Fcs 681 Proposal Draft-2

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
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
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.
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).
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.

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
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
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
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
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
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 Australia, 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
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
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
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
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
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,
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 32nd 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.
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
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
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
study to investigate the influence of a Health Belief Model-based educational intervention on
women with GDM. Pregnant women in their 24th 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
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
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
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
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
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
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.

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.

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
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
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
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
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
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
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
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.

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

APPENDIX A: Socio-Ecological Model Theory

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
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
Part II of Questionnaire Near Time of Delivery
Fasting and Postprandial Blood Glucose Tracking

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:___________
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
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
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
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
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
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?
▢ No one
27. Who has discussed how to self-monitor blood glucose levels with you?
▢ No one
28. Who has discussed the possible consequences of uncontrolled blood glucose levels?
▢ No one
Thank you very much for completing this questionnaire! ☺

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.
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.
APPENDIX F: Timeline

References
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system as an educational tool for patients with gestational diabetes. Diabetology &
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Akinci, B., Tosun, P., Bekci, E., Yener, S., Demir, T., & Yesil, S. (2010). Management of
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Banerjee, A., McTavish, S., Ray, J., Gucciardi, E., Lowe, J., Feig, D., Lipscombe, L. (2016).
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Bookari, K., Yeatman, H., & Williamson, M. (2017). Informing nutrition care in the antenatal
period: Pregnant women’s experiences and need for support. Biomed Research
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Juan Gui, Qing Liu, & Ling Feng. (2013). Metformin vs insulin in the management of
gestational diabetes: A meta-analysis. PLoS ONE, 8(5), E64585.
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Lucas, C., Charlton, K., & Yeatman, H. (2014). Nutrition Advice During Pregnancy: Do Women
Receive it and Can Health Professionals Provide it? Maternal & Child Health Journal,
18(10), 2465-2478. doi:10.1007/s10995-014-1485-0

Malta, M. B., de Barros Leite Carvalhaes, M. A., Takito, M. Y., Pamplona Tonete, V. L., Barros,
A. D., Garcia de Lima Parada, C. M., & Benício, M. D. (2016). Educational intervention
regarding diet and physical activity for pregnant women: changes in knowledge and
practices among health professionals. BMC Pregnancy & Childbirth, 161-9.
doi:10.1186/s12884-016-0957-1
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evels-made-simple/
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18, 2017, Vol.17(1)
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GESTATIONAL​ ​DIABETES​ ​INTERVENTION:

PHYSICIAN​ ​VS.​ ​REGISTERED​ ​DIETITIAN

Dr.​ ​Dena​ ​Herman

TABLE​ ​OF​ ​CONTENTS

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

nutrition​ ​knowledge​ ​retention.

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

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

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

what​ ​it​ ​really​ ​entails.

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

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

Relationship​ ​of​ ​MD​ ​and​ ​GDM

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

knowledge​ ​that​ ​is​ ​supplemented.

Relationship​ ​of​ ​RD​ ​and​ ​GDM

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

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

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

Impact​ ​of​ ​Nutrition​ ​Education

generalizability​ ​of​ ​the​ ​results.

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

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

Knowledge​ ​and​ ​Barriers

Limitations​ ​in​ ​Available​ ​Research

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

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

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

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

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

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

for​ ​approval​ ​of​ ​the​ ​study.

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

RD​ ​and​ ​MD.

APPENDIX:​ ​TABLE​ ​OF​ ​CONTENTS

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

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

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

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

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

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

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

APPENDIX​ ​B:​ ​EMAIL

Email​ ​to​ ​Hospitals

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

APPENDIX​ ​C:​ ​EXCEL​ ​DOCUMENTS

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

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

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

GESTATIONAL DIABETES INTERVENTION:

PHYSICIAN VS. REGISTERED DIETITIAN

Dr. Dena Herman

TABLE OF CONTENTS

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

nutrition knowledge retention.

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

Ecological Model Theory in Appendix: I.

Different Management Techniques and Risks of GDM

what it really entails.

meta-analysis could have the potential to be biased.

GDM management more visible to plan for action.

Relationship of MD and GDM

different methods of better GDM management.

knowledge that is supplemented.

Relationship of RD and GDM

survey of Australian Dietitians.”

dietitian particularly with nutrition assessment and macronutrient targets.

Role of RD and MD Around the World

Impact of Nutrition Education

generalizability of the results.

the consequences of their diet choices.

teaching styles that resonate with the patient.

Knowledge and Barriers

Limitations in Available Research

affiliated with the Sweet Success Program or similar programs.

levels and demonstrate better nutrition knowledge retention.

languages besides English and Spanish.

Success through the program’s Sweet Success Affiliate Locator

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

between the physician and registered dietitian.

for approval of the study.

physicians and the registered dietitians.

RD and MD.

APPENDIX: TABLE OF CONTENTS

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

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

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

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

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

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

APPENDIX A: Socio-Ecological Model Theory

APPENDIX B: EMAIL

Email to Hospitals

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

APPENDIX C: EXCEL DOCUMENTS

Part II of Questionnaire at Time of GDM Diagnosis

Part II of Questionnaire Near Time of Delivery

Fasting and Postprandial Blood Glucose Tracking

Appendix D: Nutrition Questionnaire For Women with GDM

2. What is your ethnicity?

Thank you very much for completing this questionnaire! ☺

APPENDIX E: INFORMED CONSENT FORM

Your Signature ___________ Date

Your Name (printed) ____________________________________________________________

Printed name of person obtaining consent _________________________________

APPENDIX F: Timeline

Metabolic Syndrome, 81-7. doi:10.1186/s13098-016-0161-5

without Gestational Diabetes Mellitus. PLoS ONE, 8 (9), e73486.

Health, 18(6), 1334-1342. doi:10.1007/s10903-015-0266-1

International, 1-16. doi:10.1155/2017/4856527

approach. Belmont: Wadsworth.

Diabetes in Pregnancy. (n.d.). Retrieved November 20, 2017, from

Mellitus in Oregon. Plos ONE, 7(10), 1-6. doi:10.1371/journal.pone.0047052

gestational diabetes: A meta-analysis. PLoS ONE, 8(5), E64585.

mellitus. Diabetes Research and Clinical Practice, 95(3), 352-357.