Prevalence of gestational diabetes in the Waikato region of New Zealand.

Gestational diabetes mellitus (GDM) during pregnancy is associated with health complications for both mother and infant, but patient numbers in the Waikato District Health Board region of New Zealand have not been well characterised. This study reviewed the full 2018 cohort of Waikato District Health Board hospital births (n = 4970) to report on GDM prevalence by ethnicity and age. The overall prevalence of GDM was 5.7% and is more likely to affect Asian, Pacific and Maori women as well as those of advanced maternal age.

Barriers to Screening for Gestational Diabetes Mellitus in New Zealand Following the Introduction of Universal Screening Recommendations.

Background: In 2014 the New Zealand Ministry of Health implemented a universal program of screening for gestational diabetes mellitus (GDM) in pregnancy; however, data suggest that only half of all women are being screening according to the guidelines. This study aimed to explore women's views and experiences of GDM screening and to determine what the main screening barriers are. Methods: Eighteen women were recruited from the Waikato region of New Zealand, who were either pregnant (>28 weeks of gestation) or had given birth in the last 6 months. These women participated in a semi-structured interview about their experience of GDM screening and the transcripts were thematically analyzed. Of these women, 14 had been screened for gestational diabetes (three were screened late) and four had not been screened at all. Results: Multiple barriers to screening for GDM were identified, with two overarching themes of "confusion, concerns, and access to information for screening," and "challenges to accessing and completing the screening test." Specific barriers included the preference of risk-based assessments for GDM by their leading health professional (usually a registered midwife); negative perceptions of "sugar drink test"; needing time off work and childcare; travel costs for rural women; previous negative screening experiences; and reduced health literacy. Conclusion: There appear to be both woman-, midwife-, and system-level barriers to screening for GDM. While screening is ultimately a woman's choice, there does appear to be capacity to increase screening rates by improving awareness of the updated guidelines, and making the test environment more accessible and comfortable.

Midwifery awareness of diabetes in pregnancy screening guidelines in Aotearoa New Zealand.

OBJECTIVE: Effective and timely management of gestational diabetes mellitus (GDM) requires early detection. However, screening rates have been shown to be relatively low in New Zealand, despite the introduction of national screening guidelines in 2014 which indicate that all pregnant women should be screened. Thus, the aim of this study was to explore the awareness of the New Zealand Ministry of Health Diabetes in Pregnancy screening guidelines by New Zealand midwives. DESIGN: A 24-question online survey based upon the New Zealand screening guidelines was distributed via New Zealand midwifery social media groups to explore the awareness of New Zealand midwives with regard to screening for diabetes in pregnancy. Free text comments were also allowed, these were broadly categorized and reviewed. PARTICIPANTS: 174 registered midwives in Aotearoa New Zealand completed the survey. MEASUREMENTS AND FINDINGS: All participants responded that they routinely offer glycated haemoglobin screening for detection of undiagnosed pre-gestational diabetes, and 92.9% identified that this should occur prior to 20 weeks gestation (as per the national guidelines). However, less than two thirds of midwives thought that all women should be screened for GDM, with 18.2% indicating they would only do this if immediate risk factors were present. There also appeared to be some confusion over the time period for screening for GDM with 22.9% indicating that this should occur later than the guideline-recommended timepoint of 24-28 weeks gestation. Participants who identified as Maori and community-based midwives were most likely to screen for GDM 'only if risk factors were present'. Participants practicing for more than 6 years, those aged 45-54 years, and midwives identifying as Maori were most likely to screen for GDM after 28 weeks (though these did not reach statistical significance). KEY CONCLUSIONS: The New Zealand Diabetes in Pregnancy screening guidelines do not appear to be well implemented in our sample group, particularly with regard to screening for GDM. This needs to be evaluated in a larger group of midwives, as education around the timeliness and importance of screening for all women may be required. IMPLICATIONS FOR PRACTICE: A lack of appropriate or timely screening for GDM may mean that women are not being diagnosed or managed appropriately, which in turn may have implications for both mother and child.

Barriers to Diabetes Self-Management in a Subset of New Zealand Adults with Type 2 Diabetes and Poor Glycaemic Control.

BACKGROUND: Despite the fact that there is an increasingly effective armoury of medications to treat diabetes, many people continue to have substantially elevated blood glucose levels. The purpose of this study was to explore what the barriers to diabetes management are in a cohort of people with diabetes and poor glycaemic control. METHODS: Qualitative semistructured interviews were carried out with 10 people with diabetes who had known diabetes and a recent HbA1c of >11.3% (100 mmol/mol) to explore their experiences of barriers to diabetes self-management and glycaemic control. RESULTS: Barriers to diabetes management were based around two key themes: biopsychosocial factors and knowledge about diabetes. Specifically, financial concerns, social stigma, medication side effects, and cognitive impairment due to hyperglycaemia were commonly reported as barriers to medication use. Other barriers included a lack of knowledge about their own condition, poor relationships with healthcare professionals, and a lack of relevant resources to support diet and weight loss. CONCLUSION: People with diabetes with poor glycaemic control experience many of the same barriers as those reported elsewhere, but also experience issues specifically related to their severe hyperglycaemia. Management of diabetes could be improved via the increased use of patient education and availability of locally relevant resources.

The epidemiology of diabetes in the Waikato region: an analysis of primary care data.

INTRODUCTION Diabetes mellitus is common in primary care, yet little has been reported of its primary care prevalence or the clinical characteristics of patients with Type 2 diabetes mellitus (T2DM). AIM To determine the prevalence of diabetes mellitus and clinical characteristics of diabetes patients in primary care in the Waikato region. METHODS Primary care data were extracted from the electronic records of 15 general practices for patients aged >20 years with current diabetes mellitus at 20 June 2017. Diabetes mellitus was defined as having a glycated haemoglobin (HbA1c) of ≥50mmol/mol (6.7%) or having being dispensed two or more anti-diabetic medications in the previous 12 months. Additional data collected included patients' ethnicity, age, sex and years since diagnosis. RESULTS The overall prevalence of diabetes mellitus was 5.7% and was higher for Maori (8.6%), Asian (7.0%) and Pacific peoples (9.1%) than Europeans (5.0%; all P<0.001). For patients with T2DM for whom current diabetes annual review data were available (n=2227) the mean body mass index (BMI) was 32.8±0.2kg/m2, but BMI was higher in Maori, younger patients, females and patients diagnosed <2 years previously (all P<0.001). Similarly, HbA1c levels were highest in Maori and younger patients (both P<0.001), with 40% of patients overall having a HbA1c of ≤53mmol/mol (7.0%). Approximately 70% of all patients had at least one measure of hypertension (systolic ≥130 or diastolic ≥80mmHg), or dyslipidaemia. More than 85% of patients had completed a recent retinal screen and foot check. DISCUSSION We found that management of T2DM was suboptimal, with measures for many patients not meeting clinical targets. Support should be provided to improve weight and glycaemic management, particularly for Maori, females and younger patients.

Metformin adherence in patients with type 2 diabetes and its association with glycated haemoglobin levels.

INTRODUCTION Metformin is the initial medication of choice for most patients with type 2 diabetes. Non-adherence results in poorer glycaemic control and increased risk of complications. AIM The aim of this study was to characterise metformin adherence and association with glycated haemoglobin (HbA1c) levels in a cohort of patients with type 2 diabetes. METHODS Prescription and dispensing data were used for this study. Primary care clinical and demographic data were collected from 10 general practices (October 2016-March 2018) and linked to pharmaceutical dispensing information. Metformin adherence was initially measured by calculating the proportion of patients who had optimal medication cover for at least 80% of days (defined as a medication possession ratio (MPR) of ≥0.8), calculated using dispensing data. Prescription adherence was assessed by comparing prescription and dispensing data. The association between non-adherence (MPR <0.8) and HbA1c levels was also assessed. RESULTS Of the 1595 patients with ≥2 metformin prescriptions, the mean MPR was 0.87. Fewer Maori had an MPR ≥0.8 than New Zealand European (63.8% vs. 81.2%). Similarly, Maori received fewer metformin prescriptions (P=0.02), although prescription adherence did not differ by ethnicity. Prescription adherence was lower in younger patients (P=0.002). Mean HbA1c levels were reduced by 4.8 and 5.0mmol/mol, respectively, in all and Maori patients with an MPR ≥0.8. Total prescription adherence reduced HbA1c by 3.2mmol/mol (all P<0.01). DISCUSSION Ethnic disparity exists for metformin prescribing, leading to an overall reduction in metformin coverage for Maori patients. This needs to be explored further, including understanding whether this is a patient preference or health system issue.

The prevalence of mental health medication use in a cohort of New Zealand patients with diabetes.

AIMS: Diabetes is associated with depression, anxiety and psychosis via complex bidirectional relationships that are affected by factors such as the type of diabetes and socioeconomic status. The aim of the study was to estimate the prevalence of mental health conditions in patients with diabetes in a New Zealand primary care population using proxy medication dispensing data. METHODS: Primary care data (July 1 2016 - June 30, 2018) was collected from the Patient Management System of 15 different general practices, and was linked via National Health Index number to clinical records at the Waikato District Health Board and the New Zealand Ministry of Health Pharmaceutical database. RESULTS: A total of 3978 patients with diabetes were identified from an enrolled patient population of 74,250. Of these, 18.0% of patients with diabetes were dispensed an antidepressant, anxiolytic, or antipsychotic. These medications were prescribed more in New Zealand Europeans (20.9% versus 13.9% in Maori), women, type 2 diabetes, those on insulin, and those with a higher BMI (all P<0.001). CONCLUSIONS: Approximately one fifth of patients with diabetes in primary care have mental health disorders. Appropriate management requires concomitant treatment of both the diabetes and the mental health disorder to improve patient outcomes.

Impact of a Modified Version of Baby-Led Weaning on Dietary Variety and Food Preferences in Infants.

The aim of this study was to determine whether food variety and perceived food preferences differ in infants following baby-led instead of traditional spoon-feeding approaches to introducing solids. A total of 206 women (41.3% primiparous) were recruited in late pregnancy from a single maternity hospital (response rate 23.4%) and randomized to Control (n = 101) or BLISS (n = 105) groups. All participants received government-funded Well Child care. BLISS participants also received support to exclusively breastfeed to 6 months and three educational sessions on BLISS (Baby-Led Weaning, modified to reduce the risk of iron deficiency, growth faltering, and choking) at 5.5, 7, and 9 months. Food variety was calculated from three-day weighed diet records at 7, 12, and 24 months. Questionnaires assessed infant preference for different tastes and textures at 12 months, and for 'vegetables', 'fruit', 'meat and fish', or 'desserts' at 24 months. At 24 months, 50.5% of participants provided diet record data, and 78.2% provided food preference data. BLISS participants had greater variety in 'core' (difference in counts over three days, 95% CI: 1.3, 0.4 to 2.2), 'non-core' (0.6, 0.2 to 0.9), and 'meat and other protein' (1.3, 0.8 to 1.9) foods at 7 months, and in 'fruit and vegetable' foods at 24 months (2, 0.4 to 3.6). The only differences in perceived food preferences observed were very small (i.e., <5% difference in score, at 12 months only). Infants following the modified Baby-Led Weaning were exposed to more varied and textured foods from an early age, but only an increased variety in 'fruit and vegetable' intake was apparent by two years of age.

Impact of a Modified Version of Baby-Led Weaning on Infant Food and Nutrient Intakes: The BLISS Randomized Controlled Trial.

Despite growing international interest in Baby-Led Weaning (BLW), we know almost nothing about food and nutrient intake in infants following baby-led approaches to infant feeding. The aim of this paper was to determine the impact of modified BLW (i.e., Baby-Led Introduction to SolidS; BLISS) on food and nutrient intake at 7⁻24 months of age. Two hundred and six women recruited in late pregnancy were randomized to Control (n = 101) or BLISS (n = 105) groups. All participants received standard well-child care. BLISS participants also received lactation consultant support to six months, and educational sessions about BLISS (5.5, 7, and 9 months). Three-day weighed diet records were collected for the infants (7, 12, and 24 months). Compared to the Control group, BLISS infants consumed more sodium (percent difference, 95% CI: 35%, 19% to 54%) and fat (6%, 1% to 11%) at 7 months, and less saturated fat (-7%, -14% to -0.4%) at 12 months. No differences were apparent at 24 months of age but the majority of infants from both groups had excessive intakes of sodium (68% of children) and added sugars (75% of children). Overall, BLISS appears to result in a diet that is as nutritionally adequate as traditional spoon-feeding, and may address some concerns about the nutritional adequacy of unmodified BLW. However, BLISS and Control infants both had high intakes of sodium and added sugars by 24 months that are concerning.

Effect of a Baby-Led Approach to Complementary Feeding on Infant Growth and Overweight: A Randomized Clinical Trial.

Importance: Baby-led approaches to complementary feeding, which promote self-feeding of all nonliquid foods are proposed to improve energy self-regulation and lower obesity risk. However, to date, no randomized clinical trials have studied this proposition. Objective: To determine whether a baby-led approach to complementary feeding results in a lower body mass index (BMI) than traditional spoon-feeding. Design, Setting, and Participants: The 2-year Baby-Led Introduction to Solids (BLISS) randomized clinical trial recruited 206 women (168 [81.6%] of European ancestry; 85 [41.3%] primiparous) in late pregnancy from December 19, 2012, through March 17, 2014, as part of a community intervention in Dunedin, New Zealand. Women were randomized to a control condition (n = 101) or the BLISS intervention (n = 105) after stratification for parity and education. All outcomes were collected by staff blinded to group randomization, and no participants withdrew because of an adverse event. Data were analyzed based on intention to treat. Interventions: Mothers in the BLISS group received lactation consultant support (≥5 contacts) to extend exclusive breastfeeding and delay introduction of complementary foods until 6 months of age and 3 personalized face-to-face contacts (at 5.5, 7.0, and 9.0 months). Main Outcomes and Measures: The primary outcome was BMI z score (at 12 and 24 months). Secondary outcomes included energy self-regulation and eating behaviors assessed with questionnaires at 6, 12, and 24 months and energy intake assessed with 3-day weighed diet records at 7, 12, and 24 months. Results: Among the 206 participants (mean [SD] age, 31.3 [5.6] years), 166 were available for analysis at 24 months (retention, 80.5%). The mean (SD) BMI z score was not significantly different at 12 months (control group, 0.20 [0.89]; BLISS group, 0.44 [1.13]; adjusted difference, 0.21; 95% CI, -0.07 to 0.48) or at 24 months (control group, 0.24 [1.01]; BLISS group, 0.39 [1.04]; adjusted difference, 0.16; 95% CI, -0.13 to 0.45). At 24 months, 5 of 78 infants (6.4%) were overweight (BMI≥95th percentile) in the control group compared with 9 of 87 (10.3%) in the BLISS group (relative risk, 1.8; 95% CI, 0.6-5.7). Lower satiety responsiveness was observed in BLISS infants at 24 months (adjusted difference, -0.24; 95% CI, -0.41 to -0.07). Parents also reported less food fussiness (adjusted difference, -0.33; 95% CI, -0.51 to -0.14) and greater enjoyment of food (adjusted difference, 0.25; 95% CI, 0.07 to 0.43) at 12 months in BLISS infants. Estimated differences in energy intake were 55 kJ (95% CI, -284 to 395 kJ) at 12 months and 143 kJ (95% CI, -241 to 526 kJ) at 24 months. Conclusions and Relevance: A baby-led approach to complementary feeding did not result in more appropriate BMI than traditional spoon-feeding, although children were reported to have less food fussiness. Further research should determine whether these findings apply to individuals using unmodified baby-led weaning. Trial Registration: http://anzctr.org.au Identifier: ACTRN12612001133820.

A Baby-Led Approach to Eating Solids and Risk of Choking.

OBJECTIVE: To determine the impact of a baby-led approach to complementary feeding on infant choking and gagging. METHODS: Randomized controlled trial in 206 healthy infants allocated to control (usual care) or Baby-Led Introduction to SolidS (BLISS; 8 contacts from antenatal to 9 months providing resources and support). BLISS is a form of baby-led weaning (ie, infants feed themselves all their food from the beginning of complementary feeding) modified to address concerns about choking risk. Frequencies of choking and gagging were collected by questionnaire (at 6, 7, 8, 9, 12 months) and daily calendar (at 6 and 8 months); 3-day weighed diet records measured exposure to foods posing a choking risk (at 7 and 12 months). RESULTS: A total of 35% of infants choked at least once between 6 and 8 months of age, and there were no significant group differences in the number of choking events at any time (all Ps > .20). BLISS infants gagged more frequently at 6 months (relative risk [RR] 1.56; 95% confidence interval [CI], 1.13-2.17), but less frequently at 8 months (RR 0.60; 95% CI, 0.42-0.87), than control infants. At 7 and 12 months, 52% and 94% of infants were offered food posing a choking risk during the 3-day record, with no significant differences between groups (7 months: RR 1.12; 95% CI, 0.79-1.59; 12 months: RR 0.94; 95% CI, 0.83-1.07). CONCLUSIONS: Infants following a baby-led approach to feeding that includes advice on minimizing choking risk do not appear more likely to choke than infants following more traditional feeding practices. However, the large number of children in both groups offered foods that pose a choking risk is concerning.

How different are baby-led weaning and conventional complementary feeding? A cross-sectional study of infants aged 6-8†months.

OBJECTIVES: To compare the food, nutrient and 'family meal' intakes of infants following baby-led weaning (BLW) with those of infants following a more traditional spoon-feeding (TSF) approach to complementary feeding. STUDY DESIGN AND PARTICIPANTS: Cross-sectional study of dietary intake and feeding behaviours in 51 age-matched and sex-matched infants (n=25 BLW, 26 TSF) 6-8 months of age. METHODS: Parents completed a questionnaire, and weighed diet records (WDRs) on 1-3 non-consecutive days, to investigate food and nutrient intakes, the extent to which infants were self-fed or parent-fed, and infant involvement in 'family meals'. RESULTS: BLW infants were more likely than TSF infants to have fed themselves all or most of their food when starting complementary feeding (67% vs 8%, p<0.001). Although there was no statistically significant difference in the large number of infants consuming foods thought to pose a choking risk during the WDR (78% vs 58%, p=0.172), the CI was wide, so we cannot rule out increased odds with BLW (OR, 95% CI: 2.57, 0.63 to 10.44). No difference was observed in energy intake, but BLW infants appeared to consume more total (48% vs 42% energy, p<0.001) and saturated (22% vs 18% energy, p<0.001) fat, and less iron (1.6 vs 3.6 mg, p<0.001), zinc (3.0 vs 3.7 mg, p=0.001) and vitamin B12 (0.2 vs 0.5 µg, p<0.001) than TSF infants. BLW infants were more likely to eat with their family at lunch and at the evening meal (both p≤0.020). CONCLUSIONS: Infants following BLW had similar energy intakes to those following TSF and were eating family meals more regularly, but appeared to have higher intakes of fat and saturated fat, and lower intakes of iron, zinc and vitamin B12. A high proportion of both groups were offered foods thought to pose a choking risk.