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.
1. Butte NJ, Hopkinson JMM, Mehta N, et al. Adjustments in energy expenditure and substrate utilization during late pregnancy and lactation. Am J Clin Nutr 1999; 69: 299-307.
2. Catalano PM, Tyzbir ED, Roman NM. Longitudinal changes in insulin release and insulin resistance in non-obese pregnant woman. Am J Obstet Gynecol 1991; 165; 1667-72.
3. Catalano PM, Tyzbir ED, Wolfe RR, et al. Longitudinal changes in basal hepatic glucose production and suppression during insulin infusion in normal pregnant women. Am J Obstet Gynecol 1992; 167: 913-9.
4. Catalano PM, Tyzbir ED, Wolfe RR, et al. Carbohydrate metabolism during pregnancy in control subject and women with gestational diabetes. Am J Physiol 1993; 264: E60-7.
5. Butte NJ. Carbohydrate and lipid metabolism in pregnancy: normal compared with Gestational diabetes mellitus [Review]. Am J Clin Nutr 2000; 71(suppl.): 1256S-61S.
6. Kalhan SC, D'Angelo LJ, Savin SM, Adam PAJ. Glucose production in pregnant women at term gestation. Sources of glucose for human fetus. J Clin Invest 1979; 63: 388-94.
7. Assel B, Rossi K, Kalhan D. Glucose metabolism during fasting through human pregnancy. J Clin Invest 1997; 100: 1 775-81.
8. Narod SA, De Sanjose S, Victoria C. Coffee during pregnancy: a reproductive hazard? Am J Obstet Gynecol 1991; 164: 1109-14.
9. Leviton A, Cowan L. A review of the literature relating caffeine consumption by women to their risk of reproductive hazards [Review]. Food Chem Toxicol 2002; 40: 1271-310.
10. Abel EL. Prenatal effects of alcohol [Review]. Drug Alcohol Depend 1984; 14: 1-10.
11. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 2003; 26(suppl. 1): S5-20.
12. Buchanan TM, Metzger BE, Freinkel N. Insulin sensitivity and beta cell responsiveness to glucose during late pregnancy in lean and moderately obese women with normal glucose tolerance or gestational diabetes mellitus. Am J Obstet Gynecol 1990; 162: 1008-14.
13. Coustan DR. Gestational diabetes. In: Harris MI, Cowie CC, Stern MP, et al. eds. Diabetes in America, 2nd edn. Publication 95-1468. Baltimore: National Institutes of Health; 1995, pp. 703-17.
14. Miller E, Hare JW, Clogerty JP, et al. Elevated maternal hemoglobin A1c in early pregnancy and major congenital anomalies in infants of diabetic mothers. N Engl J Med 1981; 304: 1 331-5.
15. American College of Obstetrics and Gynecology. Gestational diabetes. Practice bulletin no. 30. Obstet Gynecol 2001; 98: 525-38.
16. Jovanovic L, Bevier W, Peterson CM, for the Santa Barbara County Health Care Services Program. Birth weight change concomitant with screening for and treatment of glucose-intolerance of pregnancy: a potential cost-effective intervention. Am J Perinatol 1997; 14: 221-8.
17. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study. Int J Gynecol Obstet 2002; 78: 69-77.
18. Georgieff MK. Therapy of infants of diabetic mothers. In: Burg FD, Ingelfinger JR, Wald ER, Polin RA, eds. Current Pediatric Therapy, 15th edn. Philedephia: WB Saunders; 1995, pp. 793-803.
19. Creasy RK, Resnik R. Intrauterine growth restriction. In: Creasy RK, Resnick R, eds. Maternal-Fetal Medicine, 4th edn. Philadelphia: WB Saunders; 1999, pp. 569-89.
20. Nold JL, Georgieff MK. Infants of diabetic mothers. Pediatr Clin N Am 2004; 51: 619-3 7. Schwartz RP. Neonatal hypoglycemia: how low is too low? J Pediatr 1997; 131: 171-3.
21. Pederson J. the Pregnant Diabetic and Her Newborn, 2nd edn. Baltimore: Williams and Wilkins; 1977.
22. Weiss PA, Scholz HS, Haas J, et al. Long term follow-up of infants of mothers with Type I diabetes: evidence for hereditary and non-hereditary transmission of diabetes and precursors. Diabetes Care 2000; 23: 905-1 1.
23. Boney CM, Verma A, Tucker R, Vohr BR. Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics 2005; 115: e290-6.
24. Crowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005; 352: 2477-86.
25. Kitzmiller JL, Gavin LA, Gin GD, et al. Preconception care of diabetes: glycemic control prevents congenital anomalies. JAMA 1991; 265: 726-31.
26. Knopp RH, Magee M, Raisys V. Hypocaloric diets and ketogenesis in the management of obese gestational diabetic women. J Am Coll Nutr 1991; 10: 649-67.
27. Mills JL, Simpson JL, Driscoll SG, et al. Incidence of spontaneous abortion among normal women and insulin dependent diabetic women whose pregnancies were identified within 21 days of conception. N Engl J Med 1988; 319: 1617.
28. Rizza T, Metzger BE, Urns WJ, et al. Correlations between antepartum maternal metabolism and intelligence of offspring. N Engl J Med 1991; 325: 91 1-6.
29. Buchanan TA, Metzger BE, Freinkel N. Accelerated starvation in late pregnancy: a comparison between obese women with and without gestational diabetes mellitus. Am J Obtet Gynecol 1990; 162: 1015-20.
30. Jovanovic L, Metztger B, Knopp RH. Beta hydroxybutyrate levels in type 1 diabetic pregnancy compared with normal pregnancy. Diabetes Care 1998; 21: 1-5.
31. King J, Allen L. Nutrition during pregnancy. Washington DC: National Academy Press; 1990.
32. Magee MS, Knopp RH, Benedetti, TJ. Metabolic effects of 1200 kcal diet in obese pregnant women with gestational diabetes. Diabetes 1990; 39; 234-40.
33. Knopp RH, Magee MS, Raisys V. Hypocaloric diets and ketogenesis in the management of obese gestational diabetic women. J Am Coll Nutr 1991; 10: 649-67.
34. Combs CA, Gunderson E, Kitsmiller JL, et al. Relationship of fetal macrosomia to maternal postprandial glucose control during pregnancy. Diabetes Care 1992; 15: 1251-7.
35. Parretti E, Mecacci F, Papini M, et al. Third-trimester maternal glucose levels from diurnal profiles in nondiabetic pregnancies. Diabetes Care 2001; 24: 1319-27.
36. Jovanovic L, Peterson CM, Reed GF, et al. Maternal postprandial glucose levels and infant birth weight: the Diabetes in Early
Pregnancy study. The National institute of Child Health and Human Development - Diabetes in Early Pregnancy Study. Am J Obstet Gynecol 1991; 164: 103-1 1.
37. de Veciana M, Major CA, Morgan MA, et al. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. N Engl J Med 1995; 333: 1237-41.
38. Jovanovic L, Pettitt, DJ. Contempo updates. Linking evidence and experience: gestational diabetes mellitus. JAMA 2001; 286: 2516-18.
39. Peterson CM, Jovanovic L. Percentage of carbohydrate and glycemia response to breakfast, lunch, and dinner in women with gestational diabetes. Diabetes 1991; 40(suppl. 2): 172-4.
40. Ilic S, Jovanovic L, Pettit DJ. Comparison of the effect of saturated and monounsaturated fat on postprandial plasma glucose and insulin concentration in women with gestatonal diabetes mellitus. Am J Perinatal 2000; 16: 489-95.
41. Hill AJ, Blundell JE. Macronutrients and satiety: the effects of high protein or high carbohydrate meal on subjective motivation to eat and food preferences. Nutr Behav 1986; 3: 133-44.
42. Westerterp-Plantenga MS. The significance of protein in food intake and body weight regulation [Review]. Curr Opin Clin Nutr Metab Care 2003; 6: 635-8.
43. Kerr JF, Campbell-Brown BM, Johnstone FD. A study on the effect of high protein low carbohydrate diet on birthweight on an obstetric population. In: Sutherland HW, Stowers JM, eds. Carbohydrate Metabolism in Pregnancy and the Newborn 1978. Berlin: SpringerVerlag; 1979; pp. 518-34.
44. Herrick K, Phillips DI, Haselden S, et al. Maternal consumption of a high-meat, low-carbohydrate diet in late pregnancy: relation to adult cortisol concentrations in the offspring. J Clin Endocrinol Metab 2003; 88: 3554-60.
Was this article helpful?
I already know two things about you. You are an intelligent person who has a weighty problem. I know that you are intelligent because you are seeking help to solve your problem and that is always the second step to solving a problem. The first one is acknowledging that there is, in fact, a problem that needs to be solved.