Maximizing the Role of WIC Nutritionists in Prevention of DM2 among High Risk Clients ESTHER G. SCHUSTER, MS,RD,CDE

Transcription

1 Maximizing the Role of WIC Nutritionists in Prevention of DM2 among High Risk Clients ESTHER G. SCHUSTER, MS,RD,CDE

2 Heavy Numbers Surgeon General report: 68% of adults in U. S. are overweight or obese Nation s medical costs from obesity 147 billion 2008 Currently 2/3 of US mothers are obese/overwt. at conception 2

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4 Type 2DM: Prevalence Tripled in Last 30 Years Hispanics showed the largest increase wt. gain of lbs, doubles risk of DM 80% of diabetics are overwt. or obese 4

5 Pathophysiology of DM Metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both Several pathogenic processes are involved in the development of diabetes: Type 1, autoimmune destruction of the pancreatic β cells with consequent insulin deficiency Type 2, resulting from inadequate insulin secretion and/or diminished tissue responses to insulin impairment of insulin secretion and defects in insulin action frequently coexist, unclear which abnormality is the primary cause of hyperglycemia 5

6 Current Criteria for the Diagnosis of Type 2DM A1c > than 6.5 FBG > than 126 mg/dl (fasting, no caloric intake for at least 8 hours) two hr. plasma glucose > 200 mg/dl during oral GTT, glucose load of 75 grams a random plasma glucose of 200 mg/dl with classic symptoms of hyperglycemia 6

7 Prediabetes, Heading for Type 2 definition: A1c of or a FBS of mg/dl about 60 million Americans have prediabetes less than 10 % have been informed they have it DPP study, 10 year follow up program critical period to change behavior 7

8 Prevalence of GDM GDM accounts for 1 14 % of pregnancies 68 high risk populations not only have the > incidence, but recurrence rate with future pregnancies reported a high as 68% 69 GDM is not just a complication of pregnancy almost 50 % will develop Type 2 within 5 year period and 60% within 10 years 8

9 Diagnosing GDM 2 Step Method step 1: 50 gram, I hour GCT given at wks step 2: 100 gram OGTT who should be screened? 9

10 ADA: 2011 Recommendation: One Step Method 2 step method 1 step method 50 gram, I hr. GCT at wks FBS > 92mg/dl or 100 gram OGTT 1 hr>180 or 2 hr>153 10

11 Diagnosing Type 2DM in Pregnancy GDM has been defined as any degree of glucose intolerance with onset or first recognition during pregnancy. A1c, test to identify overt DM and early GDM A1c >5.7 or <6.5, treat as early GDM A1c < 5.7, screen again at weeks A1c > 6.5, treat as Type 2DM 11

12 Pathophysiology of GDM two key aspects of GDM: insulin resistance and impaired insulin secretion placental hormones favor a marked increase in insulin resistance during 2 ND. & 3 RD. trimester inadequate maternal pancreatic response leads to maternal hyperglycemia then fetal hyperglycemia a normal FBS is about 74 and a peak postprandial rarely over 120 mg/dl 12

13 Additional Risk for Type 2DM in the GDM Population higher pregnancy BMI, waist circumference greater wt. gain than recommended during pregnancy high postpartum waist circumference early diagnosis of GDM high FBS levels during pregnancy elevated blood pressure during pregnancy depression 13

14 Abnormal Nutrition for Fetus, Short Term Effects fetal macrosomia, cesarean delivery respiratory distress syndrome neonatal hypoglycemia, hypocalemia, polycythemia, hyperbilirubinemia, poor feeding possible SGA with overtreatment of GDM 14

15 Abnormal Nutrition for Fetus, Long term Effects increased neonatal adiposity increased hyperinsulinemia & hyperleptinemia may lead to lasting malprogramming of endocrine systems leptin and hypothalamic development intrauterine exposure to maternal DM metabolic syndrome in fetus 73 15

16 Conventional Management for GDM Diet: MNT strives for adequate E for appropriate wt. gain & euglycemia, healthy fetal outcome current caloric recommendation BS monitoring exercise insulin and oral hypoglycemia agents IOM guidelines for weight gain case study 16

17 Diet Therapy Meal distribution CHO: healthy choices versus processed CHO and sweetened beverages importance of PRO, FAT, fiber plate method flexibility important for patient cooperation 17

18 Clinical Evidence for Recent Treatment of GDM Glyburide (sulfonylurea) only OHA that has been well studied in pregnancy Metformin (biguanide) one recent highquality trial compared insulin & metformin, found metformin to effectively lower BS s and safe for pregnant women & fetus Insulin : NPH, Regular, Lispro (Humalog) 18

19 Targeting High Risk Population to Prevent DM2 Risks Intervention overweight /obese metabolic syndrome former GDM prediabetes minorities activity diet weight loss breastfeeding annual A1c 19

20 Workshop Interventions Pt. should know her ABC s waist circumference matters activity recommended birth control vitamin D f/u lacking after GDM preconception guidelines, A1c < 7 20

21 Opportunity for Effective Public Health! WIC Nutritionists ideally positioned to be part of the solution in DM prevention 1. education and support 2. small steps for behavior change 3. promotion of breastfeeding 4. future incentives 5. Reducing your risk after GDM tool from Sweet Success :sweetsuccessexpress.com 21