ABSTRACT

Objective: This study examines risk perceptions, nutrition practices, and physical activity among ever pregnant South Asian American women, and explores differences by history of GDM, a significant risk factor for the development of type 2 diabetes. Methods: The Diabetes Prevention Study (DPS) recruited a convenience sample of South Asian adults living in the metropolitan Washington DC region. Specific eligibility criteria included English proficiency; having at least one child between the ages of 5 and 15; no current diagnosis of type 2 diabetes mellitus (T2DM); and having a family history of T2DM. The present study utilizes a subset of the DPS dataset and includes 109 ever pregnant women, including 58% with a history of GDM. Results: Mean scores for perceptions of risk showed that both worry and personal control are slightly greater than “neutral” with 3.5 out 5. Therefore, women worry about T2DM yet also perceive personal control for their risk. 40.2% of all respondents use ghee (clarified butter) to cook meals and 41.7% re-use cooking oil. 35% of respondents report no physical activity in an average week. Only 39.8% of women meet the recommended guidelines for adults in the US There are no significant differences between women with or without a history of GDM for nutrition practices and physical activity. Conclusions: This study adds to the literature on GDM and missed opportunities for the prevention of future T2DM. Future research ought to explore knowledge levels on T2DM during and after pregnancy, as well as what types of intervenetions would be effective and acceptable to South Asian women.

1. INTRODUCTION

Gestational diabetes mellitus (GDM) is defined as a “glucose intolerance with the onset or first recognition of pregnancy” [1,2]. According to the American Diabetes Association (ADA), it affects nearly three to eight percent of all pregnant women [3], with approximately 135,000 cases diagnosed in the US alone [4]. Although previous estimates have found that Asian-Indians, who comprise the largest subset of South Asians, have some of the highest rates of GDM in the US with 11% compared to 4% among whites [5], little research has been conducted with this ethnic group. The Diabetes Prevention Study (DPS), a community survey of South Asian Americans living in the Washington DC region, was conducted to better understand risk perceptions and health behaviors related to type 2 diabetes mellitus (T2DM). The present manuscript is a sub-study of DPS focusing on ever pregnant women to assess differences in risk perceptions, nutrition practices, and physical activity between women with and without a history of GDM.

There are approximately 2.7 million South Asians living in the US comprising of individuals with family origins from Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka [6]. Although the South Asian population in the US has significantly increased in the last several decades, there has been limited data and research on health-related perceptions and behaviors among this growing population. More specifically, this is a community more likely to develop T2DM; to be diagnosed at younger ages; and to experience more T2DM related complications than the general population [7-9]. There are several hypotheses with ample evidence explaining the significant prevalence of T2DM among South Asian Americans, mostly centering on genetic susceptibility, increased incidence of abdominal obesity, and insulin resistance [9]. Furthermore, the Diabetes Prevention Program (DPP) estimated the cumulative incidence of T2DM was 38.4% for women with a history of GDM compared with only 25.7% for women without a history of GDM [10]. Although there is an increased risk for developing T2DM among women with a history of GDM, almost no studies have focused solely on South Asian women in the US In the last decade, population-based studies have found ethnicity to be a risk factor for GDM with Hispanic and Asian women at an increased risk [5,10,11]. A study conducted by Hedderson et al., concluded that there is an 80% increased risk of GDM among Asian Indian women and this increased risk is also prevalent in several other Asian subgroups (Chinese, Southeast Asian and Filipina) and in Mexicans and Pacific Islanders [5]. Additional studies examining Asian subgroups provide further evidence that migrant populations have a higher prevalence of GDM as compared to the prevalence in their native countries [5,12-15], suggesting that GDM is influenced by both environmental and behavioral factors, as well as genetic predisposition.

A cohort study conducted in Canada by the Ontario Ministry of Health followed over one million women aged 20 - 49 years with in-hospital live births. Study results indicated that the ageadjusted prevalence of GDM was 41% higher among Chinese and 145% higher among South Asians compared to their white counterparts [16]. Of these women, there was also an increased incidence of T2DM in the first 4 to 6 months postpartum pointing to the importance screening all women with a history of GDM. The ADA recommends screenings at 6 to 12 weeks postpartum by either fasting plasma glucose or with a oral glucose test [17,18]. In addition, women should be re-evaluated every year if results come out abnormal, and every three years if there is no impaired glucose tolerance or impaired fasting glucose detected [17]. While the ADA and the American Congress of Obstetrics and Gynecologists (ACOG) have set guidelines on screening postpartum, particularly with women who have GDM, findings suggest that many women are not screened for T2DM after delivery [19]. Although it is evident that GDM is an increased risk factor for T2DM, many women with GDM are unaware of this risk [20]. Jones et al. found that women with previous GDM have a 20% to 50% chance of developing type 2 diabetes in the next 5 to 10 years, and the prevalence may be higher depending on race/ethnicity [21].

Studies reveal that many women with a history of GDM do not only lack the knowledge of diabetes, but more so do not fully understand the relationship between how lifestyle behaviors and developing T2DM [19,22]. Further, theoretical health models suggest that risk perception is a critical determinant of health behavior [23]. Of the 90% of women in an academic managed plan who had GDM, only 16% believed they were at an increased risk for T2DM [24]. Moreover, in ethnic-specific women, specifically Pima Indians [25] and Mexican Indians [26], women did not believe that GDM increased their risk for developing T2DM postpartum. A 2009 review of the literature found that women with a history of GDM often had lower perceptions of risk for T2DM, as well as poorer levels of physical activity and nutrition [21]. To help eliminate and/or reduce the risk, interventions must address other significant contributing factors including perceived advantages and barriers to healthy lifestyle behaviors including healthy diet and exercise [21,24].

In addition to increased postpartum screening, recommendations have been put forth by the ADA and ACOG on lifestyle modifications for women with a history of GDM [3,4]. Modifications in diet, exercise, and weight reduction and/or maintenance have specifically been shown to decrease the progression of T2DM in several populations including Asians [27,28]. Moreover, although Asian-American women have the highest risk for GDM compared with other racial/ethnic groups, GDM risks and rates vary within Asian subgroups quite significantly, and therefore more attention is needed to fully understand specific populations such as South Asian women [29]. The present study utilizes data from the Diabetes Prevention Study (DPS), a community survey of South Asian adults with a family history of T2DM. The underlying purpose of DPS was to better understand risk perceptions and health behaviors in order to develop a culturally salient lifestyle intervention for this high-risk ethnic population in the US This paper examines risk perceptions, nutrition practices, and physical activity among ever pregnant South Asian American women, and explores differences by history of GDM, a risk factor for future T2DM diagnosis.

2. RESEARCH DESIGN AND METHODS

2.1. Sample and Procedures

The Diabetes Prevention Study (DPS) recruited a convenience sample of South Asian adults living in the Washington DC metropolitan region. Specific eligibility criteria included English proficiency; having at least one child between the ages of 5 and 15; no current diagnosis of T2DM; and having a family history of T2DM. For purposes of this study, South Asian is defined as individuals from the following countries: Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka. The present study utilizes a subset of the DPS dataset and includes 109 ever pregnant women, including 58% with a history of GDM.

The research team collaborated with eleven South Asian faith-based and cultural organizations in the Washington DC region for recruitment and data collection. Between July 2011 and March 2012, participants were recruited into the study. Consent was obtained prior to survey administration. To ensure privacy and reduce reporting bias, surveys were administered via individual laptop computers. Study participants completed the survey in English and were given a $25 gift card for their efforts in completing the survey. Upon survey completion, the data were stored in an encrypted file only to be read by the survey design software, SNAP surveys (SNAP Surveys Ltd., 2012).

Recruitment at sites yielded a 92% response rate, and the majority of those who declined to participate stated “not enough time” as the primary reason. People of Indian descent represent 54.7% of the South Asian population in the Washington DC region and therefore the majority of organizations (approximately 90%) in the region are tailored to this community. Significant efforts were made to reach out to all non-Indian focused organizations in the region for data collection, however 87% of participants in the study are of Indian origin.

2.2. Instrument and Measures

The survey instrument for the present study gathered information on demographic characteristics, risk perceptions, nutrition practices and physical activity, and took approximately 15 - 20 minutes to complete. Survey questions were adapted from the 2009 National Health and Nutrition Examination Survey (NHANES) [30] and Risk Perception Survey for Developing Diabetes (RPS-DD) [22].

Demographic characteristics include variables on age, marital status, parity, and country of origin. In addition, immigration status was captured by US born, US citizen, and number of years of living in the US For women with a history of GDM, additional questions were asked including: 1) number of pregnancies diagnosed with GDM, 2) type of treatment (insulin or medication versus none), and 3) whether the GDM pregnancy resulted in a c-section.

Perceptions of risk include two scales measuring “worry” and “personal control”. Both scales are based on reliable and validated measures from E.A. Walker’s 2009 Risk Perception survey [22]. Participants were asked if they strongly agree, agree, neither agree nor disagree, disagree or strongly disagree with a series of statements. Several statements were reverse coded to ensure that 1 = low worry/control and 5 = high worry/control. Three items measure “worry” as follows: 1) I worry about my family members getting diabetes, 2) I am very concerned about getting diabetes, and 3) Worrying about diabetes is very upsetting to me. The Cronbach’s alpha for the worry scale in this sample is 0.71. Six items measure “personal control” as follows: 1) Type 2 diabetes can be prevented, 2) I have little or no control over risks to my health, 3) If I am going to get diabetes, there is not much I can do about it, 4) My personal efforts help control my risk of getting diabetes, 5) Getting diabetes is all a chance of fate that is meant to be and unavoidable, and 6) Genetics and family history have everything to do with getting diabetes. The Cronbach’s alpha for the personal control scale in this sample is 0.58.

Several questions from the 2009 NHANES [30] were adapted to measure nutrition related behaviors. Participants were asked how often in an average week they: 1) skip breakfast, 2) eat potato chips, nacho chips, hot mix, crackers or popcorn, 3) eat fast food, 4) add butter, margarine, ghee (clarified butter originated in South Asia) or oil to bread, potatoes, rice or vegetables at the table, 5) eat sweets more than once a day, and 6) drink 16 oz. or more of non-diet soda, fruit juice/punch a day. All statements share the following response options: most of the time, some of the time, and rarely/never. Two additional nutrition-related questions were developed based on cultural cooking practices among South Asians as follows: 1) Do you or other family members in your home use ghee (clarified butter) in order to cook your meals (yes/no)? and 2) Do you or other family members in your home save and/or re-use the oil previously used to cook meals (yes/no)?

A series of questions on physical activity to capture type and amount of time were asked. Participants were asked separately about vigorous and moderate activity for at least 30 minutes continuously, as well as number of days per week. Examples of vigorous activity include running, bicycling, swimming, exercise classes, and basketball. Examples of moderate activity include brisk walking, yoga, and badminton. Participants could report engaging in both vigorous and moderate activity, and the amount of days differed for each. The responses were categorized as follows: No physical activity = no vigorous or moderate activity; Low physical activity = vigorous activity less than 5 days per week only or moderate activity less than 5 days per week only; Medium physical activity = vigorous activity less than 5 days and moderate activity 5 or more days per week or vigorous and moderate activity less than 5 days per week; High physical activity = vigorous and moderate activity 5 or more days per week or vigorous activity 5 or more days per week only. Given that both medium and high levels of physical activity meet the recommended guidelines for physical activity in the US, these two categories were collapsed to provide more meaningful interpretation of the data.

2.3. Analysis

Given the sample size for this study (n = 109), much of the analysis is descriptive and focuses on an overall description of the study population, including overall mean scores for risk perceptions and overall percentages for nutrition and physical activity variables. Some of the variable categories were collapsed to increase the usefulness of the information. Bivariate analysis was conducted to examine any significant differences between women with a history of GDM and those without.

3. RESULTS

The study sample consists of 109 ever pregnant females with 63 (57.8%) having a history of GDM. As shown in Table 1, the mean age for the sample is 40.2

years and the majority of respondents are currently married (96.3%), have two children (51.4%), and their country of origin is India (86.8%). Only 12.8% of participants were born in the US but 67.9% are US citizens with 89.5% having lived in the US for 11 or more years. Of the 57.8% who have ever been diagnosed with GDM, 71.4% were diagnosed with one pregnancy, 49.7% were treated with either insulin or medication; and 42.6% delivered via cesarean. There are no significant differences by GDM history and demographic characteristics.

Table 2 presents mean scores for perceptions of risk. As shown, the overall mean scores for both “worry” and personal control are slightly greater than “neutral” with 3.5 (1 = low worry/control; 5 = high worry/control). Therefore, women worry about T2DM yet also perceive personal control for their risk. For the “worry” scale, women with a history of GDM, have a higher mean score of 3.6 versus 3.3, though non-significant. For “personal control”, women with a history of GDM have a slightly higher mean score of 3.6 versus 3.5, but also non-significant.

Table 2 also presents nutrition practices by GDM status. As shown, 40.2% of all respondents use ghee (clarified butter) to cook meals; and 41.7% re-use cooking oil. Overall, 40.2% of report skipping breakfast most/some of the time; 52.8% eat “fried” snacks most/some of the time; 53.3% add butter/margarine/ghee to food at the table; and 59.4% eats sweets more than once a day. There are no significant differences between women with or without a history of GDM for any of