nutrition education for women with gdm Nutrition Education for Women With Newly Diagnosed Gestational Diabetes Mellitus: Small-group vs. Individual Counselling Ann Murphy RD BAA, Anne Guilar RD BASc, Diane Donat MD MSc FRCPC Endocrine and Diabetes Clinic,Toronto General Hospital, University Health Network,Toronto, Ontario, Canada 1 OBJECTIVE To compare the efficacy of nutrition counselling for patients with gestational diabetes mellitus (GDM) in small-group vs. individual counselling sessions as a cost-effective strategy. METHOD Patients attending a weekly GDM clinic were placed by convenience sampling into 1 of 2 categories: individual counselling or small-group counselling (2 to 4 women). Nutrition counselling, provided by a registered dietitian, consisted of a 1-hour interactive education session using a tabletop flip chart. Supporting written materials were used in both categories to reinforce the topics discussed. Subjects completed a knowledge assessment test based on the content of the counselling session, which consisted of 12 multiple-choice questions, at 3 time points: prior to nutrition counselling, immediately after counselling and 1 week after counselling. RESULTS A B S T R A C T Data were collected on 76 subjects (41 instructed individually, 35 instructed in small groups).the demographic profiles Address for correspondence: Ann Murphy Endocrine and Diabetes Clinic Toronto General Hospital 200 Elizabeth Street Toronto, Ontario M5G 2C4 Canada Telephone: (416) 340-4800, ext. 4883 Fax: (416) 340-3474 E-mail: ann.murphy@uhn.on.ca Keywords: gestational diabetes mellitus, individual counselling, small-group counselling OBJECTIF R É S U M É Comparer l efficacité du counseling en matière de nutrition de petits groupes au counseling individuel chez des patientes atteintes de diabète gestationnel (DG) du point de vue de l efficience. MÉTHODE Des patientes atteintes de DG qui se présentaient une fois par semaine à une clinique diabétologique ont été partagées en deux catégories selon un échantillonnage de commodité : counseling individuel et counseling de petits groupes (2 à 4 femmes). Le counseling était offert par une diététiste et consistait en une séance interactive d une heure au cours de laquelle on utilisait un tableau à feuilles et de la documentation écrite. Les participantes ont fait un test comprenant 12 questions à choix multiples à trois reprises : avant le counseling, immédiatement après et une semaine plus tard. RÉSULTATS Des données ont été recueillies auprès de 76 patientes (41 ayant reçu un counseling individuel et 35 ayant reçu un counseling de petit groupe). Les données démographiques des patientes des deux catégories étaient comparables pour ce qui est de la langue, de l éducation et des connaissances antérieures sur le DG. Les résultats du test effectué après le counseling montrent que les participantes avaient considérablement amélioré leurs connaissances, quelle que soit la méthode de counseling (p < 0,0001). Après le counseling, il n y avait pas de différence quant à l amélioration des connaissances entre les participantes qui avaient reçu un counseling de petit groupe et celles qui avaient reçu un counseling individuel, d après un test d équivalence (intervalle de confiance [IC] de 95 % : -3,7 à 5,5). Les résultats du test effectué une semaine après le counseling montrent que les participantes des deux catégories avaient retenu ce qu elles avaient appris (IC de 95 % : -6,2 à 2,4). Le counseling de petits groupes a fait gagner un total de 27 heures-diététiste.
CANADIAN JOURNAL OF DIABETES 2 of the 2 methods were comparable with respect to language, education and previous GDM instruction. Postcounselling results showed a significant improvement in knowledge, regardless of counselling method (p<0.0001). Postcounselling results showed no difference in knowledge improvement between participants in small-group counselling and those who received individual counselling, based on equivalence testing (95% confidence interval [CI]: -3.7 to 5.5). One-week follow-up results demonstrated that knowledge was retained in both counselling categories (95% CI: -6.2 to 2.4).A total of 27 dietitian hours were saved with small-group counselling. CONCLUSION Les femmes atteintes de DG peuvent recevoir des conseils sur la nutrition de façon efficace et efficiente en petits groupes. CONCLUSION Women with GDM can be effectively and cost-efficiently counselled on nutrition in small-group settings. INTRODUCTION Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy, with a prevalence of 3.5% to 3.8% in the non-aboriginal population and 8.0% to 18.0% in Aboriginal populations (1). Dietary strategies are the mainstay of therapy for women with GDM (1) and should be initiated in a timely manner. Group counselling has been implemented in some healthcare centres to provide timely, cost-effective education that is compatible with key tenets of adult learning (2). This study was conducted to determine whether small-group counselling meets the learning needs of women with GDM, or whether individual counselling is more appropriate. Hill reviewed the effectiveness of alternate methods of delivering adult patient education and found that group teaching was less costly, more effective in imparting knowledge and provided valuable opportunities for experiencesharing among participants compared to individual teaching (3). In a systematic review of randomized, controlled trials, Norris and colleagues found that both types of learning demonstrated mixed results for interventions that focus on knowledge, lifestyle or skills (4). More recently, Mensing and Norris noted a paucity of literature regarding the relative effectiveness of individual vs. group learning (5). Pichert determined that diabetes educators must possess excellent teaching and adherence promotion skills, and that demonstration, feedback, review, reassessment and motivation are important elements of effective instruction, regardless of the setting (6). Langer and Langer noted that women with GDM should be studied as a separate population from women with type 1 or type 2 diabetes because of the temporary aspect of the disease state, the heightened readiness of women with GDM to learn and because the psychological adjustment to GDM is different from that of type 1 or type 2 diabetes (7). The primary objective of this study was to measure and compare nutrition knowledge of women with GDM counselled in small-group or individual sessions. The secondary objective was to determine if demographic parameters had an impact on learning. METHOD Participants were recruited from a pre-existing weekly GDM clinic at Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. All subjects provided written informed consent.the study received approval from the Research Ethics Committee at Toronto General Hospital. Women diagnosed with GDM were seen in the clinic within 1 week of referral. Clinic volume varied from 1 to 4 patients per week.as patient care cannot be deferred, placement by convenience sampling into either an individual or small-group nutrition counselling session was dependent on the number of referrals received in a given week and was beyond the control of the investigators.the inclusion criterion was comfort reading in the English language. Those not participating in the study received the same level of care. A sample-size calculation was performed based on the results of a previous pilot study to have a 90% probability of detecting a difference of 10% between the mean improvement scores of the 2 methods (alpha=0.05). A total of 76 subjects (individual counselling category, n=35; small-group category, n=41 [6 groups of 2 women, 3 groups of 3 women, 5 groups of 4 women]) were recruited over an 18-month period from September 1999 to February 2001. Five patients were not included in the study due to a language barrier. A clinic day consisted of consultation with an endocrinologist, counselling by a registered dietitian and instruction on self-monitoring of blood glucose (SMBG) by a nurse (the dietitian and nurse were Certified Diabetes Educators [CDEs]). Patients were followed by the endocrinologist on a weekly basis and referred back to the nurse or dietitian as required. A similar counselling format was used for individual and small-group counselling. Ninety percent of subjects were counselled by the same dietitian. The learning
objectives outlined in Table 1 helped to maintain consistency among the various counselling sessions. Three education tools were used for both methods of counselling: a 60 cm x 75 cm tabletop flip chart, which illustrated the learning objectives of the counselling session; food models and measuring devices, which provided 3-dimensional reinforcement of portion sizes and measurements; and written material, consisting of an individualized meal plan based on the Canadian Diabetes Association Food Choice System and general nutrition guidelines. A caloric intake of 1800, 2000 or 2200 kcal per day was assigned to each subject based on pre-pregnancy body weight. The dietitian leading the session facilitated discussion and information-sharing among participants. Care was taken to ensure that education tools were culturally appropriate by incorporating a wide variety of culturally specific food choices. Food models and measuring devices provided practical portion demonstration. Subjects were encouraged to participate by identifying and discussing preferred food choices. The investigators developed a questionnaire, as a literature review did not reveal an existing knowledge questionnaire for this population. The questionnaire consisted of 12 multiple-choice questions based on the learning objectives (Table 2). A multiple-choice format was chosen for the questionnaire design because this format relies on recognition, which is a more valid measure of knowledge than openended questions or true/false questions (8). The SMOG readability formula placed the questionnaire at a grade 8 reading level (9).The questionnaire was reviewed for content by 4 independent CDEs and pretested in a pilot study of subjects drawn from the same patient population. Subjects completed the questionnaire at 3 time points: prior to the nutrition counselling session, immediately after counselling and at 1-week follow-up. Follow-up at 1 week was chosen to confirm the results obtained immediately after counselling. This ensured a high response rate, as subjects ongoing follow-up was on an individual basis. Demographic data collected in the initial questionnaire included level of education obtained, language most commonly used at home, nutrition education for women with gdm and counselling for GDM during previous pregnancy. Analysis was completed using Statistix (Analytical Software Inc.,Tallahassee, Florida, United States). RESULTS Despite the lack of randomization, there were no statistically significant differences in the demographic parameters between the counselling categories (language, p=0.6; education, p=0.2; previous counselling for GDM, p=0.6) (Table 3). Approximately half of the study population reported a language other than English as the language most commonly spoken at home. Eighteen different languages other than English were reported, with no single language predominating. This reflects the cultural diversity of the city of Toronto, Ontario, Canada, where 58% of residents are of non-british/non-canadian origin (10). Eighty percent of study participants reported receiving education beyond high school. Only 13% of subjects had received previous counselling for GDM. Analysis of covariance (ANCOVA) was used to adjust for a difference in the baseline knowledge score between methods. After counselling, a significant improvement in knowledge was noted in both the individual counselling category (29.3%, p=0.0001) and the group counselling category (30.1%, p=0.0001), with no significant difference in knowledge gain noted between the 2 counselling methods (95% CI: -3.7 to 5.5) (Table 4). In the postcounselling to 1-week follow-up interval (Table 4), the 2 counselling categories did not differ significantly and showed no decline in knowledge (95% CI: -6.2 to 2.4). The demographic parameters noted in Table 5 demonstrate: the language most commonly spoken at home did not influence the change in knowledge (95% CI: -3.1 to 6.8); the level of education reported affected change in knowledge. Those with some high school education scored 8.1% lower than those with some postsecondary education (95% CI: 2.0 to 14.1).This group also scored 6.4% lower than the overall average score; and women with previous GDM counselling had scores 3 Table 1. Nutrition counselling learning objectives At the end of the counselling session the subject will: 1. Have a basic understanding of GDM. 2. Understand how carbohydrate influences BG. 3. Be able to identify foods that contain carbohydrate. 4. Be able to identify appropriate portion sizes. 5. Understand the principles of carbohydrate distribution. 6. Be able to identify food sources of calcium. 7. Be able to plan a sample menu. BG = blood glucose Table 2. Sample questionnaire questions 1. Foods containing carbohydrate will: ( ) raise my blood sugar ( ) lower my blood sugar ( ) not affect my blood sugar 2. Which one of these foods raises blood sugar? ( ) milk ( ) margarine ( ) chicken breast 3. Each day I should have: ( ) 3 meals and no snacks ( ) 3 meals and 1 snack ( ) 3 meals and 3 snacks
CANADIAN JOURNAL OF DIABETES 4 similar to those who had not had previous counselling (95% CI: -5.8 to 7.7). Twenty-seven hours of dietitian time were saved by providing counselling for 41 subjects in 14 groups, instead of individually. DISCUSSION While a randomized, controlled trial is the preferred method of conducting research, it is not always feasible (4). In this study, a convenience sampling technique was successful in establishing 2 comparable groups. These results demonstrate that the nutrition counselling provided in small-group and individual sessions were equally effective. In a small group, the participants were encouraged Table 3. Demographic parameters of subjects by counselling method Language Individual method n (%) Small-group method* n (%) p value English only 15 (43) 19/40 (48) 0.6 English + other 20 (57) 21/40 (52) 0.6 Education Elementary 0 0 0.2 school High school 9 (26) 6/39 (15) 0.2 Postsecondary 26 (74) 33/39 (85) 0.2 Previous counselling for GDM Yes 4 (11) 6/40 (15) 0.6 No 31 (89) 34/40 (85) 0.6 *Incomplete data for small-group method Table 4. Percentage change in knowledge by counselling category Change in knowledge (%) Pre- to postcounselling interval Post- to follow-up counselling interval All subjects +29.7* +1.4 Individually +29.3* +2.5 counselled Counselled in small groups +30.1* +0.6 % difference (individual vs. group) *p=0.0001 0.8 (95% CI: -3.7 5.5) 1.9 (95% CI: -6.2 2.4) to discuss issues, ask questions and to participate in a supportive environment. It is important to note that the groups were small (2 to 4 subjects per group), and these results may not transfer to larger groups. Providing counselling to 2 to 4 women with GDM at the same time, rather than individually, resulted in a saving of 27 dietitian hours. All subjects showed a significant improvement (29.7%) in knowledge (p=0.0001), with an average score of 85.5% on the postcounselling questionnaire (Table 4), verifying that the learning objectives were met regardless of the counselling method used.there was a slight improvement in knowledge at 1-week follow-up, so no loss of knowledge had occurred. Dietitians have always strived to meet the needs of the diverse populations found in many healthcare centres across Canada. As shown by the results, cultural diversity was not a barrier to learning provided the subjects were comfortable in reading English. Dietitians must consider the educational level of clients when designing a counselling program. The results of this study indicated that subjects with only high school education did not score as well as those with postsecondary education. Nonetheless, women with high school education showed a significant improvement of 23.3% in knowledge. Further research to develop a resolution to this problem is required. Scores for women with previous counselling for GDM were not significantly different from those without previous counselling for GDM (Table 5). Therefore, one cannot assume that women will retain information from 1 pregnancy to the next, so nutrition counselling by a dietitian should be repeated for subsequent pregnancies. Table 5. Impact of demographics on knowledge scores Demographic parameters (n) Language % change in questionnaire score English only (34) +30.9 English + other (41) +29.1 Education High school (15) +23.3 More than high +31.4 school (59) Previous GDM counselling No previous +30.0 counselling (65) Previous counselling (10) +29.1 CI = confidence interval 95% CI -3.1 6.8 2.0 14.1-5.8 7.7
CONCLUSION This study demonstrated the efficacy of providing nutrition counselling in small groups of 2 to 4 individuals vs. individual counselling. Cultural diversity and previous GDM nutrition counselling did not affect knowledge results, while level of education had an impact on learning.these results demonstrate that dietitians can counsel women with GDM in smallgroup settings without compromising their learning needs. Small groups enable counselling to be performed in a costeffective fashion. nutrition education for women with gdm 5 ACKNOWLEDGEMENTS The authors gratefully acknowledge the support of Banting and Best Diabetes Centre, Faculty of Medicine, University of Toronto,Toronto, Ontario, Canada, for funding this project. The authors also acknowledge staff of the Endocrine and Diabetes Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; staff of the Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada; Marguerite Ennis, statistician; and Julie Seale, data technician. REFERENCES 1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2003;27(suppl 2):S1-S152. 2. Nichol H, Cleave B, Seto C, et al. Group education:an option for women with gestational diabetes. Beta Release. 1993; 17(2):10-17. 3. Hill J. A practical guide to patient education and information giving. Baillieres Clin Rheumatol. 1997;11:109-127. 4. Norris SL, Engelgau MM, Narayan KMV. Effectiveness of selfmanagement training in type 2 diabetes: A systematic review of randomized controlled trials. Diabetes Care. 2001;24:561-587. 5. Mensing CR, Norris SL. Group education in diabetes: Effectiveness and implementation. Diabetes Spectrum. 2003; 16:96-103. 6. Pichert JW. Improving the impact of diabetes education: A research challenge. Beta Release. 1990;14(1):7-12. 7. Langer N, Langer O. Emotional adjustment to diagnosis and intensified treatment of gestational diabetes. Obstet Gynecol. 1994;84:329-334. 8. Dunn SM, Bryson JM, Hoskins PL, et al. Development of the diabetes knowledge (DKN) scales: Forms DKNA, DKNB, and DKNC. Diabetes Care. 1984;7:36-41. 9. McLaughlin GH. SMOG grading: A new readability formula. J Reading. 1969;12:639-646. 10. Statistics Canada. 2001 community profiles. Available at: http://www12.statcan.ca/english/profil01/placesearch Form1.cfm. Accessed March 17, 2004.