abstract

Helping women lose weight for health reasons is one of the most challenging aspects of health care for midwives. Obesity is second only to smoking as a leading cause of preventable deaths. Two emerging concepts in the management of obesity are insulin resistance (IR) and the glycemic index (GI). Insulin resistance or insulin sensitivity is the reduced sensitivity of the body to insulin's effects on blood sugar. IR is linked to many other health conditions, such as type 2 diabetes, gestational diabetes (GDM), polycystic ovarian syndrome (PCOS) and metabolic syndrome X. Metabolic Syndrome X is a cluster of metabolic disorders consisting of dyslipidemia, increased blood pressure, elevated plasma glucose and a prothrombotic state. The GI measures and ranks foods based on their immediate effect on blood sugar levels. Understanding the two concepts of IR and the GI, combined with client support and education, become cornerstones for influencing behavioral changes towards health in obese clients.

International guidelines and research have been reviewed to provide a foundation for the relational framework, and different aspects of these key concepts are explained. Research examining the Body Mass Index (BMI), truncal obesity, and assays of IR is reviewed. The influence of low-GI and high-GI foods upon appetite, cravings and changes in health indicators is evaluated. Controversies surrounding IR and GI, such as measurement, ease of use, and the lasting influence on HI are discussed. This conceptual framework become the foundation for Evidence-Based Clinical Practice Guidelines (EBCPG) for clinicians to use with their clients who are at risk for IR and its related health conditions. The guidelines will help midwives recognize IR in the population they serve, and provide them with tools such as education and support.

A high BMI, truncal obesity and an affinity for carbohydrates characterize the women with IR. After an initial assessment, including obtaining a personal and family history, appropriate observations and laboratory baselines, the clinician can begin to help her client understand specific macronutrients and their impact upon her health. Identifying the benefits and properties of low glycemic carbohydrates and fiber, as well as the concerns about high glycemic carbohydrates are discussed. Specific lists of these foods are provided, and related web sites for comprehensive lists are cited. Current recommendations for fats and protein are also reviewed. Regular and lifelong exercise, and its ability to positively impact IR is discussed as part of making lifestyle changes. Education and ongoing support through a variety of methods are reviewed. The importance of normalizing blood sugars and improving lipid profiles are a major benefit to the overweight woman if she begins to increase the low glycemic carbohydrates into her diet. Follow-up will depend upon the specific clinical setting and the health of the individual involved.

As the clinician becomes familiar with ways to help the obese women make healthy food choices, and other lifestyle changes, she can begin to help the client improve her health indicators and feel good about making positive changes in her life. Nutritionists, endocrinologist, psychologists can be in integral part of a health team, depending upon the individual client needs, and the clinician's work situation and goals for practice. Guidelines for follow-up and referral are provided. An algorithm of the guidelines can be viewed to remind the clinician of the various phases of management. Improved and perhaps normal blood glucose lipid panels are the expected result of these Evidenced Based Clinical Practice Guidelines.