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Diabetes during Pregnancy : Nutrition-related guidelines to reduce complications and post-partum considerations

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  1. Diabetes during Pregnancy: Nutrition-related guidelines to reduce complications and post-partum considerations Kimberly M. Morris MS, RD, LD, CDE

  2. Types of Diabetes # 1, 2 & 3: Chronic 1. Type 1 – Autoimmune 2. Type 2 - 90-95% of all cases versus Type 11 3. Diabetes Complicated by Pregnancy – (Type 1 or Type 2 Diabetes diagnosed before Pregnancy) 4. Gestational Diabetes: • develops during pregnancy • Usually recognized during 3rd Trimester • Occurs in ~5 % of pregnancies 2 # 4: Temporary (in most cases) BUT increases risk for developing Type 23 1.Ross TA, Boucher JL, O’Connell BS, ed. American Dietetic Association Guide to Diabetes Medical Nutrition Therapy and Education. 2005; 4:40. 2.U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Child Health and Human Development. Managing Gestational Diabetes: A Patient’s Guide to a Healthy Pregnancy. July 2004; pg.4. 3. Thomas AM, Gutierrez YM. American Dietetic Association Guide to Gestational Diabetes Mellitus. 2005;10:107.

  3. Hyperglycemia During Pregnancy:Blame it on the Hormones *Hormones from the Placenta interfere with INSULIN Too Much Glucose Crosses to over the Placenta to the baby U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Child Health and Human Development. Managing Gestational Diabetes: A Patient’s Guide to a Healthy Pregnancy. July 2004; pg.3-4.

  4. The #1 Complicating Factor isA Large Baby Too Large, Too Quickly: Complicated the Labor and Delivery Process Too Much Glucose to the Baby: Baby Grows Too Large Too Quickly U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Child Health and Human Development. Managing Gestational Diabetes: A Patient’s Guide to a Healthy Pregnancy. July 2004; pg.5.

  5. 1st Trimester Metabolic Influences Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  6. 2nd and 3rd Trimester Metabolic Influences • Stored and Ingested fat becomes primary maternal fuel source to allow Glucose (sugar) and Amino acids (proteins) for fetal use • Increased energy and nutrient demands by fetus as pregnancy progresses • Inadequate calories will promote Ketosis (excessive use of Fat as fuel source) • Caloric Requirement Vary by Trimester, Pre-pregnancy BMI, & Singleton versus Twin Pregnancy • 1st Trimester – additional 32 kcal/day • 2nd Trimester – additional 356 kcal/day • 3rd Trimester – additional 496 kcal/day Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  7. IOM Weight Gain Guidelines Singleton Underweight: 28-40 lbs Normal Weight: 25-35 lbs Overweight: 15-25 lbs Obese: 11 – 20*lbs (change in guidelines: UL established)*Obese weight gain may not be necessary. ???-Weight loss ??? Twins Underweight: No Data Normal weight: 37-54 lbs Overweight: 31-50 lbs Obese: 25-42 lbs • Guidelines updated 2009 (previously updated in 1990) Target lower weight and calorie ranges for Type 2 and GDM Diabetes < 1700 kcal/day may promote ketosis Preconception Counseling Highly recommended Web MD. Pregnancy Weight Gain: New Guidelines. “How much weight Should Women Gain During Pregnancy? Maybe less than you think. Available at: http:www.webmd.com/baby/news/20090528/pregnancy-weight-gain-new-guidelines. Accessed March 2, 2010.

  8. Benefits of Physical Activity • Exercise Lowers Blood Glucose by Reducing Insulin Resistance • Exercise AFTER Eating and BEFORE post-prandial glucose test • Light to Moderate Physical Activity is Recommended • IMPORTANT! Consult with MD BEFORE starting ANY exercise program during pregnancy Thomas AM, Gutierrez YM. American Dietetic Association Guide to Gestational Diabetes Mellitus. 2005;8:85.

  9. Goals of MNT to Reduce Risk of Complications • Diet influences weight gain and fetal size • Meal plan a.Control excessive fat and glucose (Crosses the Placenta and contributes to Macrosomia) b. Provide adequate energy and nutrition to support maternal and infant needs 1 c. Provide Adequate Calories and Carbs Control Excessive Lipolysis and Prevent Ketogenesis2 • When Euglycemia cannot be achieved within recommended dietary guidelines, Medication is Required 1. ADA Guide to Gestational Diabetes Mellitus, A.M. Thomas and Y.M. Gutierrez. American Dietetic Association. 2005. 2. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  10. “I Think You Should Know that I’m Very High in Carbohydrates”

  11. MNT Guidelines to Promote Euglycemia • Carbohydrate-Controlled Meal Plan - Carbs have biggest impact on Post-prandial Blood Glucose (90-100% of carbohydrates converted to glucose within 1 hour after consumption). Post-prandial testing 1-2 hours after main meals. • CHO includes Fiber, Sugars (natural or added) and Starches. • Fiber less impact on Glucose (Insoluble Fiber not digested). Studies which showed insulin negatively correlated with fiber in 2nd and 3rd trimester used > 50 grams of dietary fiber/day. Current average intake < 20 grams/day. Recommended Dietary Fiber intake = 28 grams/day.1 1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  12. MNT Guidelines to Promote Euglycemia • Estimate Total Calorie needs based on wt. gain requirements • Example Kcal Distribution: 40% CHO, 35% Protein, 25% Fat11800 kcal/day: 40% kcal from CHO = 720 kcal from CHO ÷ 4 = 180 grams/day ÷ amongst 3 meals and 2-4 snacks/day. • RDA for CHO in pregnancy = 175 grams/day (General population = 130 grams/day). (Fetal brain requires 33 grams/day) • Individualize CHO Distribution Based on Daily Schedule • Example Distribution: B: 15-45, S: 15-30, L: 30-75, S:15-30, D: 30-75, S: 15-45 1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  13. Meal Plan Considerations • Placental Hormones Highest in the am • Less Carb at Breakfast • May Need to Limit Fruit and Milk Choices until Afternoon and/or use at Snack times • Adequate Protein – Balance CHO with Protein which also Stimulates the Pancreas to Release Insulin). • 2nd Trimester – Protein Needs Increased (Protein Needs Double with Twin Pregnancy) • Heart Healthy Fats: Omega 3 Fatty Acids (EPA/DHA) to Support Brain and Retina Development. Sources include some fish (recommend low Mercury) or Marine Algae for Vegetarians

  14. “Just Water, No Bread…I’m on a Low-Carb Diet”

  15. Meal Plan Considerations • Watch for Tendency to over-restrict CHO with post-prandial blood glucose excursions (> 120 mg/dl 2 hours post-prandial) • CHO distribution may be tweaked per hypo- and hyperglycemia considerations: • Extended length of time between meals with Hypoglycemia • Bedtime snack needed if Nocturnal Hypoglycemia • (Nocturnal hypoglycemia can cause rebound Hyperglycemia – am) • There is NO established recommendations for Carb variations based on Trimester) – RD follow-up WITH FOOD RECORDS Recommended. • Consistency of Carbohydrate Distribution to determine if medication is needed. • With Insulin Treatment, Consistency Important for Effective Dosing Changes

  16. Examples of Carbohydrates • CARBS: • Milk and Yogurts • Fruits and Fruit Juice (Juice only recommended for treating Hypoglycemia) • Grains (Whole Grains Count Too) • Beans and Starchy Vegetables • Sweets (Limit to < 1 per day) Fats, Proteins and Non-Starchy Vegetables are NOT Carbohydrates and have Minimal Impact on Blood Glucose

  17. Counting Carbohydrates • 1 Carb Choice = 15 grams of Carbohydrate Sample Meal # 2: 2 Slices of Bread = 2 Choices Tomato Slices = 0 Choices 1 Tbsp. of Peanut Butter = 0 Choices 2 Scrambled Eggs = 0 Choices Total = 2 Choices or 30 grams CHO Sample Meal # 1: 8 oz. Milk = 1 Choice 2/3 Cup Cooked Rice = 2 Choices 4 oz. Chicken Breast = 0 Choices 1 Cup Broccoli = 0 CHO Choices Total = 3 Choices or 45 grams CHO

  18. “I Don’t Think this is What your Doctor meant by Lowering your Carbs, Honey.”

  19. Glycemic Index • Ranks Carbohydrates Based on Impact on Blood Glucose • May be Used In Additionto Carb Counting • Limitations: Glycemic Response is Variable: • Variations within Individuals • Impacted by Ripeness, Cooking, ETC. • Value Changes when Mixed with Another Food • Does not correlate with nutritional quality or fiber TEST BLOOD SUGAR to MONITOR EFFECTS of CARB FOODS Glycemic Load: Better Indicator of Glycemic Response – Based on Portion Size A Low GI Index But High In Total Carbohydrate Food can Have same Glycemic Load Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  20. Whole Foods = Lower GI than Mashed or Liquid Form High Fiber or High Fat = Lower GI Ripe Foods = Higher GI Cooked = Higher GI than Raw Glycemic Index High Glycemic White Bread Watermelon Honey Rice Dates French Fries Pretzels Medium Glycemic Corn Brown & White Rice Pizza Ice Cream Regular Sugar Instant Oatmeal Whole Wheat Bread Low Glycemic Plain Yogurt Most Vegetables Whole & Soy Milk Apples & Grapes Spaghetti Beans Sweet Potatoes

  21. Sugar Substitutes “They Now Have Me Testing Equal, Sweet’N Low and Splenda. I’ve Now Developed Artificial Diabetes.”

  22. Sugar Substitutes in Pregnancy • FDA Approved 5 for use by General Population INCLUDING Pregnant Women with Diabetes1 • Studies Included: “Chronic Dietary Toxicity, Mutagenicity, Carcinogenicity, Teratogenicity, Multigenerational Reproductive Toxicity in Lab Animals and Toxicity, Metabolism and Pharmokinetics in Humans”1 • Studies Lacking on Pregnancy Outcomes and Child Development1 • Most HCP – Recommend Limiting. ADA: No More than 1-2 Diet Sodas/day. 1 Texas Diabetes Institute in San Antonio, TX – Diabetes Management Program - < 3 svgs./day 1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  23. Saccharin: Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  24. Aspartame: • Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008. • ADA Guide to Gestational Diabetes Mellitus, A.M. Thomas and Y.M. Gutierrez. American Dietetic Association. 2005.

  25. Sugar Substitutes: Neotame: • Aspartic Acid and Phenylalanine • Enzyme that Breaks Down reduces Bioavailability of Phenylalanine – Rapidly metabolized Yields Methanol • Methanol “excreted in small amounts compared with Methanol Derived from Fruits or Vegetables” • No Affect on Insulin or Fasting Glucose in Type 2 Diabetes Acesulfame Potassium: • Excreted Unchanged in the Urine (Does Not Provide Potassium) • Crosses the Placenta • Considered Safe for Pregnancy Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  26. Sugar Substitutes • Sucralose (Splenda): • Excreted Unchanged in Feces • Other Sugar Substitutes: • Not Studied in Pregnant Women with Diabetes • Not Approved for Use During Pregnancy: Alitame, Cyclamates, Neohesperidine,Thaumatin, & Stevia2 1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008. 2. ADA Guide to Gestational Diabetes Mellitus, A.M. Thomas and Y.M. Gutierrez. American Dietetic Association. 2005.

  27. Micro-Nutrient Intake and Supplementation • Focus on Whole Foods and Food Groups – NOT Single Nutrients! • Vitamins and Minerals Work in Synergy in the Body • Due to Higher Demand During Pregnancy and Common Deficiencies: Supplementation Recommended • Studies Lacking on Ideal Vitamin and Mineral Needs – Especially Related to Diabetes Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  28. Micro-Nutrient Intake Common Deficiencies in US Pregnant Women: Prenatal Supplements – vary in nutrient content – Do Not make up for Nutrients Lacking from Whole Foods in Diet Increased Risk of Deficiencies: (Lack of Studies in Women with Diabetes) *Chromium Deficiency linked to Glucose Intolerance – no effect on Glycemic Control with Supplementation Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  29. Food Safety Alcohol – Fetal Growth Restrictions, Mental Retardation, Malformations Caffeine - Crosses the Placenta – not linked to Birth Defects but 1st trimester spontaneous abortions > 300 mg/d. Methylmercury – Affect Neurological System. Crosses Placenta. FDA – Limit to Low Mercury Fish < 12 oz per week Listeria – 20 X More Likely to Occur During Pregnancy. Miscarriages, Stillbirth, Preterm Delivery. Avoid Deli Meats/Hot Dogs (Unless Steaming Hot) and Unpasteurized Dairy Products 1 oz espresso = 35 mg 1 cup brewed coffee = 135 mg 1 cup black tea = 50 mg 12 oz Tall/Small Starbucks = 375 mg. Food Safety At-A-Glance: How to Protect Yourself and Your Baby. www.cfsan.fda.gov/pregnancy.html Accessed 3/12/10.

  30. Common Deficiency Concerns • Iron Deficiency Linked to Pre-term birth and Fetal Growth Retardation • Choline (Eggs, Meat, Liver and Peanuts) – essential for Cell Membrane (Estrogen may Protect Against Deficiency) • Deficient Choline leads to Deficient Folate (Green Leafy Vegetables, Grains – fortified, and Citrus fruits) • Folate forms neural tube (formed before pregnancy recognized). Deficiency – Megaloblastic Anemia, Spontaneous Abortions, Fetal Malformations, Placental Abruption, Preterm Delivery, LBW • Excessive Folate masks B12 Deficiency- test BEFORE Supplementation • B12 Deficiency: Type 1 DM, Vegans, Inadequate GIF, B12 Absorption Problems (UL 1000 mcg/day). 1. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008. 2. ADA Guide to Gestational Diabetes Mellitus, A.M. Thomas and Y.M. Gutierrez. American Dietetic Association. 2005.

  31. Considerations with Celiac Disease and Pregnancy • Occurs in 4-12% of those with Type 1 Diabetes (Not Associated with Type 2). • Autoimmune response to Protein Fraction of Grains: Wheat, Rye, Barley, Spelt, Kamut, and Triticale or Oats Contaminated. • Inflammation of Small Intestines, Inhibits Absorption of Nutrients, Fluid Loss – Diarrhea • Wt. Loss, Abdominal Pain, Thyroid Disorders, etc. • Diagnosis Confirmed by Biopsy • Only Cure is Gluten-Free Diet – Symptoms Disappear Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  32. Considerations with Celiac Disease and Pregnancy • Screening Recommended as may be Asymptomatic to Prevent Malabsorption. • Symptoms may Include Hypoglycemia, Nausea, Vomiting, Diarrhea, Constipation • Anticipate Insulin Changes Once Treated per reduced Hypoglycemia • Untreated in Pregnancy – Studies Suggest Spontaneous Abortions, Fetal Growth Restrictions and Still Birth Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  33. Pregnancy After Bariatric Surgery • Increasingly Common with Increasing Rate of Obesity and Type 2 Diabetes • Post-surgical Dietary Concerns: Vomiting, Dumping Syndrome, Dehydration • Fetal Growth Restrictions, Anemia, (Iron, Folate, Vitamin B12 Deficiencies), C-Sections • Keep Fluids Separate from Meals • 6-9 Small Meals per Day • Adjust Gastric Band During Pregnancy???? - No RCT to Support • Kcal to Promote Minimal Wt. Gain • Ideal Wt. Gain in Obese Diabetic Pregnant Women Not Established Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. J.L. Kitzmiller et. al. American Diabetes Association. 2008.

  34. Post-partum Considerations for Women with Gestational Diabetes • Risk of recurrence in future pregnancies – may screen earlier • Gestational Diabetes = increased risk for of Developing Type 2 Diabetes: “60% of women with previous GDM, type 2 diabetes will be diagnosed during the 5-15 years after the pregnancy, depending on the racial or ethnic group”1 • Get tested 6 weeks after delivery • Get tested every 1- 3 years • Reduce Risk of Developing Type 2 by up to 58%: 2 • Reach a healthy body weight and stay there • Stay physically active • Breastfeed!!! • Thomas AM, Gutierrez YM. American Dietetic Association Guide to Gestational Diabetes Mellitus. 2005;10:107. • Thomas AM, Gutierrez YM. American Dietetic Association Guide to Gestational Diabetes Mellitus. 2005;10:102.

  35. Post-Partum Considerations for Women with Pre-existing Type 1& 2 • Type 1 & 2: A1C < 7.0 or < 6.5% before conception (1st trimester hyperglycemia increased risk of abnormalities and miscarriages). (Not a risk factor in true gestational diabetes) • Mainly Type 2: • If Overweight or Obese: promote weight loss to improve insulin resistance - reduce progressive nature of Diabetes and other co-morbidities associated with excessive body fat • Breastfeed!!!! Reduce Insulin Resistance and Expend additional calories to promote weight loss. (It takes more calories to make breast milk than to grow fetus). • 600 kcal /day 1st 6 months • 400 kcal/day 2nd 6 months

  36. Post-partum Considerations & Implications for the Fetus • Women with uncontrolled blood sugars during pregnancy can have children born with twice as much body fat • Extra fat around the abdominal area leads to insulin resistance • Infants born ‘Large for Gestational Age’ are at risk for being an overweight child • Genetic trait with GDM or with Type 2 Diabetes carried on by fetus. • An overweight child is at risk for developing diabetes before they are 30 years old • Children at risk for Diabetes: • overweight/obese • high-risk ethnic group • Inactive • Acanthosis nigricans

  37. Post-partum Counseling to Reduce Incidence of Type 2 Diabetes • Excessive Abdominal Fat and Hx. Of GDM – Risk Factors for Type 2 Diabetes • >23 million people have Diabetes Mellitus in US • 23% undiagnosed • 57 million people have Pre-Diabetes (most insurance companies do not cover including Medicare). Seton Insurance covers RD visits within our organization • Those with Pre-Diabetes will develop Type 2 Diabetes within 8-12 years without lifestyle changes American Diabetes Association. Diabetes Statistics. Available at: http://www.diabetes.org/diabetes-basics/diabetes-statistics/. Accessed March 7, 2010.

  38. Resources • http://www.SetonBabyTalk.com • http://www.GoodHealth.com • National Institute of Child Health and Human Development (NICHD) http://www.nichd.nih.gov • National Diabetes Information Clearinghouse (NDIC) http://niddk.nih.gov/health/diabetes/ndic.htm • The National Diabetes Education Program (NDEP) http://ndep.nih.gov • American Dietetic Association (ADA) Consumer Hotline http://www.eatright.org • American College of Obstetricians and Gynecologists (AGOG) http://www.acog.org • American Diabetes Association http://www.diabetes.org

  39. Thank You! Questions? Comments?