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Gestational Diabetes Mellitus

Gestational Diabetes Mellitus. Helping Your Client Make Healthy Lifestyle Choices. Introduction.

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Gestational Diabetes Mellitus

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  1. Gestational Diabetes Mellitus Helping Your ClientMake Healthy Lifestyle Choices Pat Sonnenstuhl,RN, CNM

  2. Introduction Following appropriate screening guidelines, understanding causation and associated conditions, and effectively managing the client with GDM can improve both short term and long term health conditions associated with GDM Pat Sonnenstuhl,ARNP, CNM

  3. Definitions • Gestational Diabetes (GDM) • Insulin Resistance (IR) • Glycemic Index (GI) • Syndrome X • Body Mass Index (BMI) • euglycemia Pat Sonnenstuhl,ARNP, CNM

  4. Gestational Diabetes (GDM) A carbohydrate intolerance of varying degrees and severity with onset or first recognition during pregnancy with a probable resolution after the end of pregnancy. Diabetes, glucose intolerance or insulin resistance may have existed before the pregnancy. GDM is not the same as Type 1 or Type 2 Diabetes Pat Sonnenstuhl,ARNP, CNM

  5. Insulin Resistance (IR) Insulin resistance is the resistance of the skeletal muscles and adipose to the affects of insulin. The pancreas produces more insulin, and over time cells become more and more resistant to the actions of insulin. As blood sugars and insulin increase, eventually the pancreas fails to produce enough insulin and diabetes occurs. Pat Sonnenstuhl,ARNP, CNM

  6. Glycemic Index (GI) The glycemic index ranks foods on how they affect our blood sugar levels. This index measures how quickly an individual's blood sugar increases in the two or three hours after eating. http://www.mendosa.com/gi.htm Pat Sonnenstuhl,ARNP, CNM

  7. eu·gly·ce·mi·a: Normal concentration of glucose in the blood. Also called normoglycemia. Pat Sonnenstuhl,ARNP, CNM

  8. Factors That Affect the GI • The GI of a food is influenced by the characteristics of the food or meal. • Processing, preparation, storage, physical form, and ripeness of foods affect the GI. • The GI varies within the same individual and between individuals. Pat Sonnenstuhl,ARNP, CNM

  9. Value of the GI • Each client can determine how she reacts to certain foods by monitoring food intake and postprandial blood glucose levels • The primary goal of GDM management is to achieve and maintain euglycemia throughout pregnancy to improve the outcomes for both mother and fetus Pat Sonnenstuhl,ARNP, CNM

  10. Syndrome X The loss of responsiveness of the body to insulin is associated with a ‘clustering’ of cardiovascular risk factors that includes abdominal obesity, hypertension, dyslipidemia, glucose intolerance and hyperinsulinemia. This association is referred to as the insulin resistance syndrome, which is also known as Syndrome X. Pat Sonnenstuhl,ARNP, CNM

  11. Body Mass Index (BMI) • A commonly used measure to differentiate underweight, normal weight, overweight and obesity. Obtained by dividing the weight of the subject (in kilos) by the square of his (her) height in meters. • A BMI of approximately 25 kg/m2 corresponds to about 10 percent over ideal body weight. • http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/body.html Pat Sonnenstuhl,ARNP, CNM

  12. Body Mass Index Definitions Pat Sonnenstuhl,ARNP, CNM

  13. Body Mass Index and Recommended Weigh Gain Pat Sonnenstuhl,ARNP, CNM

  14. How These Conditions Are Related Women with a history of GDM are metabolically vulnerable with insufficient ß-cell reserve, and many are insulin resistant. Pat Sonnenstuhl,ARNP, CNM

  15. How These Conditions Are Related Approximately 50 % of women who are diagnosed with gestational diabetes during pregnancy will develop it in future pregnancies, and are at a much greater risk of developing type 2 diabetes in later life. Pat Sonnenstuhl,ARNP, CNM

  16. How These Conditions Are Related The insulin resistance is the factor that exists in the woman with GDM. The aim of the lifestyle changes to be discussed here are to decrease insulin resistance. Pat Sonnenstuhl,ARNP, CNM

  17. Pregnancy Pathophysiology • Insulin resistance occurs because the hormonal changes associated with pregnancy partially block the effects of insulin. • Insulin resistance causes glucose to be shunted from the mother to the fetus to facilitate fetal growth and development. Pat Sonnenstuhl,ARNP, CNM

  18. Pregnancy Pathophysiology • During the third trimester of pregnancy, insulin resistance increases by 50%. • Maternal pancreatic beta cells increase insulin secretion almost threefold to compensate for increased insulin resistance. Pat Sonnenstuhl,ARNP, CNM

  19. Pregnancy Pathophysiology • The subsequent increase in insulin secretion causes the maternal glucose levels to increase 80% of the blood levels of non-pregnant women • If the mother’s pancreas is unable to produce sufficient insulin to overcome insulin resistance, maternal glucose levels increase and GDM occurs Pat Sonnenstuhl,ARNP, CNM

  20. Pregnancy Pathophysiology • GDM complicates pregnancy by further increasing insulin resistance • GDM disappears after pregnancy because the hormonal changes that caused insulin resistance are no longer present • Useful physiologic process out of balance Pat Sonnenstuhl,ARNP, CNM

  21. Action Plan for Prevention • Approximately 60% to 80 % of the women with GDM are obese and experience insulin resistance associated with both obesity and GDM. • A decrease in caloric intake and caloric redistribution of foods may help decrease abnormally high blood glucose levels by improving target-organ insulin sensitivity. Pat Sonnenstuhl,ARNP, CNM

  22. Laboratory Screening for GDM Demographics Who to Screen Screening

  23. Demographics of GDM • Most common medical complication of pregnancy • Occurs in 4% of all pregnancies (all ethnicities) • Changes in diagnostic criteria will increase incidence of this metabolic complication (involves a recognition of a lower level of blood glucose) Pat Sonnenstuhl,ARNP, CNM

  24. Who Should Be Screened • Women over 25 • Women who are obese • Women with a family history of diabetes • Women of ethnic/racial high risk groups • Women who have had a >9 # baby Pat Sonnenstuhl,ARNP, CNM

  25. Value of Screening During the Current Pregnancy Increased screening, identification and treatment can decrease the morbidity and mortality of GDM: • Decreased macrosomia, cesarean birth and birth trauma due to a > 4000g infant • Decreased neonatal hypoglycemia, hypocalcaemia, hyperbilirubinemia, polycythemia • Identify women at future risk for diabetes and those with insulin resistance Pat Sonnenstuhl,ARNP, CNM

  26. Routine Screening (ACOG,1994) Pat Sonnenstuhl,ARNP, CNM

  27. Screening and Diagnosis of GDM(ACOG, 1994) • Nearly 25 % of women will have a + 1hr GTT, and will need a 3 hour GTT. • A GTT is considered diagnostic for GDM when 2 or more values are met or exceeded. Pat Sonnenstuhl,ARNP, CNM

  28. Determination of GDM (ACOG, 1994) Pat Sonnenstuhl,ARNP, CNM

  29. Retesting (32-34 Weeks) When? • Negative initial test, risk factors present • Obesity • >33 years of age • Positive 1 hour screen followed by a negative OGGT • 3+/4+ glucosuria Pat Sonnenstuhl,ARNP, CNM

  30. Factors That Influence the Development of Type 2 Diabetes Mellitus Pat Sonnenstuhl,ARNP, CNM

  31. Factors That Influence the Development of Type 2 Diabetes Mellitus Pat Sonnenstuhl,ARNP, CNM

  32. Factors That Influence the Development of Type 2 Diabetes Mellitus Pat Sonnenstuhl,ARNP, CNM

  33. Teachable Moments Women with GDM and/or IR present an ideal group for diabetes prevention and education because they are teachable and usually more motivated to change behaviors and improve their long range health and the health of their families. Pat Sonnenstuhl,ARNP, CNM

  34. Teachable Moments Seen as a positive thing, the diagnosis of GDM during pregnancy identifies these women at risk and this awareness can encourage healthy lifestyle changes Pat Sonnenstuhl,ARNP, CNM

  35. Management of GDM During Pregnancy and Post Partum Healthy food Choices Encouraging Lifestyle changes Education and support Laboratory follow-up Post Partum and Beyond Teachable Moments Pat Sonnenstuhl,ARNP, CNM

  36. Healthy Food Choices Various Options Medical Nutritional Therapy Nutritional Prescription

  37. Making Healthy Food Choices • What are healthy choices ? • Goals of medical nutrition therapy respect the needs of the pregnant woman and her developing fetus • Food combination options encourage maternal euglycemia Pat Sonnenstuhl,ARNP, CNM

  38. What Are Healthy Choices ? Nutritional management is understudied, with no randomized control studies looking specifically at optimal medical nutrition for GDM, lean or obese. Pat Sonnenstuhl,ARNP, CNM

  39. What Are Healthy Choices ? Distribution of Macronutrients: Optimal distribution of calories is unknown (little consensus, wide variability, not adequate research). Pat Sonnenstuhl,ARNP, CNM

  40. What Are Healthy Choices ? The ‘ideal’ caloric recommendations for GDM are unknown or have not been well studied. Factors such as maternal height, pregravid wt, maternal age, physical activity and smoking all need to be considered. Pat Sonnenstuhl,ARNP, CNM

  41. What Are Healthy Choices ? The majority of women should eat 2200-2400 calories. Moderate calorie restrictions (to 1800) have been shown to reduce macrosomia and its associated morbidity and maternal ketonuria Pat Sonnenstuhl,ARNP, CNM

  42. Goals of Medical Nutrition Therapy Pat Sonnenstuhl,ARNP, CNM

  43. Goals of Medical Nutrition Therapy Pat Sonnenstuhl,ARNP, CNM

  44. Goal of Medical Nutrition Therapy Deborah Thomas-Dobersen suggests three reasonable options which seem to accomplish this goal Pat Sonnenstuhl,ARNP, CNM

  45. Option ITraditional Food Pyramid • High Carb/low fat 55% carbohydrate, • 25% protein, • 20% fat Http://www.mjbovo.Com/PregWt.Html Pat Sonnenstuhl,ARNP, CNM

  46. Option II Balanced Discuss with your client the effect of high GI carb foods versus low GI-carb foods 35-40% carbohydrates, 20--25% protein 35-40% fat Pat Sonnenstuhl,ARNP, CNM

  47. Option III Low Glycemic Carbohydrates • More Protein • Low GI Carbs • Appropriate Fats http://www.enteract.com/~jldavid/lowcarb/pyramid.html Pat Sonnenstuhl,ARNP, CNM

  48. Nutritional Prescription • For GDM, the nutritional prescription should satisfy the minimum requirements for pregnant women • Minimal caloric intake for those with GDM is debated • There is little risk of ketonuria when diets provide 25kcal/kg, which is based on the woman’s actual body weight Pat Sonnenstuhl,ARNP, CNM

  49. Nutritional Recommendations Distribution of total calories is: • 35-45 % carbohydrates • 20-25 % protein • 35-40 % fat Tolstoi & Jusmovich Pat Sonnenstuhl,ARNP, CNM

  50. ADA Clinical Guidelines • Restriction of carbohydrates to 35–40% of calories has been shown to decrease maternal glucose levels and improve maternal and fetal outcomes • American Diabetes Association:Clinical Practice Recommendations 2001 Pat Sonnenstuhl,ARNP, CNM

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