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Pregnancy is a time of promise and expectation, but it can also raise the possibility for some women that they will develop gestational diabetes mellitus (GDM). GDM is caused by hormones that are released by the placenta, which in turn can change the way insulin works by blocking the interaction between insulin and glucose. It is important to recognize and treat GDM promptly to minimize both fetal and maternal complications. Based on systematic review of several observational and a large cohort study, risk assessment for gestational diabetes should be done at first prenatal visit. By the time gestational diabetes is detected, the fetus is fully formed but still actively growing.
Increased risk for potential future obesity, glucose intolerance and type 2 diabetes in adolescence and early adulthood.
Given the controversy that persists in the international community about the screening and diagnosis of GDM, there is no clear answer to what is ideal. However, for women with multiple risk factors, this screening test should be offered at any stage in the pregnancy. The preferred approach consists of a 50-gram glucose drink given any time of the day (non-fasting state), followed by a one-hour plasma glucose (PG) test. An alternative one-step approach proposed by the International Association of Diabetes and Pregnancy Study Groups may be used to screen and diagnose GDM. Although the diagnosis should be taken seriously, GDM can be managed by some of the same measures with which all types of diabetes are managed. Usual management includes a combination of monitoring urinary ketones and blood glucose, as well as lifestyle interventions such as dietary changes and exercise (unless obstetrical contraindications exist or glycemic control is worsened by the activity).
To help motivate and empower patients, diabetes education and nutrition counselling should be sensitive to cultural preferences and special patient needs. Women with GDM, in an effort to control their glucose by diet, may put themselves and their baby at risk for starvation ketosis.
If glucose levels are consistently elevated, treatment with insulin is usually recommended. Cardiovascular conditioning appears to improve glycemic control primarily from increased tissue sensitivity to insulin.
The 2013 Clinical Practice Guidelines promote moderate level of activity most days of the week as part of the treatment plan. Very intense exercise activities are not generally recommended during pregnancy because they can cause a rise in blood glucose. Multiple, short exercise sessions lasting at least 10 minutes each in the course of the day should be considered. Amount and distribution of carbohydrate in the diet should be individualized based on clinical parameters such as gestational weight gain, blood glucose levels, ketones and level of serum triglycerides.
Total carbohydrates comprise 45 to 50 percent, but up to 60 percent of total energy may be acceptable for pregnancy and provide no fewer than 175 grams of carbohydrate a day to prevent ketosis. Consumption of the following non-nutritive sweeteners during pregnancy and while lactating are acceptable: Acesulfame Potassium (Acyl-K), Aspartame (Equal, Nutrasweet), Sucralose (Splenda), Steviol Glycosides (Stevia), Saccharin and sugar alcohols (xylitol, mannitol and sorbitol), but they should be consumed in moderation to not replace more nutritious food and fluid choices. Carbohydrate is recommended to be distributed throughout the day over three meals plus two to three snacks, one of which can be an evening snack, which may prevent overnight ketone formation. Requirements of energy, protein and many nutrients will be further increased in adolescent and multiple pregnancies.
Individualized meal and snack plans should take into consideration food availability, literacy, cultural preferences and lifestyle.
If women with GDM do not reach the recommended blood glucose target levels within two weeks of nutrition therapy alone, insulin therapy may be initiated.
Glyburide or metformin may be used for glycemic control in women who are nonadherent or refuse to take insulin.
In addition to the above mentioned management tools, assessment of the GDM patient’s emotional and psychosocial states are also important and consideration should be given to professional referrals as needed. Women who have had GDM are at increased risk of developing type 2 diabetes later in life by up to 12 fold, the highest prevalence being usually in the first five to 10 years postpartum.
Consult their physician and be screened for type 2 diabetes when planning another pregnancy. With prompt diagnosis and good management, women with GDM can expect to have a healthy pregnancy and a happy, healthy baby. What I need to know about Gestational Diabetes, National Institute of Diabetes and Digestive and Kidney Diseases, NIH Publication No. Rauh-Hain JA1, Rana S, Tamez H, Wang A, Cohen B, Cohen A, Brown F, Ecker JL, Karumanchi SA, Thadhani R. HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, Coustan DR, Hadden DR, McCance DR, Hod M, McIntyre HD, Oats JJ, Persson B, Rogers MS, Sacks DA.
Recommendations for Nutrition Best Practice In the Management of Gestational Diabetes Mellitus, Canadian Journal of Dietetic Practice and Research. Beata Blajer is a registered dietitian (RD) and Certified Diabetes Educator (CDE) at Southlake Regional Health Centre in Newmarket in both the Diabetes Education Centre and the Cardiac Prevention and Rehabilitation Programs.

A1c test: medlineplus medical encyclopedia, A1c is a lab test that shows the average level of blood sugar (glucose) over the previous 3 months. A1c and high post-meal blood sugars predict heart attack, A1c and post-meal blood sugars predict heart attack please scroll down to read text.
Then, using any of 11 pre-formatted charts and graphs, you can analyze your blood glucose data in detail.
Reports make it easy to see trends and patterns in your glucose levels, and meal-related changes in blood glucose.
These hormonal changes are a natural part of every pregnancy and usually don’t cause any maternal or fetal health problems. In addition, it is important for women with a history of GDM to be screened after pregnancy due to an increased risk of developing type 2 diabetes after delivery, especially the first five years. Based on the outcome of the 2008 HAPO study, a prospective observational study, and several other largescale, prospective, observational studies, the 2013 Canadian Diabetes Association Clinical Practice Guidelines expert committee have modified its diagnostic criteria for GDM in their new 2013 guidelines.
Then an Oral Glucose Tolerance Test (OGTT) is needed, consisting of 75 grams of glucose drink.
Patients are required to consume a 75-gram glucose drink, with no prior screening with the 50 gram GCT. These professionals will evaluate, assess and follow up with every GDM patient until delivery and several weeks postpartum.
The goal of therapy for women with GDM is to normalize the maternal metabolic setting to result in a normal, healthy infant. Written material in multiple languages should be available for patients, including menu ideas and food choices that best match their individual food habits and ethnic background. Older studies raised the possibility that elevated ketoacids may have detrimental effects on the fetus.
Both fasting and post-meal testing are recommended to guide therapy in order to achieve glycemic targets. If however, blood glucose levels are consistently within target, the frequency of testing can sometimes be decreased. As a result both fasting and postprandial blood glucose concentration can be reduced and, in some women with GDM, the need for insulin may be obviated. Every woman with GDM should be evaluated and followed by a registered dietitian to ensure that nutrition therapy promotes normal levels of blood glucose, appropriate weight gain and adequate nutritional intake.
Recommendations for weight gain in GDM are currently similar to national guidelines in healthy women, and vary somewhat from country to country.
Calorie requirements are calculated from the Harris Benedict Equation and are based on ideal body weight. Expectations to these recommendations may be made based on individual nutrition prescription, personal preferences and glycemic response.
Vegetarian and vegan patients should be offered plantbased protein choices and should consider the carbohydrate content of these foods. Women should be advised to follow the nutrition recommendations for general health by consuming a diet low in saturated fat, trans fat and cholesterol. A diet history will allow the dietitian to assess current eating patterns and food preferences.
The use of insulin to achieve glycemic targets has been shown to reduce fetal and maternal morbidities. Therefore screening with a 75 g OGTT (twohour) should be done between six weeks and six months postpartum to rule out diabetes, prediabetes or undiagnosed type 1 or type 2 diabetes during pregnancy. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada: Diabetes and Pregnancy. Socioeconomic status and perinatal outcomes in a setting with universal access to essential health care services.
Association between maternal serum 25-hydroxyvitamin D level and pregnancy and neonatal outcomes: systematic review and meta-analysis of observational studies. Maternal sleep-disordered breathing and adverse pregnancy outcomes: a systematic review and metaanalysis. High blood pressure before and during early pregnancy is associated with an increased risk of gestational diabetes mellitus. Maternal plasma concentrations of IGF-1, IGFBP-1, and C-peptide in early pregnancy and subsequent risk of gestational diabetes mellitus. Summary and recommendations of the Fifth International Workshop-Conference on gestational Diabetes Mellitus. Mild glucose intolerance in pregnancy and risk of cardiovascular disease: a population-based cohort study.
Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Toward universal criteria for gestational diabetes: the 75-gram glucose tolerance test in pregnancy.
Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in 3637 women without gestational diabetes. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association.
Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada: nutrition therapy. Maternal metabolic control and perinatal outcome in women with gestational diabetes treated with regula or lispro insulin: comparison with non-diabetic pregnant women. Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada: diabetes and mental health. She has a wide range of experience in different areas of food and nutrition covering diabetes, heart health, weight management, pregnancy, pediatrics and research.
The information helps you and your health care team easily and quickly spot trends, evaluate your progress, and modify your treatment plan.
As the placenta grows, it produces more of these hormones, making it increasingly difficult for the body to use insulin, hence creating what’s known as insulin resistance.

The patients will receive instructions regarding monitoring urinary ketones, self monitoring blood glucose (SMBG), insulin (if needed), diet and exercise from this healthcare team.
Therapeutic decisions should be designed to decrease both maternal and fetal morbidity and mortality.
While clinical significance of these findings are doubtful, it appears wise to check for urine ketones daily.
Suggested blood glucose monitoring includes fasting plasma glucose, one- or two-hour post meals and at bedtime, usually four to five times a day. Therefore, physical activity is encouraged as an addition to nutrition therapy unless obstetrical contraindications exist or glycemic control is worsened by the activity.
Many women find that a walk after breakfast is especially helpful, while others need to walk after each meal. In Canada, readers should refer to Health Canada guidelines, “Nutrition for a Healthy Pregnancy”. General daily calorie requirements in women with normal pre-gravid body weight range between 1,800 to 1,900 calories a day in the first trimester, with energy needs increasing during the second and third trimesters for optimal fetal growth, being 340 to 452 extra calories more a day. Carbohydrates should primarily be coming from slow-released carbohydrate sources (low to medium glycemic index) which raise post-meal blood glucose concentrations less than simple carbohydrate or high glycemic index types. The amount of carbohydrate at breakfast may need to be limited if morning glucose intolerance is present. This can be achieved by reading food labels, choosing leaner meats and dairy products as well as using lower fat cooking methods.
Recommendations for nutrition best practice in the management of gestational diabetes mellitus. GDM is a condition that develops during pregnancy, when the body is not able to make enough insulin to overcome the body’s resistance to insulin. During this insulin resistance period, the pancreatic beta cells compensate by increasing their insulin production – usually up to three times as much insulin as normal. Therefore, most Diabetes Education Centres recommend testing for ketones in the urine first thing in the morning after a long period of fasting overnight. Due to the increased risk of nocturnal hypoglycemia during pregnancy, testing during the night is often necessary in patients receiving insulin. The frequency, amount and type of exercise however, need to be addressed on an individual basis. The 2010 guidelines for weight gain during pregnancy vary by pre-pregnancy BMI and are at right. Hypocaloric diets are not recommended as they may result in maternal weight loss, starvation ketosis and poor intake of nutrients such as protein and calcium. A general guideline is 15 to 45 grams (one to three servings) of carbohydrate sources of food at breakfast and 45 to 60 grams (three to four servings) at lunch and dinner. Dose and frequency of insulin injection depends upon blood glucose levels, may start with once daily injection at bedtime. The lack of insulin causes the women’s blood glucose level to become elevated compared to the usual levels seen during pregnancy. However, in some women, the pancreas cannot produce an adequate amount of insulin and therefore they will experience higher than normal glucose levels and in turn develop gestational diabetes. Recommended blood glucose and glycated hemoglobin (A1C) levels during pregnancy are considered lower than in nonpregnant adults. However, energy intake for overweight or obese women may be slightly restricted as long as the rate of weight gain is appropriate and provided ketosis is avoided. Excess sugar can contribute to excess calories and can raise blood sugar levels quickly in people with diabetes. Snacks would generally consist of 15 grams of carbohydrate during the day and 15 to 30 grams at bedtime.
The insulin choice is usually either an intermediate acting (NPH) or a long acting, basal analogue detemir (Levemir) or glargine (Lantus).
In Canada, GDM is higher than previously thought, varying from 3.7 percent in non-Aboriginal women to up to 18 percent in Aboriginal women. The extra blood glucose can also cross the maternal placenta and increase fetal blood glucose levels as well, which in turn will stimulate the fetal pancreas to produce more insulin to normalize fetal blood glucose levels. This usually happens if there is insufficient calorie or carbohydrate intake, long periods without food between meals or snacks, or not enough insulin. Ketones should be monitored to verify that adequate calories are provided to prevent ketone formation as recommended in the CDA Clinical Practice Guidelines. If post-meal blood glucose levels remain elevated, up to four injections a day are usually recommended. Some of this high glucose in turn will be converted and stored as fat in the fetus and impact fetal weight, contributing to macrosomis.
A protein-containing food may accompany the day snacks, but is strongly recommended at bedtime. Post meal insulin choice includes rapid-acting bolus analogue aspart (Novorapid) or lispro (Humalog) over regular insulin, taken before meals, although perinatal outcomes are similar.
Upon delivery however, as blood glucose levels normalize, the fetal pancreas will reduce its insulin production. If however it is always negative, one may decrease the frequency of testing to one to two times per week. Unexpected weight gain or loss may indicate a need for further diet review or revision of the meal plan. Patients may inappropriately restrict food intake to levels less than recommended on their meal plan in an effort to control post meal blood glucose values and avoid insulin therapy. Education on insulin therapy is generally conducted by a Diabetes Educator, and injection techniques should be reviewed at each visit, as well as how food affects blood glucose and pattern management.

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