A Comparative Study of Eating Habits and Food Intake in Women with Gestational Diabetes according to Early Postpartum Glucose Tolerance Status

Transcription

1 Originl Article pissn eissn D I A B E T E S & M E T A B O L I S M J O U R N A L A Comprtive Study of Eting Hbits nd Food Intke in Women with Gesttionl Dibetes ccording to Erly Postprtum Glucose Tolernce Sttus You Jeong Hwng 1, Bo Kyung Prk 1, Sunmin Prk 2, Sung-Hoon Kim 3 1 Deprtment of Nutrition, Cheil Generl Hospitl & Women s Helthcre Center, Kwndong University College of Medicine, Seoul, 2 Deprtment of Food nd Nutrition, Hoseo University, Asn, 3 Division of Endocrinology nd Metbolism, Deprtment of Medicine, Cheil Generl Hospitl nd Women s Helthcre Center, Kwndong University College of Medicine, Seoul, Kore Bckground: Women with gesttionl dibetes mellitus (GDM) re t high risk for type 2 dibetes mellitus (T2DM) nd crdiovsculr disese (CVD); continuous life-style intervention, especilly diet, is centrl to mnging T2DM nd CVD. However, little is known bout the dietry ptterns of women with GDM fter delivery. The gol of this study ws to compre the eting hbits nd food intkes of women dignosed with GDM during the erly postprtum period. Methods: We performed 75 g orl glucose tolernce test (OGTT) in 184 women with GDM between 6 nd 12 weeks fter delivery. Bsed on the results of the OGTT, the subjects were divided into three groups ccording to the Americn Dibetes Assocition criteri; norml glucose tolernce (NGT), pre-dibetes (n=73), nd dibetes mellitus (DM). Eting hbits nd usul food intke fter delivery were investigted using questionnire, bsed on 24 hour recll, which ws dministered by trined dietitin. The dily intke dt were nlyzed using CAN Pro 3.0. Blood tests were performed pre- nd post-delivery. Results: Eting hbits were not significntly different mong the three groups. However, niml ft consumption ws significntly different mong the three groups. The intke rtio of ft clories to totl clories ws lso significntly higher in the pre-dibetes nd s. Conclusion: Although diet in the period 6 to 12 weeks postprtum did not influence glucose level, it my be importnt to educte women with GDM bout the risks of excessive niml ft intke during pregnncy nd the postprtum period in order to prevent lter onset of T2DM. Keywords: Animl ft, Erly postprtum period, Eting hbits, Food intke, Gesttionl dibetes mellitus, Rtio of ft clories INTRODUCTION Dibetes is defined s chronic metbolic disorder chrcterized by dysfunction in insulin secretion nd/or insulin ction, lso known s hyperglycemi, nd is divided into type 1 dibetes mellitus, type 2 dibetes mellitus (T2DM), nd gesttionl dibetes mellitus (GDM) [1]. GDM is common compliction of pregnncy [2], occurring in pproximtely 7% of ll pregnncies while bsed on other study subjects nd the different dignostic criteri, the prevlence rnge of vrious ethnic popultions ws reported to be between 1% nd 14% [3], nd tht number stedily incresing [4,5]. Additionlly, Corresponding uthors: Sung-Hoon Kim Division of Endocrinology nd Metbolism, Deprtment of Medicine, Cheil Generl Hospitl nd Women s Helthcre Center Kwndong University College of Medicine, 1-19 Mukjeong-dong, Jung-gu, Seoul , Kore E-mil: hoonie.kim@cgh.co.kr Sunmin Prk Deprtment of Food nd Nutrition, Hoseo University, 165 Sechul-ri, Bebng-eup, Asn , Kore E-mil: smprk@hoseo.edu Received: Jul. 12, 2010; Accepted: Dec. 27, 2010 This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License ( which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. Copyright 2011 Koren Dibetes Assocition

2 Postprtum food intke of women dignosed with GDM the prevlence of GDM is similr in Kore s in other countries (pproximtely 2% to 3%) [5]; moreover, when the dignostic criteri were updted, 4% increse in the prevlence ws reported [6]. In some women with GDM, impired glucose tolernce persists even fter delivery, or they re dignosed with dibetes. Although women with GDM return to norml glucose level fter delivery, mny of these women my develop dibetes lter in life. The prevlence of dibetes t postprtum hs been reported vriously nd increses significntly within five yers fter delivery for women previously dignosed with GDM. During follow-up in previous studies, up to 70% of women with GDM developed T2DM [7,8]. T2DM is mjor risk fctor for crdiovsculr disese (CVD), nd recent study hs shown tht it is the lrgest cuse of deth in dibetes ptients [9]. Additionlly, women who hd GDM, even fter returning to norml blood glucose levels fter delivery, re t greter risk for developing bnorml vsculr function [10]. As compred to dibetes ptients who hve no history of GDM, the incidence of chronic dibetes complictions is high in those with GDM history, especilly the mortlity rte due to crdiovsculr complictions [11]. Thus, it is very importnt to mnge nd reduce complictions erly in women with history of GDM who re t high risk of developing dibetes nd CVD. The risk fctors for GDM nd T2DM re similr - environmentl fctors such s diet, exercise, nd smoking, ll considered to be significnt. Dietry fctors tht induce obesity, especilly the consumption of sturted ftty cids were reported to be strongly linked with insulin resistnce nd CVD [12,13]. Studies on Koren GDM ptients were performed to determine dietry fctors tht ffect the pthogenesis of GDM [14] nd n effective diet for glycemic control during pregnncy [15] nd/or to describe the progression of GDM itself. However, there re very few studies which observe the types of mels consumed fter delivery. Becuse GDM is considered to put ptients t high risk for T2DM nd CVD, studies on dietry hbits fter delivery re considered to be very importnt nd my help in the prevention nd mngement of further progression to T2DM. In this study, blood tests were performed 6 to 12 weeks fter delivery. Bsed on the blood glucose results, ptients were seprted into groups: norml glucose tolernce (NGT) group, pre-dibetes group, nd dibetes mellitus (DM) group. After seprting prticipnts into their respective groups, eting hbits nd dietry intke were compred. In order to give direction to preventing T2DM nd CVD, we observed difference of diet mong three groups. METHODS Subjects At Cheil Generl Hospitl, Kwndong University College of Medicine, 196 women dignosed with GDM between Februry 2008 nd September 2009 were observed t 6 to 12 weeks fter delivery for post-gesttionl dibetes mngement. Among those dignosed with GDM, those who were dignosed 24 weeks prior to pregnncy, did not gree to the terms of the study nd those who hd given birth to twins were excluded from the study, resulting in totl of 184 surveyed ptients who prticipted in this study. A dignosis of GDM ws utilizing two step procedure, screening test nd dignostic test with Crpenter & Coustn method [1]. Dietry eduction for dibetes mngement ws provided to ll study subjects. Additionlly, t the 6 to 12 weeks fter delivery, 75 g orl glucose tolernce test (OGTT) ws performed on ech womn. Bsed on the criteri provided by the Americn Dibetes Assocition (ADA) [16], prticipnts were clssified s follows: NGT, impired fsting glucose (IFG), impired glucose tolernce (IGT) nd combined symptoms of IFG/IGT nd DM. This study seprted the ptients into three groups: the, the pre-dibetes group included the IFG, IGT nd IFG+IGT, nd the. For our study, there were 100 ptients in the, 73 ptients in the pre-dibetes group, nd 11 in the. This study ws pproved by the Cheil Generl Hospitl Institutionl Review Bord, nd ll prticipnts provided written consent. Nutritionl eduction nd recommended dily llownce After being dignosed with GDM, ll prticipnts received three-phse eduction regrding dietry mngement. Phse 1 of the eduction ws dministered individully t the dignosis of GDM nd focused on clculting the required dily clories. After the eduction, mel record ppers were provided. Phse 2 of the eduction ws performed two weeks fter the phse 1 eduction. The mel record ws reviewed in order to correct improper dietry intke in the previously plnned diet. Phse 3 of the eduction ws dministered during the hospitliztion fter delivery, tht the eduction from phse 1 ws reviewed. The food exchnge list from the Koren Dibetes Assocition nd life-size food models (Kore Mirge mod- 355

3 Hwng YJ, et l. el) were used to educte the prticipnts. In order to clculte the required cloric intke, stndrd body mss index (BMI) ws used. Considering the subjects were in the recovery of delivery, obesity ws not tken into ccount nd ll ctivities of dily life were considered s light ctivities. The mount of clories required for brestfeeding is 320 kcl per dy [17]. Therefore, tht mount ws dded to the mel pln for those ptients who were brestfeeding; no dditionl clories were dded for those subjects who were not brestfeeding. The cloric intke required by brestfeeding women fter delivery is set by the following formul [18]: Estimted energy requirement during brestfeeding (kcl)= height (m 2 ) Additionlly, in order to use the sme rtio of crbohydrtes, proteins, nd lipids consumed during the gesttionl dibetes tretment period, mels were composed using 50:20:30 rtio [15], nd consumptions of high ft met nd fish nd simple sugrs were restricted. The benefits of proper exercise nd weight mngement were lso mentioned. At 6 to 12 weeks fter delivery, eting hbits nd food intkes were investigted, nd blood tests were performed. Survey informtion Using questionnire, generl informtion nd diet were investigted. Generl informtion included ge, height, weight before pregnncy, weight t delivery, difference between before nd fter pregnncy weight, BMI prior to pregnncy, whether ptients were brestfeeding, intensity of ctivity, household income, fmily history, insulin use during pregnncy nd prity. Dietry hbits fter delivery until redmission for check-up were surveyed, including the number of mels per dy, whether or not brekfst ws consumed, the regulrity of mel time, the time tken to consume mel, whether ptients overte, frequency of mels eten t resturnts, min foods eten when ptients dined out, the number of grins, fish, vegetbles nd high ft foods consumed, verge number of sncks consumed, types of foods consumed s sncks, s well s the mounts of sweets, slty foods, high ft met nd fish nd instnt foods consumed except for min foods eten when ptients dined out, ll items in the questionnire were scored in order to compre the study groups. Good eting hbits received score of 3, moderte eting hbits received score of 2, nd poor eting hbits received score of 1. The sums for ech group were clculted. A dieticin surveyed the usul dily food intke by 24 hour-recll method using pictures of food to help ptients recll before their check-up dy. The CAN Pro 3.0 (Computer Aided Nutritionl Anlysis Progrm, version 3.0; Koren Nutrition Society, Seoul, Kore) ws used to nlyze dietry informtion, such s clories nd nutrients in the foods consumed. Blood tests were performed during the dignosis of GDM nd gin 6 to 12 weeks fter delivery. The blood test performed 6 to 12 weeks fter delivery included mesures for 2-hour postprndil blood glucose, glycted hemoglobin (HbA1c), totl cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), high-sensitive C-rective protein (hs-crp), C-peptide, systolic blood pressure (SBP), nd distolic blood pressure (DBP). During dignosis of GDM, the blood test included ll of the bove plus 1 hour blood glucose, 3 hour blood glucose, body weight 6 to 12 weeks fter delivery, BMI nd body ft percentge. Sttisticl nlysis The SAS progrm version 9.1 (SAS Institute, Cry, NC, USA) ws used for dt processing. Those who responded to the survey were seprted into three groups: NGT, pre-dibetes, nd s. The differences mong the three groups were compred, nd the medin nd interqurtile rnge (IQR) of ll items were clculted. In order to investigte the sttisticl significnce mong the three groups, the Kruskl-Wllis nonprmetric test ws used for vribles with irregulr distribution. In order to compre the dietry hbits of subjects, chisqure test ws used for the differences in frequency. Results with P vlues less thn 0.05 were considered to be sttisticlly significnt. RESULTS Generl informtion nd survey of dietry hbits After women with GDM gve birth, the subsequent mngement percentge ws 67.8%. The distribution of postprtum ptients with GDM ws 52.5% in the, 39.3% in the pre-dibetes group, nd 8.2% in the. The generl chrcteristics of the study prticipnts (Tble 1) showed tht there ws significnt difference in body weight nd BMI prior to pregnncy mong the three groups (P<0.05). About whether to use insulin, 72.7% of ptients in, 31.5% of ptients in the pre-dibetes group nd only 17.0% of ptients in the reported using insulin. As blood glucose 356

4 Postprtum food intke of women dignosed with GDM Tble 1. Clinicl chrcteristics nd life style of women with gesttionl dibetes ccording to postprtum glucose tolernce sttus Clinicl chrcteristic Pre-dibetes group (n=73) Age, yr 34.0 (5.0) 35.0 (6.0) 36.0 (5.0) Height, cm (6.0) (8.6) (5.6) Pre-pregnncy weight, kg 56.0 (12.0) 59.0 (15.3) 58.0 (21.0) Weight t delivery, kg 66.4 (11.6) 70.4 (15.0) 62.6 (13.5) Weight gin during 10.3 (5.3) 9.1 (6.2) 9.0 (7.1) Pregnncy, kg Pre-pregnncy BMI 21.9 (4.0) 23.1 (6.6) 22.4 (2.9) Brestfeeding Yes, n (%) 80 (80.0) 56 (76.7) 9 (81.8) Physicl ctivity Light, n (%) 46 (46.9) 35 (48.0) 3 (27.3) Regulr, n (%) 50 (51.0) 37 (50.7) 8 (72.7) Hevy, n (%) 2 (2.0) 1 (1.4) 0 (0.0) Income (10,000 won/mon) <100, n (%) 4 (4.1) 7 (9.6) 0 (0.0) 101 to 300, n (%) 41 (42.2) 20 (27.4) 5 (45.5) 301 to 500, n (%) 52 (53.6) 46 (63.0) 6 (54.5) Fmily history of dibetes Yes, n (%) 53 (53.0) 43 (58.9) 6 (54.6) Insulin usge in pregnncy b Yes, n (%) 17 (17.0) 23 (31.5) 8 (72.8) Prity 1, n (%) 42 (42.0) 30 (41.1) 4 (36.4) 2, n (%) 48 (48.0) 37 (50.7) 7 (63.6) 3+, n (%) 10 (10.0) 6 (8.2) 0 (0.0) Vlues re presented s medin (interqurtile rnge) or number (%). NGT, norml glucose tolernce; DM, dibetes mellitus; BMI, body mss index. Averge rnks to be significntly different t P<0.05 by Kruskl- Wllis test, b Proportions t P<0.001 by chi-squre test mong the three groups. Tble 2. Eting hbits of women with gesttionl dibetes ccording to postprtum glucose tolernce sttus Eting hbit Mel frequency, times/dy Pre-dibetes group (n=73) Three 67 (67.7) 50 (69.4) 5 (45.5) Twice 30 (30.3) 20 (27.8) 6 (54.5) Once 2 (2.0) 2 (2.8) 0 (0.0) Regulrity of mel time, dys/wk 5 to 7 53 (53.0) 45 (61.6) 7 (63.6) 3 to 4 26 (26.0) 16 (21.9) 3 (27.3) Less thn 2 21 (21.0) 12 (16.4) 1 (9.1) Overeting, dys/wk 5 to 7 3 (3.1) 2 (2.8) 0 (0.0) 3 to 4 5 (5.1) 4 (5.6) 0 (0.0) Less thn 2 90 (91.8) 66 (91.7) 11 (100.0) Frying food frequency, dys/wk 5 to 7 11 (11.0) 16 (21.9) 2 (18.2) 3 to 4 23 (23.0) 14 (19.2) 2 (18.2) Less thn 2 66 (66.0) 43 (58.9) 7 (63.6) Simple sugr food frequency, times/wk 5 to 7 9 (9.0) 6 (8.2) 0 (0.0) 3 to 4 14 (14.0) 14 (19.2) 1 (9.1) Less thn 2 77 (77.0) 53 (72.6) 10 (90.9) Slty food frequency, times/wk 5 to 7 12 (12.0) 11 (15.1) 0 (0.0) 3 to 4 15 (15.0) 9 (12.3) 1 (9.1) Less thn 2 73 (73.0) 53 (72.6) 10 (90.9) Animl ft foods nd high cholesterol food frequency Over 3 times/wk 3 (3.0) 2 (2.7) 0 (0.0) 1 to 2 times/wk 31 (31.3) 26 (35.6) 4 (36.4) Less thn 2 to 3 times/mo 65 (65.7) 45 (61.6) 7 (63.6) Instnt nd processed food frequency Over 3 times/wk 6 (6.1) 4 (5.5) 0 (0.0) 1 to 2 times/wk 43 (43.4) 26 (35.6) 4 (36.4) Less thn 2 to 3 times/mo 50 (50.5) 43 (58.9) 7 (63.6) Sum of scores of food hbits, medin (IQR) 36.0 (7.0) 35.0 (9.0) 37.0 (8.0) Vlues re presented s number (%) or medin (interqurtile rnge). There re no significntly different vlues for ny prmeter. NGT, norml glucose tolernce; DM, dibetes mellitus. levels incresed fter delivery mong ptients who hd received tretment for GDM, significnt increse in the use of insulin ws observed (P<0.001). Other fctors, including ge, height, weight t delivery, weight gin during pregnncy, brestfeeding sttus, physicl ctivity, income, fmily history nd fertility, were not significntly different mong the groups. Seventeen items from the diets of subjects 6 to 12 weeks fter delivery were investigted, but there were no significnt differences mong groups. The dietry score nd the ft score 357

5 Hwng YJ, et l. Tble 3. Dily nutrient intkes of women with gesttionl dibetes ccording to postprtum glucose tolernce sttus Nutrient Pre-dibetes group (n=73) Energy, kcl 1,902.4 (573.1) 1,893.0 (628.8) 1,841.3 (681.4) Plnt protein, g 44.2 (17.8) 40.7 (13.6) 35.5 (12.2) Animl protein, g 41.8 (26.5) 44.1 (24.0) 45.8 (37.1) Plnt ft, g 30.9 (19.5) 32.4 (18.6) 31.5 (16.1) Animl ft, g 23.9 (16.5) 28.5 (19.1) 29.6 (24.9) Crbohydrte, g (91.9) (102.6) (121.2) Fiber, g 29.5 (13.1) 27.8 (10.7) 23.8 (21.0) Plnt clcium, mg (303.5) (248.0) (466.5) Animl clcium, mg (400.7) (420.1) (253.1) Phosphorus, mg 1,444.5 (539.9) 1,377.1 (481.7) 1,359.6 (406.1) Plnt iron, mg 13.5 (6.6) 12.9 (5.8) 13.4 (9.6) Animl iron, mg 3.3 (2.3) 3.7 (2.3) 3.6 (2.6) Sodium, mg 5,961.3 (2,735.0) 6,327.0 (2,941) 4,983.6 (5,479.0) Potssium, mg 3,873.3 (1,579.0) 3,937.6 (1,784) 3,439.2 (2,286.0) Zinc, mg 10.0 (3.4) 10.2 (3.9) 10.8 (4.7) Folte, mg (246.5) (215.8) (330.7) Vitmin A, mg RE (868.1) (680.3) 1,166.7 (983.2) Vitmin B1, mg 1.3 (0.6) 1.4 (0.7) 1.2 (0.6) Vitmin B2, mg 1.6 (0.7) 1.6 (0.8) 1.5 (1.3) Nicin, mg 17.0 (9.5) 17.4 (7.7) 19.4 (7.8) Vitmin B6, mg 2.5 (1.2) 2.4 (1.2) 2.1 (0.8) Vitmin C, mg (123.3) (126.0) (148.8) Vitmin E, mg 20.1 (13.5) 19.5 (9.3) 20.1 (16.2) Cholesterol, mg (279.3) (324.4) (324.9) Vlues re presented s medin (interqurtile rnge). NGT, norml glucose tolernce; DM, dibetes mellitus. Averge rnks to be significntly different t P<0.05 by Kruskl-Wllis test mong the three groups. from the questionnire totls did not show ny significnt differences. Bsed on the survey responses, results of scores regrding the number of mels consumed per dy, regulrity, overeting, mount of ftty foods, foods contining simple sugrs, slty foods, foods high in cholesterol, instnt foods nd processed foods consumed, were shown in Tble 2. Comprison of mounts consumed during mels The results for the dietry intke of ech group re presented in Tble 3. Groups of higher blood glucose were consumed niml ft more nd there ws significnt difference in the increse mong the three groups (P<0.05). Other thn niml fts, no other nutrient intkes showed significnt difference mong the three groups. Protein, clcium nd iron from foods were seprted by whether they were from vegetbles or niml products nd were then compred. However, the results from this comprison were not sttisticlly significnt. In order to investigte the frequency of proper dietry prctices in the study subjects, totl clories consumed from protein, lipids, crbohydrtes nd sugrs were trnsformed to percentges nd then compred individully to the recommended dily intkes tught during the eductionl period (Tble 4). The increse in cloric intke from fts ws higher, but the decrese in cloric intke from crbohydrtes ws higher in (P<0.05). The protein intke of ll groups ws less thn 20% of totl cloric intke, which is recommended to consume, nd there ws no significnt difference mong the three groups. The number of prticipnts who exceeded 358

6 Postprtum food intke of women dignosed with GDM Tble 4. Recommended nd ctul intke rtios of protein, ft, nd crbohydrtes in women with gesttionl dibetes ccording to postprtum glucose tolernce sttus Nutrient Proportion of totl clories, % Pre-dibetes group (n=73) Protein 17.6 (4.3) 17.9 (4.4) 19.9 (2.3) Ft 26.2 (9.7) 29.8 (5.3) 29.6 (12.1) Crbohydrte 56.5 (10.3) 53.6 (8.2) 50.3 (14.5) Intke rtio of ech recommended nutrition, % Clorie (29.5) (36.9) 99.4 (32.4) Protein 90.8 (34.4) 95.9 (35.6) 93.5 (34.6) Ft 88.9 (40.6) (43.4) 97.1 (60.7) Crbohydrte (36.8) (42.9) 99.9(49.5) Vlues re presented s medin (interqurtile rnge). NGT, norml glucose tolernce; DM, dibetes mellitus. Averge rnks to be significntly different t P<0.05 by Kruskl- Wllis test mong the three groups. Tble 5. The proportion of ech study group exceeding the recommended ft intke Ech ft Ft intke more thn 25% of totl clories Pre-dibetes group (n=73) Yes 56 (56) 61 (83.6) 8 (72.7) Animl ft intke more thn medin of totl niml ft Yes 41 (41) 45 (61.6) 6 (54.5) Cholesterol intke more thn 300 mg Yes 54 (54) 48 (65.8) 6 (54.5) Vlues re presented s number (%). Proportions to be significntly different t P<0.05 by chi-squre test mong the three groups. the recommended mounts of totl lipids, niml ft nd cholesterol in ech study group ws determined (Tble 5). Recommended llownce is less thn 25% consumption of lipids, 300 mg of cholesterol nd medin vlue of niml ft [19]. In lipids nd niml ft consumption, there ws sttisticlly significnt difference mong the study groups (P<0.05); however, the difference in cholesterol consumption ws not significnt. Comprison of blood test results t dignosis in ptients with gesttionl dibetes Results from blood tests tht were performed during the dignosis of GDM in the study subjects were exmined nd re Tble 6. Anteprtum metbolic chrcteristics of women with gesttionl dibetes ccording to postprtum glucose tolernce sttus Anteprtum chrcteristic Pre-dibetes group (n=73) 0 hr-glucose, mg/dl 85.0 (12.0) 91.0 (14.5) 93.0 (41.0) 1 hr-glucose, mg/dl (22.0) (27.5) (38.0) 2 hr-glucose, mg/dl (21.0) (32.5) (36.0) 3 hr-glucose, mg/dl b (24.0) (30.0) (33.0) HbA1c, % 5.1 (0.5) 5.3 (0.5) 5.6 (0.7) TC, mg/dl b (61.0) (47.5) (57.0) HDL-C, mg/dl b 78.0 (17.0) 76.0 (14.0) 60.0 (40.0) LDL-C, mg/dl b (53.8) (38.6) 82.2 (29.2) TG, mg/dl (80.0) (72.0) (201.0) hs-crp, mg/dl 1.63 (2.2) 2.1 (2.8) 1.0 (3.3) C-peptide, ng/ml 1.7 (0.9) 1.8 (1.1) 2.1 (1.2) SBP, mm Hg b (14.0) (10.5) (26.0) DBP, mm Hg b 66.0 (9.0) 69.0 (8.5) 69.0 (18.0) Vlues re presented s medin (interqurtile rnge). NGT, norml glucose tolernce; DM, dibetes mellitus; HbA1c, glycted hemoglobin; TC, totl cholesterol; HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol; TG, triglyceride; hs-crp, high-sensitivity C-rective protein; SBP, systolic blood pressure; DBP, distolic blood pressure. Averge rnks to be significntly different t P<0.001, b Averge rnks t P<0.05 by Kruskl-Wllis test mong the three groups. presented in Tble 6. In the dignostic test of GDM, the 100 g OGTT, fsting blood glucose levels (P<0.001) nd blood glucose levels fter 1 hour (P<0.001), 2 hours (P<0.001), nd 3 hours (P<0.05) were significntly different mong the three groups. There ws lso significnt difference in HbA1c mong the three groups (P<0.001). In ddition, TC, HDL-C, nd LDL-C decresed s the blood glucose levels incresed, with significnt difference (P<0.05). In contrst, TG hd tendency to be high in the ; however, this ws not sttisticlly significnt. SBP nd DBP were lso significntly different mong the groups (P<0.05), while C-peptide nd hs-crp showed no sttisticl difference. Comprison of blood test results fter delivery The results from the blood tests performed 6 to 12 weeks fter delivery re shown in Tble 7. Body weight, BMI, nd body ft were sttisticlly different mong the groups (P<0.05). As the blood glucose incresed, HDL-C decresed significntly (P< 0.05), but TG (P<0.05), SBP (P<0.05), nd DBP (P<0.001) 359

7 Hwng YJ, et l. Tble 7. Metbolic chrcteristics of women with gesttionl dibetes t 6 to 12 weeks postprtum Postprtum chrcteristic incresed significntly. TC, LDL-C, hs-crp, nd C-peptide did not show significnt difference mong the groups. DISCUSSION Pre-dibetes group (n=73) Weight, kg 56.8 (12.1) 60.7 (13.1) 58.6 (16.8) BMI, kg/m (4.2) 23.9 (5.2) 22.3 (2.7) Body ft, % 31.0 (6.2) 33.7 (5.8) 29.1 (6.3) 0 hr-glucose, mg/dl b 89.0 (9.0) 95.0 (14.0) (31.0) 2 hr-glucose, mg/dl b (22.5) (31.0) (50.0) HbA1c, % b 5.5 (0.5) 5.7 (0.3) 6.2 (0.7) TC, mg/dl (41.0) (48.0) (42.0) HDL-C, mg/dl 62.0 (18.0) 55.0 (16.0) 48.0 (41.0) LDL-C, mg/dl (37.4) (40.6) (42.2) TG, mg/dl 79 (59) (85.0) (323.0) hs-crp, mg/dl 0.8 (1.2) 1.3 (2.3) 1.0 (1.5) C-peptide, ng/ml 1.2 (0.7) 1.4 (0.8) 1.4 (1.4) SBP, mm Hg (11.0) (14.0) (13.0) DBP, mm Hg b 70.0 (9.0) 73.0 (10.0) 79.0 (7.0) Vlues re presented s medin (interqurtile rnge). NGT, norml glucose tolernce; DM, dibetes mellitus; BMI, body mss index; HbA1c, glycted hemoglobin; TC, totl cholesterol; HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol; TG, triglyceride; hs-crp, high-sensitivity C- rective protein; SBP, systolic blood pressure; DBP, distolic blood pressure. Averge rnks to be significntly different t P<0.05, b Averge rnks t P<0.001 by Kruskl-Wllis test mong the three groups. The percentges of prticipnts in the, the pre-dibetes group nd the were 52.5%, 39.3%, nd 8.2%, respectively. However, this is different from the results reported by Jng et l. [20] who reported 23.2% IGT nd 15.1% dibetes in n exmintion 6 weeks fter delivery nd those of Rivs et l. [21] who reported 18.8% dibetes, 15.38% IGT, nd 11.97% IFG in n exmintion performed two to four months fter delivery. However, since pre-dibetes hs lso bnorml glucose metbolism, proportion ner 50% hs bnorml glucose metbolism t postprtum seen in ll of these studies. In studies on the dietry hbits of dibetes ptients [22] compred to those of non-dibetes subjects, dibetic ptients hd poor eting hbits such s more irregulr mel intke, more frequent overeting nd preference for slty nd gresy foods. Even in studies on GDM ptients [14], the scores for dietry hbits re significntly lower nd prticipnts report improper dietry hbits. However, differences bsed on the three groups were not observed in the dietry hbits in this study; preferred foods were similr between the groups, becuse of limited period fter delivery. So the gesttionl dibetes diet is thought to be mintined becuse ptients hve given birth very recently nd persists due to lingering hbits. However, when compred to ctul intke, s blood glucose increses, the consumption of niml fts incresed significntly, nd ptients reporting consumption of foods high in niml fts nd high in cholesterol my not be reflected their bd consumption hbits. In foreign ppers studied the reltionship between high cholesterol intke nd GDM, 50 mg/1,000 kcl increse in cholesterol consumption [23] increses the risk of GDM by 88% nd is thought to hve stronger correltion on GDM thn other fts. Additionlly, dietry cholesterol in dibetic ptients is ssocited with CVD, nd in prticulr, when more thn one egg ws consumed per dy increses the risk of CVD unlike non-dibetic people [24]. Although dietry cholesterol in this study did not show significnt difference mong groups, more thn 50% of the ptients in ll groups consumed more thn 300 mg over the recommended mount (Tble 5). Although the body weight, BMI, nd body ft mong the three groups in this study were not sttisticlly significnt, fter delivery, unlike the norml group, the blood cholesterol level did not decrese in the dibetes group. Therefore, it is thought tht trining is required regrding dietry cholesterol restrictions to prevent CVD in the high-risk dibetes group. Regrding this nutritionl eduction, it is thought tht more eduction on the specific criteri for limiting high ft foods nd foods tht re high in cholesterol is needed. Regrding the consumption of lipids, unlike in Western countries, in South Kore, it is ssumed tht individuls do not generlly consume fts in excessive mounts [22]. However, in this study, the consumption rtios of totl ft nd niml ft over the stndrd mount were significntly different mong the three groups (Tble 5), nd dietry chnges nd the consumption of lipids hve incresed in this society. There re severl different studies bout totl ft nd niml ft intkes. Some of the studies reported consumption of ft increses the risk of dibetes [25], wheres others reported tht there ws no reltionship between these mesures [26], even when d- 360

8 Postprtum food intke of women dignosed with GDM justed for BMI. Similr to results from Western studies, the consumption of niml fts nd sturted fts re considered to be ssocited with the increse in risk fctors of crdiovsculr complictions [12], suggesting tht pproprite mngement of these fctors is required. Bsed on studies on the effects of crbohydrte restriction in mels during the mngement of GDM, the recommended crbohydrte:protein:fts rtio during eduction ws 50:20:30 [15]. However, in contrst to techniques of the pst, rther thn focusing on exclusion of crbohydrtes, it is deemed importnt to emphsize the reduction of high ft food consumption. In the high blood glucose group in the present study, it ws common for more thn 25% of clories consumed to be from fts. In ddition, when the nutrient consumption rtios of the norml group fter delivery were considered, the percentges were djusted to 55% crbohydrtes nd 25% lipids. We felt tht re-eduction would be helpful to prevent postprtum dibetes, nd tht nother study on proper lloction of crbohydrtes, proteins nd lipids is required. Regrding protein nd iron intke, it hs been reported tht niml protein, or processed met consumption increses the risk of dibetes [26,27] nd niml iron intkes increse the risk of dibetes [28,29]. However, in the present study, when iron from vegetble nd niml proteins were nlyzed nd compred, there were no significnt differences. However, compred to the, it cn be seen tht the consumption of niml proteins ws higher in the pre-dibetes nd (Tble 3). For people with dibetes, the recommended protein consumption is 15% to 20% of their totl cloric intke [18]. In this study, ll subjects consumed the recommended rnge of protein intke, nd this is thought to be n effect of the nutritionl eduction. There ws no significnt difference in the intke of folic cid mong the three groups, nd when compred to the proposed verge folic cid requirement to brestfeed (450 mg from the 7th revision of the Koren dietry reference) [17], ll three groups hd been consuming less thn the recommended mount. This is consistent with the nutritionl intke survey from ll dults with IFG [30]. There re mny cses in which the nutritionl sttus of folic cid worsens during brestfeeding, nd given tht dibetes ptients hve deficiencies of folic cid, this could increse the risk of developing therosclerotic disese [30]. So fter GDM ptients give birth, the necessity to mention the need for folic cid in eduction hs been noted. In mothers exhibiting high blood glucose, we feel tht folic cid supplements should be considered. Like in prior studies of women with GDM, increses in blood lipid levels nd the risk of CVD [31,32] cn be observed. In this study, TG nd high blood pressure were significntly higher in the pre-dibetes nd. As result, it is thought tht this informtion should lso be included in prend postntl dietry eduction. This study hs limittions tht short period (6 to 12 weeks fter delivery), the number of ptients in the ws insufficient compred to those in the. Therefore, in order to recruit new ptients for the in future studies, n extended study is required. Despite these limittions, becuse lifestyles tht include proper eting hbits were not chnged short-term, nd GDM ptients re t high risk for T2DM nd CVD, mel mngement shortly fter birth is considered to be the first step towrd preventing from GDM developing into T2DM. Further studies on dditionl fctors regrding eting hbits nd types of foods consumed t six months nd one yer fter giving birth re needed. In ddition, this study strted immeditely fter women gve birth, so ptients were seprted bsed on whether they were brestfeeding or not. When the lcttion period progresses, mixed brestfeeding often tkes plce; therefore, further studies regrding nutrients required for mixed brestfeeding women who hd GDM re required. In conclusion, the short window of this study ws not sufficient to effect on the blood glucose level t 6 to 12 weeks fter giving birth. However, considering long-term dieting does hve n effect on dibetes ptients nd s mentioned erlier, when we consider the fct tht eting hbits cnnot be corrected in such short period of time, for women with GDM who re t risk for developing T2DM nd CVD, the first step towrd prevention is strting t delivery, diet mngement, prticulrly cholesterols from niml fts. And we feel strongly tht specific eductionl pln tht cn be esily understood by ptients must be implemented. CONFLICTS OF INTEREST No potentil conflict of interest relevnt to this rticle ws reported. ACKNOWLEDGMENTS This study ws supported by grnt from the Kore Helth 21 R & D Project, Ministry of Helth of Helth & Welfre, Repub- 361

9 Hwng YJ, et l. lic of Kore (Grnt no. A050463) nd from the Koren Reserch Foundtion in Kore (R ). REFERENCES 1. The Expert Committee on the Dignosis nd Clssifiction of Dibetes Mellitus. Report of the Expert Committee on the Dignosis nd Clssifiction of Dibetes Mellitus. Dibetes Cre 2002;25 Suppl 1:S Moses RG, Cheung NW. Point: universl screening for gesttionl dibetes mellitus. Dibetes Cre 2009;32: Americn Dibetes Assocition. Gesttionl dibetes mellitus. Dibetes Cre 2004;27 Suppl 1:S Dbele D, Snell-Bergeon JK, Hrtsfield CL, Bischoff KJ, Hmmn RF, McDuffie RS; Kiser Permnente of Colordo GDM Screening Progrm. Incresing prevlence of gesttionl dibetes mellitus (GDM) over time nd by birth cohort: Kiser Permnente of Colordo GDM Screening Progrm. Dibetes Cre 2005;28: Jng HC, Jung KB, Cho NH, Metzger BE. Gesttionl dibetes mellitus in Kore: is universl screening necessry? Koren J Obstet Gynecol 1996;39: Jng HC, Cho YM, Prk KS, Kim SY, Lee HK, Kim MY, Yng JH, Shin SM. Pregnncy outcome in Koren women with gesttionl dibetes mellitus dignosed by the Crpenter-Coustn criteri. J Koren Dibetes Assoc 2004;28: Setji TL, Brown AJ, Feinglos MN. Gesttionl dibetes mellitus. Clin Dibetes 2005;23: Kim C, Newton KM, Knopp RH. Gesttionl dibetes nd the incidence of type 2 dibetes: systemtic review. Dibetes Cre 2002;25: Prk SK, Prk MK, Suk JH, Kim MK, Kim YK, Kim IJ, Kng YH, Lee KJ, Lee HS, Lee CW, Kim BH, Lee KI, Kim MK, Kim DK. Cuse-of-deth trends for dibetes mellitus over 10 yers. Koren Dibetes J 2009;33: Hu J, Normn M, Wllensteen M, Gennser G. Incresed lrge rteril stiffness nd impired cetylcholine induced skin vsodilttion in women with previous gesttionl dibetes mellitus. Br J Obstet Gynecol 1998;105: Jng HC. High risk group of type II DM: gesttionl dibetes mellitus. J Koren Dibetes Assoc 2005;29: Yu SY, Hong HS, Lee HS, Choi YJ, Huh KB, Kim WY. The ssocition of insulin resistnce with crdiovsculr disese risk nd dietry fctors in Koren type 2 DM ptients. Koren J Nutr 2007;40: Dndon P, Aljd A, Chudhuri A, Mohnty P, Grg R. Metbolic syndrome: comprehensive perspective bsed on interctions between obesity, dibetes, nd inflmmtion. Circultion 2005;111: Ji SK, Jng HC, Choi H. A cse-control study of food hbits nd diet intkes of women with gesttionl dibetes mellitus. Koren J Nutr 2008;41: Prk BK. The effects of crbohydrte-restricted diet therpy in gesttionl dibetes [mster s thesis]. [Seoul]: Yonsei University; Americn Dibetes Assocition. Dignosis nd clssifiction of dibetes mellitus. Dibetes Cre 2008;31 Suppl 1:S The Koren Nutrition Society. Dietry reference intkes for Korens. Seoul: The Koren Nutrition Society; p The Koren Dietetic Assocition. Mnul of medicl nutrition therpy. 3rd ed. Seoul: The Koren Dietetic Assocition; p18, Americn Assocition of Dibetes Eductors. A core curriculum for dibetes eduction. 5th ed. Chicgo: Americn Assocition of Dibetes Eductors; p Jng HC, Yim CH, Hn KO, Yoon HK, Hn IK, Kim MY, Yng JH, Cho NH. Gesttionl dibetes mellitus in Kore: prevlence nd prediction of glucose intolernce t erly postprtum. Dibetes Res Clin Prct 2003;61: Rivs AM, Gonzlez N, Gonzlez J. High frequency of dibetes in erly post-prtum ssessment of women with gesttionl dibetes mellitus. Dibetes Metb Syndr 2007;1: Yng EJ, Kim WY. The influence of dietry fctors on the incidence of non-insulin dependent dibetes mellitus. Koren J Nutr 1999;32: Gonzlez-Clemente JM, Crro O, Gllch I, Vioque J, Humnes A, Suret C, Abell M, Gimenez-Perez G, Muricio D. Incresed cholesterol intke in women with gesttionl dibetes mellitus. Dibetes Metb 2007;33: Lu DC. Dietry cholesterol nd other nutritionl considertions in people with dibetes. Int J Clin Prct Suppl 2009; (163):15-21, Thnopoulou AC, Krmnos BG, Angelico FV, Assd-Khlil SH, Brbto AF, Del Ben MP, Djordjevic PB, Dimitrijevic- Sreckovic VS, Gllotti CA, Ktsilmbros NL, Migdlis IN, Mrbet MM, Petkov MK, Roussi DP, Tenconi MT. Dietry ft intke s risk fctor for the development of dibetes: multintionl, multicenter study of the Mediterrnen Group for the Study of Dibetes (MGSD). Dibetes Cre 2003;26: vn Dm RM, Willett WC, Rimm EB, Stmpfer MJ, Hu FB. 362

10 Postprtum food intke of women dignosed with GDM Dietry ft nd met intke in reltion to risk of type 2 dibetes in men. Dibetes Cre 2002;25: Sluijs I, Beulens JW, vn der A DL, Spijkermn AM, Grobbee DE, vn der Schouw YT. Dietry intke of totl, niml, nd vegetble protein nd risk of type 2 dibetes in the Europen Prospective Investigtion into Cncer nd Nutrition (EPIC)- NL study. Dibetes Cre 2010;33: Zhng C, Schulze MB, Solomon CG, Hu FB. A prospective study of dietry ptterns, met intke nd the risk of gesttionl dibetes mellitus. Dibetologi 2006;49: Rjpthk S, M J, Mnson J, Willett WC, Hu FB. Iron intke nd the risk of type 2 dibetes in women: prospective cohort study. Dibetes Cre 2006;29: Hwng MR, Shin MH, Rhee JA, Kweon SS, Lim HS. Effects of folic cid or scorbte supplementtion on plsm homocysteine levels nd oxidtive stress in Koren dults with impired fsting glucose. Koren J Community Nutr 2008;13: Kitzmiller JL, Dng-Kilduff L, Tslimi MM. Gesttionl dibetes fter delivery. Short-term mngement nd long-term risks. Dibetes Cre 2007;30 Suppl 2:S Meyers-Seifer CH, Vohr BR. Lipid levels in former gesttionl dibetic mothers. Dibetes Cre 1996;19: