medical nutrition therapy in gestational diabetes mellitus dr. parvin mirmiran obesity research...

Medical Nutrition Therapy in Medical Nutrition Therapy in Gestational Diabetes MellitusGestational Diabetes Mellitus

Dr. Parvin MirmiranObesity Research Center, Research Institute for Endocrine

Department of Human Nutrition, Faculty and Institute of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences

M. Akhoundan

Dr. Mirmiran / SBMU 1

Definition & Worldwide Definition & Worldwide Prevalence of GDM Prevalence of GDM

• GDMGDM is defined as any degree of glucose

intolerance with onset or first recognition

during pregnancy

• Approximately 7%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 more than 200,000 cases annually

Diabetes care, 2009Dr. Mirmiran / SBMU 2

Prevalence of GDM in Prevalence of GDM in IranIran

• According to 14 studies from 1992-2007,

the prevalence of GDM ranged between

1.3% toto 10%% in different regions of Iran.

Khoshnniat, 2009Dr. Mirmiran / SBMU 3

Dr. Mirmiran / SBMU Slide 4

Khoshnniat N, Iranian Journal of Diabetes and Lipid Disorders; 2009

Risk factors for the development Risk factors for the development of GDMof GDM

marked obesityolder agepersonal history of GDM glycosuriastrong family history of diabetes ethnicity polycystic ovary syndrome hypertension

Cheung,2009Dr. Mirmiran / SBMU 5

GDM GDM Complication

• adverse pregnancy outcomesadverse pregnancy outcomes:

macrosomia shoulder dystocia Jaundice polycythemia respiratory distress hypocalcemia


GDM GDM Complication (cont’)(cont’)

adverse pregnancy outcomes adverse pregnancy outcomes (cont’)

Increase fetal malformationmalformation and perinatalperinatal mortalitymortality

predispose the child to a diabete diabete phenotype in later life


Maternal Maternal complicationcomplication :

• Weight gainWeight gain

• Maternal hypertensive disordershypertensive disorders

• Miscarriages

• Third trimester fetal deaths

• Cesarean delivery (due fetal growth disorders)

• Long term risk of type 2 diabetes mellitusrisk of type 2 diabetes mellitus


GDM GDM Complication (cont’)(cont’)

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


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

• MNT is the primary therapy for 30 –90% of women diagnosed with GDM

Reader,2007Dr. Mirmiran / SBMU 10

Medical Nutrition Therapy Medical Nutrition Therapy (cont’)(cont’)

Goals:

• Achieve normoglycemia normoglycemia

Recommended treatment targets

ADA,2004Dr. Mirmiran / SBMU 11

Test GestationalDiabetes (mg/dl)

Fasting plasmaglucose

65-95

I hr postprandial <140

2 hr postprandial <120

• Providing the required nutrients required nutrients for normalnormal fetal growthfetal growth and maternal healthmaternal health

• Prevent excessive maternal weight gainPrevent excessive maternal weight gain, particularly in women who are overweight or have gained excess weight in pregnancy.

• Prevent ketosisPrevent ketosis




Include:Include:

• Nutrition therapyNutrition therapy

• ExerciseExercise

• Self-monitoring of blood glucose (SMBG)Self-monitoring of blood glucose (SMBG)

• Pharmacologic therapyPharmacologic therapy

• EducationEducation



Nutrition therapyNutrition therapy

Efficacy of dietary therapy for GDMEfficacy of dietary therapy for GDM

Nutrition intervention for GDM has been recognized as the cornerstone of therapycornerstone 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 birth weight lower % large-for-gestational-age Less macrosomia

Crowther ,2005 , Reader,2006 , Cheung,2009Dr. Mirmiran / SBMU 15

Nutrition therapy Nutrition therapy (cont’)(cont’)

• All women should receive individualized counselingindividualized counseling

• Food plan Food plan should be individualized individualized & culturally appropriateculturally appropriate



Maternal weight-gain & Calorie intake for Maternal weight-gain & Calorie intake for women with GDMwomen with GDM

There is no indication that normal-weightnormal-weight and

underweightunderweight women with GDM should not follow

the IOM weight-gain guidelinesIOM weight-gain guidelines and calorie intakecalorie intake


weight-gain recommendations based on

prepregnancy BMI

(BMI (kg/m2 weight-gain

normal 19.819.8– – 26.026.0

11.411.4– – 15.915.9 kgkg

overweight26.1–29.0

6.8–11.4 kg

Obese>29

kg7

(Institute of Medicine’s Nutrition for Pregnancy 1990)

Nutrition therapy Nutrition therapy (cont’)


overweight and obese women:

Severe calorie restrictionSevere calorie restriction, increases

ketonuria and ketonemia

American Diabetes Association have suggested:

a 30–33% calorie restriction fora 30–33% calorie restriction forobese women with GDM,obese women with GDM,

noting a minimum 1600-1800 calorienoting a minimum 1600-1800 calorie

Ada,2000



• 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

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



Macronutrient intakeMacronutrient intake

CarbohydrateCarbohydrate (CHO) (CHO) :: 50 to 55% 50 to 55% kcal intake

ProteinProtein: 20-2520-25 %% kcal intake

FatFat: 25-30%25-30% kcal intake



• CHO are an important dietary source of energy, vitamins, minerals & fiber content.

• CHO is the main nutrient that affects postprandial glucose levels.

• CHOCHO intake can be manipulated by: intake can be manipulated by:


controlling the total amount of amount of CHO CHO distribution of distribution of CHOCHO over several meals and snacks type of type of CHOCHO

Reader,2007 Dr. Mirmiran / SBMU 22

The ADA Standards of Medical Care state :

• the glycemic index (GI) glycemic index (GI) can provide additional benefit to total carbohydrate control

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



FiberFiber :

• SolubleSoluble (legumes, oats, fruits)

• InsolubleInsoluble (whole grain breads, cereals and some vegetables)

Both: increase satietyincrease satiety slowing absorption time slowing absorption time lower glycemic indexlower glycemic index



Carbohydrate CountingCarbohydrate Counting

Works as follows: a dietitian determines a person’s dietary needsdetermines a person’s dietary needs

the individual is given a daily CHO allowancedaily 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 mealsper meals



Carbohydrate CountingCarbohydrate Counting

• Emphasis is given to spreading the dietary intake over six meals dailysix meals daily:

• 3 main meals

• 3 snacks

Distribution of CHO in daily mealsDistribution of CHO in daily meals


mealsmeals BreakfastBreakfast Snack1Snack1 LunchLunch Snack2Snack2 DinnerDinner Snack3Snack3

CHOCHO%% 15%15% 10%10% 30%30% 10%10% 20%20% 15%15%


• Additional dietary components are usually based based upon the general recommendations for diabetes upon the general recommendations for diabetes mellitusmellitus..

• A reductionreduction in simple carbohydrates simple carbohydrates and fat fat intake intake is advisable



Fat intake:Fat intake:

• less than 10 % less than 10 % SFASFA

• up to 10 %up to 10 % PUFAPUFA

• the remainderremainder derived from MUFAMUFA



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 pregnant women for all pregnant women

(Dietary Reference Intakes for pregnancy 2001)Dietary Reference Intakes for pregnancy 2001)



Nutrition therapy Nutrition therapy (con’t)(con’t)

30

• ExerciseExercise is an obvious adjunct therapyobvious adjunct therapy to MNT for women with GDM

• light and moderate light and moderate intensity activities intensity activities such as walking for 20–30 min/day:

can be safely encouragedsafely encouraged, modest improvements in glycemic control might be

achieved

ExerciseExercise


Criteria for adding pharmacological therapyCriteria for adding pharmacological therapy

such as insulin or glyburide:such as insulin or glyburide:

• One or more blood glucose values outside the target range within a designated time frame.

• Elevated fasting glucose values alone

Pharmacologic therapyPharmacologic therapy


CONCLUSIONSCONCLUSIONS

Nutrition recommendations for women with GDM, including:

• Management of gestational weight gainManagement of gestational weight gain

• Control of calorie intakeControl of calorie intake

• Modifying macronutrient composition & distributionModifying macronutrient composition & distribution

• Providing vitamins & minerals to meet pregnancy's Providing vitamins & minerals to meet pregnancy's

needneed

Dr. Mirmiran / SBMU33

The food plan should be designed to :

FulfillFulfill minimum nutrient requirements for pregnancyfor pregnancy

Achieve glycemic goals Achieve glycemic goals without weight loss and ketonemia

BeBe culturally appropriate andand individualized to take to take into account the into account the patient’s body habituspatient’s body habitus, , weight gainweight gain, and , and physical activityphysical activity



Nutrition interventions for GDM emphasize

• healthy food choiceshealthy food choices

• portion controlportion control

• Cooking practicesCooking practices

that can be continued postpartumthat can be continued postpartum

and may help prevent later diabetes,and may help prevent later diabetes,

obesity, cardiovascular disease, andobesity, cardiovascular disease, and

cancercancer



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medical nutrition therapy in gestational diabetes mellitus dr. parvin mirmiran obesity research...

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