1. Dr. Shelley Wilkinson
18th June 2014

2. Gestational Diabetes: nutrition priorities
Dr Shelley Wilkinson
Advanced Accredited Practising Dietitian,
Mater Mothers’ Hospital, Brisbane, Australia 1

3. 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

4. Pregnancy Nutritional Requirements

6. Acknowledgement:Food systems & Policy team, Victorian Dept of Health, 2013

7. Pregnancy nutrition – dietary guidelines
Achieve and maintain a healthy weight, by being physically active and choosing amounts of nutritious food and drinks to meet your energy needs
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)
Limit your intake of food/drinks that contain added sugar, salt and/or saturated fat (and of course, in pregnancy, avoid alcohol)
Encourage, support and promote breastfeeding 
Prepare and store food safely.

8. Not eating for two, but having to eat twice as well…!

9. 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: 220μg/d (150μg/d)
Folate* RDI: 600μg/d (400μg/d) + 400μg/d
LC n3 fatty acids AI: 115mg/d (90mg/d)

10. How do we apply this in everyday settings?

11. Not eating for two, but having to eat twice as well…
Gestational weight gain guidelines
If pre-pregnancy BMI was …
GWG goal…
Rate of gain in trimesters 2 & 3
<18.5 kg/m²
12 ½ - 18kg
0.45 kg/week
kg/m²
11 ½ - 16kg
25-30 kg/m²
7-11½kg
0.28 kg/week
30+ kg/m²
5-9kg
0.22 kg/week
“Based on your weight at the beginning of pregnancy, this weight gain is recommended for the healthiest pregnancy possible”

12. 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
3rd 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

13. A key recommendation from a Qld dietitian managers’ report:
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”

14. 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

15. Pregnancy nutrition priorities
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”

16. Know your carbohydrate foods

17. 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

18. Better choices
Grain or rye bread Crackers containing whole grains or seeds Pasta or noodles Basmati or Doongara rice Sweet potato

19. Pregnancy nutrition priorities
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
Excessive CHO
Risks:
Higher BGLs and assoc. risks e.g. LGA baby
Excess GWG and associated risks
Unnecessary use of insulin

20. Used with permission.

21. Continue a healthy lifestyle after your pregnancy
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

22. 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
Weight management
Physical activity
Breastfeeding

24. How to prevent T2DM
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

25. How to prevent T2DM Weight management Physical activity
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
BF offers a safe, feasible and low–cost intervention to reduce the risk of subsequent T2DM

26. NEMO Resources Antenatal nutrition Gestational Diabetes and nutrition
Nutrition Education Materials Online
Antenatal nutrition
Gestational Diabetes and nutrition