NOTICE: We are experiencing technical issues with Academy members trying to log into the JAND site using Academy member login credentials. We are working to resolve the issue as soon as possible. Alternatively, if you are an Academy member, you can access the JAND site by registering for an Elsevier account and claiming access using the links at the top of the JAND site. Email us at [email protected] for assistance. Thanks for your patience!

Ethnic Differences in Dietary Management of Gestational Diabetes Mellitus: A Mixed Methods Study Comparing Ethnic Chinese Immigrants and Australian Women

Published:November 09, 2019DOI:



      Dietary modification is the primary intervention strategy for management of gestational diabetes mellitus (GDM), which usually occurs in the third trimester of pregnancy when women have extra nutritional needs. There is a high migration rate of ethnic Chinese people to Western countries, and those women present a high-risk group for GDM. Little is known about diet, dietary self-management, and nutritional supplementation use among ethnic Chinese migrant women with GDM compared with members of the host population with GDM.


      This study aimed to compare the perceptions and experiences of dietary self-management and nutritional needs of ethnic Chinese migrants with those of Australian-born white women with GDM in Australia.


      A predominantly qualitative mixed methods approach with a quantitative component was used. Data collection involved in-depth, semistructured interviews, and 3-day 24-hour recall diaries collected concurrently. Data analysis and management relied on NVivo (QSR International Pty Ltd), FoodWorks (FoodWorks Professional 2017, Xyris Software), and SPSS (SPSS Inc). Pearson χ2 test, independent-samples t test, and Mann-Whitney U test were used to compare nutrient intakes between groups. The Pearson correlation was used to determine the relationship between dietary patterns and nutrient intake.


      A total of 44 ethnic Chinese and 39 Australian-born white participants with GDM were recruited from two large Australian maternity services located in tertiary hospitals.


      Ethnic differences in satisfaction with GDM education influenced GDM self-management. Ethnic Chinese women with GDM perceived dietary advice received from health professionals to be lacking in cultural relevance and detail and responded by restricting their dietary intake and relying on nutritional supplementation. The perceived benefits of specific supplements produced ethnic differences in the patterns of supplement use. Cultural dietary patterns influenced dietary adequacy in pregnancy.


      This study suggests the need for provision of more concrete, prescriptive, and culturally relevant dietary and supplementation advice for ethnic Chinese women with GDM.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lee K.W.
        • Ching S.M.
        • Ramachandran V.
        • Yee A.
        • Hoo F.K.
        • Chia Y.C.
        Prevalence and risk factors of gestational diabetes mellitus in Asia: A systematic review and meta-analysis.
        BMC Pregnancy Childbirth. 2018; 18: 1-20
        • Moses R.G.
        • Morris G.J.
        • Petocz P.
        • San Gil F.
        • Garg D.
        The impact of potential new diagnostic criteria on the prevalence of gestational diabetes mellitus in Australia.
        Med J Aust. 2011; 194: 338-340
        • Wong V.W.
        • Lin A.
        • Russell H.
        Adopting the new World Health Organization diagnostic criteria for gestational diabetes: How the prevalence changes in a high-risk region in Australia.
        Diabetes Res Clin Pract. 2017; 129: 148-153
        • von Katterfeld B.
        • Li J.
        • McNamara B.
        • Langridge A.T.
        Maternal and neonatal outcomes associated with gestational diabetes in women from culturally and linguistically diverse backgrounds in Western Australia.
        Diabet Med. 2012; 29: 372-377
        • Dabelea D.
        • Crume T.
        Maternal environment and the transgenerational cycle of obesity and diabetes.
        Diabetes. 2011; 60: 1849-1855
        • Madhu S.
        Diabetes in pregnancy—a critical window of opportunity.
        Int J Diabetes Dev Ctries. 2018; 38: 1-3
        • International Organization for Migration
        World Migration Report 2018.
        The UN Migration Agency, Geneva, Switzerland2018
        • Wan C.S.
        • Abell S.
        • Aroni R.
        • Nankervis A.
        • Boyle J.
        • Teede H.
        Ethnic differences in prevalence, risk factors and perinatal outcomes of gestational diabetes mellitus: A comparison between immigrant ethnic Chinese women and Australian-born Caucasian women in Australia.
        J Diabetes. 2019; 11: 809-817
        • Mukerji G.
        • Chiu M.
        • Shah B.R.
        Gestational diabetes mellitus and pregnancy outcomes among Chinese and South Asian women in Canada.
        J Matern Fetal Neonatal Med. 2013; 26: 279-284
        • Green J.R.
        • Schumacher L.B.
        • Pawson I.G.
        • Partridge J.C.
        • Kretchmer N.
        Influence of maternal body habitus and glucose tolerance on birth weight.
        Obstet Gynecol. 1991; 78: 235-240
        • Mocarski M.
        • Savitz D.A.
        Ethnic differences in the association between gestational diabetes and pregnancy outcome.
        Matern Child Health J. 2012; 16: 364-373
        • Xiang A.H.
        • Black M.H.
        • Li B.H.
        • et al.
        Racial and ethnic disparities in extremes of fetal growth after gestational diabetes mellitus.
        Diabetologia. 2015; 58: 272-281
        • Silva J.K.
        • Kaholokula J.K.
        • Ratner R.
        • Mau M.
        Ethnic differences in perinatal outcome of gestational diabetes mellitus.
        Diabetes Care. 2006; 29: 2058-2063
      1. Australian Bureau of Statistics. 3412.0—Migration, Australia 2015-2016. Australian Bureau of Statistics, Canberra, Australia2017
        • Berry D.C.
        • Johnson Q.B.
        • Stuebe A.M.
        Monitoring and managing mothers with gestational diabetes mellitus: A nursing perspective.
        Nurs Res Rev. 2015; 5: 91-97
        • Moreno-Castilla C.
        • Mauricio D.
        • Hernandez M.
        Role of medical nutrition therapy in the management of gestational diabetes mellitus.
        Curr Diab Rep. 2016; 16: 1-9
        • 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
        • Queensland Government
        Queensland clinical guidelines: Gestational diabetes mellitus.
        (Published August 2015. Assessed September 9, 2018)
        • Heuberger R.
        Increasing empathy, knowledge, and skills regarding gestational diabetes.
        Top Clin Nutr. 2010; 25: 250-255
        • Neufeld H.T.
        Patient and caregiver perspectives of health provision practices for First Nations and Métis women with gestational diabetes mellitus accessing care in Winnipeg, Manitoba.
        BMC Health Serv Res. 2014; 14: 1-14
        • Rees S.E.
        • Chadha R.
        • Donovan L.E.
        • et al.
        Engaging patients and clinicians in establishing research priorities for gestational diabetes mellitus.
        Can J Diabetes. 2017; 41: 156-163
        • Suraiya A.H.N.
        • Zahara A.M.
        • Nazlena M.
        • Suzana S.
        • Norazlin M.
        • Sameeha M.
        Perspectives of healthcare professionals and patients on management of gestational diabetes mellitus: A qualitative study in Negeri Sembilan, Malaysia.
        Malays J Nutr. 2016; 21: 393-399
        • Blumer H.
        Symbolic Interactionism: Perspective and Method.
        University of California Press, Los Angeles, CA1986
        • Verburg P.E.
        • Tucker G.
        • Scheil W.
        • Erwich J.J.H.M.
        • Dekker G.A.
        • Roberts C.T.
        Seasonality of gestational diabetes mellitus: A South Australian population study.
        BMJ Open Diabetes Res Care. 2016; 4: 1-8
        • Minichiello V.
        • Aroni R.
        • Hays T.
        In-Depth Interviewing: Principles, Techniques, Analysis.
        Pearson Education Australia, Frenchs Forest, New South Wales, Australia2008
        • Corbin J.
        • Strauss A.
        Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory.
        3rd ed. Sage, CA2008
      2. NVivo 11 Pro [computer software]. Doncaster, Victoria, Australia: QSR International Pty Ltd; 2015.

        • Creswell J.W.
        • Clark V.L.P.
        Designing and Conducting Mixed Methods Research.
        2nd ed. Sage, Los Angeles, CA2011
        • Twinn S.
        An exploratory study examining the influence of translation on the validity and reliability of qualitative data in nursing research.
        J Adv Nurs. 1997; 26: 418-423
        • Irvine F.
        • Roberts G.
        • Bradbury-Jones C.
        The researcher as insider versus the researcher as outsider: Enhancing rigour through language and cultural sensitivity.
        in: Doing Cross-Cultural Research. Springer, Dordrecht, Netherlands2008: 35-48
        • Gibson R.S.
        • Ferguson E.L.
        An Interactive 24-Hour Recall for Assessing the Adequacy of Iron and Zinc Intakes in Developing Countries.
        HarvestPlus Technical Monograph Series, Washington, DC2008
      3. Wrieden W, Peace H, Armstrong J, Barton K. A short review of dietary assessment methods used in National and Scottish research studies. Paper presented at: Working Group on Monitoring Scottish Dietary Targets; September 2003. Edinburgh, Scotland. Accessed December 20, 2018.

        • Johnson R.K.
        Dietary intake—how do we measure what people are really eating?.
        Obes Res. 2002; 10: 63S-68S
        • Shim J.-S.
        • Oh K.
        • Kim H.C.
        Dietary assessment methods in epidemiologic studies.
        Epidemiol Health. 2014; 36: 1-8
        • Westerterp K.R.
        • Goris A.H.
        Validity of the assessment of dietary intake: Problems of misreporting.
        Curr Opin Clin Nutr Metab Care. 2002; 5: 489-493
        • Australian Bureau of Statistics
        Australian Health Survey: Users’ Guide, 2011-13.
        (Updated 2015. Accessed September 21, 2018)
        • De Keyzer W.
        • Huybrechts I.
        • De Vriendt V.
        • et al.
        Repeated 24-hour recalls versus dietary records for estimating nutrient intakes in a national food consumption survey.
        Food Nutr Res. 2011; 55: 7307
        • Barrett-Connor E.
        Nutrition epidemiology: How do we know what they ate?.
        Am J Clin Nutr. 1991; 54: 182S-187S
      4. FoodWorks 9 [computer software]. FoodWorks Professional 2017. Brisbane, Queensland, Australia: Xyris Software, 2017
      5. AusFoods 2017 [computer software]. Developed by Xyris, 2017 (Software (Brisbane, Queensland, Australia))
      6. Food Standards Australia New Zealand. AUSNUT 2011–13 – Australian Food Composition Database. [dataset] Canberra, Australia: FSANZ, 2014. Accessed September 21, 2018.

        • National Health and Medical Research Council
        Australian Guide to Healthy Eating.
        (Updated 2017. Accessed December 12, 2017)
      7. Statistical Package for Social Sciences 23.0 (SPSS version 23.0) [computer program]. Armonk, NY: IBM Corp; 2015.

      8. Department of Health and Aging. Nutrient reference values for Australia and New Zealand: Including recommended dietary intakes. Canberra, Australia: National Health and Medical Research Council. Published September 2017. Accessed September 9, 2018.

        • Centre for Food Safety
        Nutrient and health—maintain optimal nutrient intake.
        (2018. Accessed December 12, 2018)
        • National Academy of Sciences
        Dietary Reference Intakes.
        Nutr Rev. 1997; 55: 319-326
        • Department of Health and Ageing
        Nutrient reference values for Australia and New Zealand: Executive summary. National Health and Medical Research Council, Australian Government.
        (Published September 9, 2005. Accessed September 30, 2018)
        • Chinese Nutrition Society
        The Chinese Dietary Guidelines 2016.
        Chinese Nutrition Society, Beijing, China2016
        • Ministry of Health and Welfare
        Dietary Reference Intakes, DRIs. 7th ed. Taiwan Ministry of Health and Welfare.
        (Published 2011. Accessed September 9, 2018)
        • Ministry of Health
        Recommended dietary allowances. Singapore Ministry of Health.
        (Revised February 28, 2019. Accessed March 5, 2019)
        • National Coordinating Committee on Food and Nutrition
        Recommended nutrient intakes for Malaysia. Ministry of Health Malaysia.
        (Published 2017. Accessed September 9, 2018)
        • Khan N.C.
        • Hoan P.V.
        Vietnam recommended dietary allowances 2007.
        Asia Pac J Clin Nutr. 2008; 17: 409-415
      9. National Health and Medical Research Council. Advice on eating for you and your baby. Canberra, Australia: Department of Health and Aging. Accessed December 12, 2018.

        • Wah Y.Y.E.
        • McGill M.
        • Wong J.
        • Ross G.P.
        • Harding A.-J.
        • Krass I.
        Self-management of gestational diabetes among Chinese migrants: A qualitative study.
        Women Birth. 2019; 32: e17-e23
        • Razee H.
        • van der Ploeg H.P.
        • Blignault I.
        • et al.
        Beliefs, barriers, social support, and environmental influences related to diabetes risk behaviours among women with a history of gestational diabetes.
        Health Promot J Austr. 2010; 21: 130-137
        • Choi T.S.
        • Walker K.Z.
        • Palermo C.
        Culturally tailored diabetes education for Chinese patients: A qualitative case study.
        J Transcult Nurs. 2017; 28: 315-323
        • Winsor S.
        • Smith A.
        • Vanstone M.
        • Giacomini M.
        • Brundisini F.
        • DeJean D.
        Experiences of patient-centredness with specialized community-based care: A systematic review and qualitative meta-synthesis.
        Ont Health Technol Assess Ser. 2013; 13: 1-33
        • Stevenson F.A.
        • Cox K.
        • Britten N.
        • Dundar Y.
        A systematic review of the research on communication between patients and health care professionals about medicines: The consequences for concordance.
        Health Expect. 2004; 7: 235-245
        • Majeed-Ariss R.
        • Jackson C.
        • Knapp P.
        • Cheater F.M.
        A systematic review of research into black and ethnic minority patients’ views on self-management of type 2 diabetes.
        Health Expect. 2015; 18: 625-642
        • Hure A.
        • Young A.
        • Smith R.
        • Collins C.
        Diet and pregnancy status in Australian women.
        Public Health Nutr. 2009; 12: 853-861
        • Louie J.C.Y.
        • Markovic T.P.
        • Ross G.P.
        • Foote D.
        • Brand-Miller J.C.
        Higher glycemic load diet is associated with poorer nutrient intake in women with gestational diabetes mellitus.
        Nutr Res. 2013; 33: 259-265
        • Kozlowska A.
        • Jagielska A.M.
        • Okreglicka K.M.
        • et al.
        Dietary vitamin and mineral intakes in a sample of pregnant women with either gestational diabetes or type 1 diabetes mellitus, assessed in comparison with Polish nutritional guidelines.
        Ginekol Pol. 2018; 89: 581-586
        • Lim S.-Y.
        • Yoo H.-J.
        • Kim A.-L.
        • et al.
        Nutritional intake of pregnant women with gestational diabetes or type 2 diabetes mellitus.
        Clin Nutr Res. 2013; 2: 81-90
        • Shin M.-K.
        • Kim Y.-S.
        • Kim J.-H.
        • Kim S.-H.
        • Kim Y.
        Dietary patterns and their associations with the Diet Quality Index-International (DQI-I) in Korean women with gestational diabetes mellitus.
        Clin Nutr Res. 2015; 4: 216-224
        • Krige S.
        • Booley S.
        • Levitt N.
        • Chivese T.
        • Murphy K.
        • Harbron J.
        Dietary intake and beliefs of pregnant women with gestational diabetes in Cape Town, South Africa.
        Nutrients. 2018; 10: 1-21
        • Cheng Y.
        • Dibley M.J.
        • Zhang X.
        • Zeng L.
        • Yan H.
        Assessment of dietary intake among pregnant women in a rural area of western China.
        BMC Public Health. 2009; 9: 1-9
        • Liu F.-L.
        • Zhang Y.-M.
        • Parés G.V.
        • et al.
        Nutrient intakes of pregnant women and their associated factors in eight cities of China: A cross-sectional study.
        Chin Med J (Engl). 2015; 128: 1778-1786
        • Li Y.H.
        • Chen S.X.
        • Chen X.M.
        • Zhuo X.Y.
        • Wei X.L.
        • Zheng C.X.
        Nutritional analysis of 195 women with gestational diabetes mellitus in Fuzhou.
        Strait J Prev Med. 2012; 18: 16-18
        • Xu T.
        • He Y.
        • Dainelli L.
        • et al.
        Healthcare interventions for the prevention and control of gestational diabetes mellitus in China: A scoping review.
        BMC Pregnancy Childbirth. 2017; 17: 1-10
        • Perkins A.V.
        • Vanderlelie J.J.
        Multiple micronutrient supplementation and birth outcomes: The potential importance of selenium.
        Placenta. 2016; 48: S61-S65
        • Yang Q.-H.
        • Carter H.K.
        • Mulinare J.
        • Berry R.
        • Friedman J.
        • Erickson J.D.
        Race-ethnicity differences in folic acid intake in women of childbearing age in the United States after folic acid fortification: Findings from the National Health and Nutrition Examination Survey, 2001-2002.
        Am J Clin Nutr. 2007; 85: 1409-1416
        • Ramírez-Vélez R.
        • Correa-Bautista J.E.
        • Triana-Reina H.R.
        • González-Jiménez E.
        • Schmidt-RioValle J.
        • González-Ruíz K.
        Use of dietary supplements by pregnant women in Colombia.
        BMC Pregnancy Childbirth. 2018; 18: 1-8
        • Gollust S.E.
        • Lantz P.M.
        Communicating population health: Print news media coverage of type 2 diabetes.
        Soc Sci Med. 2009; 69: 1091-1098
        • Watson L.F.
        • Brown S.J.
        • Davey M.A.
        Use of periconceptional folic acid supplements in Victoria and New South Wales, Australia.
        Aust N Z J Public Health. 2006; 30: 42-49
        • Taiwan Ministry of Health and Walfare
        Maternal Health Booklet. Taiwan, China: Health Promotion Administration.
        Ministry of Health and Welfare, 2017
        • Singapore Ministry of Health
        Healthy start for your pregnancy. Health Promotion Board.
        (Published July 10, 2018. Accessed September 10, 2018)
        • Tang L.
        • Lee A.H.
        • Yau K.K.
        • Hui Y.V.
        • Binns C.W.
        Consumption of dietary supplements by Chinese women during pregnancy and postpartum: A prospective cohort study.
        Matern Child Nutr. 2017; 13: e12435
        • Blumfield M.L.
        • Hure A.J.
        • Macdonald-Wicks L.
        • Smith R.
        • Collins C.E.
        A systematic review and meta-analysis of micronutrient intakes during pregnancy in developed countries.
        Nutr Rev. 2013; 71: 118-132
        • Gibson R.S.
        Principles of Nutritional Assessment.
        Oxford University Press, New York, NY2005


      C. S. Wan is a PhD candidate, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia; and School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.


      H. Teede is an endocrinologist, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; and the Department of Endocrinology and Diabetes, Monash Health, Clayton, Victoria, Australia.


      A. Nankervis is an endocrinologist, Departments of Diabetes and Endocrinology, The Royal Melbourne and Royal Women's Hospitals, Parkville, Victoria, Australia, and the Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia.


      R. Aroni is a senior lecturer, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; and Medical School, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia.