Effects of a Web/Smartphone-based Lifestyle Coaching Program on Gestational Weight Gain in Pregnant Women With Gestational Diabetes

Gestational diabetes mellitus (GDM) is defined as glucose intolerance of any degree with onset or first recognition during pregnancy. In Singapore, 20-30% of pregnant women are affected by GDM. If poorly controlled, GDM is associated with various maternal and perinatal morbidities such as increased cesarean deliveries, preeclampsia, preterm labour, macrosomia, neonatal hypoglycemia etc. It is well recognized now that GDM is also associated with long-term metabolic complications in mothers and offspring. Women with a history of GDM have increased risk of GDM in subsequent pregnancies, and at high risk of developing Type 2 diabetes after pregnancy. Infants born to mothers with GDM are also at increased risk of developing obesity and diabetes in later life. An increasing number of studies, including studies in Singapore, suggest that screening and management of GDM can be cost-effective, although these results are highly dependent on intervention efficacy.

In Singapore, individuals with GDM are first advised to adopt diet modification, and if glycemic control is not on target despite diet control, insulin therapy is the next line of treatment. In all cases, patients need to perform self-monitoring of blood glucose (SMBG) to guide treatment decisions. These strategies aim to reduce the risks maternal and perinatal complications. In addition to that, preventing excessive gestational weight gain (GWG) is another important goal in women with GDM. This is because excessive GWG is not only associated with higher risks of delivering a large for gestational age infant, but is also the strongest risk factor for postpartum weight retention, and an important predictor for future development of Type 2 diabetes. Lifestyle intervention programs have been shown to be effective in reducing GWG in pregnant women.

One thing in common among diet modification, SMBG and achieving optimum GWG is that they involve self-management, and hence require a certain degree of self-efficacy in women with GDM. To achieve this in the National University Hospital (NUH), patients are referred to a gestational diabetes clinic for education. At this time, if the patient's plasma glucose at 0 minute and/or 120 minutes of a 75g oral glucose tolerance test (OGTT) is <7.0 mmol/L and <11.1 mmol/L respectively, this is conducted in a group teaching session lasting 1 - 1.5 hours, with 4 - 6 patients per group, led by a diabetes nurse educator and a dietitian. If the patient's plasma glucose at 0 minutes and/or 120 minutes of a 75g OGTT is ≥7.0 and ≥11.1 mmol/L respectively, this is conducted in an individual session lasting 1 hour with a diabetes nurse educator and a dietitian. Patients are initiated on capillary glucose monitoring, typically 7 times a day, 2-3 days in a week. Subsequently, their care is provided by their obstetrician until such time as the obstetrician feels that insulin is required, in which case they are often referred back to the endocrinology service for the initiation and management of insulin therapy. Capillary glucose monitoring is carried out using a glucometer that is purchased by the patient, and the patient duly records blood glucose on a paper record which will be shown to her obstetrician at the clinic appointments every 2 - 4 weeks. In addition, weight is generally monitored at the clinic visit. Advice on diet and lifestyle modification is provided by the obstetrician based on the results of capillary glucose monitoring at the clinic visit. In between appointments, there is limited interaction between healthcare providers unless the patient identifies a problem and contacts the provider.

This arrangement has some limitations. Firstly, it has been demonstrated that spacing learning activities over a period of time improves encoding and long term retention of information. As such, the current method of providing all the education that a patient needs in a single session is less likely to be optimal for retention of information. Secondly, the collection of information (through capillary glucose monitoring) is often separated from any feedback from health care providers by days or weeks. In general, the lifestyle activities (whether diet or physical activities) which generate any abnormal blood glucose results occur in close proximity to the glucose readings (often hours before rather than weeks). By the time feedback is received, the patient often does not recall the events that generated the abnormal readings. More importantly, it does not provide any meaningful feedback to the patient that allows modification of the risk of an episode of hyperglycemia. In fact, this generates a significant amount of distress for the patient. It has been shown that the distress perceived in response to a stressor is much greater when the person experiencing the stressor does not have a way to control the occurrence of the stressor. In this context, the lack of timely feedback that is actionable related to blood glucose or weight, results in significant distress on the part of patients and results in a failure to adhere to efforts to monitor or control blood glucose. In a recent mixed-methods feasibility study to assess acceptability of mobile-application based support tool for women with GDM in NUH, most reported significant stress from the burden of management and desire for supporting tools that would aid control of blood glucose as an adjunct to self-monitoring.

It is the investigators' hypothesis that by providing education that is spaced out over 1-2 weeks and providing feedback that is timely and actionable to the patient, it will improve adherence to lifestyle modification, reduce patient distress and improve clinical outcomes for women with GDM.