7/18/2017. Update on GDM: Nutrition and Risks for Mother and Baby

Transcription

1 Update on GDM: Nutrition and Risks for Mother and Baby Alyce Thomas RDN Nutrition Consultant St. Joseph s Regional Medical Center Paterson, NJ Disclosure to Participants Board Member/Advisory Panel Sweet Success Express NJ WIC Governor s Council for Prevention of Developmental Disabilities National Institute of Child Health Development Academy of Nutrition and Dietetics Chair- Elect, Diabetes Care and Education DPG Honors Committee Participant, DPBRN/DCE Joint Research Project This Is What We Do! No fruit or milk in the morning No more than 30 gm of carbohydrates for breakfast Keep carbohydrates to no more than 45% of total calories Restrict calories to obese women to 12 kcal/kg Increase protein for better blood glucose control But Where Is The Evidence! Why Evidence-based Practice? Improved quality of care Increased patient safety Decreased variation in practice Efficient use of resources Increased likelihood of achieving desired patient outcomes Improved client, provider & payer satisfaction Increased credibility of the RDN within the healthcare team 1

2 Evidence-Based Nutrition Practice Guidelines Evidence Summaries & Conclusion Statements = what the evidence says Evidence-Based Practice Steps Guideline Recommendations = course of action for the practitioner based on the evidence Systematic vs Narrative Reviews Pae C. Psychiatry Investig Systematic Review Topics Medical Nutrition Therapy (MNT) Prevention of Gestational Diabetes with MNT Calories Macronutrients Dietary Patterns (Glycemic Index, DASH) Distribution of Meals and Snacks 2016 Guideline: 5 Outcomes Search Plan BG control: fasting, postprandial, A1C Maternal weight gain Fetal growth/birth weight Adverse fetal/neonatal outcomes: mortality, macrosomia, LGA, SGA, shoulder dystocia, jaundice, hypoglycemia, prematurity Adverse maternal outcomes: mortality, birth mode, hypertension, preeclampsia, insulin therapy Inclusion Criteria Age: 19+ Nutrition-related problem or condition Weight status Intervention Outcomes: report > 1 Study design preferences Size of study groups: (> 10/study group) Study drop-out rates: <20% Year range: Authorship Peer-reviewed Language: English Exclusion Criteria Age: < 13 Nutrition-related problem or condition Weight status Intervention Outcomes Study design Size of study groups (<10/comparison group) Study drop-out rate: > 20% Year range: < 2000 Authorship Language: not English Other: animal studies, abstracts, presentations 2

3 2008 Guideline Not Reviewed Risk Assessment and Screening Pregnant Women at Risk for GDM MNT for Pregnant Women with IGT Assessment of BMI and Weight Gain Blood and Glucose Monitoring/Ketone Testing Promotion of Breastfeeding Pharmacological Therapy Prevention of Recurrence/Type 2 Diabetes 2016 GDM Recommendations Updated Nutrition Assessment 4 Calories Macronutrients - 2 Micronutrients Physical Activity High-Intensity Sweeteners Alcohol Nutrition Monitoring and Evaluation New Referral to RDN Frequency and Duration of MNT Macronutrients Micronutrients Meal and Snack Distribution 2016 Gestational Diabetes Guideline Topics Screening and Referral Referral to an RDN Nutrition Assessment Assessment of Food/Nutrition-related History of Women with GDM Assessment of Anthropometric Measurement of Women with GDM Assessment of Biochemical Data, Medical Tests, and Procedures of Women with GDM Assessment of Nutrition-Focused Physical Findings and Client History of Women with GDM Nutrition Intervention Medical Nutrition Therapy Frequency and Duration of MNT Calorie Prescription Macronutrient Requirements Carbohydrate Prescription Carbohydrate and Post Prandial Breakfast Glycemia Meal and Snack Distribution Dietary Vitamin and Mineral Intake Vitamin and Mineral Supplementation Use of High-Intensity Sweeteners Alcohol Intake Physical Activity Nutrition Monitoring and Evaluation Nutrition Monitoring and Evaluation 15 Grade Conclusion Statements Grading Scale I Strong/Good II Fair III Limited/Weak IV Expert Opinion V Grade not assigned Strength of Evidence Elements Strong study design; consistent findings Strong study design with minor methodological errors; weaker design; inconsistent results Weak design; inconclusive findings; inconsistent findings No studies available; conclusion based on usual practice or informed commentators No evidence Statement Rating Strong Fair Weak Consensus Insufficient Evidence Recommendations Rating Scale Definition Benefits of the recommended approach clearly exceed the harms Benefits exceed the harms, but quality of evidence is not as strong Quality of evidence that exists is suspect Expert opinion supports the guideline recommendation though scientific evidence did not present consistent results Lack of pertinent evidence and/or unclear balance between benefits and harms Category Conditional Recommendations: or Conditional Statement Broadly applicable to the target population and do not impose restraints on their pertinence. Clearly define a specific situation or population. 3

4 RDN Referral Individualized MNT Achieve and maintain normoglycemia Appropriate weight gain Meeting essential nutrients References ADA 2017 Evidence Level: A Endocrine Society 2013 Evidence Level: 1 Strong Nutrition Assessment 4 Domains Food/Nutrition-related History Anthropometric Measurements Biochemical Data, Medical Tests and Procedures Nutrition-Focused Physical Findings and Client History Consensus Effectiveness of MNT Intervention Provided by RDN on Outcomes 5 studies evaluated MNT intervention improved outcomes Maternal outcomes hypertensive disorders, hospitalizations, premature births, insulin therapy, C/S Neonatal outcomes deaths, NICU admissions, birth weight, LGA, prevalence of macrosomia and shoulder dystocia RDNs should provide MNT that includes individual nutrition prescriptions and nutrition counseling for GDM women Strong MNT Frequency and Duration No evidence of optimal frequency and duration to improve outcomes Joslin Diabetes Center (2011) Minimum of 3 MNT encounters Provide regular and frequent MNT visits: initial min, 2 nd visit (30-45 min) within one week, and third visit within 2-3 weeks. Additional visit schedule every 2-3 weeks or as needed until delivery. Consensus What is the Effect of Caloric Consumption on Outcomes? 2008 Is there a particular caloric intake recommendation for appropriate weight gain? What is the relationship between caloric restriction, weight management and ketonuria for obese women with GDM? 2016 What is the effect of caloric consumption on fetal/neonatal and maternal outcomes? Caloric Consumption and Outcomes 3 international studies 2 used in 2008 guideline (2000, 2005) Romon women with GDM or mild gestational hyperglycemia Intensive counseling with RD and endo 1800 kcal/day; 50-55% carb; 15% protein and 30-35% fat Mean dietary intake At diagnosis During treatment Energy (kcal/day) Carbohydrate (g/day) (47.1 %) (43.4%) Fat (g/day) (37%) ( 38%) Protein (g/day) (15.5 %) (18.5%) Outcomes no association between calories and infant BW incidence of macrosomia BW associated with GA Romon, Journal of Amer Dietetic Assoc,

5 2016 Calorie Prescription Individualize the calorie prescription based on the following: Nutrition assessment Dietary Reference Intakes Institute of Medicine weight gain guidelines Fair No definitive research suggests a specific optimal calorie intake in GDM 1 study showed no adverse effects when calorie intake was decreased by 30% in obese women Carbohydrates 2008 Is there a specific amount, type, form of carbohydrate, fat and protein for women with GDM? Minimum 175 g carb based on DRI Carb: < 45% of total calories to prevent hyperglycemia Limited research on fiber and GI 2016 What impact does total amount of carbohydrates have on outcomes? Carbohydrate Impact on Outcomes Cypryk women 45% carb (avg 202 g) vs 60% carb (avg 270 g) Significant in post meal BG in lower carb for all meals Only at lunch & dinner in higher carb No NS difference between groups in obstetric outcomes 52 GDM Control Diet: 55% carb DASH Diet 67% carb C/S rate GDM in Iran: 90% Moreno-Castillo women 40% carb vs 55% carb to the need for insulin therapy No NS differences in insulin treatment or obstetric outcomes Low Glycemic Diets in GDM Treatment 99 GDM Randomized to LGI or MGI Louie et al. Diabetes Care; 2013 Impact of CHO Type/Amount on Postprandial Breakfast Glycemia Cypryk 2007 Compared low-cho diet to high-cho diet in PPBG in low-cho diet compared to high-cho diet Hernandez 2014 Compared low GI to medium GI Higher 1 & 2 hr PPBG in MGI Both PPBG were within current treatment levels Louie 2013 Compared low-gi (45) breakfast (included fruit, bread & milk) to high-gi (80) Lower peak BG levels in LGI Perichart-Perrera 2012 Compared LGI to all types of CHO diet (45% CHO) Both were effective in improving glycemic control No NS difference between groups 2 hr post breakfast 5

6 Effective Nutrition Interventions DASH Diet with 65 % carb (Asemi 2012, Asemi 2013) Diet providing 45-60% energy from carbohydrates (Cypryk 2007) Diet providing 40-45% energy from carbohydrates (Perichart-Perrera 2009) Low-glycemic index (GI) diet (Louie 2013, Moses 2009, Afaghi 2013) Consumption of fiber ~ g/day in conjunction with a low-gi diet (Afaghi 2013, Grant 2011, Moses 2009) 2016 Carbohydrate Recommendations Carbohydrate Prescription Individualize the amount & type of CHO Based on nutrition assessment, treatment goals, BG response and patient needs Limited evidence to recommend an ideal amount of CHO Carbohydrate and Post Prandial Breakfast Glycemia Individualize the amount & type of CHO at breakfast Based on nutrition assessment, treatment goals, BG response and patient needs Modify to achieve BG targets Limited evidence does not confirm ideal amount or type of CHO Nutrition counseling provided by a dietitian (Moses 2009) Meal and Snack Distribution No evidence to evaluate impact of meal and snack distribution Joslin Diabetes Center small meals & snacks suggested to PP hyperglycemia ACOG meals & 2-3 snacks suggested to fluctuations in PP glucose CDAPP 3 meals and several snacks recommended to prevent hypoglycemia, particularly if on insulin or glyburide Consensus Pregnancy Approved High Intensity Sweeteners Saccharin Aspartame Acesulfame potassium Sucralose Neotame Advantame Extracts: Steviol glycosides Luo Han Guo Physical Activity minutes PA, minimum of 3 times a week common discomforts of pregnancy without negative effect on maternal or neonatal outcomes Improves glycemic control 2016 Daily moderate exercise > 30 minutes Improved glycemic control Help to achieve appropriate weight gain Recommend aerobic and non-weight bearing exercises Diane Reader RDN, CDE Manager, Diabetes Professional Education International Diabetes Center Minneapolis, MN 6

7 Disclosure to Participants Notice of Requirements For Successful Completion Please refer to learning goals and objectives Learners must attend the full activity and complete the evaluation in order to claim continuing education credit/hours Conflict of Interest (COI) and Financial Relationship Disclosures: Presenter: Diane Reader, RDN, CDE No COI/Financial Relationship to disclose Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity Off-Label Use: Participants will be notified by speakers to any product used for a purpose other than for which it was approved by the Food and Drug Administration. Risks for Mother and Baby: Outline Mother s development Type 2 after GDM GDM unmasked Type 2 diabetes Polycystic Ovary Syndrome Child s development of type 2 and obesity after hyperglycemia in utero Interventions to reduce risk Breastfeeding; weight reduction; medications Role of the CDE Diabetes Self-Management Education Algorithm of Care and Action Steps The Role of the CDE with Diabetes and Pregnancy There are 4 critical times to assess, adjust, provide and refer for DSME Preconception Pregnancy GDM Pregnancy Type 2 DM Type 2 DM/ Obesity Prevention Postpartum Mother and Infancy Powers MA et al. Joint Position Statement on DSME. Diabetes Care, TDE, JAND 39 (2015) Draft January 2017 Mother s Risk to Develop Type 2 Pathophysiology of GDM: Insulin Requirements The diagnosis of GDM provides the opportunity to identify a person at risk for developing type 2 And we know that we can at least delay the onset of DM Insulin Requirements of Pregnancy 3 Times normal 2 Times normal Normal Insulin Resistance Relative Insulin Deficiency Gestational Diabetes BASICS 3 rd ed IDC

8 Glucose (mg/dl) Relative Function Natural History of Type 2 Diabetes GDM Unmasks Type Pre-diabetes metabolic syndrome Onset Diabetes Incretin action Years Post-meal glucose Fasting glucose Insulin resistance Adapted from: UKPDS 33: Lancet 1998; 352, ; DeFronzo RA. Diabetes. 37:667, 1988; Saltiel J. Diabetes. 45: , Robertson RP. Diabetes. 43:1085, 1994; Tokuyama Y. Diabetes 44:1447, Polonsky KS. N Engl J Med 1996;334:777. Insulin level Development of Type 2 Obesity and Insulin Resistance Central obesity is critical factor: Waist to hip ratio >1 Waist >40 inches in men Waist >35 inches in women Abdominal adipose tissue is more metabolically active than subcutaneous fat. Increased release of FFA, TNF-a leading to insulin resistance. -Cell Function* 50 (%) Relative Insulin Deficiency 100 *HOMA = homeostasis model assessment; IGT = impaired glucose tolerance. Dashed line shows extrapolation forward and backward from years 0 to 6 based on HOMA data from UKPDS. Lebovitz. Diabetes Rev. 1999, 7: UKPDS Group. UKPDS 16 Diabetes 1995, 44: IGT Postprandial Type 2 hyperglycemia diabetes phase I Loss of first-phase insulin secretion Type 2 diabetes phase III Type 2 diabetes phase II Years from Diagnosis What is the incidence of type 2 diabetes after GDM pregnancy? Predictors of Diabetes in Women with Previous GDM 8 year risk of postpartum diabetes = 52.7% CLOSE Increased risk in women if : Required insulin BMI > 30 More than 2 prior pregnancies Auto-antibodies to GAD ( glutamic acid decarboxylase) autoimmunity test Relative risk 7.43 higher than non-gdm Bellamy; The Lancet, May 09 Lobner K. DIABETES, March 2006 Diabetes Prevention Program with Women with History of GDM 3234 people at high risk for developing DM: IGT and BMI >24 kg/m2 Lifestyle intervention had 58% lower incidence Metformin had 31% lower incidence Women with hx of GDM: Lifestyle or Metformin equal effectiveness at 31% lower incidence Cases per 100 person years DPP With GDM Pre-Conception Counseling Risk counseling Fetal, Neonatal, Obstetric, Maternal Birth control Assessment of glucose control A1C <6.5% As close to normal as possible without causing undo hypoglycemia Complications/Comorbidities Post-partum Guidelines Diabetes Prevention Program Research Group. Diabetes Care Ratner R. Prevention of diabetes in women with hx of GDM. J Clin Endocrinology Metab. Dec P

9 Fetal Concerns in Pregestational Diabetes Diabetes Embryopathy Congenital malformations (cardiac/neural tube most common) Approx 4-12% vs 2-4% in general population 4-5% in well controlled DM 10-12% with A1C over 8.5% Spontaneous abortions 15-30% vs 10-25% in general population Malformations or Spontaneous Abortion by A1C Polycystic Ovarian Syndrome (PCOS) Common endocrine disorder in women of reproductive age Hyperandrogensim Chronic anovulation Polycystic ovaries Associated with insulin resistance and obesity Not well understood Greene MF, Hare JW, Cloherty JP et al, Teratology :225 PCOS and GDM Probably higher incidence of GDM in women with PCOS Difficult to assess due to more than one way to diagnose GDM and PCOS Women with PCOS should be screened in first trimester and not wait until weeks Metformin Metformin used in treatment of PCOS to reduce insulin resistance Increases fertility and decreases risk of miscarriage Pregnancy category B Does cross placenta Emerging data about efficacy and safety often related to GDM patients MiG (Metformin in Gestational Diabetes) No increase in neonatal morbidity or macrosomia Rowan JA, et al. Metformin versus insulin in GDM. NEJM, May 2008 Metformin vs. Insulin Type 2 Diabetes and Pregnancy Hickman: no significant differences in glycemic control; less hypoglycemia; preferred metformin 28 women in study (14 metformin+ and 14 insulin) 43% on metformin needed supplemental insulin Total insulin doses: 21 units vs 86 units (insulin only) Refuerzo: pilot study primary outcome A1C<7% 19 women in study (8 metformin and 11 insulin) No failed metformin therapy, i.e. needed insulin Similar maternal and fetal outcomes MATERNAL HYPERGLYCEMIA AND CHILDHOOD OBESITY AND TYPE 2 Hickman et al. Am J Perinatology. 30;6,2013 Refuerzo et al. Am J Perinatology

10 Pedersen Hypothesis Maternal hyperglycemia Reece, Coustan, Gabbe. Diabetes in Women. 3 rd edition. Page 165 Fetal hyperglycemia Fetal Hyperinsulinemia (β-cell hypertrophy /hyperplasia) Excessive fetal growth Macrosomia/ large for gestational age Post-partum rate of C-section; difficult deliveries Maternal hypertension Other problems GDM and Childhood Obesity Pima Indians studies in 1980s showed relationship between in utero hyperglycemia and development of childhood obesity and type 2 diabetes Sommer- German (2015) Moms with GDM- 21% of kids overweight Moms without GDM- 10.4% overweight Carlsson- Sweden (2014) Children of moms with GDM heavier Overweight moms with normal glycemia had overweight children Hyperglycemia Adverse Pregnancy Outcomes Trial-HAPO Strong continuous association of maternal glucose levels with Increased birth weight Primary C section Cord-blood C-peptide Post-partum hypoglycemia Post HAPO Trial Study 870 Chinese (Hong Kong) women in HAPO trial that did not know their glycemic 7 years after study mother and child Maternal hyperglycemia in pregnancy is independently associated with offsprings risk of abnormal glucose tolerance, obesity and higher BP at 7 years in girls and not boys Metzger B et al. NEJM. 2008;358: Tam, et al. Diabetes Care, May 2017 Childhood Obesity and Metabolic Imprinting Interventions to Reduce Risks Breastfeeding Weight reduction Medications Hiller TA, et al. Diabetes Care, September

11 Research on the Impact of Breastfeeding on Offspring Breastfed in delivery room had lower rate of postpartum hypoglycemia (10% vs 28%) (Cherok) Dose-dependent effect: for each additional month of BF provides a 4% reduction in childhood obesity risk (Harder) Study of 80 youth with type 2 DM compared to control (Myer-Davis) Breastfed in type 2 = 31.3% compared to 63.5% Myer-Davis, Diabetes Care March 2008 Chertok, 2009 Research on the Impact of Breastfeeding on Mothers Women who breastfed decreases woman s risk of becoming overweight, developing metabolic syndrome and T2DM 704 women in CARDIA study Ferrara study comparing a telephone call vs usual care increased likelihood to partially or exclusively breastfeed (62.7% vs 47.7%) SWIFT study (study of women, infant feeding and type 2) of women with GDM Exclusive or mostly BF vs exclusive or mostly formula fed, had lower FPG, and DM at 6-9 wks Gunderson, 2012 Practice Applications Future Areas for Research 1. Does protein and fat effect glycemic levels? Individualize the food plan and unless contraindicated, encourage physical activity Don t forget to discuss other non-pregnancy food issues; for example, food safety Women with GDM need postpartum education Their risk for developing type 2 diabetes Interventions to reduce risk Preconception planning is important to assess glycemia and prevent congenital anomalies Women with PCOS should be screened in 1 st trimester for GDM 2. Is there a difference in nutrient requirements in GDM than non-gdm pregnant women? 3. Is the distribution of macronutrients (as well as amount and type) important? 4. Definitive answers regarding calorie recommendations for women with GDM 5. Does fruit or milk in the morning make a difference? Future Areas for Research 6. Ways to increase education and intervention to women with history of GDM 7. Identification in the first trimester of women at risk for GDM and excessive weight gain and interventions to reduce risks 8. Initiatives to reduce obesity in children and adults in the US 11