9/28/2017. Recommendations are based on the 2016 Gestational Diabetes Mellitus Guideline of the Academy Evidence Analysis Library

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1 The Latest Nutrition Recommendations Maria Duarte-Gardea, PhD, RD, LD, Chair Diana Gonzalez, DCN, RD Alyce Thomas, RD Diane Reader, RD, LD, CDE Rebecca Gregory, MS, RD, LDN, CDE Susan Wang, MS, RD, CD, CDE Kyle Thompson, DCN, RDN, LDN, CNSC: No conflict of interest to disclose Diane M. Reader, RDN, CDE: No conflict of interest to disclose Diana Gonzales-Pacheco, DCN, RDN: No conflict of interest to disclose Recommendations are based on the 2016 Gestational Diabetes Mellitus Guideline of the Academy Evidence Analysis Library Expert Working Group (EWG) was assembled EWG followed the Academy of Nutrition and Dietetics Evidence Analysis Process for conducting systematic reviews and developing guidelines Effectiveness of MNT for treatment and prevention of GDM Effect of varying levels of calorie consumption Impact of amount and type of carbohydrate, protein, and fat consumption Effect of dietary patterns based on DASH (Dietary Approaches to Stop Hypertension) and glycemic index Impact of distribution of meals and snacks 1

2 Insulin Requirements of Pregnancy 9/28/2017 The scientific literature was systematically searched using criteria developed by the EWG 29 studies were included in the systematic review Trained evidence analysts extracted data and critically appraised each article Draft evidence summaries and tables were prepared by lead analysts The EWG reviewed and graded the evidence The EWG summarized the evidence in 12 conclusion statements The EWG used the results of their systematic review to prepare the 2016 GDM Nutrition Practice Guideline 11 topics, 18 evidence-based nutrition practice recommendations Recommendations were rated Strong, Fair, Weak, Consensus, Insufficient Evidence The 2016 Guideline was externally reviewed by 14 experts in GDM, and revised as appropriate by the EWG prior to publication Interventions typically within the scope of practice of a certified exercise physiologist or other exercise professional, athletic trainer, or behavioral or psychological professional, for which adequate training in physical activity interventions or behavioral therapy is necessary Preconception nutrition guidance for the prevention of GDM Postpartum prevention of diabetes Prevention of recurrence of GDM or progression to Type 2 diabetes At the end of this session, the participant will be able to: Describe the critical step of referral and components within the steps of the nutrition care process Identify research that supports the association of medical nutrition therapy and glucose management, and positive maternal and fetal outcomes Describe best practices and implementation for individualized diet prescriptions to manage glucose fluctuations in women with GDM GDM is diabetes that is first diagnosed in the second and third trimester of pregnancy that is not clearly either preexisting type 1 or type 2 diabetes. (ADA 2017) Due to the epidemic of obesity and diabetes in women of childbearing age, there is an increase in diagnose of type 2 diabetes Test women with risk factors in the first trimester for type 2 diabetes (and rarely type 1 diabetes) using usual diagnostic testing Classify them with preexisting diabetes, probably type 2 3 Times normal 2 Times normal Normal Insulin Resistance Relative Insulin Deficiency Gestational Diabetes BASICS 3 rd ed IDC

3 First prenatal visit If at high risk (Hx GDM, LGA, fam hx, pre-pregnancy BMI >30) do an A1C test - A1C > 6.5% = type 2 DM - A1C < 6.5% - test weeks Weeks Gestation Diagnostic Criteria 100 gm OGTT Fasting > 95 1 hour > hour > hour > 140 Meet or exceed 2 or more values Or, fasting > 105 Screening: All women between weeks - 1 hour, 50 gm random GCT If > 200 = GDM If mg/dl then schedule 100 gm OGTT within one week OGT Test Used Threshold Organization # abnormal values (mg/dl; equal to or greater than) WHO 1999 ACOG ADA ADA 75 gm 1 abnormal 100 gm* 2 abnormal 75 gm 1 abnormal * 50 gm OGCT > 130 or 140 mg/dl WHO-World Health Organization ACOG-American College of Obstetricians and Gynecologists ADA- American Diabetes Association Fasting 1 hr 2 hr 3 hr Maternal hyperglycemia Fetal hyperglycemia Fetal Hyperinsulinemia (β-cell hypertrophy /hyperplasia) Excessive fetal growth Macrosomia/ Large for gestational age (LGA) Post-partum rate of C-section; difficult deliveries Frequency (%) Birth Weight > 90th Percentile Glucose Categories Fasting One Hour Two Hour Strong continuous association of maternal glucose levels with: Increased birth weight Primary C section Cord-blood C-peptide Post-partum hypoglycemia Reece, Coustan, Gabbe. Diabetes in Women. 3 rd edition. Page 165 Metzger B et al. NEJM. 2008;358: studies were evaluated: MNT intervention improved outcomes Maternal Outcomes Less hypertension Fewer hospitalizations Fewer premature births Less need for insulin therapy Fewer C-sections Neonatal Outcomes Fewer deaths Fewer NICU admissions Lower birth weight Fewer baby s with macrosomia and LGA Less shoulder dystocia The RDN should provide MNT that includes an individual nutrition prescription and nutrition counseling for all women diagnosed with GDM. Research indicates that MNT provided by an RDN as part of a comprehensive nutrition intervention that includes individualization of MNT is effective in improving blood glucose control and neonatal and maternal outcomes. Improved outcomes included lower birth weight and a reduction in the following: Incidence of macrosomia (LGA), need for insulin therapy, hypertensive disorders of pregnancy and maternal hospitalizations, neonatal intensive care unit (NICU) admissions and neonatal deaths, premature births and rate of shoulder dystocia, bone fracture and nerve palsy. Rating: Strong 3

4 The RDN should provide regular and frequent MNT visits to women with GDM to optimize outcomes. Visits should include: an initial 60 to 90 minute MNT visit a second MNT visit (30 to 45 minutes) within one week a third MNT visit (15 to 45 minutes) within two to three weeks Additional MNT visits should be scheduled every two to three weeks or as needed for the duration of the pregnancy. MNT assists the woman with GDM in meeting her blood glucose and weight gain targets, contribute to a well-balanced food intake and promote fetal and maternal well-being. If diagnosed between weeks of gestation, there is only week until delivery to refer immediately and to have appointment within one week of referral Supported by national professional organizations American Diabetes Association (ADA) American College of Obstetricians and Gynecologists (ACOG) Endocrine Society s Diabetes in Pregnancy Clinical Practice Guidelines Rating: Consensus (no evidence of optimal frequency and duration to improve outcomes in systematic review) Pregnant women who are diagnosed with GDM should be referred to a RDN for MNT. Individualized MNT is important in helping pregnant women with GDM achieve and maintain normal glycemic levels appropriate weight gain essential nutrients for pregnancy promote positive maternal and fetal outcomes Strong 24 year old Mexican-American G2P1 Maternal grandmother Type 2DM Mother Pre-diabetes Homemaker, caring for five year old The registered dietitian nutritionist (RDN) should assess the food and nutritionrelated history of women with gestational diabetes mellitus (GDM) including, but not limited to: Monitoring Evaluation Intervention Diagnosis Assessment 4 Domains Nutrition-Focused Physical Findings and Client History Age, # of fetuses, medical & dental histories, obstetric history, education, health literacy and numeracy Biochemical Data, Medical Tests and Procedures Glycemic tests, SMBG, maternal & fetal testing, nutritional anemia profile, vitamin D, thyroid & kidney function Anthropometric Measurements Height, weight, BMI, weight changes Food/Nutrition-related History Food, beverage and nutrient intake, appetite, diet history and behavior, GI discomforts, psychosocial, food safety, pharmacological therapy, substance use, physical activity Consensus 4

5 Age: 24 years old Single fetus Weeks: 28 Previous OB history: no GDM in first pregnancy Family history: yes to maternal grandmother; mother has pre-diabetes General health- excellent Other medical history: depression Educational level: high school diploma Social history: married, one child, homemaker At first prenatal visit: A1C = 4.9% (normal < 5.7%) At 26 weeks: 50 gm GCT= 155 mg/dl At 27 weeks: 100 gm OGTT Fasting = 82 mg/dl 1 hour = 187 mg/dl 2 hour = 163 mg/dl 3 hour = 110 mg/dl Diagnosis of GDM Other lab tests: Hgb 13 g/dl; thyroid- normal Ultrasound: Normal findings for gestational age Time of Test Fasting: Before breakfast GDM-ADA mg/dl GDM-ACOG mg/dl < 95 < 95 1 hr post meal <140 < hr post-meal < Pre-pregnant weight: 138 pounds Height: 61 inches BMI: 26.1 Weight gain as of 30 weeks: 22 pounds Weight today: 160 pounds Weight gain goal for Overweight: pounds Self-monitoring of Blood Glucose - Fasting - One or two hrs after 3 meals Institute of Medicine (IOM) Recommended total Rate of gain in 2 nd and 3 rd BMI category wt gain Trimesters Underweight (<18.6) lb. 1 lb/week Normal ( ) lb. 1 lb/week ACOG Practice Bulletin. Obstet-Gynecol, August Clinical Recommendations, Diab Care, 40, (Supp 1) January 2017 Overweight ( ) lb. 2/3 lb/week Obese (>30) lb. ½ lb/week Diet recall: 9 AM: sweet bread, sweetened coffee 2 PM: Pasta soup, roasted meat, lettuce, tomato, 6 corn tortillas, chips and salsa, lemonade Other topics First trimester nausea; no problems for 1 month Food cravings for lemonade Has enough money for groceries Monitoring Evaluation Assessment Diagnosis 5 PM: Fruit snack Intervention 7 PM: Cereal with milk 5

6 Three international studies Ho et al, kcal/kg in non-obese (pre-preg wt) Romon et al, 2001 Minimum caloric restriction 1,800 kcals Normal, overweight, obese pre-pregnancy BMI Rae et al, % calorie reduction Obese pre-pregnancy BMI The evidence of the effect of varying levels of caloric consumption on outcomes is inconclusive. No significant differences in most outcomes: 1,384kcal to 1,863kcal per day All BMI categories Obese women, GWG slowed after caloric reduction 1,560kcal and 1,630kcal per day Without adverse effects. Reported vs. actual caloric intake tendency to over-restrict Inconsistent stratification by pre-pregnancy BMI & pre-pregnancy weights not described More research needed: on evaluating calorie consumption (kcal/kg pre-pregnancy weight) on fetal or neonatal and maternal outcomes The RDN should individualize the calorie prescription based on a thorough nutrition assessment with guidance from relevant references (DRI, IOM) Encourage adequate caloric intake to promote: fetal/neonatal and maternal health achieve glycemic goals promote appropriate gestational weight gain (GWG). Fair Current wt: 72.7 kg Pre-pregnancy BMI: 26.1 Wt gain of 22 lbs (10 kg) at 30 wks DASH Diet Glycemic Index a) 1800 kcal/d = 25 kcal/kg b) 2180 kcal/d = 30 kcal/kg 6

7 In women with GDM what impact do dietary patterns based on the DASH diet have on fetal/neonatal and maternal outcomes? In women with GDM what impact do dietary patterns based on the glycemic index have on fetal/neonatal and maternal outcomes? Two RCT s DASH diet VS Standard diet Both groups: 40-55% CHO, 10-20% protein, 25-30% fat DASH group consumed more CHO (65-67%), less fat (17-18%) Asemi et al.nutrition, 2013;29(4) Asemi et al. Eur J Clin Nutr 2014;68: DASH group More CHO More dietary fiber 5.8 servings vegetables 5.9 servings fruit Less sucrose Less dietary cholesterol Less sodium Asemi, et al. Nutrition 2013;29(4): Asemi et al. Eur J Clin Nutr 2014;68: Maternal Outcomes Improved Glucose tolerance & HgbA1c Insulin resistance Lipid profile C-section deliveries* Grade III *high c-section rate with GDM Fetal Outcomes Lower Birth weight Macrosomia Head circumference Ponderal indices The rise in blood glucose after eating a food containing 50 grams of carbohydrate. Six studies evaluated impact of GI Dietary Patterns Low and Medium GI diets Varying amounts of CHO Low GI = 0 to 55 Medium GI = 56 to 69 High GI = 70 or greater Source: Augustin et al. Nutr Metab Cardiovasc Dis 2015; 25(9):

8 Maternal Outcomes Glycemic control Reduced need for insulin therapy Reduced GWG Fetal Outcomes Trend lower birth weight Interpretation of results is limited, due to inability to compare diets across studies and none of the studies included a comparison to the high glycemic index (HGI) diet. The RDN should individualize both the type and amount of CHO for women with GDM based on nutrition assessment, treatment goals, blood glucose response and patient needs. Rating: Fair Grade III In women with GDM, what impact does the amount or type of carbohydrate consumed have on post-prandial breakfast glycemia? The RDN should individualize both the amount and type of CHO for women with GDM based on nutrition assessment, treatment goals, blood glucose response and patient needs. Limited evidence does not confirm an ideal amount of CHO, but suggests an interaction between the amount and type of CHO. Several studies showed positive effects on glycemic control and neonatal/fetal and maternal outcomes: Low GI (< 55) or medium GI (55-69) diets (36.7% to > 60% CHO) DASH diets (> 65% CHO) Two studies evaluating amount of CHO alone reported mixed results: 202g CHO/d more effective at reducing PPBG compared to >270g CHO/d 23% incidence of LGA infants with CHO intake < 211g per/d, but no LGA when greater than 211g per day. Limited evidence was found to demonstrate the impact of the type or amount of carbohydrate (CHO) consumption on post-prandial breakfast glycemia in women with GDM. Interpretation of results challenging Inability to compare diets across studies (varying amounts of CHO and GI) prescribed vs. reported intakes lack of description of the breakfast meal. Grade III Rating: Fair GDM: Carbohydrate and Post Prandial Breakfast Glycemia The RDN should individualize both the amount and type of CHO at breakfast based on nutrition assessment, treatment goals, blood glucose response and patient needs. If continued elevated breakfast PPBG, the RDN may further modify the amount or the type of CHO at breakfast to achieve blood glucose targets. Low or medium glycemic index (GI) diets with 42-60% CHO (GI for breakfast meal <55; 15g to > 60g) Lower total CHO (45% vs 60%) Low GI breakfast with fruit, bread, and milk Rating: Fair 8

9 No evidence to evaluate the impact of distribution of meals and snacks on outcomes Referred to: Joslin Diabetes Center (2011) Six to eight individualized small meals and snacks American College of Obstetricians and Gynecologists (2013) Three meals and 2-3 snacks California Diabetes & Pregnancy Program Sweet Success Guidelines for Care (Shields & Tsay, 2015) Three meals & several snacks Suggest limiting CHO s at breakfast In women with GDM, the RDN should distribute the total calories and CHO into smaller meals and multiple snacks per day. Individualized distribution based on: Blood glucose levels, physical activity and medication and adjusted as needed Three meals and two or more snacks Distributes CHO intake Reduce post-prandial blood glucose fluctuations Rating: Consensus Diet recall: 9 AM: sweet bread, sweetened coffee 2 PM: Pasta soup, roasted meat, lettuce, tomato, 6 corn tortillas, chips and salsa, 12 oz lemonade 5 PM: Fruit snack 7 PM: Cereal with milk Breakfast 2 eggs, 2 corn tortilla, nopales, 1/8 avocado, coffee w/sugar substitute AM Snack Sliced apples, peanut butter, yogurt Lunch Pinto beans, roasted meat, vegetables (summer squash, corn, green chile), 2 corn tortillas, sugar free lemonade PM Snack Cheese quesadilla (corn tortilla) with salsa Dinner 2 Fish (tilapia) tacos, filling for tacos (shredded cabbage, tomatoes, onions, jalapenos, tomatillos salsa), fresh berries for dessert HS ½ sandwich (whole wheat bread, turkey, cheese, 1/8 avocado) with carrot and celery sticks Diet Recall 1800 kcals 285 g CHO Minimal protein Minimal fruit & vegetables Suggested Meal Plan 1800 kcals 190 g CHO Protein at all meals & snacks Fruit & Vegetables Monitoring Evaluation Intervention Assessment Diagnosis Minimal calcium Calcium Healthy fats 9

10 Monitoring Evaluation Assessment Intervention Diagnosis The RDN should monitor and evaluate the following components at each visit and compare to desired individual outcomes. Food and Nutrition Outcomes: Daily food intake in relation to post-meal glucose readings Food and beverage choices Calorie intake and serving sizes Appetite and meal frequency Anthropometric measurements: weight changes Biochemical data, medical tests and procedure outcomes: Self-monitoring of blood glucose (SMBG) Fetal and maternal testing and lab testing Rating: Consensus SMBG Fasting BG: mg/dl 1 hr post breakfast: mg/dl 1 hr post lunch: mg/dl 1 hr post dinner: mg/dl Weight: 161# ( +1 #) Activity: Added 15 min walk after lunch and dinner Food Plan: Post-breakfast BG elevated, suggest substitute beans for one tortilla Eat smaller meals and more frequently Eliminate sweetened beverages SMBG FBG and 2 hr PP remain in target Wt: 163# (up 2 #) Activity: Walking 20 min after lunch and dinner Food Plan: Feeling hungry after lunch Add more protein and vegetables Consider nuts Infant birth weight: 7# 13 oz Total gestational weight gain (GWG): 28# Current Wt: 143# Weight goal: # 75 g OGTT FBG 93 mg/dl (N= <100 mg/dl) 2 hr 127 mg/dl (N= <140 mg/dl) DASH diet Continue walking after meals Frequency of MNT visits Meal/snack distribution Breakfast CHO Dietary patterns Appropriate caloric intake Talk to administration, medical director or OB department to ensure protocol in place for referral of patients with GDM to RDNs! MNT improves maternal and fetal outcomes Individualize food plan to achieve appropriate weight gain, good nutrition and blood glucose control More liberal with carbohydrate if high fiber and minimally processed foods Adjust calories based on glycemic control and GWG Smaller portions and more frequent meals and snacks Consider DASH or Glycemic Index dietary patterns in addition to carbohydrate counting 10