Introduction stress than necessary.(8,10) Some quantitative studies suggested


Gestational diabetes is one of the most prevalent complications of
pregnancy and its major outcomes threaten both the mother and her fetus (1).
Gestational diabetes is defined as any glucose intolerance or insulin
resistance which occurs or is diagnosed during pregnancy (2-3). The prevalence
of gestational diabetes in the United States varies between 7% and 18% (2). In
Iran, the prevalence of this disorder has been reported as 4.9% (3).
Gestational diabetes is accompanied by many complications, such as hypertension
during pregnancy, increase in the rate of cesarean delivery, preterm labor, and
increase in amniotic fluid. Diabetes
mellitus has a strong relationship with stress and nervous tensions; therefore, stress,
inappropriate nutrition, obesity, and inactivity are considered as the undeniable risk
factors of this disease

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Although pregnancy can be a positive experience for many women, a
variety of biomedical and social factors may make it a time of stress .(5-7)

Stress and anxiety in a gestational diabetes (GDM) pregnancy have been
investigated in the literature to exam whether the GDM diagnosis could affect
how women perceive their health and therefore create more stress than

Some quantitative studies suggested that the stress and anxiety levels
in women at diagnosis were no different compared to women with a normal
pregnancy or that they declined and became similar to the levels in a normal
pregnancy group by the end of the pregnancy. (8, 9 ,10)

It is logical to assume that after GDM diagnosis, dietary modifications
could increase the stress and anxiety levels of these women. A number of
qualitative studies on women’s experiences with GDM revealed that emotional
distress and a sense of losing control in this group were related to being
unable to achieve blood glucose targets, difficulties in following dietary and
exercise advice, or insulin injection.


Anxiety disorders are common and most frequent among all other
psychiatric disorders. They bear a substantial “risk” and inability load,
comparable to what is observed in chronic diseases, such as diabetes mellitus (11, 12). Research has shown that the relation between depression, anxiety
disorders and diabetes is bound to hyperglycaemia, diabetes complication and
restraints imposed by the disease (13,14). The occurrence of depression in individuals with diabetes
mellitus seems to be related to socio-economic status, (15) family status, (16) obesity, (17) smoking habits, (18) physical
activity, (19) and sedentary life.

Physical and mental stress raises blood sugar level and inhibits
insulin release in the body eventually leading to diabetes (20). One of the
best treatment strategies to decrease stress and mental disorders of the women
with gestational diabetes is using relaxation in order to improve their
physical, psychological, and social functions. Relaxation gives the patients a
feeling that the treatment has been effective and the disease is getting
improved. It also reduces the blood glucose level (21). Moreover, relaxation
increases the secretion of endorphins or analgesic hormones, but reduces the
secretion of adrenaline hormone (22). Furthermore, it improves blood
circulation and reduces anxiety and depression by creating more positive
attitudes and improving brain function. Consequently, it increases the cellular
energy and one’s confidence (23). Relaxation is a method which can make changes
in physical and emotional conditions and can, subsequently, reduce
stress-induced behaviors (24).

The effects of relaxation on improvement of diabetes mellitus have
been noted in several studies (25-29).

Since the effect of relaxation on diabetes has not been confirmed
in all the related studies and diabetes mellitus type 2, rather than
gestational diabetes, has been investigated in most of them, the current study
aims to evaluate the effect of relaxation on
anxiety level of the women with gestational diabetes.

Materials and Methods

The present controlled clinical trial was performed on 58 pregnant
women with gestational diabetes who had referred to Hafez hospital, Shiraz,
Iran. The study lasted for 3 months from February to April 2013. The inclusion
criteria of the study were having gestational diabetes, not using insulin
injection and psychiatric medications, having no history of previous
relaxation, being 18 to 40 years old, gestational age of 24 to 30 weeks, and
not changing their diet or physical activity during the study. On the other
hand, the exclusion criteria of the study were unwillingness to cooperate in
any stage of the study, being absent in more than one session of the training
classes, not doing relaxation exercises at home for more than 5 days, and
having pregnancy complications during the study.

Based on the previous studies (30-32), considering the error of 5%,
power of 80%, and effect size of 45%, and using the following formula: , a 50-subject sample size (25 ones in each group) was
determined for the study. Nevertheless, considering the loss rate of 10%,
longitudinal nature of the study, and repeated measurements, the sample size
was increased to 58 subjects (29 in each group) using the following formula: .

The study samples were divided into a control and an intervention
group using the table of random numbers and permutation block randomization.
During the research, 11 patients, 8 in the intervention group and 3 in the
control group, were excluded from the study due to preterm labor and not
attending the training classes. After all, the study continued with 58
patients, 29 in each group. The study data were collected using a general
information questionnaire, including demographic characteristics, history of
pregnancy, and family history of diabetes, a relaxation chart including
questions about the frequency, length, and time of relaxation, and a form for
recording of level of anxiety.


In the intervention group, relaxation training was conducted for 3
weeks in the form of five 45-minute sessions both theoretically and practically
along with discussion as well as question and answer. The first session of the
intervention included training on the nature and mechanism of diabetes,
explaining the nature of stress and its effect on body, identifying the
stressors in pregnancy, and understanding the concept of relaxation. In second
session, different breathing techniques and body positions during relaxation
were taught. The third session was about how to relax the muscles in various
parts of the body after stress. The fourth session was about relaxation through
conditioning. Finally, the fifth session was concerned with training of
differential relaxation and relaxation along with the positive mental imagery.
From the second session, all the exercises were done practically. The training
was done alike for all the patients in a relaxed environment with air
conditioning and proper lighting. The principles of Herbert Benson were used in
this method (33).

The patients were encouraged by the researcher to practice
relaxation techniques at home for a month. They were also provided with a chart
for recording relaxation exercises to evaluate their performance as well as a
CD with soft music background about how to do relaxation. They were also
contacted through telephone by the researcher three times a week. The control
group, on the other hand, continued its prior treatment.

Data collection instruments included a demographic
questionnaire, and the Spielberg’s state anxiety inventory.

This test consists of two distinct hidden and obvious sections (In this
study, anxiety inventory was used). This
section included 20 obvious expressions of apparent anxiety. Meaning of obvious anxiety The person’s feelings were at that moment.

scores of apparent anxiety scores ranged from 80 to 20. After the conclusion 

obtained from the research units, In
anxious groups With a score of above 43 The non-anxious group was classified
with a
Score lower than 43.

After completing the consent forms, taking the Ethics Committee
code of 92-6614, and registering the study at IRCT with code of 2013091014612
N1, the samples were entered into the study.

collection instruments included a demographic questionnaire, and the Spielberg’s
state anxiety inventory. anxiety level measured in both groups before , immediately after and one month after the intervention. Then, the data were entered into
the SPSS statistical software (v. 16) and analyzed using Chi square test, Repeated Measure Paired
sample t test.


,were used to compare the variables in the two
groups.Researchers have indicated that when people have nervous tensions, stress
hormones including cortisol, catecholamines, glucagon, and growth hormone are
secreted. These four hormones increase blood sugar. When stress increases, body
reacts to the condition by increasing the secretion of some hormones eventually
providing a large amount of energy (glucose and lipid) for the cells. In
diabetic patients, such a coping response does not work properly and the amount
of insulin is not enough for taking the extra energy into the cells; therefore,
glucose increases in blood (34). Hence, signs of stress are more detectable in
the individuals suffering from diabetes (35).

Roy (1993) and Chan (2002) reported an increase in the activity of
hypothalamus-pituitary-adrenal axis in the patients with diabetes (36,37).

There were limited quantitative studies in the literature that measured
stress and anxiety levels in women with GDM. (38 ,39 ,40)

One study reported that the diagnosis of GDM did not have an adverse
effect on emotional status compared to the emotional status in a normal
pregnancy population. (40)Langer and Langer reported that insulin use did not
have significant negative mood impact on women with GDM compared to diet

Another study reported that the anxiety
level at GDM diagnosis was higher but declined toward the end of the pregnancy
and became similar to the anxiety level in a normal pregnancy group.

In the Mcginnis relaxation
study, there is also a tremendous effect on type 2 diabetes. In the study, McGrady
also showed the role of relaxation on the anxiety level of diabetic patients
who are dependent on insulin.(41,42)


Several other studies have also been
carried out on the effectiveness of relaxation in chronic pains, migraine
headaches, heart diseases, and inflammatory bowel diseases. The positive effect
of relaxation has been confirmed in all these studies (43-45).

the study by Jalbon et al., the treatment was carried out for less than one
month and relaxation was performed on the subjects with low stress levels. (46)



on the findings of the current study, it seems that relaxation has been
effective in controlling anxiety. It can be concluded that all methods of
relaxation can have similar outcomes, but what is certain is that Benson’s
technique is more applicable because of its simplicity and ease of use. Since
stress management is one of the important elements of diabetes metabolic
control, relaxation training classes from the very first weeks of pregnancy can
be effective in this regard. Further studies with larger sample

sizes and longer follow-up periods are recommended to
be conducted on the issue