7.

Problems with the dietary pattern and lifestyle:

Dietary factors and GDM

Many evidences has related diet to the development of glucose intolerance. An extensive
body of literature has reported both protective and risk-enhancing associations between
particular dietary factors and type 2 diabetes in adult men and nonpregnant women. These
studies suggest that the quality of dietary carbohydrate and fat intake may be more relevant to
type 2 diabetes risk than is the total amount of these nutrients. Specific types of carbohydrates
may be protective [eg, whole grains], and specific types of fats [eg, trans fat] may be risk
enhancing . Dietary treatment/counseling has long been recommended for women who
develop GDM. However, studies of the association between dietary factors and the risk of
development of GDM have just emerged. A limited number of studies have examined diet
before and/or during pregnancy in association with GDM risk .

Dietary factors during pregnancy and GDM risk

Earlier studies on the effect of diet during pregnancy, many of which were cross-sectional or
retrospective in design, suggested that macronutrient components of the diet in mid
pregnancy may predict incidence or recurrence of GDM. Polyunsaturated fat intake may be
protective against glucose intolerance in pregnancy, and high intake of saturated fat may be
detrimental. A recent prospective study that considered the correlation of nutrients showed
that higher intake of fat and lower intake of carbohydrates may be associated with increased
risk of GDM and impaired glucose tolerance. In addition, in a prospective study of pregnant
women, lower plasma vitamin C and vitamin D concentrations in early pregnancy were
significantly associated with increased GDM risk.

Prepregnancy diet and GDM risk

A number of pregravid dietary factors were recently associated with the risk of glucose
intolerance during pregnancy. These were based on data primarily from a large prospective
study, the Nurses’ Health Study II.

Western dietary pattern and red meat.

Strong positive associations were observed between the Western dietary pattern score and
GDM risk, whereas the prudent dietary pattern score was significantly and inversely
associated with GDM risk, even after adjustment for major risk factors for GDM, such as
family history of diabetes, prepregnancy body mass index (BMI), physical activity, parity,
and so forth. The prudent dietary pattern was characterized by a high intake of fruit, green
leafy vegetables, poultry, and fish, whereas the Western pattern was characterized by a high
intake of red meat, processed meat, refined grain products, sweets, french fries, and pizza.
The association with the Western pattern was largely explained by intake of red and
processed meat products. Pregravid intake of red and processed meats were both significantly
and positively associated with GDM risk, independent of known risk factors for type 2
diabetes and GDM. For instance, after the adjustment for major risk factors for GDM, which
include prepregnancy BMI, physical activity, parity, and other dietary risk factors, those who
consumed >6 servings of red meat/wk had a more than 1.7-fold increased risk of GDM
compared with those women who consumed <1.5 servings of red meat/wk . Although the
precise molecular mechanisms are unclear, the observed associations of red and processed
meat intakes with GDM risk are biologically plausible. First, they could be related to several
possible biologically adverse effects of components in red and processed meats, such as
saturated fat and cholesterol, on insulin sensitivity and β cell function that might be relevant
to the pathophysiology of GDM. In the present study, the strong association of red meat and
processed meat with GDM risk remained significant after further adjustment for these other
dietary factors that included fatty acids and cholesterol, which indicates that components of
red meat and processed meat other than these nutrients might also be relevant to the
pathogenesis of GDM. Heme iron in red meat might also contribute to the increased risk of
GDM, because body iron overload has been postulated to promote insulin resistance and
increase the risk of type 2 diabetes. More recently, iron supplements and increased iron stores
in pregnant women without iron deficiency were related to an increased risk of GDM (75).
However, the association between processed meat and GDM risk remained strong after
adjustment for heme iron. Nevertheless, it is also plausible that other unidentified
components in red meat and processed meat can contribute to the adverse effect on GDM
related to them .

Dietary fiber and glycemic index.

Pregravid consumption of dietary fiber (ie, total, cereal, and fruit fiber) was significantly and
inversely associated with GDM risk. In contrast, dietary glycemic load was positively
associated with GDM risk. The glycemic index is a relative measure of the glycemic effect of
the carbohydrates in different foods. Each 10-g/d increment in total fiber intake was
associated with a 26% (95% CI: 9%, 49%) decrease in risk; each 5-g/d increment in cereal or
fruit fiber was associated with a 23% (9–36) or 26% (5–42) decrease, respectively. The
combination of high glycemic load and a low-cereal-fiber diet was associated with a 2.15-
fold increased risk of GDM compared with the reciprocal diet.

Sugar-sweetened beverages.
Sugar-sweetened beverages are the leading source of added sugars in Americans’ diets. In
animal models and human studies, a high-sugar diet decreases insulin sensitivity and insulin
secretion. In the Nurses’ Health Study II, after adjustment for age, parity, race, physical
activity, smoking, alcohol intake, prepregnancy BMI, and Western dietary pattern, intake of
sugar-sweetened cola was positively associated with the risk of GDM. Compared with
women who consumed <1 serving/mo, those who consumed ≥5 servings/wk of sugar-
sweetened cola had a 22% greater GDM risk.
In summary, epidemiologic studies on the role of dietary factors in the development of GDM
are at their early stage. Although the observational design of this study does not prove
causality, available data did provide evidence that supports the theory that dietary factors may
play a role in the development of GDM. Large prospective studies on dietary factors both
before and during pregnancy and the risk of GDM are warranted.

8. Medical Nutritional therapy for gestational Diabetes mellitus:

 Maternal weight gain and calorie intake:
There is a strong correlation between infant birth weight and maternal pregravid BMI for
women who begin pregnancy in the normal and underweight categories. Women with normal
BMI (19.8–26.0 kg/m2) were recommended to gain a total of 25–35 lb (11.4–15.9 kg).
For overweight women (BMI 26.1–29.0 kg/m 2), the weight-gain recommendation is 15–25 lb
(6.8–11.4 kg). Obese women with a BMI >29 kg/m 2 need to gain 15 lb. As BMI increases,
the correlation between infant size and maternal gain weakens to the point that there is no
correlation between weight gain and infant size in obese women. Obese women, regardless of
weight gain, produce larger infants as a result of GDM. (macrosomia). For women at high
risk for excessive weight gain, interventions need to begin in the first trimester. Suggested
ways to manage weight gain are recording food intake, plotting weight gain on a graph at
each visit, setting behavioral goals, participating in a group, and receiving individually
tailored mailings or periodic newsletters.

Restricting calories has been a strategy for controlling weight gain, glucose levels, and
avoiding macrosomia in infants of women with GDM. Severe calorie restriction, <1,500
calories per day or 50% restriction, increases ketonuria and ketonemia. In one study, high
levels of third-trimester β-hydroxybutyrate resulted in lowered mental developmental index
scores and average Stanford-Binet scores. This study has been regularly cited to support
guidelines that recommend avoiding ketonemia/ketosis due to severe calorie restriction.
Modest calorie restriction, 1,600–1,800 or a 33% reduction in intake, does not lead to ketosis
but controls weight gain and glucose levels in obese women and has been more successful in
reducing the progression of GDM.

 Carbohydrates and postprandial glucose control:

The IOM Food and Nutrition Board recommends 45–65% of total calories from carbohydrate
for a healthy diet. Carbohydrates are an important dietary source of energy, vitamins,
minerals, and fiber content.
The 2002 Dietary Reference Intake Report set a minimum level of 130 g/day for nonpregnant
women and 175 g carbohydrate per day for pregnancy; this is an additional 33 g carbohydrate
for fetal brain development and functioning. This new minimum recommendation provides
an important basis for the level of carbohydrate restriction for women with GDM.

Elevated glucose values, and in particular postprandial glucose elevations, are associated with
adverse outcomes in GDM. Carbohydrate is the main nutrient that affects postprandial
glucose levels. Carbohydrate intake can be manipulated/ altered by controlling the total
amount of carbohydrate, the distribution of carbohydrate over several meals and snacks, and
the type of carbohydrate. These modifications need not affect the total caloric intake
level/prescription.

In addition to the total amount of carbohydrate, the type of carbohydrate may also be a factor.
In recent years, the glycemic index has received attention as a nutrition intervention to
improve glucose control among nonpregnant people. Foods with a low glycemic index (<55)
produce a lower postmeal glucose elevation and area under the curve. Foods with a high
glycemic index (>70) show higher postprandial values. Studies compared low-fiber (20 g),
moderate-fiber (40–60 g), and high-fiber (70–80 g) diets in non–insulin-requiring women
with GDM. It also demonstrated that high-fiber diets were associated with a lowering of
blood glucose levels.

 Nutrient needs, vitamins, minerals, and sweeteners:

 Dietary reference intakes for pregnancy

Nutrient RDA or AI* for pregnancy

Energy +340 kcal/day second trimester

Nutrient RDA or AI* for pregnancy

+452 kcal/day third trimester

Carbohydrate 175 g/day

Total fiber 28 g/day*

Linoleic acid 13 g/day*

α-Linolenic acid 1.4 g/day*

Protein (g · kg−1 · day−1) 1.1 (additional 25 g/day)

Total water 3.0 l/day (∼12 cups)

Sodium 1.5 g/day*

Potassium 4.7 g/day*

Calcium 1,000 mg/day

Phosphorus 0.7 g/day

Magnesium 350 mg/day

Copper 1,000 μg/day

Iodine 200 μg/day

Iron 27 mg/day

Zinc 11 mg/day

Vitamin A 770 μg/day retinol activity equivalents

Vitamin C 85 mg/day

Vitamin D 5 μg/day*

Vitamin E 15 mg/day

Vitamin K 90 μg/day*
 Nutrient RDA or AI* for pregnancy

Thiamin 1.4 mg/day

Riboflavin 1.4 mg/day

Niacin 18 mg/day

Vitamin B6 1.9 mg/day

Folate 600 μg/day

Vitamin B12 2.6 μg/day

It is important that the pregnant women should take required amounts of vitamins, minerals
which is essential for the overall metabolism of the women. There is no evidential change in
the micronutrient requirement as the calorie and carbohydrate intake has very minimal effect
on the utilization of micronutrients.

Nutritional drinks:

The patient Ms. S can take PRO PL once a day with a dose of 10 g/ serving. It is also to be
remembered that it can be taken with minimal or no added sugar. It cannot be consumed
more than once a day as it also provides calorie and has 4.5g of carbohydrates per serving
(10g). It can be taken under physician/ dietitian supervision.

EQUAL as a substitute for sugar:

Yes , she can take aspartame, commonly traded as EQUAL, as a better substitute for sugar as
it is non- calorific, safe for administration, approved by FDA, can be taken as much as
50mg/kg bodyweight of the person.