ ​was​ ​the​ ​cold​ ​cereal​ ​you​ ​bran​ ​or​ ​fiber 16.​ ​In​ ​the​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​eat​ ​breads
​ ​ ​ ​ ​ ​ ​ ​ ​cereal​ ​(such​ ​as​ ​Cheerios,​ ​Shredded​ ​Wheat, ​ ​ ​ ​ ​ ​ ​or​ ​rolls​ ​AS​ ​PART​ ​OF​ ​SANDWICHES
​ ​ ​ ​ ​ ​ ​ ​ ​Raisin​ ​Bran,​ ​Bran​ ​Flakes,​ ​Grape-Nuts, ​ ​ ​ ​ ​ ​ ​(including​ ​burger​ ​and​ ​hot​ ​dog​ ​rolls)?
​ ​ ​ ​ ​ ​ ​ ​ ​Granola,​ ​Wheaties,​ ​or​ ​Healthy​ ​Choice)? ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​17)
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Almost​ ​never​ ​or​ ​never ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​day
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​About​ ​¼​ ​of​ ​the​ ​time​ ​ ​▢​ ​About​ ​¾​ ​of​ ​the​ ​time ​ ​ ​ ​ ​ ​ ​ ​▢​ ​2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​2+​ ​ ​times​ ​per​ ​day
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​About​ ​½​ ​of​ ​the​ ​tim​ ​ ​ ​ ​▢​ ​Almost​ ​always/​ ​always ​ ​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week
​ ​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​ ​time​ ​per​ ​day

13c.​ ​How​ ​often​ ​was​ ​the​ ​cold​ ​cereal​ ​you​ ​ate​ ​any​ ​other 16a.​ ​Each​ ​time​ ​you​ ​ate​ ​bread​ ​or​ ​rolls​ ​AS​ ​PART
​ ​ ​ ​ ​ ​ ​ ​ ​type​ ​of​ ​cold​ ​cereal​ ​(such​ ​as​ ​Corn​ ​Flakes,​ ​Rice ​ ​ ​ ​ ​ ​ ​ ​ ​OF​ ​SANDWICHES,​ ​how​ ​many​ ​did​ ​you
​ ​ ​ ​ ​ ​ ​ ​ ​Krispies,​ ​Frosted​ ​Flakes,​ ​Special​ ​K,​ ​Froot ​ ​ ​ ​ ​ ​ ​ ​ ​usually​ ​eat?
​ ​ ​ ​ ​ ​ ​ ​ ​Loops,​ ​Cap'n​ ​Crunch,​ ​or​ ​others)? ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​slice​ ​or​ ​half​ ​a​ ​roll
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Almost​ ​never​ ​or​ ​never ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​2​ ​slices​ ​or​ ​1​ ​roll
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​About​ ​¼​ ​of​ ​the​ ​time​ ​ ​▢​ ​About​ ​¾​ ​of​ ​the​ ​time ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​More​ ​than​ ​2​ ​slices​ ​or​ ​more​ ​than​ ​1​ ​roll
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​About​ ​½​ ​of​ ​the​ ​time​ ​ ​▢​ ​Almost​ ​always/​ ​always

14.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​eat​ ​fruit 17.​ ​In​ ​the​ ​past​ ​week,​ ​how​ ​often​ ​did​ ​you​ ​eat​ ​breads
​ ​ ​ ​ ​ ​ ​(fresh,​ ​canned,​ ​or​ ​frozen)? ​ ​ ​ ​ ​ ​ ​or​ ​dinner​ ​rolls,​ ​NOT​ ​AS​ ​PART​ ​OF
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​15) ​ ​ ​ ​ ​ ​ ​SANDWICHES?
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1-2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​times​ ​per​ ​day ​ ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​18)
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​2-3​ ​times​ ​per​ ​day ​ ​ ​ ​ ​ ​ ​▢​ ​1-2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​3+​ ​times​ ​per​ ​day ​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​2+​ ​ ​times​ ​per​ ​day

14a.​ ​Each​ ​time​ ​you​ ​ate​ ​fruit,​ ​how​ ​much​ ​did​ ​you 17a.​ ​Each​ ​time​ ​you​ ​ate​ ​breads​ ​or​ ​dinner​ ​rolls,
​ ​ ​ ​ ​ ​ ​ ​ ​usually​ ​eat? ​ ​ ​ ​ ​ ​ ​ ​ ​NOT​ ​AS​ ​PART​ ​OF​ ​SANDWICHES,​ ​how
​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Less​ ​than​ ​¼​ ​cup ​ ​ ​ ​ ​ ​ ​ ​ ​much​ ​did​ ​you​ ​usually​ ​eat?
​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​¼​ ​to​ ​¾​ ​cup ​ ​ ​▢​ ​1​ ​slice​ ​or​ ​1​ ​dinner​ ​roll​ ​ ​ ​ ​ ​ ​ ​▢​ ​2+​ ​slices​ ​or​ ​2+​ ​rolls
​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​More​ ​than​ ​¾​ ​cup ​ ​ ​▢​ ​2​ ​slices​ ​or​ ​2​ ​dinner​ ​rolls
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​44

18.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​eat​ ​pasta, 21a.​ ​Each​ ​time​ ​you​ ​ate​ ​tortillas,​ ​how​ ​much​ ​did​ ​you
​ ​ ​ ​ ​ ​ ​spaghetti,​ ​or​ ​other​ ​noodles? ​ ​ ​ ​ ​ ​ ​ ​ ​usually​ ​eat?
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​19) ​ ​ ​ ​ ​ ​ ​▢​ ​ ​1​ ​small​ ​tortilla​ ​or​ ​½​ ​large​ ​one
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week ​ ​ ​ ​ ​ ​ ​▢​ ​ ​2​ ​small​ ​tortillas​ ​or​ ​1​ ​large​ ​one
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​day ​ ​ ​ ​ ​ ​ ​▢​ ​ ​3​ ​small​ ​tortillas​ ​or​ ​ ​1​ ​½​ ​large​ ​ones
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​▢​ ​2+​ ​times​ ​per​ ​day ​ ​ ​ ​ ​ ​ ​▢​ ​ ​More​ ​than​ ​3​ ​small​ ​tortillas

18a.​ ​Each​ ​time​ ​you​ ​ate​ ​pasta,​ ​spaghetti,​ ​or​ ​other 22.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​drink
​ ​ ​ ​ ​ ​ ​ ​ ​noodles,​ ​how​ ​much​ ​did​ ​you​ ​usually​ ​eat? ​ ​ ​ ​ ​ ​ ​soda​ ​or​ ​pop?
​ ​ ​ ​ ​ ​ ​▢​ ​ ​Less​ ​than​ ​1​ ​cup ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​23)
​ ​ ​ ​ ​ ​ ​▢​ ​ ​1​ ​to​ ​3​ ​cups ​ ​ ​ ​ ​ ​▢​ ​1-2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​2-3​ ​times​ ​per​ ​day
​ ​ ​ ​ ​ ​ ​▢​ ​More​ ​than​ ​3​ ​cups ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​4-5​ ​times​ ​per​ ​day
​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​6+​ ​times​ ​per​ ​day

19.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​eat​ ​jam, 22a.​ ​Each​ ​time​ ​you​ ​drank​ ​soda​ ​or​ ​pop,​ ​how​ ​much
​ ​ ​ ​ ​ ​ ​jelly,​ ​or​ ​honey​ ​on​ ​bagels,​ ​muffins,​ ​or​ ​bread/rolls? ​ ​ ​ ​ ​ ​ ​ ​ ​did​ ​you​ ​usually​ ​drink?
​ ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​20) ​ ​ ​▢​ ​Less​ ​than​ ​12​ ​ounces​ ​or​ ​less​ ​than​ ​1​ ​can​ ​or​ ​bottle
​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week ​ ​ ​▢​ ​12​ ​to​ ​16​ ​ounces​ ​or​ ​1​ ​can​ ​or​ ​bottle
​ ​ ​ ​ ​ ​ ​▢​ ​2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​day ​ ​ ​▢​ ​More​ ​than​ ​16​ ​ounces​ ​or​ ​more​ ​than​ ​1​ ​can​ ​or​ ​bottle
​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​▢​ ​2+​ ​times​ ​per​ ​day

19a.​ ​Each​ ​time​ ​you​ ​ate​ ​jam,​ ​jelly,​ ​or​ ​honey,​ ​how 23.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​drink
​ ​ ​ ​ ​ ​ ​ ​ ​much​ ​did​ ​you​ ​usually​ ​eat? ​ ​ ​ ​ ​ ​ ​sports​ ​drinks​ ​(such​ ​as​ ​PowerAde/​ ​Gatorade)?
​ ​ ​ ​ ​ ​ ​▢​ ​Less​ ​than​ ​1​ ​teaspoon ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​24)
​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​to​ ​3​ ​teaspoons ​ ​ ​ ​ ​ ​▢​ ​1-2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​1-2​ ​times​ ​per​ ​day
​ ​ ​ ​ ​ ​ ​▢​ ​More​ ​than​ ​3​ ​teaspoons ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​2-3​ ​times​ ​per​ ​day
​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​▢​ ​3+​ ​times​ ​per​ ​day

20.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​eat​ ​rice​ ​or 23a​.​ ​Each​ ​time​ ​you​ ​drank​ ​soda​ ​or​ ​pop,​ ​how​ ​much
​ ​ ​ ​ ​ ​ ​other​ ​cooked​ ​grains​ ​(such​ ​as​ ​bulgur,​ ​cracked ​ ​ ​ ​ ​ ​ ​ ​ ​did​ ​you​ ​usually​ ​drink?
​ ​ ​ ​ ​ ​ ​wheat,​ ​or​ ​millet)? ​ ​ ​▢​ ​Less​ ​than​ ​12​ ​ounces​ ​or​ ​less​ ​than​ ​1​ ​can​ ​or​ ​bottle
​ ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​21) ​ ​ ​▢​ ​12​ ​to​ ​16​ ​ounces​ ​or​ ​1​ ​can​ ​or​ ​bottle
​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week ​ ​ ​▢​ ​More​ ​than​ ​16​ ​ounces​ ​or​ ​more​ ​than​ ​1​ ​can​ ​or​ ​bottle
​ ​ ​ ​ ​ ​ ​▢​ ​2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​day
​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​▢​ ​2+​ ​times​ ​per​ ​day

20a.​ ​Each​ ​time​ ​you​ ​ate​ ​rice​ ​or​ ​other​ ​cooked​ ​grains, 24.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​eat
​ ​ ​ ​ ​ ​ ​ ​ ​how​ ​much​ ​did​ ​you​ ​usually​ ​eat? potatoes​ ​(fries,​ ​tater​ ​tots,​ ​mashed,​ ​boiled,​ ​baked)?
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​Less​ ​than​ ​½​ ​cup ​ ​ ​ ​ ​ ​ ​▢​ ​Never
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​½​ ​to​ ​1½​ ​cups ​ ​ ​ ​ ​ ​ ​▢​ ​1-2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week
​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​More​ ​than​ ​1½​ ​cups ​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​▢​ ​2+​ ​times​ ​per​ ​day

21.​ ​In​ ​this​ ​past​ ​week​,​ ​how​ ​often​ ​did​ ​you​ ​corn​ ​or 24a.​ ​Each​ ​time​ ​you​ ​ate​ ​potatoes,​ ​how​ ​much​ ​did
​ ​ ​ ​ ​ ​ ​flour​ ​tortillas? you​ ​usually​ ​eat?
​ ​ ​ ​ ​ ​ ​▢​ ​Never​ ​(skip​ ​to​ ​question​ ​22) ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​small​ ​potato​ ​or​ ​less​ ​than​ ​½​ ​cup
​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​5-6​ ​times​ ​per​ ​week ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​medium​ ​potato​ ​or​ ​½​ ​to​ ​1​ ​cup
​ ​ ​ ​ ​ ​ ​▢​ ​2​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​time​ ​per​ ​day ​ ​ ​ ​ ​ ​ ​▢​ ​1​ ​large​ ​potato​ ​or​ ​more​ ​than​ ​1​ ​cup
​ ​ ​ ​ ​ ​ ​▢​ ​3-4​ ​times​ ​per​ ​week​ ​ ​ ​ ​ ​▢​ ​2+​ ​times​ ​per​ ​day
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​45

Part​ ​III:​ ​The​ ​last​ ​few​ ​questions​ ​are​ ​to​ ​get​ ​a​ ​measure​ ​of​ ​what​ ​you​ ​have​ ​discussed​ ​with​ ​your​ ​physician
and/or​ ​dietitian​ ​so​ ​far.​ ​Please​ ​answer​ ​each​ ​question​ ​to​ ​the​ ​best​ ​of​ ​your​ ​knowledge.​ ​Select​ ​all​ ​that​ ​apply.

25. Who​ ​has​ ​discussed​ ​the​ ​benefits​ ​of​ ​doing​ ​exercise​ ​on​ ​blood​ ​glucose​ ​management?
▢​ ​My​ ​physician/gynecologist
▢​ ​A​ ​registered​ ​dietitian/nutritionist
▢​ ​Another​ ​health​ ​professional​ ​(please​ ​describe):_______________
▢​ ​No​ ​one

26. Who​ ​has​ ​discussed​ ​foods​ ​that​ ​may​ ​raise​ ​your​ ​blood​ ​glucose​ ​levels?
▢​ ​My​ ​physician/gynecologist
▢​ ​A​ ​registered​ ​dietitian/nutritionist
▢​ ​Another​ ​health​ ​professional​ ​(please​ ​describe):_______________
▢​ ​No​ ​one

27. Who​ ​has​ ​discussed​ ​how​ ​to​ ​self-monitor​ ​blood​ ​glucose​ ​levels​ ​with​ ​you?
▢​ ​My​ ​physician/gynecologist
▢​ ​A​ ​registered​ ​dietitian/nutritionist
▢​ ​Another​ ​health​ ​professional​ ​(please​ ​describe):_______________
▢​ ​No​ ​one

28. Who​ ​has​ ​discussed​ ​the​ ​possible​ ​consequences​ ​of​ ​uncontrolled​ ​blood​ ​glucose​ ​levels?
▢​ ​My​ ​physician/gynecologist
▢​ ​A​ ​registered​ ​dietitian/nutritionist
▢​ ​Another​ ​health​ ​professional​ ​(please​ ​describe):_______________
▢​ ​No​ ​one

Thank​ ​you​ ​very​ ​much​ ​for​ ​completing​ ​this​ ​questionnaire!​ ​☺


Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​46

APPENDIX​ ​E:​ ​INFORMED​ ​CONSENT​ ​FORM

You​ ​are​ ​being​ ​asked​ ​to​ ​take​ ​part​ ​in​ ​an​ ​observational​ ​study​ ​of​ ​how​ ​your​ ​experience​ ​with
gestational​ ​diabetes​ ​management​ ​has​ ​been​ ​and​ ​the​ ​impacts​ ​that​ ​consultations​ ​with​ ​a​ ​different
internal​ ​medicine​ ​staff​ ​will​ ​have​ ​on​ ​your​ ​conclusive​ ​health​ ​and​ ​well-being.​ ​Please​ ​read​ ​this​ ​form
carefully​ ​and​ ​ask​ ​any​ ​questions​ ​you​ ​may​ ​have​ ​before​ ​agreeing​ ​to​ ​take​ ​part​ ​in​ ​the​ ​study.

What​ ​the​ ​study​ ​is​ ​about:​​ ​The​ ​purpose​ ​of​ ​this​ ​study​ ​is​ ​to​ ​learn​ ​how​ ​women​ ​with​ ​gestational
diabetes​ ​receive​ ​medical​ ​support​ ​from​ ​different​ ​hospital​ ​staff​ ​members,​ ​particularly​ ​the​ ​primary
care​ ​physician​ ​and​ ​the​ ​Registered​ ​Dietitian.​ ​It​ ​will​ ​be​ ​asked​ ​of​ ​you​ ​to​ ​have​ ​a​ ​flexible​ ​schedule
and​ ​make​ ​a​ ​minimum​ ​of​ ​3​ ​hours​ ​available​ ​each​ ​week​ ​for​ ​careful​ ​collection​ ​of​ ​blood​ ​glucose
values,​ ​attendance​ ​of​ ​consultations​ ​and​ ​interviews,​ ​and​ ​completion​ ​of​ ​survey​ ​assessments.

What​ ​we​ ​will​ ​ask​ ​you​ ​to​ ​do:​​ ​If​ ​you​ ​agree​ ​to​ ​be​ ​in​ ​this​ ​study,​ ​we​ ​will​ ​conduct​ ​an​ ​interview​ ​with
you.​ ​The​ ​interview​ ​will​ ​include​ ​questions​ ​about​ ​your​ ​age,​ ​previous​ ​pregnancies,​ ​the​ ​diabetes
education​ ​you​ ​have​ ​received,​ ​when​ ​you​ ​were​ ​diagnosed,​ ​and​ ​your​ ​food​ ​intake​ ​.​ ​The​ ​interview
will​ ​take​ ​about​ ​30​ ​minutes​ ​to​ ​complete.​ ​With​ ​your​ ​permission,​ ​we​ ​would​ ​also​ ​have​ ​access​ ​to
your​ ​medical​ ​records​ ​to​ ​obtain​ ​recorded​ ​blood​ ​glucose​ ​(sugar)​ ​levels.

Eligibility​ ​Criteria:​ ​To​ ​be​ ​eligible​ ​to​ ​participate​ ​in​ ​study,​ ​you​ ​must​ ​be​ ​over​ ​the​ ​age​ ​of​ ​18,​ ​be
expecting​ ​a​ ​single​ ​baby​ ​(no​ ​twins,​ ​triplets,​ ​etc),​ ​have​ ​a​ ​diagnosis​ ​of​ ​Type​ ​I​ ​or​ ​Type​ ​II​ ​Diabetes
prior​ ​to​ ​pregnancy,​ ​or​ ​a​ ​serious​ ​health​ ​condition​ ​other​ ​than​ ​gestational​ ​diabetes,​ ​obesity,​ ​or
preeclampsia.

Risks​ ​and​ ​benefits​:​ ​There​ ​is​ ​the​ ​risk​ ​that​ ​you​ ​may​ ​find​ ​some​ ​of​ ​the​ ​questions​ ​about​ ​your​ ​health
conditions​ ​to​ ​be​ ​sensitive.​ ​There​ ​are​ ​no​ ​benefits​ ​to​ ​you.​ ​Participants​ ​that​ ​are​ ​unable​ ​to​ ​monitor
blood​ ​glucose​ ​values​ ​at​ ​home​ ​will​ ​be​ ​given​ ​the​ ​opportunity​ ​to​ ​visit​ ​a​ ​clinic​ ​for​ ​blood​ ​glucose
collection​ ​and​ ​analysis.​ ​The​ ​condition​ ​of​ ​gestational​ ​diabetes​ ​is​ ​an​ ​ever-growing​ ​condition​ ​that
impacts​ ​an​ ​estimate​ ​of​ ​about​ ​12.4%​ ​of​ ​women​ ​in​ ​the​ ​Los​ ​Angeles​ ​County.​ ​Further​ ​information
obtained​ ​in​ ​this​ ​study​ ​of​ ​could​ ​benefit​ ​researchers​ ​and​ ​have​ ​a​ ​profound​ ​impact​ ​on​ ​understanding
the​ ​condition.
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​47

Compensation​:​ ​Due​ ​to​ ​limited​ ​funds,​ ​there​ ​will​ ​not​ ​be​ ​any​ ​compensation​ ​in​ ​this​ ​study.

Confidentiality:​​ ​Your​ ​answers​ ​will​ ​be​ ​confidential.​ ​Each​ ​participant​ ​will​ ​be​ ​assigned​ ​a​ ​5​ ​digit
code​ ​number.​ ​All​ ​data​ ​recorded​ ​will​ ​be​ ​connected​ ​to​ ​the​ ​code​ ​and​ ​not​ ​your​ ​name.​ ​In​ ​any​ ​sort​ ​of
report​ ​we​ ​make​ ​public,​ ​we​ ​will​ ​not​ ​include​ ​any​ ​information​ ​that​ ​will​ ​make​ ​it​ ​possible​ ​to​ ​identify
you.​ ​Research​ ​records​ ​will​ ​be​ ​kept​ ​in​ ​a​ ​locked​ ​file;​ ​only​ ​the​ ​primary​ ​researchers​ ​will​ ​have​ ​access
to​ ​the​ ​records.

Voluntary​ ​Participation​:​ ​Taking​ ​part​ ​in​ ​this​ ​study​ ​is​ ​completely​ ​voluntary.​ ​You​ ​may​ ​skip​ ​any
questions​ ​that​ ​you​ ​do​ ​not​ ​want​ ​to​ ​answer.​ ​If​ ​you​ ​decide​ ​to​ ​skip​ ​some​ ​of​ ​the​ ​questions​ ​for​ ​any
reason,​ ​it​ ​will​ ​not​ ​affect​ ​your​ ​participation​ ​in​ ​this​ ​study.​ ​If​ ​you​ ​decide​ ​to​ ​take​ ​part,​ ​you​ ​are​ ​free​ ​to
withdraw​ ​at​ ​any​ ​time.

If​ ​you​ ​have​ ​questions​:​ ​The​ ​researchers​ ​conducting​ ​this​ ​study​ ​are​ ​Alejandra​ ​Perez,​ ​Karina
Almanza,​ ​and​ ​Itzel​ ​Dzul.​ ​Please​ ​ask​ ​any​ ​questions​ ​you​ ​have​ ​now.​ ​If​ ​you​ ​have​ ​questions​ ​later,
you​ ​may​ ​contact​ ​Dr.​ ​Besnilian​ ​at​ ​annette.besnilian@csun.edu.​ ​If​ ​you​ ​have​ ​any​ ​questions​ ​or
concerns​ ​regarding​ ​your​ ​rights​ ​as​ ​a​ ​subject​ ​in​ ​this​ ​study,​ ​you​ ​may​ ​contact​ ​the​ ​Institutional
Review​ ​Board​ ​(IRB)​ ​at​ ​607-255-5138​ ​or​ ​access​ ​their​ ​website​ ​at​ ​http://www.irb.csun.edu.

Statement​ ​of​ ​Consent​:​ ​I​ ​have​ ​read​ ​the​ ​above​ ​information,​ ​and​ ​have​ ​received​ ​answers​ ​to​ ​any
questions​ ​I​ ​asked.​ ​I​ ​consent​ ​to​ ​take​ ​part​ ​in​ ​the​ ​study.​ ​In​ ​addition​ ​to​ ​agreeing​ ​to​ ​participate,​ ​I​ ​give
my​ ​consent​ ​to​ ​hospital​ ​staff​ ​to​ ​allow​ ​the​ ​researchers​ ​access​ ​into​ ​my​ ​medical​ ​file.

Your​ ​Signature​ ​___________________________________​ ​Date​ ​________________________

Your​ ​Name​ ​(printed)​ ​____________________________________________________________

Printed​ ​name​ ​of​ ​person​ ​obtaining​ ​consent​ ​_________________________________


Date_______________

This​ ​consent​ ​form​ ​will​ ​be​ ​kept​ ​by​ ​the​ ​researcher​ ​for​ ​at​ ​least​ ​three​ ​years​ ​beyond​ ​the​ ​end​ ​of
the​ ​study.
Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​48

APPENDIX​ ​F:​ ​Timeline


Gestational​ ​Diabetes​ ​Intervention:​ ​Physician​ ​vs.​ ​Registered​ ​Dietitian,​ ​49

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Ali,​ ​H.​ ​I.,​ ​Jarrar,​ ​A.​ ​H.,​ ​El​ ​Sadig,​ ​M.,​ ​&​ ​Yeatts,​ ​B.​ ​Y.​ ​(​ ​2013​ ​)​ ​Diet​ ​and​ ​carbohydrate​ ​food

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without​ ​Gestational​ ​Diabetes​ ​Mellitus.​ ​PLoS​ ​ONE,​ ​8​ ​(9),​ ​e73486.

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Akinci,​ ​B.,​ ​Tosun,​ ​P.,​ ​Bekci,​ ​E.,​ ​Yener,​ ​S.,​ ​Demir,​ ​T.,​ ​&​ ​Yesil,​ ​S.​ ​(2010).​ ​Management​ ​of

gestational​ ​diabetes​ ​by​ ​physicians​ ​in​ ​Turkey.​ ​Primary​ ​Care​ ​Diabetes​,​ ​4(3),​ ​173-180.

Banerjee,​ ​A.,​ ​McTavish,​ ​S.,​ ​Ray,​ ​J.,​ ​Gucciardi,​ ​E.,​ ​Lowe,​ ​J.,​ ​Feig,​ ​D.,​ ​Lipscombe,​ ​L.​ ​(2016).

Reported​ ​health​ ​behavior​ ​changes​ ​after​ ​a​ ​diagnosis​ ​of​ ​gestational​ ​diabetes​ ​mellitus

among​ ​ethnic​ ​minority​ ​women​ ​living​ ​in​ ​canada.​ ​Journal​ ​of​ ​Immigrant​ ​and​ ​Minority

Health​,​ ​18(6),​ ​1334-1342.​ ​doi:10.1007/s10903-015-0266-1

Bookari,​ ​K.,​ ​Yeatman,​ ​H.,​ ​&​ ​Williamson,​ ​M.​ ​(2017).​ ​Informing​ ​nutrition​ ​care​ ​in​ ​the​ ​antenatal

period:​ ​Pregnant​ ​women’s​ ​experiences​ ​and​ ​need​ ​for​ ​support.​ ​Biomed​ ​Research

International​,​ ​1-16.​ ​doi:10.1155/2017/4856527

Boyle,​ ​M.​ ​A.,​ ​&​ ​Holben,​ ​D.​ ​H.​ ​(2013).​ ​Community​ ​nutrition​ ​in​ ​action:​ ​an​ ​entrepreneurial

approach.​ ​Belmont:​ ​Wadsworth.

Diabetes​ ​in​ ​Pregnancy.​ ​(n.d.).​ ​Retrieved​ ​November​ ​20,​ ​2017,​ ​from

https://www.ucsfhealth.org/education/diabetes_in_pregnancy/

Epidemiology​ ​and​ ​Genomics​ ​Research​ ​Program.​ ​(n.d.).​ ​Retrieved​ ​November​ ​22,​ ​2017,​ ​from
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