الفهرس 
Significance of the StudyOnly 14 pages are availabe for public view
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Abstract
Gestational diabetes mellitus (GDM) is one of the most common medical disorders found in pregnancy. It affects between 2-14% of pregnancy worldwide. The prevalence of GDM ultimately reflects the background rate of type 2 diabetes. There has also been an increase in the rate of GDM over the last generation, possibly related to community lifestyle factors as well as better case ascertainment
It is associated with short and long term morbidity in both mother and child. Adverse infant outcomes include macrosomia, hypocalcemia, erythemia, hypoglycemia, jaundice, and birth trauma.Borderline GDM has been linked with higher rates of cesarean sections and induced deliveries, shoulder dystocia and birth injuries, and pathogenesis in the offspring of overweight and metabolic syndrome. High intake of saturated fat, low intake of polyunsaturated fat, and excessive gestational weight gain may increase the risk of GDM. Physical activity is also associated with decreased risk of GDM .
Major risk factors for GDM include older age in pregnancy, a family history of diabetes, pre-pregnancy overweight, previous GDM and race or ethnicity. Modifiable factors include excess adiposity, physical activity, and diet. Dietary components associated with GDM risk include macro-nutrients, micronutrients, and individual foods, such as refined carbohydrates, saturated and transfats, heme iron, and processed meat. Evidences have suggested that both diet and physical activity altered the increase in insulin resistance especially during mid and late pregnancy. Therefore, behavioral interventions were important to promote pregnant women practicing healthy diet in order to prevent subsequent obesity and GDM.
Pregnancy may be an optimal period for interventions because pregnant women are often motivated to make lifestyle changes to benefit their unborn child. Some dietary intervention studies have shown improvements in dietary intakes among pregnant women, for example, an increase in the intakes of polyunsaturated fat, dietary fiber, vegetables, fruits, whole grains and fish and a decrease in the intakes of saturated fat, sugary food, refined grain, high-fat meat and fast food
Thus, this study was undertaken to investigate effect of lifestyle counseling (regular physical activity, healthy diet, and healthy weight gain) on pregnancy outcomes among women at high risk for gestational diabetes mellitus.. It was conducted beginning of October 2017 to end of august 2018 in two settings at Shebin El-Kom city; namely Quibli MCH Center and Bahry MCH Center. The participants included100 women at 8–12 weeks gestation euglycemic with at least one or more gestational diabetes mellitus GDM risk factor ;(Body mass index BMI >25 kg/m, glucose intolerance in any earlier pregnancy, newborn’s macrosomia (>4000 g) in any earlier pregnancy, family history of diabetes (at first and second degree relatives), maternal age >35 years and not less than 18 years), women didn’t have prepregnant type 1 or 2 diabetes ,singleton pregnancy, not have physical restriction preventing physical activity , not have clinical history for psychiatric illness, not taking drugs affecting glucose level as well as willing to participate in the study.
These mothers were equally subdivided into two groups. Study group who receive lifestyle counselling about diet, exercise and healthy weight gain during pregnancy .Control group who were left for the routine antenatal care.
Four instruments were developed and used by the researcher to collect the necessary data. Instrument one; an interviewing questionnaire I (Structured Demographic Data Questionnaire), which included socio-demographic characteristics, family history, medical history, obstetric history, as well as clinical data which include prepregnancy weight, height. Body Mass Index (BMI). Instrument two; a Life style assessment sheet (pre and post)which include assessment of dietary intake and habits collected using the 24 Hours Dietary Recall for three days including Friday. as well as physical activity. Instrument three; Laboratory Investigations sheet include oral glucose tolerance test OGTT following 75-g glucose load at initial visit to all high risk cases and at 24-28 weeks gestation. Instrument Four; a Semi structured questionnaire for follow up and assessing maternal and neonatal outcomes which include maternal gestational weight gain .Assessment of maternal condition ,vital signs, mode of delivery, any complications during pregnancy, labor and early postpartum. Neonatal outcomes which include weight adjusted to gestational age, Apgar score at one minute and five minutes, any congenital defects, need for resuscitations, and admission to ICU and Neonatal physical assessment by pediatrician.
Reliability of the instruments was established by Cronbach alpha test. A pilot study was carried out on 10 women (who were excluded from the sample) to ascertain the clarity and the applicability of the instruments.
Data of instrument one and two were collected from the 2 groups through an interview schedule during the 8-12 weeks gestation at MCH centers. It was conducted individually and in total privacy. Data of instrument three collected from study group only pre and post
interventions, by researcher who provide lifestyle counselling about healthy diet, regular physical activity, exercise and healthy weight gain during pregnancy using guidance booklet .Data of instrument four for follow up were collected throughout all pregnancy period, labor, and early postpartum through follow up visits or telephone calling or net.
The findings of the study revealed that:
There was a statistically significant differences after life style counselling on diet, exercise and GWG between two groups regarding oral glucose tolerance test with higher incidence of oral glucose intolerance in control group 14% than study group.
There was a statistically significant difference after life style counselling on diet, exercise and GWG regarding gestational weight gain, study group has significantly lesser total gestational weight gain as compared to control groups. The majority of study group assume average (normal) gestational weight gain in compared to control group who assume (exactly half) excess gestational weight gain.
There was a statistically significant difference after life style counselling on diet, exercise and GWG regarding complications of current pregnancy between two groups with higher incidence in control group24%. The percentage of gestational diabetes was 14% in control group and 4% in study group, preterm labor occur 10% in control group and only 2% in study group. Other complications like gestational hypertension and preeclampsia occur in 2% of control group only.
There was also, a statistically significant difference after life style counselling on diet, exercise and GWG regarding complications during labor and postpartum between two groups with higher incidence in control group. The incidence of cesarean section was higher in control group 82%, than study group72%. Forceps delivery occur 4% in control group. This supported the third study hypothesis.
There was no statistically significant difference after life style counselling on diet, exercise and GWG regarding fetal and neonatal complications but there was modest higher in percentage of fetal and neonatal complications in control group than study group. Neonatal complications were 14%, neonatal underweight was 4% and macrosomia of newborn was 8% in control group. Congenital defects occur 4% in control group (2% hypospadias, and 2% congenital hydrocele).stillbirth was 2% in control group.
There was a statistically significant difference after life style counselling on diet, exercise and GWG regarding performing physical activity (walking) between control and study. There was, also a statistically significant difference regarding eating vegetables or fruit between control and study.
There was high statistically significant difference after life style counselling on diet, exercise and GWG regarding total calories, fat, carbohydrates and protein per day pre and Post Intervention in study group.
Based on the finding of this study, the following are recommended:
1- It is recommended that pre pregnancy care facilities and clinics to do proper screening in identifying risk of pre pregnancy BMI and continue proper antenatal monitoring for good gestational weight gain in order to prevent GDM.
2- Prepare training programs for nurses about the importance of lifestyle modification intervention in reducing maternal and perinatal complications among high risk women as a routine antenatal care.
3- Encouraging dietary counselling at the antenatal visits for all pregnant women with elevated risk, as it could influence their dietary intakes for better maternal and neonatal outcomes.
4- Encouraging all pregnant women, without contraindications to exercising, should be active and participate in mild-to-moderate exercise for at least 30 minutes on most days of the week and pregnant women who are overweight or obese should be encouraged to follow an exercise programme in order to optimize health outcomes for both the woman and her infant. Encouraging women at risk for gestational diabetes to increase their physical activity daily and explain the benefits of exercise in increasing insulin sensitivity.
5- Prepare programs about the importance of maintaining healthy body weight through following healthy diet, performing physical activity and being active all the time to assume healthy pregnancy and fetus and make these programs free and available for public.
6- Risk assessment should take place at the first prenatal visit.
7- Screening for gestational diabetes mellitus (GDM): should be performed on patients with risk factors during the first trimester. If negative at first visit, they should be retested at 24 and 28 weeks.
1. Performing a 50-g glucose challenge test and if 1-h plasma glucose >130 mg/dL or > 140 mg/dl.
2. Move to the 100-g OGTT for diagnosis.
8- Screening for late onset gestational diabetes mellitus (GDM).
9- Future studies should be recommended as:
- Replication of this study is recommended with several design changes such as, using large sample size; using of randomized selection to achieve appropriate representation of population; and conducting the study in a larger scale to include multicenter.
- An organized, consistent using a structured program tailored to society needs on lifestyle counselling able to reduce incidence of GDM through modifying potential risk behavior. Therefore, it is important to counsel all women at risk of GDM during antenatal visit at primary health care on the importance of diet, physical activity and weight management.
- The promotion of maternal health, particularly in terms of weight and obesity prevention, requires a tripartite approach: (i) encouraging weight loss/management to enter pregnancy at a healthy BMI; (ii) prevention of excessive GWG via appropriately targeted interventions integrated into routine care; and (iii) promotion of postpartum weight loss and return to (healthy) pre-pregnancy BMI.
- Designing simple booklets about healthy diets and exercise (healthy meals, healthy food choices, safe and regular exercise) and distribute it at the out-patient clinics, schools and university and preconception facilities to benefit individuals at risk for GDM.
- Exploring the effect of dietary and physical activity counselling initiated already before pregnancy is also relevant in future studies.
- Further studies are recommended especially on debatable issues like screening methods for gestational diabetes mellitus and the role of counseling in the prevention of Gestational Diabetes Mellitus.
- Mass media should be utilized in disseminating simple, correct, relevant and evidence-based information to the importance of lifestyle modification intervention (physical activity, healthy diet, and gestational weight gain) to all women pre, during and after pregnancy.
- Further studies about a possible benefit of breastfeeding to reduce the risk of diabetes and related risks for both mother and child