Gestational diabetes is a period of glucose intolerance that manifests at the beginning of the third trimester. Metabolic changes in the normal pregnant women also have a degree of insulin resistance that shunts glucose preferentially to the fetus. To maintain blood glucose levels within a tight range, the normal pregnant woman must increase her insulin secretion up to 4-fold. When the pancreas is not able to compensate for the increased insulin needs of pregnancy, GDM occurs resulting in hyperglycemia and hyperinsulinemia in both
Santa Barbara Diabetes Initiative • Sansum DiabetesResearch Institute • 2219 Bath Street, Santa Barbara, CA93105 • (805) 682-7638 • www.sansum.org In collaboration with Santa Barbara neighborhood Clinics and American Indian Health & Services Funded in part bythe Hutton Foundation and the Andrew Burnett Foundation
Figure 26.2 The one-page handout used in Santa Barbara county.
Nutrition Jump Start...
For Improved Blood Sugar Control
*Foods To Avoid*
Cold Cereal ■ Bread • Tortilla ■ Rice/Pasta • Soda Pastries • Dressing
Oranges Bananas • Melon • Peaches • Plums • Potato
Grapes • Squash • Juice • Mango • Dried Fruit • Ketchup ^
* Foods To Limit* (1-2 servings per meal)
• 11 cup cooked lentils
• 3 cups plain air-popped popcorn
*Foods You Can Enjoy* Vegetables
Olive Oil ■ Avocado Sour Cream Butter
Note: Not an exhaustive list
• Cottage Cheese
• Limes Tomatoes Apples
Lettuce/spinach Carrots Celery Mushrooms Green Beans Cucumber Broccoli Asparagus Cabbage Nopal mother and fetus. These increased glucose and insulin levels manifest a multitude of fetal and maternal complications, the most prevalent being macrosomia. Other complications include hypoglycemia, erythrocytosis, hypocalcemia and hypomagnesia, hyperbilirubinema, iron redistribution, respiratory distress, and neurological effects. Poor gestational metabolic management can be directly linked to the level of neurological functioning of the child and these children are more prone to develop metabolic syndromes such as Type 2 diabetes. This would affect generations to come as well. The management of gestational diabetes mellitus is based upon the synergistic effects of medical nutritional therapy, exercise, and an insulin regimen when necessary. Therefore, the identification and treatment of GDM is crucial.
Screening tests using at-risk formulations and oral glucose tolerance tests remain a point of controversy. Universal screening would be optimal to identify those with GDM. The research clearly shows the benefit of expanding screening and providing medical nutritional therapy, glucose monitoring, and insulin therapy to all women who manifest even minor elevations of glycemia. And thereby decrease perinatal complications, such as macrosomia. Maternal postpartum depression rates may also be improved with improved care during pregnancy.
Multiple studies have correlated fetal complications such as macrosomia to 1-h postprandial glucose levels. By restricting carbohydrate concentration in the euglycemic diet and modifying the caloric intake based on pre-gravid weight, success has been achieved in reducing large for gestational age and macrosomic infants. The euglycemic diet targets a pre-prandial glucose of 90 mg/dL or less and a 1-h postprandial of 120 mg/dL. Optimal glucose levels have been heavily debated and there is not currently a universal standard. However, research has shown that normal pregnant women in the third trimester have lower pre-prandial and postprandial glucose concentrations than nonpregnant women. This would support advocating lower standards of <90 mg/dL pre-prandially and 120 mg/dL postprandially for women with gestational diabetes.
Hypocaloric diets have been explored and appear safe for the obese gestational diabetic woman. The American College of Obstetrics and Gynecology advocate consideration of the mother's pre-gravid weight when considering the caloric needs per kg per day. The presence of maternal ketonemia and ketouria is controversial with respect to fetal development, and the mechanisms and outcomes associated with ketonemia resulting from uncontrolled glucose levels and starvation may be different with respect to detriment to the fetus.
Fat content also remains controversial although studies have shown that meals with saturated fat as compared to mono-unsaturated fat result in the same-hour postprandial glucose level, but the duration of the level is shorter facilitating lower insulin dosages. High protein/low carbohydrate diets are also controversial and in normal pregnant women have been correlated to lower birthweights and adult offspring increased cortisol levels. However, satiety is also important and protein malnutrition should be avoided in pregnancy. More research is necessary to determine the effect of these macromolecules on normal pregnant individuals and those with GDM.
Overall, medical nutritional therapy is one of the staples of GDM management. Women with GDM are very compliant and most are willing to make dietary changes in their lives for the benefit of their baby. The successful triad of medical nutritional therapy, exercise, and insulin therapy for GDM is essential to achieving, not only healthy babies, but also to assure that generations to will begin life with normal metabolism and thus and future metabolic aberrancy is reduced in the offspring.
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