Renaming gestational diabetes mellitus: A psychosocial argument Bharti Kalra, Yashdeep Gupta1, Manash P. Baruah2 Department of Obstetrics and Gynaecology, Bharti Hospital, Karnal, Haryana, 1Department of Medicine, Government Medical College and Hospital, Chandigarh, 2Department of Endocrinology, Excel Care Hospitals, Guwahati, Assam, India

“My mother‑in‑law thinks I had diabetes since childhood,” cried our patient during a follow‑up visit, 3 days after having been diagnosed with gestational diabetes mellitus (GDM). “I have nothing to do with this treatment,” declared her husband as the insulin prescription was handed to him, adding that her brothers should bear the expenses of such ‘‘costly’’ therapy. A few days later, she suffered intrauterine fetal loss. Quite predictably, marital discord followed. Improbable as it may seem, such lack of empathy to antenatal women is not uncommon in societies with gender discrimination. The diagnosis of GDM is accompanied by significant psychological complications. Maternal stress is not the only negative impact that comes with GDM. A ‘‘diabetic’’ label may lead to family conflicts, especially in gender‑bias cultures. Suggestions, such as the existence of diabetes prior to marriage, purposely not disclosed to in‑laws, are common. Other innuendo that women face include opinions about GDM being her fault, as she eats too much, or does not carry out her fair share of domestic chores. Maternal concerns include fear for the unborn child’s health, and one’s own biological, social, and nutritional health. While we understand that this sounds unreal to some readers, it is harsh reality for many. Seen not only in India, studies around the globe also validate the effect of psychological ill effects with diagnosis of GDM. Access this article online Quick Response Code: Website: www.ijem.in DOI: 10.4103/2230-8210.123539

A Canadian study described the experiences of women diagnosed with GDM as ‘‘living a controlled pregnancy,’’ followed by a process of adaptation to the diagnosis while burdened by the moral obligation to be a responsible mother and being worried about potential impact on future health.[1] Another study from the United States on women with GDM and type 2 diabetes identified three primary themes such as concern for the infant, concern for self, and sensing a loss of personal control over their health.[2] An elegant study exploring the experiences of Swedish women describes the diagnosis of GDM as a process of ‘‘stun to gradual balance.’’[3] Evidence suggests that a diagnosis of GDM may increase a woman’s anxiety,[4] result in poorer health perceptions and a less positive pregnancy experience when compared with nondiabetic controls.[5] The maternal exposure to unwanted stress, especially with diagnosis of GDM may, in fact, increase the risk of type 1 and type 2 diabetes in the unborn offspring.[6,7] A possible mediator is increased corticosteroid exposure to the fetus, which is inadequately protected by an ‘‘immature 11 β‑hydroxysteroid dehydrogenase system in the placenta during the early pregnancy.’’[8] The phrase GDM brings with it significant psychosocial morbidity. The main aim of timely diagnosis of GDM is to improve short‑term maternal and fetal outcomes. The other important aim is to recognize women who stand at high risk for future diabetes and cardiovascular disease and motivate them for lifestyle modification. The two large trials evaluating women for short‑term maternal and neonatal outcomes had found that 80%‑90% of women were controlled on medical nutrition therapy alone.[9,10] Thereafter, some may not have diabetes for their rest of life and the others at variable time interval. The rates of progression to diabetes may not even be akin to prediabetes, especially with newer American Diabetes Association criteria for diagnosis.[11] Do we, then, really need to couple the term ‘‘diabetes mellitus’’ with ‘‘Gestational’’ which in

Corresponding Author: Dr. Bharti Kalra, Department of Obstetrics and Gynaecology, Bharti Hospital, Kunjpura Road, Karnal ‑ 132 001, Haryana, India. E‑mail: [email protected]

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Kalra, et al.: Renaming GDM

literary sense is defined as “onset or first recognition in pregnancy” in the terminology of GDM.[11] Irrespective of cutoffs as defined by various tests for diagnosis of GDM, what we are trying, is to assess the degree of glucose tolerance. Subjects who do not “pass” these tests should be labelled exactly so: ‘‘Glucose intolerant.’’ This is similar to the older term “carbohydrate intolerance of pregnancy”, but is more specific. Alternatives like Gestational Dysglycemia of Nutritional Origin (GDNO); ‘‘Pregnancy Related Intolerance to Glucose’’ (PRIG) highlight pathophysiology, and reinforce the near‑universal need for, and adequacy of Medical Nutrition therapy (MNT).[12] With this onomastic (renaming) exercise, the negative effects of phrase ‘‘GDM’’ can be minimized, without diluting the positive impact of therapeutic intervention. These terms will avoid the social stigma of diabetes mellitus that ‘‘GDM’’ label carries and prevent discrimination that may occur against young, newly married women with GDM. Renaming of the entity existing for decades will not be easy. It does come with opposing thoughts too. Some do feel that avoiding term diabetes in GDM will decrease the motivation of adopting healthy lifestyle among women to prevent future risk of diabetes. This may be true in some women. Evans and O’Brien[13] reported that for some women the knowledge acquired about diabetes, while pregnant served to enhance motivation and self‑efficacy to make lifestyle alterations. Recent studies, however, suggest a contrarian approach in the majority of women. In fact, the motivation for adoption of healthy lifestyle during pregnancy among GDM is motivated by thinking about the health of the baby, not by concern for oneself.[14] Psychological support from partners and families are other positive facilitators for management.[14] A European study found that pregnancy motivated behavior changes to benefit the unborn child, but after delivery these changes were often not maintained.[15] Women were aware of their risk of developing diabetes but did not always act on such knowledge. Tiredness, maternal attachment, and childcare demands were prominent barriers in the early postnatal months. Later domestic chores, professional work, responsibility toward family, and of course developmental issues of the child became more significant barriers.[15] A recent Australian study evaluated nearly 400 women diagnosed with GDM ≤3 years previously, to describe women’s reflections on the experience of having a pregnancy affected by GDM. The negative experiences namely shock, fear and anxiety (8.9%); uncertainty and scepticism (9.4%); adapting to life with GDM (11.6%); the need for support (17.2%); abandoned (14.9%); overwhelmed the positive ones, such as an opportunity S594

to improve one’s health (9.6%); better awareness (3.5%); staying healthy and preventing diabetes (13.7%).[16] The Australian Carbohydrate Intolerance Study has provided evidence of the benefits of treating GDM on postnatal quality of life. Health professional support may also be an important determinant of longer term health status.[9] But outside the strict setting of clinical research, the recent Australian study does not validate this fact in most women with GDM. Majority believed that health professionals instilled ‘‘guilt’’ and ‘‘fear’’ in them during their pregnancy. Others reported feeling isolated by the diagnosis and lack of information and support from health professionals.[16] The phrase GDM brings with it significant psychosocial morbidity. If this can be minimized by using a less threatening synonym, this onomastic exercise should be encouraged. A nutritional eponym for GDM will be appropriate, as it will describe both the pathophysiologic, and therapeutic, basis of the disease.[12] This editorial hopes to stimulate debate in this direction.

References 1.

Evans MK, Patrick LJ, Wellington CM. Health behaviours of postpartum women with a history of gestational diabetes. Can J Diabetes 2010;34:227‑32. 2. Nolan JA, McCrone S, Chertok IR. The maternal experience of having diabetes in pregnancy. J Am Acad Nurse Pract 2011;23:611‑8. 3. Persson M, Winkvist A, Mogren I. ‘From stun to gradual balance’–women’s experiences of living with gestational diabetes mellitus. Scand J Caring Sci 2010;24:454‑62. 4. Lawson EJ, Rajaram S. A transformed pregnancy: The psychosocial consequences of gestational diabetes. Sociol Health Illn 1994;16:536‑62. 5. Kim C, Vahratian A. Self‑rated health and health care use among women with histories of gestational diabetes mellitus. Diabetes Care 2010;33:41‑2. 6. Virk J, Li J, Vestergaard M, Obel C, Lu M, Olsen J. Early life disease programming during the preconception and prenatal period: Making the link between stressful life events and type‑1 diabetes. PLoS One 2010;5:e11523. 7. Li J, Olsen J, Vestergaard M, Obel C, Kristensen JK, Virk J. Prenatal exposure to bereavement and type‑2 diabetes: A Danish longitudinal population based study. PLoS One 2012;7:e43508. 8. McTernan CL, Draper N, Nicholson H, Chalder SM, Driver P, Hewison M, et al. Reduced placental 11beta‑hydroxysteroid dehydrogenase type 2 mRNA levels in human pregnancies complicated by intrauterine growth restriction: An analysis of possible mechanisms. J Clin Endocrinol Metab 2001;86:4979‑83. 9. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS, Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352:2477‑86. 10. Landon MB, Spong CY, Thom E, Carpenter MW, Ramin SM, Casey B, et al. Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal‑Fetal Medicine Units Network. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med 2009;361:1339‑48.

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Kalra, et al.: Renaming GDM 11. American Diabetes Association. Standards of medical care in diabetes–2013. Diabetes Care 2013;36 Suppl 1:S11‑66. 12. Kalra S, Baruah MP, Gupta Y, Kalra B. Gestational diabetes: An onomastic opportunity. Lancet Diabet Endocrinol 2013;1:91. 13. Evans MK, O’Brien B. Gestational diabetes: The meaning of an at‑risk pregnancy. Qual Health Res 2005;15:66‑81. 14. Carolan M, Gill G, Steele C. Women’s experiences of factors that facilitate or inhibit gestational diabetes self‑management. BMC Pregnancy Childbirth 2012;12:99. Available from: http://www. biomedcentral.com/1471‑2393/12/99 [Last accessed on 2013 Oct 25]. 15. Lie ML, Hayes L, Lewis‑Barned NJ, May C, White M, Bell R. Preventing type 2 diabetes after gestational diabetes: Women’s

experiences and implications for diabetes prevention interventions. Diabet Med 2013;30:986‑93. 16. Morrison MK, Lowe JM, Collins CE. Australian women’s experiences of living with gestational diabetes. Women Birth 2013, Available from: http://www.dx.doi.org/10.1016/j.wombi. 2013.10.001 [Last accessed on 2013 Nov 10].

Cite this article as: Kalra B, Gupta Y, Baruah MP. Renaming gestational diabetes mellitus: A psychosocial argument. Indian J Endocr Metab 2013;17:S593-5. Source of Support: Nil, Conflict of Interest: None declared.

Indian Journal of Endocrinology and Metabolism / 2013 / Vol 17 / Supplement 3


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