Attitudes of women with gestational diabetes toward diet and exercise: a qualitative study

Abstract Objective Gestational diabetes (GDM) refers to glucose intolerance of varying severity first occurring in pregnancy. Following a diagnosis of GDM, exercise and dietary modification has a positive effect on improving glycemic control. Lifestyle changes affected in pregnancies affected by GDM have beneficial effects on long-term health if continued following birth. In addition, the psychological impact of a diagnosis of GDM should not be overlooked. Reports of maternal stress, anxiety, and fear are commonly reported issues in the literature. Support, both socially and from health care professionals, is also linked with higher rates of success in GDM management. Research to date had focused on women’s reaction to a diagnosis of GDM, their mood and quality of life following a diagnosis, and their knowledge or opinions on the management of GDM. This qualitative study explored the attitudes of women with GDM toward these lifestyle changes, specifically diet and exercise. Women were also asked to identify advice that would be useful for other women newly diagnosed with GDM. Methods With ethical approval a qualitative study was conducted using semi-structured interviews which were examined using Thematic Analysis. Patients were invited to participate and gave written consent after a discussion with a study researcher. The question plan for semi-structured interviews was designed with the advice of patient advocates. Recurrent themes were developed until the saturation of data. Results Thirty-two women took part in the study. Time, convenience, and lack of educational awareness were common barriers to healthy eating and physical activity plans. Enablers for change included meal planning and organization. Women regarded their diets pre-diagnosis as healthy, with small “tweaks” (such as portion control) required to comply with recommendations. Another significant facilitator to change was support from the woman’s partner. This also set a benchmark for plans of diet maintenance within the family structure after pregnancy. Unlike dietary changes, a consistent theme was that exercise was considered a “chore” in managing GDM and was unlikely to be continued in the long term. Practical advice offered by participants for other women with GDM included organization, realistic approaches, and lack of self-blame. Conclusion Women reported that changes in diet would be more achievable in the long term than changes in exercise patterns. Partners and the clinical team were significant sources of support. Women’s views are crucial to providing clinicians with a comprehensive and holistic understanding of disease management. Involving women in self-care decisions and empowering women to manage their own health are key contributors to long-term behavior change as well as service provision and policy implementation


Introduction
Gestational diabetes (GDM) refers to glucose intolerance of varying severity occurring in pregnancy [1]. GDM is an important public health concern with well-documented adverse maternal and perinatal outcomes coupled with the known risks for the mother of developing type 2 diabetes mellitus (T2DM) and for her offspring of developing obesity and metabolic syndrome [2][3][4].
Diet and exercise are the cornerstones of GDM management, even when women require treatment with oral hypoglycemics or insulin therapy. Exercise prior to and during early pregnancy confers a protectivekeffect against the development of GDM [5]. Following a diagnosis, exercise has a positive effect on improving glycemic control [6] and can also lead to long-term adjustments in health behaviors [7].
Women's views are crucial to provide clinicians with a comprehensive and holistic understanding of disease management [8][9][10]. Involving women in self-care decisions and empowering women to manage their own health are key contributors to long-term behavior change as well as service provision and policy implementation [11][12][13]. Support, both socially and from health care professionals, is also linked with higher rates of success in GDM management [9,10,12,[14][15][16].
Research to date had focused on women's reaction to a diagnosis of GDM, their mood and quality of life following a diagnosis, and their knowledge or opinions on the management of GDM [9,10,[17][18][19]. Access to a dietitian for individualized advice is seen by women as an enabler to their care; in contrast lack of tailored physical activity assessment is a barrier [20]. This study aims to explore the attitudes of women with a new diagnosis of GDM to the required lifestyle changes, specifically dietary and exercise alterations. Secondary aims included exploring women's attitudes toward a diagnosis of GDM as well as advice they would offer other women with a new diagnosis of GDM.

Materials and methods
This was a qualitative study of maternal perceptions of diet and exercise in women diagnosed with GDM. Women attending the Diabetes and Pregnancy service of the National Maternity Hospital (NMH) were invited to participate. The NMH is a large tertiarylevel unit in the city of Dublin with nearly 10,000 births per year. Over 800 women attend the Diabetes and Pregnancy service, which is staffed by a full multidisciplinary team. Following a diagnosis of GDM, women are invited to attend an education session on GDM diagnosis and management [15]. The majority of women manage their GDM with diet and exercise alone. A small subgroup of women (100/year) requires medical therapy (metformin and/or insulin) to maintain euglycemia.
Qualitative research was performed following the consolidated criteria for reporting qualitative research (COREQ) recommendations [21]. A detailed literature review on the subject was performed and a series of questions were developed to act as a foundation for the interviews. Given that this is a personal and possibly sensitive subject, women attending for care were asked to help develop the foundation questions to ensure that they were appropriate, respectful and meaningful. The involvement of women as "experts by experience" in planning the questions aimed to reduce the possibility of inadvertent bias in the research team [22]. Ten women gave feedback on the interview guide resulting in a baseline plan (see Table 1); as interviews progressed and new themes developed this guide was modified to allow exploration of developing themes.
Ethical approval was obtained from NMH Ethics Committee. Information leaflets outlining the study were offered to women and they were given at least 15 min to read them without the researcher present. Participants were enrolled from either the antenatal clinic or postnatal wards. A confirmed diagnosis of GDM, age over 18, and ability to speak English were the inclusion criteria. Following informed written consent, semi-structured interviews were conducted on a one-on-one basis where the woman could talk freely in response to questions in the interview guide. The interviews were recorded on dedicated research Dictaphones. Demographic information was obtained from all participants, including age, parity, gestation at diagnosis of GDM, risk factors, ethnicity, and educational level (second level ¼ high school, third Questions were developed based on expert opinion, literature review and consultation with women with GDM -"Experts by experience." level ¼ university). Age, parity, and gestational age were described with median (range) and risk factors, ethnicity, and educational levels as raw numbers and percentages.
Women were asked about their general attitude toward diet and exercise, possible differences in these attitudes after diagnosis of GDM and possible measures taken to improve these outcomes. Questions regarding personal attitudes to exercise specifically focused on factors acting as facilitators or barriers. A secondary theme studied was women's experiences and perceptions of a diagnosis of GDM. Finally, participants were requested to contribute advice for other women that they may find useful after a diagnosis of GDM. The study aimed to recruit consenting women until the saturation of themes.
Women were interviewed by one of two trained researchers: SS (Smyth, obstetrics resident) or KM (Mulligan, medical student) in order to reduce bias. None of the interviewers were involved in patient care. Researchers reflected on their own personal biases prior to interviews and were reflexive throughout the research process. Reflection and reflexivity meant examining that the research team examined their own judgments, beliefs, practices, and previous biases that may have affected the research process. Reflexivity also examines the person (researcher) making judgments on the research data, helping also to make previously unconscious biases conscious, allowing reflection on results and increasing the trustworthiness of the data [23].
The qualitative research method was Thematic Analysis. This is a "flexible and useful research tool" which can "potentially provide a rich and detailed, yet complex, account of data" [24,25]. Interviews took approximately 10-20 min. Audiotapes were transcribed verbatim by the researchers and the transcripts were entered into NVivo and coded. No specific patientidentifying information was transcribed. Transcripts were read and reread as codes were assigned. A deductive approach was used. Data were coded following the individual guiding question of the interview guide, narrowing, and defining the codes that presented in the data initially. The codes were then observed and grouped several times while themes were identified. Themes were developed from data that was prevalent, important, and substantial across interviews. Saturation of themes was defined when refinements did not add any new substantial themes.
Trustworthiness was enhanced by two methods: method checking and triangulation [25]. A variation of member checking was used, where instead of reviewing themes with the original participants (not possible due to anonymity and high patient turnover) themes were reviewed with a different group of patients to see if they saw them as authentic. Triangulation was via researchers where the interviewing researchers initially analyzed data and the other researchers reviewed identified themes (Rutter, Harrington, Hatunic, Higgins).

Results
Women with a diagnosis of GDM were invited to attend. Thirty-two women consented to take part in the study and were interviewed. One postnatal participant declined. Baseline demographics are shown in Table 2. Eighteen women were interviewed during pregnancy (AN ¼ antenatal) and fourteen were interviewed on the postnatal ward (PN ¼ postnatal) in the days following birth. Overall themes illustrating women's attitude toward diet and exercise are shown in Table 3.
With regard to their own personal diets, many women felt that their diet pre-diagnosis with GDM was healthy-which they defined as one showing balance and moderation with food groupings including a variety of foods and use of fresh ingredients: "My diet is reasonably healthy, I do have a sweet tooth but I think everything in moderation is OK" (PN6) "I think I have a healthy diet most of the time, it is balanced" (PN7).
Following the diagnosis of GDM (and especially after lifestyle education class) women reported that they could now see where their diets could be improved, in particular with respect to portion size: "Showing what all the portion sizes look like is really crucial" (AN3). Women commonly referred to these changes as being small "tweaks:" "From my experience just following the diet and those few little tweaks made all the difference" (AN2)" A significant facilitator to change was the support from the woman's partner and/or family, or the future health of the fetus: "With kids it's about a conscious decision not give them convenience food, especially when they eat so much, you need to give them healthy stuff" (AN8)" Such support was considered a benchmark for plans to maintain dietary changes within the family structure following the pregnancy: "In fairness A (partner) had to make an effort to buy biscuits now that S (daughter) is born, we knew we would be having visitors; we don't keep trash in the house anymore" (PN5) Barriers identified by the women in facilitating these changes included lack of time, educational awareness and convenience: "Convenience, time-it's not that people don't know they just ignore it" (PN5) With regard to exercise, an overwhelming theme was the barriers to meeting exercise recommendations in pregnancy: "Time is a problem, that's why I try and build it into work, lunchtime is the best for me"(AN17). Prior to a diagnosis of GDM multiple barriers to exercise were identified, including time, childcare, disinterest and lack of motivation: "I don't like it-I find it boring" Some had reasonable concerns regarding family life: "I just don't think I have the time with four babies to look after" (PN14). Unlike dietary changes, a consistent theme was that exercise was considered a "chore" in managing GDM and was unlikely to be continued in the long term. "I don't like exercising, It's something I do because I know I have to" (PN11).
For others, their experience of the physical benefits of exercise as well as improvements in overall wellbeing and mental health were identifiable promoters of exercise. Women were aware of the benefits in general but did not appear to believe these benefits would apply to them as individuals. While women initially felt that fatigue secondary to their pregnancy would be an unfavorable factor, they reported increased energy levels and improved sleeping patterns: "Good head space too" (PN9). Exercise was also found to be a motivating factor in glycemic control: "Exercise helps with the blood sugars as well as your mood" (PN5).
The influence of their partner in exercise promotion was a major factor for the women in maintaining an exercise program: "I don't want to go on my own and my husband already has his exercise from cycling to work" (PN6).
With regard to women's attitudes to a diagnosis of GDM, all interviewed women reported an increase in stress and anxiety levels. Many women reported feelings of shock or anger in the initial weeks following their diagnosis: "You feel guilty about it" (AN16)". There was a real wish for reassurance: "I think if someone had said "this is not your fault" at an earlier stage that would have been better" (AN12).
Regarding advice for other women, though the participants all agreed that a diagnosis of GDM was initially met with a negative response, they felt empowered by the help, support and results ultimately obtained through the specialized Diabetes and Pregnancy clinic. "Don't panic, you just need to make some changes in your kitchen and some good changes overall for your lifestyle" (PN2) Specific advice offered to other women with GDM included the importance of organization, realistic approaches and lack of self-blame. Table 2. Demographics of women participating in semi-structured interviews exploring their attitude toward diet and exercise before and after a diagnosis of GDM (gestational diabetes mellitus).

Discussion
This study shows that women felt that their diets prior to pregnancy were healthy, contributing to their sense of surprise and shock at GDM diagnosis. After the initial diagnosis many self-restricted their dietary intake. This ceased once they had a formal consultation with the dietitian, with only small "tweaks" being required. In contrast, exercise was often seen negatively and as a necessary extra burden. Women in this study who were experiencing GDM for the first time were often surprised with the diagnosis-a common finding in other studies [10,13,17,18,26,27]. Many of the participants did not know their risk factors for GDM, highlighting a lack of knowledge [28]. Like other studies, many participants were aggrieved that they were not advised to lose weight before pregnancy or modify risk factors [13,18]. Women were concerned at the increased risks posed on their pregnancies. Women who had GDM in a prior pregnancy coped better with the diagnosis of GDM; however, they felt the lifestyle changes now being necessary for a longer length of time (often from the first trimester) was burdensome for them. The addition of insulin therapy was perceived as another burden. Some women were concerned about self-injecting, particularly abdominally, as they were worried this would affect the baby. This contrasts with another study which showed that insulin was an easier option given the barriers to diet and lifestyle change (including time constraints, financial and family responsibilities and social temptations) [29].
Though the participants all agreed that a diagnosis of GDM was initially met with a negative response, they felt empowered by the help, support and results ultimately obtained through the specialized Diabetes and Pregnancy clinic. Generally, women felt that the necessary lifestyle and dietary changes were manageable with many aiming to maintain these changes following the pregnancy. This is a gratifying result as other studies showed that mood state and quality of life decreased significantly as lifestyle adjustments were perceived as daunting [13,27] though others agree that team support is an enabler of care [20]. The difference between these two findings may be due to individual circumstances, women's resilience, or timing of interview. There may also have been an element of social desirability bias [30].
Stress and anxiety can occur in women with GDM when personal food preferences conflict with dietary advice, or when dealing with social scenarios where appropriate food can be difficult to source [31,32]. Receiving tailored advice from the dietitian was a pivotal point for women in their diet and lifestyle plan. This reiterates the importance of multi-disciplinary team support [10,15]. While many women initially struggle with the diagnosis, and the difficulty in living their "normal" life [13,19] at the end it is seen as an opportunity to enact dietary and activity changes [33].
Changes in physical activity levels were noted to be associated with greater stress than those required for dietary improvement. Most of the interviewed women did not enjoy exercise at any previous stage and for those who did enjoy it, exercise was often curtailed by social factors such as work and childcare. Walking was the preferred physical activity of the study participants. Many felt that classes expensive and difficult to access, especially amongst non-Irish women interviewed.
Other studies have highlighted the importance of cultural sensitivity and appropriateness of advice [19,[33][34][35][36]. In a study of women from South Asia living away from their home country, many felt that parks and streets were unsafe and cultural/familial constraints impacted on their ability to exercise [37]. Providing culturally appropriate information can improve trust of women attending the service [26]. The interviewees felt that the exercise changes commenced in pregnancy were unlikely to be maintained with resolution of GDM following birth of their baby. Time constraints and lack of interest were the main barriers cited for this. This is an area that requires future focus and attention.
Previous studies have suggested that a lack of understanding of the needs of women with GDM by healthcare professionals may result in alienation, lack of trust and "deceitful action" [13,35]. In this study, though women echoed the initial stress and anxiety that the diagnosis caused, they had a good understanding of the important issues and took ownership of this information. Participants advised that meal planning, shopping lists and organization were good tools for dietary change. Measurement of portion size was another large contributing factor to better glycemia, and this was identified as an easily adjustable medium of change. Overall women reported that they would offer reassurance and support to others newly diagnosed with GDM. They felt that it would have been helpful and beneficial for them to have talked with someone who had been through the process and recommended that this be implemented as part of their education session. The women also report that they would advise others to attend their appointments with the dietitian and adhere to the recommended changes. This was found to be especially true for women who had a prior diagnosis of GDM and who thought they were still compliant with previous advice. Attendance at the Diabetes and Pregnancy clinic and scan appointments were highlighted as being time-consuming; however, women stressed the importance of compliance with these visits.
It should be noted that to reduce future risk of the development of type 2 diabetes (T2DM), targeted support in diet and lifestyle change is required [35,38]. Continued support for long-term behavior change should be facilitated. Effectiveness of GDM lifestyle interventions has been shown to dwindle three to four years postnatally, with motivation being mostly that of weight loss rather than wish to reduce the risk of T2DM [39]. Insight into the lived experience with a diagnosis of GDM can help guide T2DM risk-reduction strategies [40].
No article can be written in 2022 without reference to our new clinical world of care. While guidelines made pragmatic changes to care because of the pandemic [41], the recommendation is that care should return to normal as soon as was possible. The increase in video consultations, especially with dietetics, may improve patient experience and support women in the fundamental management of their diagnosis of GDM. As with many things, changes forced during the pandemic may help us all improve care, and women's experiences of these services must be explored [42,43].
Future research could also focus on maintenance of lifestyle changes instituted in pregnancy as a method to control of GDM. Continued healthy eating coupled with improved physical activity levels are known to improve general health and well-being which reduces the burden of chronic disease.
Strengths of this study include the involvement of women in the development of the questions, ensuring the questions were sensitive, relatable and comprehensive; inclusion of women from a diverse range of backgrounds and ethnicities to provide different perspectives. Possible limitations of the study include: the possibility of bias, due to the interviewers own personal lens on the subject or the interviewees wishing to give the interviewer the socially desirable response; interviewee recollection bias in the postnatal period may have been an issue; participants were recruited from one center. While there were a reasonable number of participants for a qualitative research paper, as with any qualitative research findings may be contextspecific and not apply to other situations.
This study highlights the contrasting attitudes of women with a diagnosis of GDM toward diet compared to exercise. The literature has ample advice for improving compliance rates of GDM management, for example, provision of targeted programs for culturally and socially diverse parturient [12,29,37] and review of barriers to engagement [24,30,39,44]. We are unaware of any other study that has provided women's' advice to other women with a new diagnosis of GDM. This advice may be used to encourage motivation, reduce stress and anxiety associated with the diagnosis and maintains compliance with lifestyle changes.