Presentation on theme: "Dr. Shelley Wilkinson 18th June 2014. Gestational Diabetes: nutrition priorities Dr Shelley Wilkinson Advanced Accredited Practising Dietitian, Mater."— Presentation transcript:
Dr. Shelley Wilkinson 18th June 2014
Gestational Diabetes: nutrition priorities Dr Shelley Wilkinson Advanced Accredited Practising Dietitian, Mater Mothers’ Hospital, Brisbane, Australia
A window of opportunity During pregnancy: health service contact more receptive to health messages intergenerational effects Behaviours with demonstrated outcomes: diet/nutrition, healthy weight gain (+breastfeeding) sufficient physical activity smoking cessation Guidelines: Australian dietary guidelines (incl. gestational weight gain, GWG) Gestational Diabetes Mellitus (GDM) Nutrition practice guidelines QHealth Obesity guidelines
Pregnancy Nutritional Requirements
Acknowledgement:Food systems & Policy team, Victorian Dept of Health, 2013
Pregnancy nutrition – dietary guidelines 1. Achieve and maintain a healthy weight, by being physically active and choosing amounts of nutritious food and drinks to meet your energy needs 2. Eat a wide variety of food every day – including vegetables; fruit; grain foods (preferably wholegrain); protein foods (e.g. meat, fish, eggs, nuts, legumes), and dairy (mostly reduced fat) 3. Limit your intake of food/drinks that contain added sugar, salt and/or saturated fat (and of course, in pregnancy, avoid alcohol) 4. Encourage, support and promote breastfeeding 5. Prepare and store food safely.
Not eating for two, but having to eat twice as well…
Energy requirements 1st trimester = no additional requirements 2nd trimester = +1400kJ/d 3rd trimester = +1900kJ/d Nutrient requirements Protein RDI: 60g/d (46g/d) Iron RDI: 27mg/d (8mg/d) Iodine* RDI: 220 μ g/d (150 μ g/d) Folate*RDI: 600 μ g/d (400 μ g/d) μ g/d LC n3 fatty acids AI: 115mg/d (90mg/d) Not eating for two, but having to eat twice as well…
How do we apply this in everyday settings?
Gestational weight gain guidelines If pre-pregnancy BMI was …GWG goal…Rate of gain in trimesters 2 & 3 <18.5 kg/m²12 ½ - 18kg0.45 kg/week kg/m²11 ½ - 16kg0.45 kg/week kg/m²7-11½kg0.28 kg/week 30+ kg/m²5-9kg0.22 kg/week Not eating for two, but having to eat twice as well… “Based on your weight at the beginning of pregnancy, this weight gain is recommended for the healthiest pregnancy possible”
GDM + Medical Nutrition Therapy (MNT) primary intervention strategy for managing BGLs in GDM Improvements in important outcomes (e.g. insulin, BGL control), documented in ADA Nutrition Practice Guidelines validation study MNT according to an evidence-based appointment schedule Minimum: one-hour ‘new’, two+ reviews, plus postnatal follow up 3 rd trimester dietetic counselling following a GDM diagnosis can slow weight gain and reduce the incidence of macrosomia Australian Carbohydrate Intolerance Study Routine care vs dietary advice, BGL monitoring, insulin Significant decrease in serious perinatal complications and improvements in self-reported maternal health status
How do we measure up? A key recommendation from a Qld dietitian managers’ report: “a demonstration project implementing and evaluating the GDM nutrition guidelines to facilitate its dissemination and adoption across Queensland”
Pregnancy nutrition priorities “MNT primarily involves a carbohydrate- controlled meal plan that: promotes optimal nutrition for maternal and fetal health, with adequate energy for appropriate gestational weight gain, and maintenance of normoglycaemia, and absence of ketosis ” American Diabetes Association 2008
Carbohydrate component of the diet that has the greatest influence on BGLs commonly proposed options for reducing the post-prandial response: Reduce total CHO intake, if excessive (NB minimum 175g CHO) Re-distribute CHO across the day (eg 3 meals, 3-4 snacks) Lower glycaemic index CHO Physical activity post meals Even so, in pregnancy... “there is little evidence for a recommended amount and type of CHO or its distribution.... The best indicators at this time are the results of self- monitoring of BGL, food records, and weight gain” Pregnancy nutrition priorities
Know your carbohydrate foods
Carbohydrates are in many foods Include carbohydrate in each meal and snack Aim to eat every 2 ½ to 3 hours Aim to eat similar amounts of carbohydrate across meals A good way to measure carbohydrates is to think of them as exchanges that you mix and match over meals
Better choices Grain or rye bread Crackers containing whole grains or seeds Pasta or noodles Basmati or Doongara rice Sweet potato
Excessive CHO Risks: Higher BGLs and assoc. risks e.g. LGA baby Excess GWG and associated risks Unnecessary use of insulin The CHO Dilemma... Suboptimal CHO Risks: High BGLs, if resulting hunger leads to overeating Poor intake of associated nutrients (vit, min, fibre etc) Suboptimal weight gain and associated risks e.g. SGA Starvation ketosis Pregnancy nutrition priorities
Used with permission.
Repeat Oral Glucose Tolerance Test (OGTT) 6 – 12 weeks after delivery Repeat OGTT every one to two years Greater risk of developing gestational diabetes again developing Type 2 diabetes in later life Reduce your risk by continuing a healthy lifestyle after your pregnancy Continue a healthy lifestyle after your pregnancy
How to prevent T2DM Weight management Physical activity Breastfeeding Diabetes Prevention Program (DPP) Aim: to reduce the incidence of T2DM in high risk populations 1. Participation in a lifestyle program Individualised counselling, multiple contacts (monitoring/support) Goals: - Weight reduction > 5-7% - Total fat intake <30% total energy - Saturated fat intake <10% total energy - Fibre intake >15g/1000kcal - Moderate intensity physical activity > 150mins/week 2. Use of Metformin 3. Control group
Lifestyle intervention was more effective than Metformin in reducing the risk of developing T2DM Sub-analysis: Compared women with Hx GDM vs No GDM Both lifestyle and Metformin intervention reduced the incidence of diabetes by approximately 50% compared w/ control Intensive lifestyle intervention was more effective in the non-GDM group, and the GDM group were not able to sustain the lifestyle changes over time The combination of increased risk, less physical activity and consistent weight gain in the GDM group highlights the importance of follow up and intervention for these women How to prevent T2DM
Australian Dietary guideline Women post-GDM: - Are less likely to BF than women without GDM (~delayed lactogenesis II) - Are twice as likely to develop T2DM if don’t BF - Have a 15% decrease in risk of T2DM/yr of lactation - That have a higher intensity of BF = improved fasting BGLs and lower insulin levels Lowest postpartum T2DM risk in women who BF > 9/12 (improved glucose homeostasis) Exclusive BF increases postpartum weight loss, reduced long term obesity and lower prevalence of the metabolic syndrome Weight management Physical activity Breastfeeding How to prevent T2DM BF offers a safe, feasible and low–cost intervention to reduce the risk of subsequent T2DM