Transcript Gestational Diabetes - Seton Healthcare Family

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Diabetes during Pregnancy:
Nutrition-related guidelines to
reduce complications and postpartum considerations
Kimberly M. Morris MS, RD, LD, CDE
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Types of Diabetes
# 1, 2 & 3:
1. Type 1 – Autoimmune
Chronic
2. Type 2 - 90-95% of all cases versus Type 11
3. Diabetes Complicated by Pregnancy – (Type 1 or Type 2
Diabetes diagnosed before Pregnancy)
4. Gestational Diabetes:

develops during pregnancy

Usually recognized during 3rd Trimester

# 4:
Temporary (in
most cases) BUT
increases risk for
developing Type
23
Occurs in ~5 % of pregnancies 2
1.Ross TA, Boucher JL, O’Connell BS, ed. American Dietetic Association Guide to Diabetes Medical Nutrition Therapy and Education. 2005;
4:40.
2.U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Child Health and Human Development.
Managing Gestational Diabetes: A Patient’s Guide to a Healthy Pregnancy. July 2004; pg.4.
3. Thomas AM, Gutierrez YM. American Dietetic Association Guide to Gestational Diabetes Mellitus. 2005;10:107.
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Hyperglycemia During Pregnancy:
Blame it on the Hormones
• Insulin =
Hormone
that
processes
GLUCOSE
• GLUCOSE
= Energy
from Food
GLUCOSE
enters the
blood
stream
Too Much
Glucose
Crosses to
over the
Placenta
to the
baby
Complications
PANCREAS Does
not make
(enough)* Insulin
to stabilize blood
glucose levels
*Hormones
from the
Placenta
interfere
with INSULIN
Too Much
GLUCOSE
builds up in
the blood
U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Child Health and Human Development.
Managing Gestational Diabetes: A Patient’s Guide to a Healthy Pregnancy. July 2004; pg.3-4.
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The #1 Complicating Factor is
A Large Baby
Too Much
Glucose to
the Baby:
Baby Grows
Too Large Too
Quickly
Too Large,
Too Quickly:
Complicated
the Labor and
Delivery
Process
U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Child Health and Human Development. Managing
Gestational Diabetes: A Patient’s Guide to a Healthy Pregnancy. July 2004; pg.5.
+ 1st Trimester Metabolic Influences
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al.
American Diabetes Association. 2008.
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2nd and 3rd Trimester Metabolic
Influences

Stored and Ingested fat becomes primary maternal fuel source to
allow Glucose (sugar) and Amino acids (proteins) for fetal use

Increased energy and nutrient demands by fetus as pregnancy
progresses

Inadequate calories will promote Ketosis (excessive use of Fat as
fuel source)

Caloric Requirement Vary by Trimester, Pre-pregnancy BMI, &
Singleton versus Twin Pregnancy

1st Trimester – additional 32 kcal/day

2nd Trimester – additional 356 kcal/day

3rd Trimester – additional 496 kcal/day
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American
Diabetes Association. 2008.
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IOM Weight Gain Guidelines

Guidelines updated 2009 (previously updated in 1990)
Singleton
Underweight: 28-40 lbs
Normal
: 25-35 lbs
Overweight: 15-25 lbs
Obese: 11 – 20*lbs
(change in guidelines: UL
established)*Obese weight gain may
Twins
Underweight: No Data
Normal weight: 37-54 lbs
Overweight: 31-50 lbs
Obese: 25-42 lbs
not be necessary. ???-Weight loss ???
Target lower weight and calorie ranges for Type 2
and GDM Diabetes
< 1700 kcal/day may promote ketosis
Preconception Counseling Highly recommended
Web MD. Pregnancy Weight Gain: New Guidelines. “How much weight Should Women Gain During Pregnancy? Maybe less than you
think. Available at: http:www.webmd.com/baby/news/20090528/pregnancy-weight-gain-new-guidelines. Accessed March 2, 2010.
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Benefits of Physical Activity
 Exercise
Lowers Blood Glucose by Reducing
Insulin Resistance
 Exercise
AFTER Eating and BEFORE post-prandial
glucose test
 Light
to Moderate Physical Activity is
Recommended
 IMPORTANT!
Consult with MD BEFORE starting
ANY exercise program during pregnancy
Thomas AM, Gutierrez YM. American Dietetic Association Guide to Gestational Diabetes Mellitus. 2005;8:85.
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Goals of MNT to Reduce Risk of
Complications

Diet influences weight gain and fetal size

Meal plan
a.Control excessive fat and glucose (Crosses the Placenta and contributes
to Macrosomia)
b. Provide adequate energy and nutrition to support maternal and infant
needs 1
c. Provide Adequate Calories and Carbs Control Excessive Lipolysis and
Prevent Ketogenesis2

When Euglycemia cannot be achieved within recommended
dietary guidelines, Medication is Required
1. ADA Guide to Gestational Diabetes Mellitus, A.M. Thomas and Y.M. Gutierrez. American Dietetic Association. 2005.
2. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et.
al. American Diabetes Association. 2008.
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“I Think You
Should Know
that I’m Very
High in
Carbohydrates”
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MNT Guidelines to Promote
Euglycemia

Carbohydrate-Controlled Meal Plan - Carbs have biggest
impact on Post-prandial Blood Glucose (90-100% of
carbohydrates converted to glucose within 1 hour after
consumption). Post-prandial testing 1-2 hours after main
meals.

CHO includes Fiber, Sugars (natural or added) and Starches.
 Fiber less impact on Glucose (Insoluble Fiber not
digested). Studies which showed insulin negatively
correlated with fiber in 2nd and 3rd trimester used > 50
grams of dietary fiber/day. Current average intake < 20
grams/day. Recommended Dietary Fiber intake = 28
grams/day.1
1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al.
American Diabetes Association. 2008.
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MNT Guidelines to Promote
Euglycemia



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
Estimate Total Calorie needs based on wt. gain
requirements
Example Kcal Distribution: 40% CHO, 35% Protein, 25%
Fat11800 kcal/day: 40% kcal from CHO = 720 kcal from
CHO ÷ 4 = 180 grams/day ÷ amongst 3 meals and 2-4
snacks/day.
RDA for CHO in pregnancy = 175 grams/day (General
population = 130 grams/day). (Fetal brain requires 33
grams/day)
Individualize CHO Distribution Based on Daily Schedule
Example Distribution: B: 15-45, S: 15-30, L: 30-75, S:15-30, D:
30-75, S: 15-45
1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American
Diabetes Association. 2008.
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Meal Plan Considerations

Placental Hormones Highest in the am
 Less Carb at Breakfast

May Need to Limit Fruit and Milk Choices until Afternoon
and/or use at Snack times

Adequate Protein – Balance CHO with Protein which also
Stimulates the Pancreas to Release Insulin).


2nd Trimester – Protein Needs Increased (Protein Needs Double
with Twin Pregnancy)
Heart Healthy Fats: Omega 3 Fatty Acids (EPA/DHA) to
Support Brain and Retina Development. Sources include
some fish (recommend low Mercury) or Marine Algae for
Vegetarians
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“Just Water, No
Bread…I’m on a
Low-Carb Diet”
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Meal Plan Considerations

Watch for Tendency to over-restrict CHO with post-prandial blood glucose
excursions (> 120 mg/dl 2 hours post-prandial)

CHO distribution may be tweaked per hypo- and hyperglycemia
considerations:

Extended length of time between meals with Hypoglycemia

Bedtime snack needed if Nocturnal Hypoglycemia

(Nocturnal hypoglycemia can cause rebound Hyperglycemia – am)

There is NO established recommendations for Carb variations based on
Trimester) – RD follow-up WITH FOOD RECORDS Recommended.

Consistency of Carbohydrate Distribution to determine if medication is
needed.

With Insulin Treatment, Consistency Important for Effective Dosing
Changes
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Examples of Carbohydrates
 CARBS:
 Milk
and Yogurts
 Fruits and Fruit Juice (Juice only recommended
for treating Hypoglycemia)
 Grains (Whole Grains Count Too)
 Beans and Starchy Vegetables
 Sweets (Limit to < 1 per day)
Fats, Proteins and Non-Starchy Vegetables are NOT
Carbohydrates and have Minimal Impact on
Blood Glucose
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Counting Carbohydrates

1 Carb Choice = 15 grams of Carbohydrate
Sample Meal # 2:
Sample Meal # 1:
2 Slices of Bread = 2 Choices
8 oz. Milk = 1 Choice
Tomato Slices = 0 Choices
2/3 Cup Cooked Rice = 2 Choices
1 Tbsp. of Peanut Butter = 0 Choices
4 oz. Chicken Breast = 0 Choices
2 Scrambled Eggs = 0 Choices
1 Cup Broccoli = 0 CHO Choices
Total = 2 Choices or 30 grams CHO
Total = 3 Choices or 45 grams CHO
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“I Don’t Think this is
What your Doctor
meant by Lowering
your Carbs, Honey.”
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Glycemic Index

Ranks Carbohydrates Based on Impact on Blood Glucose

May be Used In Additionto Carb Counting

Limitations: Glycemic Response is Variable:

Variations within Individuals

Impacted by Ripeness, Cooking, ETC.

Value Changes when Mixed with Another Food

Does not correlate with nutritional quality or fiber
TEST BLOOD SUGAR to MONITOR EFFECTS of CARB FOODS
Glycemic Load: Better Indicator of Glycemic Response – Based on
Portion Size
A Low GI Index But High In Total Carbohydrate Food can Have same
Glycemic Load
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care.
J.L. Kitzmiller et. al. American Diabetes Association. 2008.
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Glycemic Index

Whole Foods = Lower GI than Mashed or Liquid Form

High Fiber or High Fat = Lower GI

Ripe Foods = Higher GI

Cooked = Higher GI than Raw
High Glycemic
Medium Glycemic
Low Glycemic
White Bread
Corn
Plain Yogurt
Watermelon
Brown & White Rice
Most Vegetables
Honey
Pizza
Whole & Soy Milk
Rice
Ice Cream
Apples & Grapes
Dates
Regular Sugar
Spaghetti
French Fries
Instant Oatmeal
Beans
Pretzels
Whole Wheat Bread
Sweet Potatoes
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Sugar Substitutes
“They Now Have Me
Testing Equal,
Sweet’N Low and
Splenda. I’ve Now
Developed Artificial
Diabetes.”
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Sugar Substitutes in Pregnancy

FDA Approved 5 for use by General Population INCLUDING
Pregnant Women with Diabetes1

Studies Included: “Chronic Dietary Toxicity, Mutagenicity,
Carcinogenicity, Teratogenicity, Multigenerational
Reproductive Toxicity in Lab Animals and Toxicity,
Metabolism and Pharmokinetics in Humans”1

Studies Lacking on Pregnancy Outcomes and Child
Development1

Most HCP – Recommend Limiting. ADA: No More than 1-2
Diet Sodas/day. 1 Texas Diabetes Institute in San Antonio, TX –
Diabetes Management Program - < 3 svgs./day
1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L.
Kitzmiller et. al. American Diabetes Association. 2008.
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Saccharin:
In Use Since 1880’s
1970’s – Bladder Tumors in Male Rat Offspring Exposed
in utero
1985 – Council of Scientific Affairs of the AMA – No
Evidence of Increase in Bladder Tumors in Humans –
Use with “Careful Consideration” in Pregnancy.
2001- Removed from List of Potential Carcinogens
Excreted Unchanged by Kidney
Saccharin Crosses the Placenta – Slow Fetal Clearance
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al.
American Diabetes Association. 2008.
Aspartame:
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1. Metabolized to Aspartic Acid and
Phenylalanine – Avoid if PKU
2. Methanol/Formic Acid – Formaldehyde – May
Cause:
a. Headaches
b. Neurobehavioral Problems
c. Brain Tumors in Adults
d. Fetal Optic Nerve Damage
1. 2002-2003 – Health Canada,
Scientific Committee on Food of
European Commission, & United
Kingdom Food Standards Agency
and French Food Safety Agency - No
Health Hazard1
2. Methanol Concentrated
on Fetal Side is “minimal”
per amount Aspartame
Ingested1
5. Does Not
Transfer to Breast
Milk2
3. Minimally Crosses
Placenta at doses 2 X
Human ADI – Pregnant
Monkeys1
1.
2.
4. Ingested at 3 X of ADI
for Humans – no risk to
fetus in Lab Animals1
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American
Diabetes Association. 2008.
ADA Guide to Gestational Diabetes Mellitus, A.M. Thomas and Y.M. Gutierrez. American Dietetic Association. 2005.
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Neotame:

Aspartic Acid and Phenylalanine

Enzyme that Breaks Down reduces Bioavailability of Phenylalanine –
Rapidly metabolized Yields Methanol

Methanol “excreted in small amounts compared with Methanol
Derived from Fruits or Vegetables”

No Affect on Insulin or Fasting Glucose in Type 2 Diabetes
Acesulfame Potassium:

Excreted Unchanged in the Urine (Does Not Provide Potassium)

Crosses the Placenta

Considered Safe for Pregnancy
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller
et. al. American Diabetes Association. 2008.
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Sugar Substitutes
 Sucralose

(Splenda):
Excreted Unchanged in Feces
 Other
Sugar Substitutes:

Not Studied in Pregnant Women with Diabetes

Not Approved for Use During Pregnancy:
Alitame, Cyclamates, Neohesperidine,Thaumatin, & Stevia2
1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al.
American Diabetes Association. 2008.
2. ADA Guide to Gestational Diabetes Mellitus, A.M. Thomas and Y.M. Gutierrez. American Dietetic Association. 2005.
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Micro-Nutrient Intake and
Supplementation

Focus on Whole Foods and Food Groups – NOT Single
Nutrients!

Vitamins and Minerals Work in Synergy in the Body

Due to Higher Demand During Pregnancy and Common
Deficiencies: Supplementation Recommended

Studies Lacking on Ideal Vitamin and Mineral Needs –
Especially Related to Diabetes
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al.
American Diabetes Association. 2008.
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Micro-Nutrient Intake
Common Deficiencies in US Pregnant
Women:
Copper
• Magnesium
• Potassium
Selenium
• Niacin
• Riboflavin
Thiamine
• Choline
• Vitamin A & E
Prenatal Supplements – vary in
nutrient content – Do Not make
up for Nutrients Lacking from
Whole Foods in Diet
Increased Risk of Deficiencies:
Multi-fetal
Gestation
Tobacco
Smokers
Alcohol/
Drug
Abusers
IronDeficiency
Anemia
(Lack of Studies in
Women with Diabetes)
Vegetarians
Overall
Poor
Diet
*Chromium Deficiency linked to Glucose Intolerance – no effect
on Glycemic Control with Supplementation
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al.
American Diabetes Association. 2008.
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Food Safety
Alcohol – Fetal Growth Restrictions, Mental Retardation,
Malformations
Caffeine - Crosses the Placenta – not linked to Birth Defects but
1st trimester spontaneous abortions > 300 mg/d.
1 oz espresso = 35 mg
1 cup brewed coffee = 135 mg
1 cup black tea = 50 mg
12 oz Tall/Small Starbucks = 375 mg.
Methylmercury – Affect Neurological System. Crosses Placenta.
FDA – Limit to Low Mercury Fish < 12 oz per week
Listeria – 20 X More Likely to Occur During Pregnancy.
Miscarriages, Stillbirth, Preterm Delivery. Avoid Deli
Meats/Hot Dogs (Unless Steaming Hot) and Unpasteurized
Dairy Products
Food Safety At-A-Glance: How to Protect Yourself and Your Baby. www.cfsan.fda.gov/pregnancy.html Accessed 3/12/10.
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Common Deficiency Concerns

Iron Deficiency Linked to Pre-term birth and Fetal Growth
Retardation

Choline (Eggs, Meat, Liver and Peanuts) – essential for Cell
Membrane (Estrogen may Protect Against Deficiency)

Deficient Choline leads to Deficient Folate (Green Leafy Vegetables,
Grains – fortified, and Citrus fruits)

Folate forms neural tube (formed before pregnancy recognized).
Deficiency – Megaloblastic Anemia, Spontaneous Abortions, Fetal
Malformations, Placental Abruption, Preterm Delivery, LBW

Excessive Folate masks B12 Deficiency- test BEFORE
Supplementation

B12 Deficiency: Type 1 DM, Vegans, Inadequate GIF, B12 Absorption
Problems (UL 1000 mcg/day).
1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American
Diabetes Association. 2008.
2. ADA Guide to Gestational Diabetes Mellitus, A.M. Thomas and Y.M. Gutierrez. American Dietetic Association. 2005.
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Considerations with Celiac
Disease and Pregnancy

Occurs in 4-12% of those with Type 1 Diabetes (Not
Associated with Type 2).

Autoimmune response to Protein Fraction of Grains: Wheat,
Rye, Barley, Spelt, Kamut, and Triticale or Oats Contaminated.

Inflammation of Small Intestines, Inhibits Absorption of
Nutrients, Fluid Loss – Diarrhea

Wt. Loss, Abdominal Pain, Thyroid Disorders, etc.

Diagnosis Confirmed by Biopsy

Only Cure is Gluten-Free Diet – Symptoms Disappear
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al.
American Diabetes Association. 2008.
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Considerations with Celiac
Disease and Pregnancy

Screening Recommended as may be Asymptomatic to
Prevent Malabsorption.

Symptoms may Include Hypoglycemia, Nausea, Vomiting,
Diarrhea, Constipation

Anticipate Insulin Changes Once Treated per reduced
Hypoglycemia

Untreated in Pregnancy – Studies Suggest Spontaneous
Abortions, Fetal Growth Restrictions and Still Birth
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L.
Kitzmiller et. al. American Diabetes Association. 2008.
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Pregnancy After Bariatric Surgery

Increasingly Common with Increasing Rate of Obesity and Type 2 Diabetes

Post-surgical Dietary Concerns: Vomiting, Dumping Syndrome, Dehydration

Fetal Growth Restrictions, Anemia, (Iron, Folate, Vitamin B12 Deficiencies), CSections

Keep Fluids Separate from Meals

6-9 Small Meals per Day

Adjust Gastric Band During Pregnancy???? - No RCT to Support

Kcal to Promote Minimal Wt. Gain

Ideal Wt. Gain in Obese Diabetic Pregnant Women Not Established
Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L.
Kitzmiller et. al. American Diabetes Association. 2008.
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Post-partum Considerations for
Women with Gestational Diabetes

Risk of recurrence in future pregnancies – may screen earlier

Gestational Diabetes = increased risk for of Developing Type 2
Diabetes: “60% of women with previous GDM, type 2 diabetes
will be diagnosed during the 5-15 years after the pregnancy,
depending on the racial or ethnic group”1

Get tested 6 weeks after delivery

Get tested every 1- 3 years

Reduce Risk of Developing Type 2 by up to 58%: 2



Reach a healthy body weight and stay there
Stay physically active
Breastfeed!!!
1. Thomas AM, Gutierrez YM. American Dietetic Association Guide to Gestational Diabetes Mellitus. 2005;10:107.
2. Thomas AM, Gutierrez YM. American Dietetic Association Guide to Gestational Diabetes Mellitus. 2005;10:102.
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Post-Partum Considerations for Women
with Pre-existing Type 1& 2

Type 1 & 2: A1C < 7.0 or < 6.5% before conception (1st
trimester hyperglycemia increased risk of abnormalities and
miscarriages). (Not a risk factor in true gestational diabetes)

Mainly Type 2:

If Overweight or Obese: promote weight loss to improve insulin
resistance - reduce progressive nature of Diabetes and other comorbidities associated with excessive body fat

Breastfeed!!!! Reduce Insulin Resistance and Expend additional
calories to promote weight loss. (It takes more calories to make
breast milk than to grow fetus).

600 kcal /day 1st 6 months

400 kcal/day 2nd 6 months
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Post-partum Considerations &
Implications for the Fetus

Women with uncontrolled blood sugars during pregnancy can have children born with
twice as much body fat

Extra fat around the abdominal area leads to insulin resistance

Infants born ‘Large for Gestational Age’ are at risk for being an overweight child

Genetic trait with GDM or with Type 2 Diabetes carried on by fetus.

An overweight child is at risk for developing diabetes before they are 30 years old

Children at risk for Diabetes:

overweight/obese

high-risk ethnic group

Inactive

Acanthosis nigricans
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Post-partum Counseling to Reduce
Incidence of Type 2 Diabetes

Excessive Abdominal Fat and Hx. Of GDM – Risk Factors for
Type 2 Diabetes

>23 million people have Diabetes Mellitus in US

23% undiagnosed

57 million people have Pre-Diabetes (most insurance
companies do not cover including Medicare). Seton
Insurance covers RD visits within our organization

Those with Pre-Diabetes will develop Type 2 Diabetes within
8-12 years without lifestyle changes
American Diabetes Association. Diabetes Statistics. Available at: http://www.diabetes.org/diabetes-basics/diabetes-statistics/.
Accessed March 7, 2010.
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Resources

http://www.SetonBabyTalk.com

http://www.GoodHealth.com

National Institute of Child Health and Human Development (NICHD)
http://www.nichd.nih.gov

National Diabetes Information Clearinghouse (NDIC)
http://niddk.nih.gov/health/diabetes/ndic.htm

The National Diabetes Education Program (NDEP) http://ndep.nih.gov

American Dietetic Association (ADA) Consumer Hotline
http://www.eatright.org

American College of Obstetricians and Gynecologists (AGOG)
http://www.acog.org

American Diabetes Association http://www.diabetes.org
Thank You!
Questions?
Comments?