Dr. Shelley Wilkinson 18th June 2014

Gestational Diabetes: nutrition priorities

Dr Shelley WilkinsonAdvanced Accredited Practising Dietitian,

Mater Mothers’ Hospital, Brisbane, Australia

A window of opportunityDuring pregnancy:• health service contact

• more receptive to health messages

• intergenerational effects

Behaviours with demonstrated outcomes:• diet/nutrition, healthy weight gain (+breastfeeding)

• sufficient physical activity

• smoking cessation

Guidelines:• Australian dietary guidelines (incl. gestational weight gain, GWG)

• Gestational Diabetes Mellitus (GDM) Nutrition practice guidelines

• QHealth Obesity guidelines

Pregnancy Nutritional Requirements

Acknowledgement:Food systems & Policy team, Victorian Dept of Health, 2013

Pregnancy nutrition – dietary guidelines

1. Achieve and maintain a healthy weight, by being physically active and choosing amounts of nutritious food and drinks to meet your energy needs

2. Eat a wide variety of food every day – including vegetables; fruit; grain foods (preferably wholegrain); protein foods (e.g. meat, fish, eggs, nuts, legumes), and dairy (mostly reduced fat)

3. Limit your intake of food/drinks that contain added sugar, salt and/or saturated fat (and of course, in pregnancy, avoid alcohol)

4. Encourage, support and promote breastfeeding 

5. Prepare and store food safely.

Not eating for two, but having to eat twice as well…

Energy requirements1st trimester = no additional requirements2nd trimester = +1400kJ/d3rd trimester = +1900kJ/d

Nutrient requirementsProtein RDI: 60g/d (46g/d)Iron RDI: 27mg/d (8mg/d)Iodine* RDI: 220μg/d (150μg/d)Folate* RDI: 600μg/d (400μg/d) + 400μg/dLC n3 fatty acids AI: 115mg/d (90mg/d)

Not eating for two, but having to eat twice as well…

How do we apply this in everyday settings?

Gestational weight gain guidelines

If pre-pregnancy BMI was …

GWG goal…

Rate of gain in trimesters 2 & 3

<18.5 kg/m² 12 ½ - 18kg 0.45 kg/week

18.5-24.9 kg/m² 11 ½ - 16kg 0.45 kg/week

25-30 kg/m² 7-11½kg 0.28 kg/week

30+ kg/m² 5-9kg 0.22 kg/week

Not eating for two, but having to eat twice as well…

“Based on your weight at the beginning of

pregnancy, this weight gain is

recommended for the healthiest

pregnancy possible”

GDM + Medical Nutrition Therapy (MNT)• primary intervention strategy for managing BGLs in

GDM• Improvements in important outcomes (e.g. insulin, BGL

control), documented in ADA Nutrition Practice Guidelines validation study

• MNT according to an evidence-based appointment schedule• Minimum: one-hour ‘new’, two+ reviews, plus postnatal

follow up

• 3rd trimester dietetic counselling following a GDM diagnosis can slow weight gain and reduce the incidence of macrosomia

• Australian Carbohydrate Intolerance Study • Routine care vs dietary advice, BGL monitoring, insulin• Significant decrease in serious perinatal complications and

improvements in self-reported maternal health status

How do we measure up?A key

recommendation from a Qld dietitian managers’ report:

“a demonstration project implementing

and evaluating the GDM nutrition

guidelines to facilitate its dissemination and

adoption across Queensland”

Pregnancy nutrition priorities

“MNT primarily involves a carbohydrate- controlled meal plan that:

• promotes optimal nutrition for maternal and fetal health,

• with adequate energy for appropriate gestational weight gain,

• and maintenance of normoglycaemia,

• and absence of ketosis”American Diabetes Association 2008

Carbohydrate

•component of the diet that has the greatest influence on BGLs

•commonly proposed options for reducing the post-prandial response:

• Reduce total CHO intake, if excessive (NB minimum 175g CHO)• Re-distribute CHO across the day (eg 3 meals, 3-4 snacks)• Lower glycaemic index CHO• Physical activity post meals

Even so, in pregnancy

. . . “there is little evidence for a recommended amount and type of CHO or its distribution . . . . The best indicators at this time are the results of self-monitoring of BGL, food records, and weight gain”

Pregnancy nutrition priorities

Know your carbohydrate foods

Carbohydrates are in many foods

Include carbohydrate in each meal and snack

Aim to eat every 2 ½ to 3 hours

Aim to eat similar amounts of carbohydrate across meals

A good way to measure carbohydrates is to think of them as exchanges that you mix and match over meals

Better choicesGrain or rye breadCrackers containing whole grains or seedsPasta or noodlesBasmati or Doongara riceSweet potato

Excessive CHO

Risks:• Higher BGLs and assoc. risks

e.g. LGA baby• Excess GWG and associated

risks• Unnecessary use of insulin

The CHO Dilemma . . .

Suboptimal CHO

Risks:• High BGLs, if resulting

hunger leads to overeating

• Poor intake of associated nutrients (vit, min, fibre etc)

• Suboptimal weight gain and associated risks e.g. SGA

• Starvation ketosis

Pregnancy nutrition priorities

Used with permission. www.greatideas.net.au

Repeat Oral Glucose Tolerance Test (OGTT)

6 – 12 weeks after delivery

Repeat OGTT every one to two years

Greater risk of • developing gestational diabetes again• developing Type 2 diabetes in later life

Reduce your risk by continuing a healthy lifestyle after your pregnancy

Continue a healthy lifestyle after your pregnancy

How to prevent T2DM

• Weight management• Physical activity• Breastfeeding

Diabetes Prevention Program (DPP) Aim: to reduce the incidence of T2DM in high risk populations

1. Participation in a lifestyle program• Individualised counselling, multiple contacts (monitoring/support)• Goals:

- Weight reduction > 5-7%- Total fat intake <30% total energy- Saturated fat intake <10% total energy- Fibre intake >15g/1000kcal- Moderate intensity physical activity > 150mins/week

2. Use of Metformin

3. Control group

• Lifestyle intervention was more effective than Metformin in reducing the risk of developing T2DM

• Sub-analysis: Compared women with Hx GDM vs No GDM• Both lifestyle and Metformin intervention reduced the incidence

of diabetes by approximately 50% compared w/ control• Intensive lifestyle intervention was more effective in the non-

GDM group, and the GDM group were not able to sustain the lifestyle changes over time

The combination of increased risk, less physical activity and consistent weight gain in the GDM group highlights the importance of follow up and intervention for these women

How to prevent T2DM

Australian Dietary guideline

Women post-GDM:

- Are less likely to BF than women without GDM (~delayed lactogenesis II)

- Are twice as likely to develop T2DM if don’t BF

- Have a 15% decrease in risk of T2DM/yr of lactation

- That have a higher intensity of BF = improved fasting BGLs and lower insulin levels

Lowest postpartum T2DM risk in women who BF > 9/12 (improved glucose homeostasis)

Exclusive BF increases postpartum weight loss, reduced long term obesity and lower prevalence of the metabolic syndrome

Weight management Physical activity Breastfeeding

How to prevent T2DM

BF offers a safe, feasible and low–cost intervention to reduce the

risk of subsequent T2DM

NEMO Resources

Nutrition Education Materials Online

• Antenatal nutrition• Gestational Diabetes and

nutrition http://www.health.qld.gov.au/nutrition/nemo_antenatal.asp