Abstract
Women with prior gestational diabetes face a highly increased risk of type 2 diabetes and are difficult to recruit for follow-up care, possibly due to a loss of professional support in the care pathway. This study aimed to explore Danish health professionals’ experiences of the challenges in the care pathway for women with prior gestational diabetes, the obstacles to continuity of care, and the possibility of better preventing type 2 diabetes. Qualitative semi-structured interviews with 12 healthcare professionals were conducted. The interviews were analyzed using inductive content analysis. The study adheres to the COREQ checklist. The findings are organized into five main categories. The conclusions indicate that gestational diabetes is easily overlooked due to a lack of information sharing and continuity across health care delivery systems. Creating a management plan and engaging general practice nurses as designated health professionals may improve the care pathway and better prevent type 2 diabetes.
Keywords
Background
Women with prior gestational diabetes mellitus (GDM) face a greatly increased risk of early-onset type 2 diabetes mellitus (T2DM). 1 A recent systematic review suggests that women with GDM have an 8.3% greater risk of T2DM. 2 They are thus urged to participate in postpartum screening and lifestyle interventions to decrease this risk and prevent T2DM. 3 In Denmark, all citizens have free access to healthcare services, which are funded through taxes. The Danish healthcare delivery system consists of primary, hospital, psychiatric, and elderly care. 4 In their care pathway, women with GDM need both specialized care during pregnancy and birth (hospital care) and follow-up care by their general practitioner (GP) (primary care). However, women with prior GDM find the existing care pathway unsatisfying. 5 Thus, a lack of continuity of care between the hospital and primary care limits women’s participation in screening. 6 Reid et al. define continuity of care as a combination of information, relationships, and management continuity that bridges past, present, and future care. 7 A lack of postpartum communication and coordination between hospitals and GPs has been shown to be common in many healthcare settings and potentially leave women with an unmet need for postpartum information and guidance.5,8 However, when health professionals actively support the transition of women with GDM from the hospital to primary care, increased participation in T2DM screening has been reported. 9 Furthermore, prevention planning consultations with a designated health professional increase the number of women choosing to participate in diabetes screening. 10
Prolonged undiagnosed diabetes is associated with a decrease in quality of life, a higher risk of diabetes complications, and increased healthcare use and related costs. 1 An early onset of T2DM is related to increased morbidity and mortality. 11 For women with a GDM predisposition to the early onset of T2DM, the International Diabetes Federation recommends that lifestyle or pharmacological interventions be initiated within three years of the GDM diagnosis to maximize prevention and halve the risk of developing diabetes. 12
Studies have found that the participation of women with prior GDM in screening for T2DM by their GP drops after the first postnatal consultation. 13 Women with prior GDM are difficult to recruit for preventive lifestyle interventions. 14 Scholars have identified multiple reasons for poor participation in screening and preventive lifestyle interventions, including the fear of being diagnosed and the many everyday barriers experienced by mothers with small children.15–17 As women with prior GDM find the existing care pathway unsatisfying, 5 providing continuity of care may be an important mean to ensure a more patient-centered approach and encourage women to participate in both screening and health promotive and preventive activities. Previous studies of the care pathway for women with pregnancy complicated by GDM have mainly illuminated women’s perspectives. These studies practically contribute to care development by providing detailed information and knowledge on women as experts of their illness and care.6,15 However, as Arthur Kleinman and others have established, health professionals’ and patients’ perspectives differ significantly. 18 Health professionals may offer professional experiences of the healthcare system and generalized knowledge of care provision for multiple women with prior GDM; they may also identify the perceived challenges to and facilitating factors of interprofessional collaboration, communication, and coordination. Specifically, health professionals may offer knowledge of the strengths and limitations of resources and expertise in maternity care services to clarify when, how, and why the care pathway may challenge women with prior GDM and how this can be changed. This knowledge may inspire improved care and thereby better prevent T2DM.
This study explored the experiences of diverse groups of health professionals regarding challenges in the care pathway for women with prior GDM, continuity of care, and the possibility of better preventing T2DM.
Methods
This study employed an exploratory and descriptive qualitative design 19 based on semi-structured interviews. This design was considered appropriate for obtaining an in-depth understanding of the experiences of a diverse group of health professionals concerning women’s care pathways after GDM. Qualitative designs can provide rich subjective descriptions of complex phenomena. 20 The reporting was guided by the recommendations of the consolidated criteria for reporting qualitative research (COREQ) checklist. 21
Setting
The study was undertaken in central and northern Jutland, Denmark. Healthcare professionals in both primary and hospital care who worked in public hospitals, private practice, and community care service were included. 4 The interviews lasted approximately 45 minutes each and were conducted in a location chosen by the participants; some preferred a clinical setting while others chose a private setting. The interviews were conducted between April 2018 and October 2019 by three female junior researchers among the authors who have a background in nursing or midwifery and public health.
Participants and recruitment
Participants were recruited from the diverse group of professionals who play a major role in health promotion and prevention for women with GDM and in the prevention of T2DM. The recruitment employed purposeful intensity sampling, which is often used in qualitative research to identify and select information-rich cases related to the phenomenon of interest. 22 The choice of an explorative and descriptive study aim, the sampling of information-rich cases, and the use of established theory on continuity of care and quality of dialogue drew on Malterud et al.’s concept of information power and their principles for assessing approximate sample size. 23 Ultimately, the research team aimed to include 10–15 participants. Invitation letters were sent to potential participants with a primary role in maternity care for women with a GDM diagnosis. The distribution of the letters was aided by the use of professional networks. The authors’ former employers and their networks were used to recruit participants from both primary and hospital care. Initially, eight participants were included, but the recruitment process was resumed to increase information power. As suggested by Malterud et al., 23 the sample size was revisited throughout the research process. It was thus concluded that sufficient information power was reached when 12 participants with diverse professional backgrounds and experiences of women’s care pathway after GDM were included. Obstetricians and other hospital care professionals with a primary focus on the treatment of the medical conditions and perinatal risks of mother and child were excluded.
Data collection
An interview guide was created by the authors containing the themes ‘The care pathway across primary and hospital care’ and ‘Health professionals as resources in the care pathway’. Given the interest in obtaining detailed descriptions of health professionals’ experiences, the participants were asked open-ended questions such as ‘What is your experience of the care pathway for women with GDM?’ and ‘Based on your experience, which professional groups could contribute to creating continuity of care for these women?’. Participants were encouraged to share their professional opinions, challenges, and experiences openly.
Respect is especially important when interviewing peers, as believing that one’s professional knowledge is under scrutiny by a fellow professional can cause participants to become cautious about sharing information in order to protect their professional reputation. 24 Thus, the script for briefing and debriefing included verbal acknowledgment of the participants’ professional role in maternity care services and their contribution to the understanding of the care pathway for women with GDM. The first interview was conducted as a pilot to allow for testing and revision of the interview guide. 25 No need for major changes was detected, so the pilot interview was included. All the interviews were recorded and transcribed by one researcher; the accuracy of the transcription was then cross-checked by the research team. The participants were offered the opportunity to review the transcriptions and analysis but declined. The three junior researchers analyzed each transcript for codes, subcategories, categories, and main categories in consultation with an experienced researcher. All the recordings were deleted after transcription, and the data were stored on a password-protected external hard drive.
Data analysis
The analysis was inspired by inductive content analysis. 26 The coding was performed manually, as the body of data was manageable and manual coding allows the researcher to become familiar with the data. 27 Each transcript was read, and codes reflecting the participants’ words were identified line by line and categorized into subcategories by the three junior researchers. After all the transcripts were coded, the research team determined which subcategories clustered logically into categories based on content and meaning. This led to a consensus on five main categories.
Using a reiterative process, all the authors cooperated in qualifying and validating the categories by meeting regularly to discuss and review the data and examine how the codes and categories supported one another. This was done until no further categories emerged. As the sample size was revisited during the analysis, it became clear that communication between the participants and the junior researchers was strong and contributed to the quality of the dialogue, as all the participants possessed expert knowledge in the research field, which enabled them to provide rich information.
Ethical considerations
Danish legislation requires that qualitative studies be based on the informed consent of participants and not on ethical approval from a national or public agency. 28 However, in keeping with good research practice, the Regional Committee on Health Research Ethics was consulted (journal no. 2021-000438). The recommendations of the Danish Ministry of Higher Education and Science 29 and those of the Declaration of Helsinki to ensure participants’ safety and rights 30 were followed. All the participants received verbal and written information regarding the study, as well as briefings and debriefings on anonymity, confidentiality, the study’s aims, and the option to withdraw consent at any time.
Findings
Three child health nurses, one nurse from an obstetric care unit, three GPs, three midwives, and two nurses employed in general practice (henceforth GP nurse) accepted the invitation to participate. The participants’ characteristics are presented in Table 1.
Participants’ characteristics.
The interviewed health professionals formed a relatively homogeneous group owing to the purposeful sampling in national maternity care services. Still, their diversity in terms of education, experience, and clinical and geographic setting offered a broad perspective on the care pathway for women with prior GDM, the challenges relating to continuity of care, and how the latter may be mitigated.
The analysis produced five main categories: ‘Lack of information sharing between health professionals and healthcare delivery systems’, ‘Lack of coordination between health professionals and healthcare delivery systems’, ‘Health professionals as resources to ensure continuity of care’, ‘Barriers to enhanced continuity in women’s care pathways’ and ‘Opportunities to support enhanced continuity of care for women with a GDM diagnosis’. An example of how subcategories were transferred into main categories is presented in Table 2.
Subcategories to main categories.
GDM: gestational diabetes mellitus; GP: general practitioner.
An example of the process of transferring the text into codes, subcategories and main categories can be seen in Table 3.
From text to main categories.
GDM: gestational diabetes mellitus; GP: general practitioner.
Lack of information sharing between health professionals and healthcare delivery systems
All the health professionals spontaneously mentioned that an inadequate flow of information between hospital and primary care may cause experiences of a lack of continuity of care among women with prior GDM. One midwife said: Well, I think it sometimes can be because they ‘flutter’ between hospital and primary care … I do think there should be better collaboration between midwife, medical specialists, and GP. That way, it would not be the pregnant woman who should be the messenger … that way, there would be more continuity of care. (Midwife 1)
Overall, the data indicate that a lack of information sharing between healthcare delivery systems and health professionals left women with the responsibility of communicating information about the GDM diagnosis to professionals and of organizing their own participation in follow-up screening and health preventive and promotive activities. Two participants argued that this responsibility was suitably placed with the women. It is actually the patient’s own responsibility. The question is whether they are properly informed, since we do not see them afterward. I think there is a problem with missing information from ‘in there’ [the hospital]. (GP Nurse 2)
However, most participants did not share the perception that women are solely responsible for involvement in follow-up screening and promotive and preventive health activities, especially as they observed that women struggled with the responsibility. Lack of information, communication, coordination, and a uniform approach were generally viewed as challenges in women’s care pathways, which could result in a lack of health professional support if the health professionals are unaware of GDM. A midwife explained: There is very little communication between [healthcare delivery systems], at least toward the GP. Well, as a midwife, you have access to their hospital journal and are able to see the notes made since. … My impression is that the GP is very detached from that [information about the patient]. (Midwife 3)
The GPs and child health nurses (representing the two professional groups mainly involved in postnatal care) both highlighted their experience of a lack of information sharing about women’s GDM diagnosis after birth: We are usually not informed about the women’s GDM diagnosis … it is not something we get to know about. (Child Health Nurse 1)
Overall, a lack of knowledge about a prior GDM diagnosis, which was missing in the routine postpartum information flow, was experienced as a key problem that hampers follow-up.
Regardless of professional background, all the participants were aware of women’s risk of T2DM after a GDM diagnosis, but the data reveal considerable professional uncertainty about the responsibility for reminding and supporting women to participate in follow-up screening and preventive and promotive health activities in long-term care after parturition. I do not know whether the hospital is seeing them after the birth, if they have been consulting [with] them during the pregnancy; that is not something I am aware of. (GP 1)
For women with a pregnancy complicated by GDM, the sharing of information primarily occurred during the pregnancy, creating a gap in information between hospital and primary care. I think one reason why it is complicated could be the lack of communication or handover … from the hospital … and then when they are discharged and have to be followed by GPs they are … probably lost in that gap. (GP 1)
The risk of failing to mention a GDM diagnosis due to insufficient information sharing between healthcare delivery systems and health professionals was clearly presented by the three groups involved in women’s long-term care after giving birth: GPs, GP nurses, and child health nurses.
Lack of coordination between health professionals and healthcare delivery systems
All the participants shared the understanding that GPs held the formal responsibility for the women’s long-term care and follow-up. A GP stated: Well, we are usually responsible for them as well as for most other patients. (GP 3)
Two of the participating GPs made clear that, even when they were aware of the GDM diagnosis and associated risk of developing T2DM, they rarely brought up the plan for follow-up themselves. I was aware of the increased risk of developing T2DM, but I’m not aware of any courses where you, after some time, have followed up on it. … it has been sporadic … incidental. (GP1)
Furthermore, clear information on GDM during pregnancy was needed; accordingly, all three GPs called for a detailed management plan that would make both the diagnosis and recommended follow-up visible and available to them. One GP suggested: Perhaps the hospital could somehow share information … well, a final journal note, or maybe a ‘guideline’. (GP 1)
The need for a clear guideline and management plan in women’s postpartum period was expressed by all the health professionals: Well, as we do not have a systematic approach or any standard plan to follow, I maybe understand why we do not get the information [about GDM] … it’s only the GP … this should be considered. (Child Health Nurse 1)
The professionals consistently explained that their knowledge of the GDM diagnosis was often based on remembering the medical history of the individual patient: If the women themselves do not mention it, and you kind of overlook it or just don’t remember, or if someone else has seen the patient and completed the pregnancy papers … then I think it could be missed. (GP 2)
In the postpartum period, the health professionals seemed to focus on the women’s immediate concerns rather than on the GDM diagnosis and need for follow-up.
Health professionals as resources to ensure continuity of care
All the participants contributed several suggestions for improving the care pathway for women with a GDM diagnosis. They all saw themselves and their profession as possible resources in this process and described their professional relationship with the woman as valuable and trusting. They did, however, also clearly indicate that the relationship was defined by their allocated and specialized role in the national maternity care program and, thus, by the specific context and time in which they interacted with a patient: Well, after they have given birth, I don’t really play a part. Well, of course, I know they have to attend follow-up, but I don’t really meet them until their next pregnancy. (Midwife 2)
Given that the medical condition of GDM was handled by specialists in the hospital, professionals in the primary care system would not have GDM as their main focus in antenatal and postnatal contacts with patients. The health professionals perceived their relationship with the women as being defined by their professional role, so it was limited to a short period of interaction. Thus, they pointed to the need for a designated health professional to ensure continuity in women’s care pathways by guiding them toward participation in screening and health promotive and preventive activities. A nurse in the obstetric care unit said: If only someone could lead the way for them and guide them in the right direction … we need to get them the help they need during the period in their lives when they are highly stressed as families with young children. (Nurse in the obstetric care unit)
Most of the participants stressed the importance of creating a smooth transition between hospital and primary care to ensure that women obtain health professional support. However, none of the health professionals saw themselves as having a continuing role through antepartum, postpartum, and long-term care after the birth, so nobody was able to establish long-term continuity of care.
Barriers to enhanced continuity in women’s care pathways
While all the participants felt that enhanced continuity of care was needed, they also identified several barriers, including limited consultation time for health professionals to interact with the women and a lack of financial resources to assume new tasks or develop new forms of interaction. They also noted the considerable number of assignments they already completed in their role in the national maternity care service. In the hospital care, the focus was on the specialized treatment of GDM and reduction of perinatal and maternal risks during pregnancy and birth, whereas GDM was generally out of focus in primary care consultations, both before and after birth. A midwife explained: No, I don’t [bring up the plan for follow-up during antenatal consultations]. There are thousands of other things that come first in the 20 minutes [the allocated time of an antenatal consultation], as you also must check the baby and listen to the heartbeat and all the other stuff. So, no, I don’t. (Midwife 2)
All the participants acknowledged the barriers to engaging the primary professional who has responsibility for bridging the disconnected events in the GDM care pathway. The most important perceived barrier was a lack of time during contacts and consultations.
Overall, the study participants gave signs of resistance to assuming an expanded role to ensure follow-up and enhanced continuity of care for women with a GDM diagnosis, and all the participants stressed that more resources would be needed for them to focus more on GDM.
Opportunities to support enhanced continuity of care for women with a GDM diagnosis
While all the health professionals recognized themselves as potential resources in supporting enhanced continuity of care, GPs were often singled out as the most appropriate health professionals to ensure adequate follow-up. A midwife said: No, I don’t really think it lies within our job function. … I think it’s the GP who has this function. (Midwife 2)
The GP’s clinic was seen as the most obvious place to ensure extended follow-up for the women. As the GPs have a joint role in general health services and the national maternity care program, they were perceived to be best suited to accept the role of designated health professionals. A midwife stressed: An obvious possibility could be at the child’s medical examination [at the GP’s clinic], I think. She has a medical at eight weeks postpartum, right, to have a gynecological examination. … And, afterward, it could be at the child’s annual examination that you somehow relate to the fact that mom had complications throughout the pregnancy, so thereby we would actually follow them for at least six years. (Midwife 3)
Routine postpartum consultations at the GP’s clinic could thus be used to offer women information and guidance about participation in screening and promotive and preventive health activities. The participants compared the task of following up on women with prior GDM to following up on other groups of patients in general practice; a task often undertaken by GP nurses. The potential of GP nurses to serve as designated health professionals was accentuated by the GPs: The nurses in our clinic would probably perform the test, but they could also reach out to them. (GP 3)
GP nurse 2 stated that the women themselves were responsible for follow-up, but she saw no obstacles to taking on an expanded role: It’s really just the level of information shared from the hospital to us that’s needed, because, as soon as they’re in our system, I see no challenge in making a system for them as well. We [GP nurses] do that for all our other chronically ill patients. (GP Nurse 2)
It appeared both possible and acceptable for GP nurses to set up a system that could facilitate women’s booking of timely appointments for follow-up screening and offer them individual support and an ongoing relationship with a health professional.
Discussion
The findings of this study suggest that a lack of information sharing between health professionals and healthcare delivery systems hampers continuity of care for women with prior GDM, causing a GDM diagnosis to be easily overlooked and resulting in a fragmented care pathway. Furthermore, recommendations for follow-up and professional responsibilities in the care pathway for these women are unclear. An adequate flow of information across healthcare delivery systems and enhanced coordination are needed. These goals might be achieved by introducing a management plan. Limited time and resources and a focus on care defined by specialism were identified as barriers for most professionals in taking responsibility for helping women with GDM. Increased continuity, information, and support could potentially be ensured by allocating the women a designated health professional (e.g. GP nurse).
This study confirms that the current organization of care for women with prior GDM in Denmark leaves many women with the sole responsibility for accessing follow-up care and health promotive and preventive activities, which adds to the risk of underdiagnosed and undertreated T2DM. This corroborates a recent Danish study that found that women were responsible for sharing the information of their GDM diagnosis in the postpartum period. 31 This problem may be rooted in a lack of information sharing, which makes it difficult for professionals in long-term postpartum care to identify women with prior GDM. In Denmark, encounters between health professionals and patients are recorded in databases that are specific to hospital or primary care. 4 Information about the patient is thus available across hospital and primary care only when provided in, for example, a discharge summary. An Australian study found that better information sharing was required for GPs to identify a prior GDM diagnosis during the postpartum period. 6 Similarly, the Danish study reports that GPs needed a more elaborate report on the previous information given to the women, 31 which suggests that enhancing the visibility of the GDM diagnosis may enable professionals to identify women with GDM and offer them an informed choice regarding the options for follow-up care. According to Reid et al., information sharing between health professionals and healthcare delivery systems is a key factor to ensure continuity of care. When care is delivered by several providers, management plans are particularly important in highlighting treatment approaches, treatment goals, and patient responsibilities in order to ensure continuity of care. 7 A lack of shared information across healthcare delivery systems may thus hamper continuity of care as GPs and GP nurses need information about the diagnosis to act on it. Awareness of the GDM diagnosis is therefore necessary to provide women with the support they require. However, this study found that even when the GPs had been informed of the women’s GDM diagnosis, they did not always address the need for postpartum screening and health preventive and promotive activities. The reason for this might be the uncertainty concerning the follow-up plan. This problem calls for a GDM management plan and interdisciplinary communication and coordination. The management plan would need to describe ways to share information about the women’s GDM diagnosis and coordinate the follow-up plan. Kilgour et al. found that discharge summaries are important for identifying women with prior GDM and recommended that these summaries communicate clear, concise plans for the postpartum period, including an overview of the test details. 6 A United-States-based study described a need for electronic communication to fill information gaps, beginning with prenatal care; both the women and the care providers in this study believed that the available communication was disorganized. 32 As in many other countries, the sharing of patient data between hospital and primary care in Denmark is regulated by strict data protection rules. 33 The introduction of management plans for women with GDM must therefore be rooted in a political decision, as it might require communication across the databases of diverse healthcare delivery systems to ensure coordination and continuity of care.
Smoothing the care pathway may not be sufficient to improve women’s care and health outcomes, however. The health professionals in this study identified several barriers to ensuring continuity of care, including limited time and resources. Still, time and resources may not be the main factors behind health professionals’ reluctance to address the possible consequences of GDM. For example, two studies have found that the primary focus of health professionals in primary care is to reduce stress among new mothers and address concerns about the baby and birth.32,34 Whether the obstacle is time, resources, or concern for the well-being of women and infants, the outcome remains an increased risk that women leave consultations without adequate support. As a result, women do not get the information they need to make an informed decision about follow-up and engagement in promotive and preventive health activities.
Based on the results of this study, it is further suggested that continuity through past, present, and future GDM care could be ensured by designating a health professional to help women bridge the gaps in healthcare delivery systems. This corroborates the findings of Kilgour et al., who showed that Australian women were more likely to attend the postpartum screening when health professionals addressed their need to be present. 35 A United-States-based study has also accentuated the need for a designated health professional to accept responsibility for following up on a GDM diagnosis. 32 Reid et al. found that when a health professional accepts responsibility in the ongoing relationship, relational continuity is established, which contributes to continuity of care. 7 This measure, therefore, would likely have a positive impact on women’s participation in the follow-up. Often, GP nurses know the women before their pregnancy and sometimes see them during it (e.g. for blood tests or blood pressure check-ups) and after the birth (e.g. for child vaccinations). They could thus offer continuity throughout pregnancy and in long-term care after the birth, focusing on health promotion and the prevention of T2DM, thereby improving the care pathway.
In this study, undertaken in a Danish setting, GP nurses were identified as the group best positioned to assume the role of designated health professional and ensure continuity, as they already undertake similar tasks in the GP clinic. Other professional groups employed as GP staff (e.g. nurse midwives) may be equally well equipped to take on this task. However, small GP clinics may not be able to create a new assignment unless it is accompanied by additional financial resources. Changing current practices, therefore, would require political support. Of course, the fact that the early onset and increased rates of T2DM bring considerable costs, both financially and personally,1,36 provides a weighty argument for reconsidering the existing care pathway for women with GDM and strengthening long-term continuity of care to better prevent T2DM.
Strengths and limitations
The trustworthiness of content analysis depends on the availability of rich, appropriate, and well-saturated data. 37 The trustworthiness of this study is thus validated at every stage of the research, including preparation, organization, and reporting. At the preparation stage, the authors reflected on the design and appropriateness of the methodology. At the organization stage, each transcript was read and categorized in a reiterative process in which all the authors cooperated to qualify and validate the categories and increase the confirmability of the data’s accuracy, relevance, and meaning. 38 The results were reported analytically and supported by quotations from the participants to illustrate and clarify the main categories. The analytical process was presented in Table 2 to increase transferability. The number of participants in this study may be considered a limitation. The use of purposeful intensity sampling, however, drew upon information-rich sources, with an emphasis on the information and insights of the participants. A small sample size allows the researcher to reach information power when the participants’ characteristics, experiences, and knowledge are specific to the study’s aim. 24 In the present study, the participants comprised professionals with specialized, highly relevant, up-to-date knowledge and experience. Rich and nuanced data were produced during the interviews, generating novel insights and ensuring that information power was achieved. A disadvantage of the purposeful intensity sampling strategy is that it can be difficult for the reader to judge the trustworthiness of the sample if full details are not provided. 37 The participants’ characteristics (Table 1) and the description of the sampling method were thus provided to confirm the study’s credibility. 38
Conclusion
The findings of this study exposed several challenges in the care pathway of women with GDM. Insufficient information sharing and a lack of coordination, as well as barriers such as lack of time and resources were identified as key elements affecting continuity of care.
Women’s care pathways could potentially be improved by the development of a management plan and by assigning nurses in general practice as designated health professionals, which provides an opportunity to support the women. This could promote continuity, information sharing, and patient-centered care throughout pregnancy and the postpartum period, and ensure an improvement of the current clinical practice to prevent early onset of T2DM.
