Psychosocial management of diabetes in pregnancy

Educational Attainment, Decision-Making Preferences, and Interest in Evidence-Based Diabetes Prevention among Women with a History of Gestational Diabetes Mellitus

Background: The Diabetes Prevention Program (DPP) showed that lifestyle change or metformin is equally efficacious in preventing diabetes in women who have had gestational diabetes mellitus (GDM). Few studies have investigated the relationship between education and willingness to engage in either intervention and between education and preferred decision-making style. Methods: Within a large health system, we surveyed insured women 18-64 years old with a history of GDM, identified through the electronic health record. We estimated preference for decision-making style and interest in DPP lifestyle change and/or metformin by educational level, using multivariate logistic regression models controlling for age, race, and ethnicity. Results: Our sample (n = 264) was 36% Latino, 29% Asian, 28% non-Latino white, and 5% African American, with a mean age of 37 years. In terms of education, 31% had a postgraduate degree, 41% were college graduates, and 29% did not graduate from college. In multivariate analyses, willingness to engage in either intervention did not vary by education. Women who did not graduate from college were more likely to leave medical decisions to their provider (p = 0.004) compared to women with a college or postgraduate degree. However, regardless of education, over 80% of women preferred to make medical decisions themselves or jointly with their provider. Conclusions: Most women prefer to play an active role in their own medical decisions and have an interest in both evidence-based diabetes prevention strategies. This suggests that shared decision-making is appropriate for many women with a history of GDM and different levels of educational attainment.

The GlucoCoper - An Exploratory Study to Assess Coping Mechanisms of Women Diagnosed with Diabetes Mellitus

Diabetes distress can be managed effectively by coping-skill training. To improve coping skills, one must begin by analysing current coping styles of an individual. The GlucoCoper has been developed as a brief, simple, easy-to-administer tool for assessing the coping mechanism of people with diabetes mellitus. The GlucoCoper includes six items rated on a graphic visual analogue scale. These include four items to assess positive coping skills (acceptance, optimism, planning and action) and two items to assess negative coping mechanisms (negativity and blame). The current single centre prospective study analysed the six-item GlucoCoper as a tool to identify coping skills in antenatal women with diabetes, and correlated them with level of diabetes distress. Greater duration of diabetes was related with lower optimism; while poor glycaemic control (high glycated haemoglobin [HbA1c]) was related with high negativity and low scores for planning. Highly educated subjects revealed greater negativity, while those from a rural background exhibited higher blame scores of =7.00 for negativity, =4.00 for planning, and =5.00 for action. These factors should prompt detailed evaluation and intervention. The findings of the current study suggest that GlucoCoper can be used as a screening tool for dysfunctional coping skills in pregnancy complicated by diabetes. Negativity, planning and action, the three domains which correlate strongly with the GlucoCoper score, can be used to create a three-item GlucoCoper, to be used as a brief and effective screening tool for dysfunctional coping skills in pregnancy complicated by diabetes.

Relationship between depression and diabetes in pregnancy: A systematic review

AIM

To systematically review the literature on women with both diabetes in pregnancy (DIP) and depression during or after pregnancy.

METHODS

In this systematic literature review, PubMed/MEDLINE and EMBASE were searched (13 November 2015) using terms for diabetes (type 1, type 2, or gestational), depression, and pregnancy (no language or date restrictions). Publications that reported on women who had both DIP (any type) and depression or depressive symptoms before, during, or within one year after pregnancy were considered for inclusion. All study types were eligible for inclusion; conference abstracts, narrative reviews, nonclinical letters, editorials, and commentaries were excluded, unless they provided treatment guidance.

RESULTS

Of 1189 articles identified, 48 articles describing women with both DIP and depression were included (sample sizes 36 to > 32 million). Overall study quality was poor; most studies were observational, and only 12 studies (mostly retrospective database studies) required clinical depression diagnosis. The prevalence of concurrent DIP (any type) and depression in general populations of pregnant women ranged from 0% to 1.6% (median 0.61%; 12 studies). The prevalence of depression among women with gestational diabetes ranged from 4.1% to 80% (median 14.7%; 16 studies). Many studies examined whether DIP was a risk factor for depression or depression was a risk factor for DIP. However, there was no clear consensus for either relationship. Importantly, we found limited guidance on the management of women with both DIP and depression.

CONCLUSION

Given the increasing prevalence of diabetes and depression, high-quality research and specific guidance for management of pregnant women with both conditions are warranted.

Timing of Delivery in Gestational Diabetes Mellitus: Need for Person-Centered, Shared Decision-Making

Gestational diabetes mellitus (GDM) is a medical as well as obstetric challenge, which needs person-centered management. The timing of delivery of women with GDM is discussed by various obstetric professional bodies. We highlight pertinent medical, obstetric, and psychosocial factors which may influence the timing of delivery in women with GDM. This commentary proposes a person-centered approach to decide the delivery timing in GDM and supports shared decision-making based upon the individual's biopsychosocial characteristics and environmental factors.

Stress exposure and psychological stress responses are related to glucose concentrations during pregnancy

OBJECTIVES

The role of stress in the development of gestational diabetes mellitus (GDM) has so far been neglected. We investigated the impact of stress exposure (pregnancy-related and pregnancy-unrelated major life events), psychological stress responses (perceived stress, subjective experience of stress, anxiety, depression, sleep), and physiological stress responses (salivary cortisol, plasma copeptin levels) on glucose concentrations during pregnancy.

DESIGN

Cross-sectional study, including 203 pregnant women at the maternity department of a Swiss university hospital.

METHODS

All women underwent routine screening for GDM with a 75-g oral glucose-tolerance test at 24-30 weeks of gestation. Pregnancy-related and pregnancy-unrelated major life events, perceived stress, general psychological distress, anxiety, depression, and amount of sleep were assessed by validated self-report questionnaires. Cortisol was measured using fasting and bedtime saliva samples, and copeptin using fasting plasma. All data were collected before communication of the screening test results.

RESULTS

Significant positive associations were found between the number of pregnancy-related major life events and fasting glucose, while there was no association with pregnancy-unrelated major life events. More anxiety and depressive symptoms, a higher general level of distress, and a shorter duration of sleep were related to fasting glucose, although the latter two were no longer significant when age and BMI were controlled for. However, physiological stress responses were not associated with glucose concentrations. When testing for unique associations with fasting glucose, more general distress and shorter duration of sleep independently accounted for higher fasting glucose levels. Finally, when comparing women with and without GDM, we found that women who subsequently received the diagnosis of GDM reported more pregnancy-related life events.

CONCLUSIONS

Some indicators of stress exposure and psychological stress responses were associated with fasting glucose concentrations in pregnant women, thus representing important risk factors for GDM development. Statement of contribution What is already known on this subject? Only approximately half of women with gestational diabetes mellitus (GDM) report any known risk factors. Women after GDM diagnosis reported more major life events compared to healthy pregnant controls. What does this study add? Stress exposure and psychological stress responses were associated with fasting glucose concentrations in pregnant before women were aware of their GDM diagnosis. These represent important risk factors for GDM development and potential targets for intervention.