Gestational Diabetes Mellitus: Overview and Risk Factors

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PhD in Nutrition Sciences
 
Faculty  and Institute of Nutrition and Food Technology, Shahid
Beheshti University of Medical Sciences
 
Medical Nutrition Therapy in
Gestational Diabetes Mellitus
 
Definition & Worldwide Prevalence of GDM
2
 
GDM
 is defined as any degree of glucose
    intolerance with onset or first recognition
    during pregnancy
 
Approximately 
7%
 of all pregnancies are complicated  by
GDM
 
ranging from 
1 to 14% 
depending on
the population studied
 the diagnostic tests
 
more than 
more than 
200,000
200,000
 
 
cases annually
 
Diabetes care, 2009
 
Prevalence of GDM in Iran
3
 
According to 14 studies from 1992-2007, the
prevalence of GDM ranged between 
1.3%
 
 
to
to
 
 
10%
in different regions of 
Iran
.
 
Khoshniat, 2009
 
 
Dr. Mirmiran / SBMU
Slide 4
 
 
Khoshniat N, Iranian Journal of Diabetes and Lipid Disorders; 2009
Khoshniat N, Iranian Journal of Diabetes and Lipid Disorders; 2009
 
Pathophysiology
5
 
 
 In first trimester and early second trimester, increased
insulin sensitivity occurs due to relatively higher levels of
estrogen.
 
 in late second and early third trimesters, increased insulin
resistance and reduced sensitivity due to a number of
antagonistic hormones especially, 
placental lactogen
, 
leptin
,
progesterone
, 
prolactin
, 
cortisol 
and 
adiponectin
.
 
 
Risk Factors for Development of GDM
6
 
Cheung,2009
 
 Age >25years
 
• BMI >25kg/m²
 
• Increased weight gain during pregnancy
 
• Previous history of large for gestational age infants
 
• History of GDM during previous pregnancies
• Ethnic group ( East Asian, Pacific Island ancestry)
 
• Elevated fasting or random blood glucose levels during pregnancy
 
 • Family history of diabetes in first degree relatives
 
 • History of type I or type II Diabetes Mellitus
 
GDM 
Complication
7
 
   
   
Adverse Pregnancy Outcomes
Adverse Pregnancy Outcomes
:
 
 macrosomia
 shoulder dystocia
 Jaundice
 polycythemia
 respiratory distress
 Hypocalcemia
 Risk of developing diabetes later in life
 
Cheung,2009
 
GDM Complication
8
 
Maternal Complication
Maternal Complication
 
:
 
Weight gain
 Maternal 
hypertensive disorders
 Miscarriages
 Third trimester fetal deaths
 Cesarean delivery (due fetal growth disorders)
 Long term 
risk of type 2 diabetes mellitus
 
Cheung,2009
9
 
Screening should be done during the 
24th to 28th 
week of
pregnancy using a 100-g oral glucose tolerance test (OGTT).
 
Fasting glucose 
of more than 
92 mg/dL
I-hour glucose 
of more than 
180 mg/dL
2-hour glucose 
of 
153 mg/dL 
or more
3-hour glucose 
of 
140 mg/dL 
or more
 
GDM Screening
10
 
The results of recent systematic reviews showed that adherence to
a 
healthier dietary pattern
, like 
Mediterranean
 dietary pattern,
and reducing the intake of sugar sweetened cola, potatoes, fatty
foods, sweets can 
decrease
 the incidence of 
GDM
, especially in
women at higher risk and before getting pregnant.
 
Maternal Dietary Patterns and GDM
 
D. A. Schoenaker, 2016
11
 
Western dietary pattern 
was high in sweets, jams, mayonnaise, soft drinks, salty snacks,
solid fat, high-fat dairy products, potatoes, organ meat, red meat, processed foods.
Western dietary pattern was associated with 
increased risk 
of 
GDM
.
12
 
 
Medical Nutrition Therapy
Medical Nutrition Therapy
(MNT) in GDM
(MNT) in GDM
 
Medical Nutrition Therapy (MNT)
13
 
 
The 
American Diabetes Association 
recommends that all
women with GDM receive nutrition counseling by a registered
dietitian (RD).
 
MNT is the 
primary therapy
 
for 
30 –90% 
of women diagnosed
with GDM.
 
Individualization of MNT depending on maternal  weight and
height, physical activity level, and lifestyle is recommended.
 
 
 
 
Reader,2007
 
Medical Nutrition Therapy 
(cont’)
14
 
Goals
:
Achieve 
normoglycemia
normoglycemia
 
    Recommended treatment targets
 
 
 
ADA,2004
15
 
Goals
:
 
Providing the 
required nutrients 
for 
normal
 
fetal
growth 
and 
maternal health.
 
Prevent excessive maternal weight gain
, particularly
in women who are overweight or have gained excess weight
in pregnancy.
 
Prevent ketosis.
 
Medical Nutrition Therapy 
(cont’)
 
Medical Nutrition Therapy 
(cont’)
16
 
Include:
Nutrition therapy
Exercise
Self-monitoring of blood glucose (SMBG)
Pharmacologic therapy
Education
 
17
 
Nutrition
Nutrition
 Therapy
 Therapy
 
Efficacy of Dietary Therapy for GDM
18
 
Nutrition
 intervention for GDM has been recognized as the
cornerstone of therapy.
 
In patients receive diet therapy:
In patients receive diet therapy:
Fewer patients require insulin therapy
Decrease HbA1c
lower serious perinatal complications among the infants:
 lower perinatal mortality
 lower % large-for-gestational-age
 Less macrosomia
 
Crowther ,2005, Reader,2006, 
Cheung,2009
 
Nutrition Therapy 
(cont’)
19
 
All women should receive 
individualized counseling
individualized counseling
 
Food plan 
Food plan 
should be 
individualized
individualized
 
 
& 
culturally appropriate
culturally appropriate
 
Cheung,2009
to provide adequate calories & nutrients
to meet
the needs of pregnancy and consistent
with the blood glucose goals
 
Nutrition Therapy 
(cont’)
20
 
“Do the Institute of Medicine and other
recommendations for weight gain and
calorie intake apply to the woman with
GDM?”
 
    
Weight gain during pregnancy for women with
GDM should be similar to that of women without
diabetes”
 
Reader,2007
21
 
weight-gain recommendations based on
prepregnancy BMI
 
Nutrition Therapy 
Nutrition Therapy 
(cont’)
 
(Institute of Medicine’s Nutrition for  Pregnancy 1990)
 
Nutrition Therapy 
(cont’)
22
 
Overweight and obese women
:
Severe calorie restriction 
<1500 
calories per day or 50%
restriction increases 
ketonuria
 and 
ketonemia
.
 
American Diabetes Association have suggested:
 
 
ADA,2000
 
Nutrition Therapy 
(cont’)
23
 
Calorie formulas 
have been suggested in articles and guidelines for
GDM:
 35–40 kcal/kg
  
for underweight
 
 30 –35 kcal/kg for normal weight
 
 25–30
 
kcal/kg for overweight
 
 23–25 kcal/kg 
(pregravid weight)
 for
obese
 
Reader,2007
 
Nutrition Therapy 
(cont’)
24
 
Macronutrient Intake
 
Carbohydrate
Carbohydrate
 
 
(CHO)
(CHO)
:
:
 
 
50 to 55% 
50 to 55% 
kcal intake
 
Protein
Protein
:
 
20-25
20-25
 
%
%
 kcal intake
 
Fat
Fat
:
 
25-30%
25-30%
 kcal intake
 
Cheung,2009
 
Nutrition Therapy 
(cont’)
25
 
Carbohydrate
 
The 2002 Dietary Reference Intake Report set a minimum
level of 
130 g/day 
for 
non-pregnant
 women and 
175
g/day
 
for 
pregnancy
; this is an additional 45 g
carbohydrate for fetal brain development and functioning.
An 
evening snack 
is usually needed to prevent accelerated
ketosis overnight.
 
Cheung,2009
 
Nutrition Therapy 
(cont’)
26
 
Carbohydrate
 
Carbohydrates are not as well tolerated at 
breakfast
 as
they are at other meals because of increased levels of
cortisol
 and 
growth hormones
.
 
Initial food plan may have 
approximately 30 g of
carbohydrate
 
at breakfast. To satisfy hunger, 
protein
foods 
can be added because they do not affect blood
glucose levels.
 
Cheung,2009
 
Nutrition Therapy 
(cont’)
 
Dr. Mirmiran / SBMU
27
 
CHO
 are an important dietary source of energy, vitamins,
minerals & fiber content.
 
CHO
 is the main nutrient that affects postprandial glucose
levels.
 
CHO
CHO
 intake can be manipulated by:
 intake can be manipulated by:
 
Controlling the total 
amount of 
amount of 
CHO
CHO
 
 
Distribution of 
Distribution of 
CHO
CHO
 
 
over several
   
 meals and snacks
  
  
Type of 
Type of 
CHO
CHO
 
Reader,2007
 
Nutrition Therapy 
(cont’)
28
 
The ADA Standards of Medical Care state :
 
Glycemic Index (GI) 
Glycemic Index (GI) 
can provide additional benefit to
total carbohydrate control
 
GI =  (iAUC
test food
/iAUC
glucose
) x 100
 
Foods with a 
low GI (<55)
low GI (<55)
        produce a 
lower postmeal glucose 
elevation
 
Foods with a 
high GI (>70)
high GI (>70)
        show 
higher postprandial glucose 
values
 
Reader,2007
 
Nutrition Therapy 
(cont’)
29
 
Glycemic load (GL)
Glycemic load (GL)
 
GL
Food
 = GI
Food
 x amount (g) of available
carbohydrate
Food
 per serving/100
 
high
 with 
GL≥20
intermediate
 with 
GL of 11-19
low
 with 
GL≤10
 
Reader,2007
 
Nutrition Therapy 
(cont’)
30
 
The 
glycemic index 
may have some benefits, but may be problematic as
well. Concerns include:
 
Single food items, rather than combinations of foods, can impact blood
sugar differently
 
Doesn't consider all variables that affect blood sugar, such as how food
is prepared or 
how much is eaten
 
Only includes foods that contain carbohydrates
 
Doesn't rank foods based on nutrient content, foods with a low GI
ranking may be high in calories, sugar or saturated fat.
 
Nutrition therapy 
(cont’)
31
 
Nutrition therapy 
(cont’)
32
 
Nutrition Therapy 
(cont’)
33
 
10 Low-Glycemic Fruits for Diabetes
 
Cherries (GI:20, GL:6)
Grapefruit (GI:25, GL:3)
Dried apricot (GI:32, GL:9)
Pears (GI:38, GL:4)
Apples (GI: 39, GL:5)
Oranges (GI:40, GL: 5)
Plums (GI: 40, GL: 2)
Strawberries (GI:41, GL:3)
Peaches (GI: 42, GL: 5)
Grapes (GI: 53, GL: 5)
 
 
Nutrition Therapy 
(cont’)
GI
 
or
 GL?
Though the 
GL
 of 
watermelon
 is low, be sure to
balance any meals containing 
watermelon
 with low-
GI
foods to minimize any potential blood sugar spikes.
34
 
Watermelon
 
GI: 72, 
GL: 2
 
Nutrition Therapy 
(cont’)
35
 
Choose complex CHO contain
 
Fiber
:
 
Soluble
Soluble
 (legumes, oats, oat bran, barley, nuts, fruits)
Insoluble
Insoluble
 (whole grain breads, cereals and some vegetables, seeds)
 
Both
:
 
 
Increase satiety
Increase satiety
 
Slowing absorption time
Slowing absorption time
 Lower glycemic index
 Lower glycemic index
 
 
 
Reader,2007
 
Nutrition Therapy 
(cont’)
36
 
Carbohydrate Counting
 
Works as follows:
  A dietitian 
determines a person’s dietary needs
determines a person’s dietary needs
  The individual is given a 
daily CHO allowance
daily CHO allowance
  Divided into a pattern of 
meals & snacks
meals & snacks
     according to individual preferences
  The carbohydrate allowance can be expressed in
     
grams or as the number of carbohydrate     portions
grams or as the number of carbohydrate     portions
allowed 
allowed 
per meals
per meals
 
Nutrition Therapy 
(cont’)
37
 
Carbohydrate Counting
 
Emphasis is given to spreading the dietary intake over 
six
meals daily
:
 
3 main meals
3 snacks
 
 Distribution of CHO in daily meals
 Distribution of CHO in daily meals
 
Nutrition Therapy 
(cont’)
38
 
Nutrition Therapy 
(cont’)
39
 
Example: 35 year old woman diagnosed with GDM, at weeks 28 of her
pregnancy,
Pre-pregnancy weight: 90, height 1.70, BMI:  31
 
The nutrition prescription is the following:
Calories:
 
2000
Carbohydrates
 (50%): 
250 g
Protein
 (20%): 
100 g
Fat
 (30%): 
66 g
 
 
Nutrition Therapy 
(cont’)
40
 
Fat intake:
 
 
 
Less than 10 %
Less than 10 %
 
 
SFA (
SFA (
animal fat contained in cuts of
meat; dairy products, such as milk, butter and cheeses; and
the skin of chicken, turkey, and other poultry)
 
 
Up to 10 %
Up to 10 %
 
PUFA
PUFA
  (are found in fish, soybean products,
walnuts, and flaxseeds.)
 The 
remainder
remainder
 derived from
 
 
MUFA (
MUFA (
are found in
avocados, nuts, seeds, olive oil, canola oil, and peanut butter.)
 
Cheung,2009
 
Nutrition Therapy 
(cont’)
41
 
Protein intake:
Protein intake:
 
Dietary proteins and amino acids are important modulators of
glucose metabolism, and a diet high in 
protein
 may impact
glucose homeostasis 
by promoting 
insulin resistance 
and
increasing 
gluconeogenesis
.
 
Most protein sources don’t have carbohydrates and won’t raise
blood sugar, but be sure to check vegetarian sources of protein,
such as 
beans and legumes
, which can 
contain carbohydrates
.
 
Cheung,2009
 
Nutrition Therapy 
(cont’)
42
 
Nutrient needs
 
There is 
no indication 
no indication 
that women with GDM should not
follow the 
same guidelines 
same guidelines 
for nutrient intakes 
for all
for all
pregnant women
pregnant women
(
Dietary Reference Intakes for pregnancy 2001)
Dietary Reference Intakes for pregnancy 2001)
 
Reader,2007
 
Nutrition therapy 
(con’t)
43
 
 
Exercise
44
 
Exercise
Exercise
 is an 
obvious adjunct therapy
obvious adjunct therapy
 
to MNT for women
with GDM to improve maternal glycemia.
 
 
light and moderate 
light and moderate 
intensity activities 
intensity activities 
such as walking for
20–30 min/day:
 
 can be 
safely encouraged
safely encouraged
,
modest improvements in glycemic control might be
achieved
 
Reader,2007
 
Recommendations
45
 
Breakfast Tips:
 
Eat a small breakfast.
 
Eat whole-grain bread products.
 
Eat a food that has protein. This will help you to: feel full, get enough protein for you
and your baby, control your blood sugar.
 
Do not eat cereal or fruit.
 
Do not drink fruit juice at breakfast or any other time of the day. Fruit juice raises
your blood glucose very quickly.
 
 
 
Recommendations
46
 
Fat Tips:
 
Fat contains calories to help supply energy to you and your baby. Fat helps your
body absorb 
vitamins A, D, E and K
. Fat also gives you 
essential fatty acids
, which
help your 
baby's brain
 and nervous system develop.
 
It is important to focus on eating healthful fats. The following foods are good
sources of 
healthful fats
:
 
Most nuts and seeds
Peanut butter (natural or trans fat-free)
Cooking oils (olive, canola, peanut or flaxseed)
Avocados
Fatty fish (salmon or trout)
 
 
 
Recommendations
47
 
Tips to remember:
 
If you are hungry, add vegetables or a protein food to your
carbohydrate snacks.
 
Focus on eating healthful fats.
 
If your blood glucose is high when you wake up, have a 
bedtime
snack 
that includes both protein and carbohydrates. This will help
keep your blood glucose in check during the night.
 
 
CONCLUSIONS
48
 
Women with GDM (and women with preexisting diabetes) should
be encouraged to breastfeed because 
breastfeeding
 is associated
with a reduced 
incidence of future T2DM 
(Stuebe, 2005).
 
For women with GDM who are overweight or obese or with
above-recommended weight gain during pregnancy, weight loss is
advised after delivery.
 
Weight loss 
reduces the 
risks of recurrent GDM 
or future
development of 
T2DM.
 
CONCLUSIONS
49
 
The food plan should be designed to:
 
Fulfill
Fulfill
 
 
minimum nutrient requirements 
for  pregnancy
for  pregnancy
 
Achieve glycemic goals 
Achieve glycemic goals 
without 
weight loss 
and
ketonemia
 
Be
Be
 
 
culturally appropriate 
and
and
 
 
individualized
 
 
to take
to take
into account the 
into account the 
patient’s body habitus
patient’s body habitus
, 
, 
weight gain
weight gain
, and
, and
physical activity
physical activity
 
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Gestational Diabetes Mellitus (GDM) is defined as any level of glucose intolerance first detected during pregnancy, affecting approximately 7% of pregnancies globally. In Iran, GDM prevalence varies between 1.3% to 10%. Factors like age, BMI, weight gain, and family history influence GDM development. Pathophysiological changes in insulin sensitivity occur throughout pregnancy due to hormonal fluctuations. Understanding these aspects is crucial for managing GDM effectively.


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  1. Medical Nutrition Therapy in Gestational Diabetes Mellitus Gestational Diabetes Mellitus Dr. Fatemeh Sedaghat PhD in Nutrition Sciences Faculty and Institute of Nutrition and Food Technology, Shahid BeheshtiUniversity of Medical Sciences

  2. Definition & Worldwide Prevalence of GDM Definition & Worldwide Prevalence of GDM GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy Approximately 7% of all pregnancies are complicated by GDM ranging from 1 to 14% depending on the population studied the diagnostic tests more than 200,000 cases annually Diabetes care, 2009 2

  3. Prevalence of GDM in Iran Prevalence of GDM in Iran According to 14 studies from 1992-2007, the prevalence of GDM ranged between 1.3% to 10% in different regions of Iran. 3 Khoshniat, 2009

  4. Khoshniat N, Iranian Journal of Diabetes and Lipid Disorders; 2009 Dr. Mirmiran / SBMU Slide 4

  5. Pathophysiology Pathophysiology In first trimester and early second trimester, increased insulin sensitivity occurs due to relatively higher levels of estrogen. in late second and early third trimesters, increased insulin resistance and reduced sensitivity due to a number of antagonistic hormones especially, placental lactogen, leptin, progesterone, prolactin, cortisol and adiponectin. 5

  6. Risk Factors for Development of GDM Risk Factors for Development of GDM Age >25years BMI >25kg/m Increased weight gain during pregnancy Previous history of large for gestational age infants History of GDM during previous pregnancies Ethnic group ( East Asian, Pacific Island ancestry) Elevated fasting or random blood glucose levels during pregnancy Family history of diabetes in first degree relatives History of type I or type II Diabetes Mellitus 6 Cheung,2009

  7. GDM GDM Complication Complication Adverse Pregnancy Outcomes: macrosomia shoulder dystocia Jaundice polycythemia respiratory distress Hypocalcemia Risk of developing diabetes later in life 7 Cheung,2009

  8. GDM Complication GDM Complication Maternal Complication : Weight gain Maternal hypertensive disorders Miscarriages Third trimester fetal deaths Cesarean delivery (due fetal growth disorders) Long term risk of type 2 diabetes mellitus 8 Cheung,2009

  9. GDM Screening GDM Screening Screening should be done during the 24th to 28th week of pregnancy using a 100-g oral glucose tolerance test (OGTT). Fasting glucose of more than 92 mg/dL I-hour glucose of more than 180 mg/dL 2-hour glucose of 153 mg/dL or more 3-hour glucose of 140 mg/dL or more 9

  10. Maternal Dietary Patterns and GDM Maternal Dietary Patterns and GDM The results of recent systematic reviews showed that adherence to a healthier dietary pattern, like Mediterranean dietary pattern, and reducing the intake of sugar sweetened cola, potatoes, fatty foods, sweets can decrease the incidence of GDM, especially in women at higher risk and before getting pregnant. 10 D. A. Schoenaker, 2016

  11. Western dietary pattern was high in sweets, jams, mayonnaise, soft drinks, salty snacks, solid fat, high-fat dairy products, potatoes, organ meat, red meat, processed foods. Western dietary pattern was associated with increased risk of GDM. 11

  12. Medical Nutrition Therapy Medical Nutrition Therapy (MNT) in GDM (MNT) in GDM 12

  13. Medical Nutrition Therapy (MNT) Medical Nutrition Therapy (MNT) The American Diabetes Association recommends that all women with GDM receive nutrition counseling by a registered dietitian (RD). MNT is the primary therapy for 30 90% of women diagnosed with GDM. Individualization of MNT depending on maternal weight and height, physical activity level, and lifestyle is recommended. 13 Reader,2007

  14. Medical Nutrition Therapy Medical Nutrition Therapy (cont ) (cont ) Goals: Achieve normoglycemia Recommended treatment targets Test Gestational Diabetes (mg/dl) Fasting plasma glucose 65-95 I hr postprandial <140 2 hr postprandial <120 14 ADA,2004

  15. Medical Nutrition Therapy (cont) Goals: Providing the required nutrients for normalfetal growth and maternal health. Prevent excessive maternal weight gain, particularly in women who are overweight or have gained excess weight in pregnancy. Prevent ketosis. 15

  16. Medical Nutrition Therapy Medical Nutrition Therapy (cont (cont ) ) Include: Nutrition therapy Exercise Self-monitoring of blood glucose (SMBG) Pharmacologic therapy Education 16

  17. Nutrition Nutrition Therapy Therapy 17

  18. Efficacy of Dietary Therapy for GDM Efficacy of Dietary Therapy for GDM Nutrition intervention for GDM has been recognized as the cornerstone of therapy. In patients receive diet therapy: Fewer patients require insulin therapy Decrease HbA1c lower serious perinatal complications among the infants: lower perinatal mortality lower % large-for-gestational-age Less macrosomia 18 Crowther ,2005, Reader,2006, Cheung,2009

  19. Nutrition Therapy Nutrition Therapy (cont (cont ) ) All women should receive individualized counseling Food plan should be individualized & culturally appropriate to provide adequate calories & nutrients to meet the needs of pregnancy and consistent with the blood glucose goals 19 Cheung,2009

  20. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Do the Institute of Medicine and other recommendations for weight gain and calorie intake apply to the woman with GDM? Weight gain during pregnancy for women with GDM should be similar to that of women without diabetes 20 Reader,2007

  21. Nutrition Therapy Nutrition Therapy (cont ) (cont ) weight-gain recommendations based on prepregnancy BMI ) BMI (kg/m2 weight-gain (kg) Underweight 18.5 normal 18.5 25.0 overweight 25 29.9 Obese >29 12-18 11.3 15.3 kg 6.8 11.3 kg 7 kg 21 (Institute of Medicine s Nutrition for Pregnancy 1990)

  22. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Overweight and obese women: Severe calorie restriction <1500 calories per day or 50% restriction increases ketonuria and ketonemia. American Diabetes Association have suggested: 22 ADA,2000

  23. Nutrition Therapy Nutrition Therapy (cont (cont ) ) Calorie formulas have been suggested in articles and guidelines for GDM: 35 40 kcal/kg for underweight 30 35 kcal/kg for normal weight 25 30 kcal/kg for overweight 23 25 kcal/kg (pregravid weight) for obese 23 Reader,2007

  24. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Macronutrient Intake Carbohydrate (CHO):50 to 55% kcal intake Protein:20-25% kcal intake Fat:25-30% kcal intake 24 Cheung,2009

  25. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Carbohydrate The 2002 Dietary Reference Intake Report set a minimum level of 130 g/day for non-pregnant women and 175 g/day for pregnancy; this is an additional 45 g carbohydrate for fetal brain development and functioning. An evening snack is usually needed to prevent accelerated ketosis overnight. 25 Cheung,2009

  26. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Carbohydrate Carbohydrates are not as well tolerated at breakfast as they are at other meals because of increased levels of cortisol and growth hormones. Initial food plan may have approximately 30 g of carbohydrate at breakfast. To satisfy hunger, protein foods can be added because they do not affect blood glucose levels. 26 Cheung,2009

  27. Nutrition Therapy Nutrition Therapy (cont ) CHO are an important dietary source of energy, vitamins, minerals & fiber content. CHO is the main nutrient that affects postprandial glucose levels. (cont ) CHO intake can be manipulated by: Controlling the total amount of CHO Distribution of CHO over several meals and snacks Type of CHO Dr. Mirmiran / SBMU 27 Reader,2007

  28. Nutrition Therapy Nutrition Therapy (cont ) (cont ) The ADA Standards of Medical Care state : Glycemic Index (GI) can provide additional benefit to total carbohydrate control GI = (iAUCtest food/iAUCglucose) x 100 Foods with a low GI (<55) produce a lower postmeal glucose elevation Foods with a high GI (>70) show higher postprandial glucose values 28 Reader,2007

  29. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Glycemic load (GL) GLFood = GIFood x amount (g) of available carbohydrateFood per serving/100 high with GL 20 intermediate with GL of 11-19 low with GL 10 29 Reader,2007

  30. Nutrition Therapy Nutrition Therapy (cont ) (cont ) The glycemic index may have some benefits, but may be problematic as well. Concerns include: Single food items, rather than combinations of foods, can impact blood sugar differently Doesn't consider all variables that affect blood sugar, such as how food is prepared or how much is eaten Only includes foods that contain carbohydrates Doesn't rank foods based on nutrient content, foods with a low GI ranking may be high in calories, sugar or saturated fat. 30

  31. Nutrition therapy (cont) 31

  32. Nutrition therapy (cont) 32

  33. Nutrition Therapy Nutrition Therapy (cont (cont ) ) 10 Low-Glycemic Fruits for Diabetes Cherries (GI:20, GL:6) Grapefruit (GI:25, GL:3) Dried apricot (GI:32, GL:9) Pears (GI:38, GL:4) Apples (GI: 39, GL:5) Oranges (GI:40, GL: 5) Plums (GI: 40, GL: 2) Strawberries (GI:41, GL:3) Peaches (GI: 42, GL: 5) Grapes (GI: 53, GL: 5) 33

  34. Nutrition Therapy Nutrition Therapy (cont ) (cont ) GI GI or or GL? GL? Though the GL balance any meals containing watermelon foods to minimize any potential blood sugar spikes. GL of watermelon watermelon is low, be sure to watermelon with low-GI GI WatermelonGI: 72, GL: 2 34

  35. Nutrition Therapy Nutrition Therapy (cont (cont ) ) Choose complex CHO contain Fiber: Soluble (legumes, oats, oat bran, barley, nuts, fruits) Insoluble (whole grain breads, cereals and some vegetables, seeds) Both: Increase satiety Slowing absorption time Lower glycemic index 35 Reader,2007

  36. Nutrition Therapy Nutrition Therapy (cont (cont ) ) Carbohydrate Counting Works as follows: A dietitian determines a person s dietary needs The individual is given a daily CHO allowance Divided into a pattern of meals & snacks according to individual preferences The carbohydrate allowance can be expressed in grams or as the number of carbohydrate portions allowed per meals 36

  37. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Carbohydrate Counting Emphasis is given to spreading the dietary intake over six meals daily: 3 main meals 3 snacks Distribution of CHO in daily meals meals Breakfast Snack1 Lunch Snack2 Dinner Snack3 CHO% 15% 12.5% 25% 12.5% 25% 10% 37

  38. Nutrition Therapy Nutrition Therapy (cont ) (cont ) 38

  39. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Example: 35 year old woman diagnosed with GDM, at weeks 28 of her pregnancy, Pre-pregnancy weight: 90, height 1.70, BMI: 31 The nutrition prescription is the following: Calories: 2000 Carbohydrates (50%): 250 g Protein (20%): 100 g Fat (30%): 66 g Meals Breakfast Snack1 Lunch Snack2 Dinner Snack3 CHO% 15% 12.5% 25% 12.5% 25% 10% gram 38 32 62 32 62 25 39

  40. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Fat intake: Less than 10 % SFA (animal fat contained in cuts of meat; dairy products, such as milk, butter and cheeses; and the skin of chicken, turkey, and other poultry) Up to 10 % PUFA (are found in fish, soybean products, walnuts, and flaxseeds.) The remainder derived from MUFA (are found in avocados, nuts, seeds, olive oil, canola oil, and peanut butter.) 40 Cheung,2009

  41. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Protein intake: Dietary proteins and amino acids are important modulators of glucose metabolism, and a diet high in protein may impact glucose homeostasis by promoting insulin resistance and increasing gluconeogenesis. Most protein sources don t have carbohydrates and won t raise blood sugar, but be sure to check vegetarian sources of protein, such as beans and legumes, which can contain carbohydrates. 41 Cheung,2009

  42. Nutrition Therapy Nutrition Therapy (cont ) (cont ) Nutrient needs There is no indication that women with GDM should not follow the same guidelines for nutrient intakes for all pregnant women (Dietary Reference Intakes for pregnancy 2001) 42 Reader,2007

  43. Nutrition therapy (cont) 43

  44. Exercise Exercise Exercise is an obvious adjunct therapy to MNT for women with GDM to improve maternal glycemia. light and moderate intensity activities such as walking for 20 30 min/day: can be safely encouraged, modest improvements in glycemic control might be achieved 44 Reader,2007

  45. Recommendations Recommendations Breakfast Tips: Eat a small breakfast. Eat whole-grain bread products. Eat a food that has protein. This will help you to: feel full, get enough protein for you and your baby, control your blood sugar. Do not eat cereal or fruit. Do not drink fruit juice at breakfast or any other time of the day. Fruit juice raises your blood glucose very quickly. 45

  46. Recommendations Recommendations Fat Tips: Fat contains calories to help supply energy to you and your baby. Fat helps your body absorb vitamins A, D, E and K. Fat also gives you essential fatty acids, which help your baby's brain and nervous system develop. It is important to focus on eating healthful fats. The following foods are good sources of healthful fats: Most nuts and seeds Peanut butter (natural or trans fat-free) Cooking oils (olive, canola, peanut or flaxseed) Avocados Fatty fish (salmon or trout) 46

  47. Recommendations Recommendations Tips to remember: If you are hungry, add vegetables or a protein food to your carbohydrate snacks. Focus on eating healthful fats. If your blood glucose is high when you wake up, have a bedtime snack that includes both protein and carbohydrates. This will help keep your blood glucose in check during the night. 47

  48. CONCLUSIONS CONCLUSIONS Women with GDM (and women with preexisting diabetes) should be encouraged to breastfeed because breastfeeding is associated with a reduced incidence of future T2DM (Stuebe, 2005). For women with GDM who are overweight or obese or with above-recommended weight gain during pregnancy, weight loss is advised after delivery. Weight loss reduces the risks of recurrent GDM or future development of T2DM. 48

  49. CONCLUSIONS CONCLUSIONS The food plan should be designed to: Fulfill minimum nutrient requirements for pregnancy Achieve glycemic goals without weight loss and ketonemia Be culturally appropriate and individualized to take into account the patient s body habitus, weight gain, and physical activity 49

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