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Nutritional Management of Gestational Diabetes and Nutritional Management of Women. Two Different Therapies or the Same? CLINICAL DIABETESVOL. PRACTICAL POINTERS Nutritional Management of. Gestational Diabetes and Nutritional Management of Women With a History of Gestational. Diabetes: Two Different Therapies or the Same? Deborah Thomas- Dobersen, RD, MS, CDEGestational diabetes mellitus. ![]() GDM) is defined as carbohydrate intolerance of varying degrees of severity with onset or. This definition applies regardless of whether insulin. It does not exclude the. GDM is the. most common medical complication of pregnancy,2 occurring in 4% of all. United States (all ethnicities),3 or approximately 1. In addition, it is increasing in prevalence globally. The. incidence of this metabolic complication of pregnancy will also notably increase if the. O'Sullivan and Mahan data by Carpenter and. Coustan as suggested by the 4th International Workshop- Conference on GDM are accepted and. The new diagnostic criteria are suggested in part because of the. GDM, macrosomia of the infant. Currently, the American. Diabetes Association is sponsoring the writing of a technical paper that will assess the. Although. there is still considerable controversy regarding the clinical importance of GDM and its. GDM. The major cause. GDM is macrosomia (birth weight > 4,0. Other causes of neonatal. Women with. GDM have a significant risk of developing GDM with a subsequent pregnancy, with recurrence. Studies show that. GDM develop type 2 diabetes mellitus 7–1. The. diagnosis of GDM appears to unmask those women with inadequate - cell reserve who are at substantial risk of developing. This ability to predict who may go on to develop type 2 diabetes gives a. Diabetes. Prevention Program of the National Institutes of Health. Of even. greater potential significance are the potential influences that GDM may have on the. Long- term follow- up studies show an increased risk for. GDM. present during the index pregnancy. Given the newer. understanding of the importance of GDM, it is unfortunate that nutritional management, the. There are no randomized, controlled studies. GDM, lean or obese. Yet. there are published reports of clinic programs that were able to get good infant and. GDM using a wide range of. Langer, 5. 5% carbohydrate, 2. Jovanovic, 4. 0% carbohydrate. This article offers practical pointers that seem to make sense. The. Diabetes Care and Education (DCE) Practice Group of the American Dietetic Association is. Information on the results of this study may be obtained after January 2. American Dietetic Association's web site: http: //www. Medical. Nutrition Therapy for GDMA registered. RD, CDE) is specifically qualified to. GDM. To find a qualified dietitian, call your local. American Diabetes Association or the American Dietetic Association Consumer. Hotline (1- 8. 00- 3. Web site http: //www. Maternal. Weight Gain. Maternal weight. gain, an index of nutrition, strongly influences infant birth weight, the primary. Pre- pregnancy weight is a crude index of. These two nutrition- related factors, maternal weight. Table 1. Recommended Weight. Gain in Pregnancy. Pre- pregnancyweight status. Recommendedrange of weight (lbs)A. Obese. 35–4. 52. 8–4. In 1. 99. 0, the Institute of Medicine released. Table 1). 1. 5 The total amount of weight gain is not as important as the weekly. Most women are diagnosed with GDM during the second or third trimester, when. Many women are. gaining almost 2 lb/week when they are diagnosed with GDM. Slowing down the rate of weight. A weight gain graph is a helpful tool to share with women. GDM. A curve approximating the desired rate of weight gain starting from where the. Figure 1). Often after being. GDM, a woman's weight gain may cease for a period to 1–2 weeks. This. seems to be common and harmless in the absence of small to moderate ketones. Sweets often. add as many as 2. A change in body composition may also be to blame when the. If weight gain is not resumed after 2. Calorie. intake must take into account maternal height, pregravid weight, maternal age, gestational. Whether one looks at organizations (National Research. Council, American Diabetes Association, American College of Obstetrics and Gynecology), or. Joslin Diabetes Center, International Diabetes Center. Sweet Success, etc.), the calorie level recommended for GDM varies widely. To give one. guideline, 3. In the long run, this. The initial calorie level. Inadequate. weight gain needs more calories in the face of small to moderate ketones. Excessive weight. A detailed diet history before initiating meal plans can. When a. woman is eating a well- balanced diet without excessive fat and sugar, with meals and. For the. majority of women with GDM, a calorie level of 2,2. Having women keep food records helps both as a behavioral change tool and as a. For obese women. with GDM, severe calorie restriction, 5. Moderate calorie restrictions (3. However, some risk to the fetus may occur in. Table 2. Goals for Medical. Nutrition Therapy in GDM1. Optimal. nutrition for developing fetus. Optimal. nutrition for mother. Maternal. euglycemia without distorting diet. The goals in determining. GDM (Table 2). The last. Table 2 is predicated on the assumption that most patients with GDM will not. Therefore, the impression that. GDM or diagnosed with type 2 diabetes later. To date. three different approaches to maternal euglycemia in GDM are emerging. Central to all is. GDM, and that increasing maternal hyperglycemia leads to. One approach uses a higher- carbohydrate/lower- fat diet, of. The second approach advocates use of carbohydrate. This approach uses. Clapp also notes that exercise. Of concern. when restricting carbohydrates is: 1. Nutritionists are not naive enough to suggest. As. the per centage of carbohydrates in the diet is decreased, the percentage of fats. Therefore, whenever carbohydrate restriction is used, a high er- fat diet is. They need to show 1) that these women are not staying on. Certainly the. cost- effectiveness of delaying the onset of type 2 diabetes is greater than that of not. Gregory showed theoretical savings of more than $7. In addition to the. Many women are more insulin resistant in the early morning and can tolerate. The division of calories into three meals and three or. Self- monitoring. Blood Glucose. Self- monitoring of. SMBG) is essential to any program that attempts to intensively treat GDM. Meters and lancet devices are much more easily. Monitoring. will give these women immediate feedback about portion size, particular foods that cause. With this. information, women are free to make choices and to see the effects of those choices in a. Studies have shown that SMBG helps with adherence to the goals of treatment. Patients are more likely to believe the. SMBG allows. adjustments to be made to the meal plan/exercise program to normalize blood glucose. Without SMBG, the meal plan, solely a starting point, cannot be individualized to. And lastly, SMBG allows the earlier. The number. of blood glucose readings to obtain daily can be anywhere from 4 to 7. Postprandial. glucose levels are more closely related to fetal risks than are fasting levels. Therefore. in addition to fasting levels, postprandial blood glucose readings are recommended. There. is no consensus on whether a 1- hour or a 2- hour postprandial reading is best. Ketone. Testing. Although the. It is recommended for. For dietitians who. It is an inexpensive tool that. In the future. there will be a better quantitative test that measures serum betahydroxybutyrate, the more. Food. Records. The simple process. The food record does not need to be shown to. It does not have to be analyzed for calories. It is a well- known behavioral tool. Three days of food. Food records after education on the meal plan will help practitioners assess. Anytime blood glucose. Luckily for most of us, remembering a meal eaten 2 hours ago is. This information proves helpful in trying to assess whether the high. Exercise. The use of exercise. GDM has received more attention lately. A regular exercise. For GDM, however, it has added. It has been found in a small study to lower fasting and postprandial. Bung and Artal encourage. They recommend an. The. American College of Obstetrics and Gynecology has published guidelines for safe exercise. In general, for a healthy pregnancy, moderate regular exercise of a. Hypertensive women, however, should not. Brisk. walking, cycling, and swimming are often done safely by pregnant women. Communities often. Exercising for 1. GDM. Putting. It All Together. The tools mentioned. SMBG, ketonuria, food intake, weight gain, and. GDM. Each tool adds a piece to the puzzle, which together gives. SMBG and food records. For example, some women can tolerate more. Records of rate of. For. example, a very obese woman with no weight gain over a 1- month period but whose records. Many very obese women have weight gains and rates of weight gains much lower. Telephone/fax. management can be a cost- effective means of using these tools to make course corrections. In many programs, women with GDM are asked to call/fax records in weekly. A. health care practitioner (RD, CDE) skilled in working with these women can use the records. If a woman receives a. SMBG, ketonuria, and food records, it reinforces the. This type of program also catches the high blood. Many. times when blood glucose is elevated, a patient who has been instructed to call will not. A weekly call- or- get- called program will not let this. My particular bias is. Breast- Feeding. Extensive research. Breast- feeding is. GDM, as it is associated with better maternal. Postpartum. Recommendations. At 6–1. 2 weeks postpartum. A resulting fasting blood glucose of. A fasting. plasma glucose of 1. At the 2- hour level, a plasma glucose < 1. Yet women with a history of GDM. Yet if type 2 diabetes is delayed by 6 years, the risk of. The 4th International. Workshop- Conference on Gestational Diabetes Mellitus included more emphasis on the. GDM. All women with a history of GDM. Such women should.
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