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Guidelines for Medical Nutrition Therapy in Gestational Diabetes Mellitus: Systematic Review and Critical Appraisal

      Abstract

      Background

      Medical nutrition therapy is the cornerstone of gestational diabetes mellitus treatment. However, guidelines often present contradictory guidance to health care practitioners.

      Objective

      To systematically review and critically appraise medical nutrition therapy guidelines for treating patients with gestational diabetes mellitus.

      Design

      We searched Medline, the Cochrane Library, Guidelines International Network, and Google Scholar to retrieve clinical practice guidelines (CPGs) for medical nutrition therapy in gestational diabetes mellitus from professional or governmental organizations, published in English, between January 1, 2007, and November 24, 2018. CPGs were reviewed and appraised using the Appraisal of Guidelines, Research, and Evaluation II instrument.

      Results

      Of 1,286 retrieved articles, 21 CPGs fulfilled the inclusion criteria. CPGs of the Academy of Nutrition and Dietetics, Diabetes Canada, and Malaysia Health Technology Assessment Section received the greatest overall scores and the highest scores concerning rigor of recommendations development. Many CPGs failed to involve multidisciplinary teams in their development, including patients, and often, dietitians. Applicability of the recommendations was low, lacking facilitators and tools to enhance implementation. Many CPGs demonstrated low editorial independence by failing to disclose funding and competing interests. More medical nutrition therapy recommendations were incorporated in the Academy of Nutrition and Dietetics and Malaysia Health Technology Assessment Section CPGs. The Malaysia Health Technology Assessment Section, Diabetes Canada, Academy of Nutrition and Dietetics, and Endocrine Society guidelines were recommended by the review panel herein without modifications. Overall, the CPGs suggested the consumption of adequate protein and the selection of foods with low glycemic index, divided into three main meals and two to four snacks. Weight gain recommendations were mostly based on the Institute of Medicine body mass index thresholds.

      Conclusions

      With few exceptions, the main developmental limitations of the appraised CPGs involved low rigor of recommendations development, lack of multidisciplinary stakeholder involvement, low applicability, and inadequate editorial independence. This indicates a need for developing more clear, unbiased, practical, and evidence-based CPGs.

      Keywords

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      References

        • Egan A.M.
        • Vellinga A.
        • Harreiter J.
        • et al.
        Epidemiology of gestational diabetes mellitus according to IADPSG/WHO 2013 criteria among obese pregnant women in Europe.
        Diabetologia. 2017; 60: 1913-1921
        • Pantzartzis K.A.
        • Manolopoulos P.P.
        • Paschou S.A.
        • Kazakos K.
        • Kotsa K.
        • Goulis D.G.
        Gestational diabetes mellitus and quality of life during the third trimester of pregnancy.
        Qual Life Res. 2019; 28: 1349-1354
        • Poulakos P.
        • Mintziori G.
        • Tsirou E.
        • et al.
        Comments on gestational diabetes mellitus: From pathophysiology to clinical practice.
        Hormones. 2015; 14: 335-344
        • Dipla K.
        • Triantafyllou A.
        • Grigoriadou I.
        • et al.
        Impairments in microvascular function and skeletal muscle oxygenation in women with gestational diabetes mellitus: Links to cardiovascular disease risk factors.
        Diabetologia. 2017; 60: 192-201
        • Kintiraki E.
        • Goulis D.G.
        Gestational diabetes mellitus: Multi-disciplinary treatment approaches.
        Metabolism. 2018; 86: 91-101
        • Savvaki D.
        • Taousani E.
        • Goulis D.G.
        • et al.
        Guidelines for exercise during normal pregnancy and gestational diabetes: A review of international recommendations.
        Hormones. 2018; 17: 521-529
        • Duarte-Gardea M.O.
        • Gonzales-Pacheco D.M.
        • Reader D.M.
        • et al.
        Academy of Nutrition and Dietetics gestational diabetes evidence-based nutrition practice guideline.
        J Acad Nutr Diet. 2018; 118: 1719-1742
        • Moreno-Castilla C.
        • Mauricio D.
        • Hernandez M.
        Role of medical nutrition therapy in the management of gestational diabetes mellitus.
        Curr Diab Rep. 2016; 16: 22
        • American Diabetes Association
        Management of diabetes in pregnancy: Standards of medical care in diabetes—2018.
        Diabetes Care. 2018; 41: S137-S143
      1. Pregnancy and Diabetes Guidelines: Approaches to Practice. Nova Scotia: Diabetes Care Program of Nova Scotia, Halifax2014
        • Yamamoto J.M.
        • Kellett J.E.
        • Balsells M.
        • et al.
        Gestational diabetes mellitus and diet: A systematic review and meta-analysis of randomized controlled trials examining the impact of modified dietary interventions on maternal glucose control and neonatal birth weight.
        Diabetes Care. 2018; 41: 1346-1361
        • Dabelea D.
        • Mayer-Davis E.J.
        • Lamichhane A.P.
        • et al.
        Association of intrauterine exposure to maternal diabetes and obesity with type 2 diabetes in youth: The SEARCH case-control study.
        Diabetes Care. 2008; 31: 1422-1426
        • Hernandez T.L.
        • Brand-Miller J.C.
        Nutrition therapy in gestational diabetes mellitus: Time to move forward.
        Diabetes Care. 2018; 41: 1343-1345
        • Kelley K.W.
        • Carroll D.G.
        • Meyer A.
        A review of current treatment strategies for gestational diabetes mellitus.
        Drugs Context. 2015; 4: 212282
        • Utz B.
        • Kolsteren P.
        • De Brouwere V.
        A snapshot of current gestational diabetes management practices from 26 low-income and lower-middle-income countries.
        Int J Gynecol Obstet. 2016; 134: 145-150
        • Stirrat L.I.
        • Denison F.C.
        • Love C.D.
        • Lindsay R.S.
        • Reynolds R.M.
        Screening and management of gestational diabetes mellitus in Scottish obstetric units: A national survey.
        Scott Med J. 2015; 60: 37-43
        • Jiwani A.
        • Marseille E.
        • Lohse N.
        • Damm P.
        • Hod M.
        • Kahn J.G.
        Gestational diabetes mellitus: Results from a survey of country prevalence and practices.
        J Matern Neonatal Med. 2012; 25: 600-610
        • Agarwal M.M.
        • Shah S.M.
        • Al Kaabi J.
        • Saquib S.
        • Othman Y.
        Gestational diabetes mellitus: Confusion among medical doctors caused by multiple international criteria.
        J Obstet Gynaecol Res. 2015; 41: 861-869
        • Paschou S.A.
        • Anagnostis P.
        • Wolffenbuttel B.H.R.
        • Goulis D.G.
        The need for precision medicine in gestational diabetes mellitus.
        Maturitas. 2018; 118: 74-75
        • Agarwal M.
        Consensus in gestational diabetes mellitus: Looking for the Holy Grail.
        J Clin Med. 2018; 7: 123
        • Woolf S.H.
        • Grol R.
        • Hutchinson A.
        • Eccles M.
        • Grimshaw J.
        Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines.
        BMJ. 1999; 318: 527-530
      2. Shaneyfelt T. In guidelines we cannot trust.
        Arch Intern Med. 2012; 172: 1633
        • Donnellan C.
        • Sweetman S.
        • Shelley E.
        Health professionals’ adherence to stroke clinical guidelines: A review of the literature.
        Health Policy (New York). 2013; 111: 245-263
        • Fischer F.
        • Lange K.
        • Klose K.
        • Greiner W.
        • Kraemer A.
        Barriers and strategies in guideline implementation—a scoping review.
        Healthcare. 2016; 4: 36
        • Gayet-Ageron A.
        • Poncet B.
        • Guerre P.
        • et al.
        Specific information about the WHO guidelines for gestational diabetes screening improves clinical practices.
        J Eval Clin Pract. 2008; 14: 36-42
        • Persson M.
        • Winkvist A.
        • Mogren I.
        Surprisingly low compliance to local guidelines for risk factor based screening for gestational diabetes mellitus: A population-based study.
        BMC Pregnancy Childbirth. 2009; 9: 53
        • Boudoulas K.D.
        • Leier C.V.
        • Geleris P.
        • Boudoulas H.
        The shortcomings of clinical practice guidelines.
        Cardiology. 2015; 130: 187-200
      3. Improving Physician Adherence to Clinical Practice Guidelines Barriers and Strategies for Change. New England Healthcare Institute, Cambridge, MA2008
        • Bozzetti F.
        • Mariani L.
        • Laviano A.
        Compliance of health professionals with the recommendations of the ESPEN Clinical Practice Guidelines: Results of ad hoc questionnaire.
        ESPEN J. 2014; 9: e34-e38
        • Macqueen G.
        • Santaguida P.
        • Keshavarz H.
        • et al.
        Systematic review of clinical practice guidelines for failed antidepressant treatment response in major depressive disorder, dysthymia, and subthreshold depression in adults.
        Can J Psychiatry. 2017; 62: 11-23
        • Institue of Medicine Committee on Clinical Practice
        Guidelines for Clinical Practice.
        National Academies Press, Washington, DC1992
      4. AGREE Next Steps Consortium. The AGREE II instrument. http://www.agreetrust.org. Published 2009. Accessed March 1, 2019.

        • Ng J.Y.
        • Liang L.
        • Gagliardi A.R.
        The quantity and quality of complementary and alternative medicine clinical practice guidelines on herbal medicines, acupuncture and spinal manipulation: Systematic review and assessment using AGREE II.
        BMC Complement Altern Med. 2016; 16: 425
        • Grammatikopoulou M.G.
        • Theodoridis X.
        • Gkiouras K.
        • et al.
        AGREEing on the guidelines for the nutritional management of adult severe burn patients.
        JPEN J Parent Enter Nutr. 2018 October 15; ([Epub ahead of print])
        • Brouwers M.C.
        • Qaseem A.
        • Spithoff K.
        • Florez I.D.
        Guidelines to limit added sugar intake.
        Ann Intern Med. 2017; 167: 219
        • AGREE Collaboration
        Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: The AGREE project.
        Qual Saf Heal Care. 2003; 12: 18-23
        • Makarski J.
        • Brouwers M.C.
        • AGREE Enterprise
        The AGREE Enterprise: A decade of advancing clinical practice guidelines.
        Implement Sci. 2014; 9: 103
        • Brouwers M.C.
        • Kho M.E.
        • Browman G.P.
        • et al.
        AGREE II: Advancing guideline development, reporting and evaluation in health care.
        J Clin Epidemiol. 2010; 63: 1308-1311
        • Inzucchi S.E.
        • Bergenstal R.M.
        • Buse J.B.
        • et al.
        Management of hyperglycemia in type 2 diabetes: A patient-centered approach: Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).
        Diabetes Care. 2012; 35: 1364-1379
        • Inzucchi S.E.
        • Bergenstal R.M.
        • Buse J.B.
        • et al.
        Management of hyperglycemia in type 2 diabetes, 2015: A patient-centered approach: Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes.
        Diabetes Care. 2015; 38: 140-149
        • Davies M.J.
        • D’Alessio D.A.
        • Fradkin J.
        • et al.
        Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).
        Diabetologia. 2018; 61: 2461-2498
      5. Committee on Practice Bulletins–Obstetrics. ACOG Practice Bulletin No. 190: Gestational diabetes mellitus.
        Obstet Gynecol. 2018; 131: e49-e64
      6. Diagnosis and Treatment of Gestational Diabetes. Royal College of Obstetricians and Gynaecologists, London, UK2011 (Scientific Impact Paper no 23)
        • Management of Diabetes
        A National Clinical Guideline.
        Scottish Intercollegiate Guidelines Network, Edinburgh, Scotland2017
        • Screening
        Diagnosis and Management of Gestational Diabetes in New Zealand: A Clinical Practice Guideline.
        New Zealand Ministry of Health, Wellington, New Zealand2014
        • Hod M.
        • Kapur A.
        • Sacks D.A.
        • et al.
        The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care.
        Int J Gynecol Obstet. 2015; 131: S173
        • Blumer I.
        • Hadar E.
        • Hadden D.R.
        • et al.
        Diabetes and pregnancy: An Endocrine Society clinical practice guideline.
        J Clin Endocrinol Metab. 2013; 98: 4227-4249
      7. Clinical Practice Guidelines: Management of Diabetes in Pregnancy. Malaysia Health Technology Assessment Section, Putrajaya, Malaysia2017
        • Guidelines for the Management of Gestational Diabetes Mellitus
        Hong Kong Special Administrative Region of the People's Republic of China: Hong Kong College of Obstretricians and Gynaecologists.
        2016
        • Kleinwechter H.
        • Schäfer-Graf U.
        • Bührer C.
        • et al.
        Gestational diabetes mellitus (GDM) diagnosis, therapy and follow-up care.
        Exp Clin Endocrinol Diabetes. 2014; 122: 395-405
      8. General Practice Management of Type 2 Diabetes: 2016-18. Royal Australian College of General Practitioners and Diabetes Australia, Melbourne, Australia2016
      9. Italian Standards for Diabetes Mellitus. Italian Association of Diabetologists, Diabete Italia, and Italian Society of Diabetology, Torino, Italy2007
      10. Pregnancy and Diabetes: Global Guideline. International Diabetes Federation, Brussels, Belgium2009
        • Feig D.S.
        • Berger H.
        • Donovan L.
        • et al.
        Diabetes and pregnancy.
        Can J Diabetes. 2018; 42: S255-S282
      11. National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus. Indian Ministry of Health and Family Welfare, New Delhi, India2014
      12. Guidelines for the Management of Pre-Gestational and Gestational Diabetes Mellitus from Pre-Conception to the Postnatal Period: Changing Practice to Support Service Delivery. Irish Health Service Executive, Dublin, Ireland2010
      13. National Institute for Health and Care Excellence. Diabetes in Pregnancy: Management from Preconception to the Postnatal Period. London, UK; 2015.

        • Wielgoś M.
        • Bomba-Opoń D.
        • Czajkowski K.
        • Wender-Ożegowska E.
        • Hod M.
        Towards a European consensus on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care. The Polish Diabetes in Pregnancy Study Group and FIGO.
        Ginekol Pol. 2017; 88: 46-49
      14. Evidence-Based Nutrition Guidelines for the Prevention and Management of Diabetes. Diabetes UK, London, UK2018
        • American Diabetes Association
        Professional Practice Committee: Standards of medical care in diabetes-2018.
        Diabetes Care. 2018; 41: S3
        • Handu D.
        • Moloney L.
        • Wolfram T.
        • Ziegler P.
        • Acosta A.
        • Steiber A.
        Academy of Nutrition and Dietetics methodology for conducting systematic reviews for the Evidence Analysis Library.
        J Acad Nutr Diet. 2016; 116: 311-318
        • Guyatt G.H.
        • Oxman A.D.
        • Vist G.E.
        • et al.
        GRADE: An emerging consensus on rating quality of evidence and strength of recommendations.
        BMJ. 2008; 336: 924-926
        • Institute of Medicine
        Weight Gain During Pregnancy.
        National Academies Press, Washington, DC2009
        • Rosenfeld R.M.
        • Shiffman R.N.
        Clinical practice guideline development manual: A quality-driven approach for translating evidence into action.
        Otolaryngol Head Neck Surg. 2009; 140: S1-S43
        • Gronseth G.S.
        • Moses L.
        • Thomas W.
        • et al.
        Clinical Practice Guideline Process Manual..
        American Academy of Neurology (AAN) Guideline Development Subcommittee, St Paul, MN2011
        • Adamski M.
        • Gibson S.
        • Leech M.
        • Truby H.
        Are doctors nutritionists? What is the role of doctors in providing nutrition advice?.
        Nutr Bull. 2018; 43: 147-152
        • Womersley K.
        • Ripullone K.
        Medical schools should be prioritising nutrition and lifestyle education.
        BMJ. 2017; 359: j4861
        • Thomas L.E.
        How evidence-based medicine biases physicians against nutrition.
        Med Hypotheses. 2013; 81: 1116-1119
        • Møller G.
        • Andersen H.K.
        • Snorgaard O.
        A systematic review and meta-analysis of nutrition therapy compared with dietary advice in patients with type 2 diabetes.
        Am J Clin Nutr. 2017; 106: 1394-1400
        • Briggs Early K.
        • Stanley K.
        Position of the Academy of Nutrition and Dietetics: the role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes.
        J Acad Nutr Diet. 2018; 118: 343-353
        • Cluzeau F.
        • Wedzicha J.A.
        • Kelson M.
        • et al.
        Stakeholder involvement: How to do it right.
        Proc Am Thorac Soc. 2012; 9: 269-273
        • Institute of Medicine
        Clinical Practice Guidelines We Can Trust. Standards for Developing Trustworthy Clinical Practice Guidelines (CPGs).
        The National Academies, Washington, DC2011
        • Armstrong M.J.
        • Bloom J.A.
        Patient involvement in guidelines is poor five years after institute of medicine standards: Review of guideline methodologies.
        Res Involv Engagem. 2017; 3: 19
        • Krige S.M.
        • Booley S.
        • Levitt N.S.
        • Chivese T.
        • Murphy K.
        • Harbron J.
        Dietary intake and beliefs of pregnant women with gestational diabetes in Cape Town, South Africa.
        Nutrients. 2018; 10: 1183
        • Hui A.L.
        • Sevenhuysen G.
        • Harvey D.
        • Salamon E.
        Food choice decision-making by women with gestational diabetes.
        Can J Diabetes. 2014; 38: 26-31
        • Ge L.
        • Wikby K.
        • Rask M.
        “Is gestational diabetes a severe illness?” exploring beliefs and self-care behaviour among women with gestational diabetes living in a rural area of the south east of China.
        Aust J Rural Health. 2016; 24: 378-384
        • Hui A.L.
        • Sevenhuysen G.
        • Harvey D.
        • Salamon E.
        Stress and anxiety in women with gestational diabetes during dietary management.
        Diabetes Educ. 2014; 40: 668-677
        • Rabassa M.
        • Garcia-Ribera Ruiz S.
        • Solà I.
        • Pardo-Hernandez H.
        • Alonso-Coello P.
        • Martínez García L.
        Nutrition guidelines vary widely in methodological quality: An overview of reviews.
        J Clin Epidemiol. 2018; 104: 62-72
        • American Diabetes Association
        Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications.
        Diabetes Care. 2002; 25: S50-S60
        • Bhaumik S.
        • Jagadesh S.
        • Ellatar M.
        • Kohli N.
        • Riedha M.
        • Moi M.
        Clinical practice guidelines in India: Quality appraisal and the use of evidence in their development.
        J Evid Based Med. 2018; 11: 26-39
        • Boyd E.A.
        • Akl E.A.
        • Baumann M.
        • et al.
        Guideline funding and conflicts of interest.
        Proc Am Thorac Soc. 2012; 9: 234-242
        • Sawka A.M.
        • Magalhães L.
        • Gafni A.
        • Lewis G.F.
        Competing interests in development of clinical practice guidelines for diabetes management: Report from a multidisciplinary workshop.
        J Multidiscip Healthc. 2008; 1: 29-34
        • Morgan R.L.
        • Florez I.
        • Falavigna M.
        • et al.
        Development of rapid guidelines: 3. GIN-McMaster Guideline Development Checklist extension for rapid recommendations.
        Heal Res Policy Syst. 2018; 16: 63
        • Gilmore I.
        Maintaining guideline transparency and pragmatism in the post-truth era.
        Addiction. 2019; 114: 604-605
        • Norris S.L.
        • Holmer H.K.
        • Ogden L.A.
        • Burda B.U.
        Conflict of interest in clinical practice guideline development: A systematic review.
        PLoS One. 2011; 6: e25153
      15. Farquhar C, Hill S, Bero L, Tovey T. Cochrane policy on commercial sponsorship of Cochrane Reviews and Cochrane Groups. https://community.cochrane.org/organizational-info/resources/policies/commercial-sponsorship-policy. Published 2014. Accessed March 4, 2019.

        • Eichacker P.Q.
        • Natanson C.
        • Danner R.L.
        Surviving sepsis — practice guidelines, marketing campaigns, and Eli Lilly.
        N Engl J Med. 2006; 355: 1640-1642
        • Draffin C.R.
        • Alderdice F.A.
        • McCance D.R.
        • et al.
        Exploring the needs, concerns and knowledge of women diagnosed with gestational diabetes: A qualitative study.
        Midwifery. 2016; 40: 141-147
        • Taousani E.
        • Savvaki D.
        • Tsirou E.
        • et al.
        Regulation of basal metabolic rate in uncomplicated pregnancy and in gestational diabetes mellitus.
        Hormones. 2017; 13: 235-250
        • Xu Z.
        • Wen Z.
        • Zhou Y.
        • Li D.
        • Luo Z.
        Inadequate weight gain in obese women and the risk of small for gestational age (SGA): A systematic review and meta-analysis.
        J Matern Neonatal Med. 2017; 30: 357-367
        • Wei J.
        • Heng W.
        • Gao J.
        Effects of low glycemic index diets on gestational diabetes mellitus.
        Medicine (Baltimore). 2016; 95: e3792
        • Zhang R.
        • Han S.
        • Chen G.-C.
        • et al.
        Effects of low-glycemic-index diets in pregnancy on maternal and newborn outcomes in pregnant women: A meta-analysis of randomized controlled trials.
        Eur J Nutr. 2018; 57: 167-177
        • American Dietetic Association
        Nutrition Care Process and Model Part I: The 2008 Update.
        J Am Diet Assoc. 2008; 108: 1113-1117
        • Fitch C.
        • Keim K.S.
        Position of the Academy of Nutrition and Dietetics: Use of Nutritive and Nonnutritive Sweeteners.
        J Acad Nutr Diet. 2012; 112: 739-758
        • Reid A.E.
        • Chauhan B.F.
        • Rabbani R.
        • et al.
        Early exposure to nonnutritive sweeteners and long-term metabolic health: A systematic review.
        Pediatrics. 2016; 137: e20153603
        • Maslova E.
        • Strøm M.
        • Olsen S.F.
        • Halldorsson T.I.
        Consumption of artificially-sweetened soft drinks in pregnancy and risk of child asthma and allergic rhinitis.
        PLoS One. 2013; 8: e57261
        • Azad M.B.
        • Sharma A.K.
        • de Souza R.J.
        • et al.
        Association between artificially sweetened beverage consumption during pregnancy and infant body mass index.
        JAMA Pediatr. 2016; 170: 662-670
        • Archibald A.J.
        • Dolinsky V.W.
        • Azad M.B.
        Early-life exposure to non-nutritive sweeteners and the developmental origins of childhood obesity: Global evidence from human and rodent studies.
        Nutrients. 2018; 10: 194
        • Ellis P.D.
        The Essential Guide to Effect Sizes: Statistical Power, Meta-Analysis, and the Interpretation of Research Results.
        Cambridge University Press, New York, NY2010
        • Ioannidis J.P.
        • Lau J.
        Pooling research results: Benefits and limitations of meta-analysis.
        Jt Comm J Qual Improv. 1999; 25: 462-469

      Biography

      E. Tsirou is an endocrinology resident and a doctoral degree candidate, Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece.

      Biography

      D. Savvaki is a doctoral degree candidate, Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece.

      Biography

      D. G. Goulis is an associate professor of Reproductive Endocrinology, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece.

      Biography

      M. G. Grammatikopoulou is a senior lecturer, Department of Nutrition and Dietetics, Alexander Technological Educational Institute, and a scientific associate, Laboratory of Hygiene, Social and Preventive Medicine, and Medical Statistics, Aristotle University of Thessaloniki, Thessaloniki, Greece.

      Biography

      K. Gkiouras is a scientific associate, Laboratory of Clinical Pharmacology, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.

      Biography

      X. Theodoridis is a postgraduate student, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece; at the time of the study, he was a postgraduate student, Medical School, Faculty of Health Sciences, University of Thessaly, Larissa, Greece.

      Biography

      A. Petalidou is a postgraduate student, Medical School, Faculty of Health Sciences, University of Thessaly, Larissa, Greece.

      Biography

      E. Taousani is a doctoral degree candidate, Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece, and a senior lecturer, Department of Midwifery, Alexander Technological Educational Institute, Thessaloniki, Greece.

      Biography

      A. Tsapas is an associate professor of medicine and lead investigator, Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece, and head, Diabetes Centre, Second Medical Department, Ippokration General Hospital, Thessaloniki, Greece.