1. Diabetes in Pregnancy Diabetes: a leading complication in pregnancy Forms of diabetes include: –Type 1 diabetes—Results from destruction of insulin-producing cells of pancreas –Type 2 diabetes—Due to body’s inability to use insulin normally, or produce enough insulin –Gestational—CHO intolerance with 1st onset during pregnancy

2. Gestational Diabetes In about 2-12% of pregnant women (increases with obesity) Women developing gestational diabetes appear to be predisposed to insulin resistance, and have impaired insulin production Related to metabolic changes favoring oxidative stress and elevated blood glucose

3. Potential Consequences of Gestational Diabetes Elevated glucose from mother – risk of adverse outcomes. –Spontaneous abortion, stillbirth, neonatal death –Congenital anomalies –  insulin   glucose uptake & triglyceride formation in fetus Fetal changes  likelihood later in life: –Insulin resistance and/or Type 2 diabetes –High blood pressure –Obesity

4. Adverse Outcomes Associated with Gestational Diabetes

5. Risk Factors for Gestational Diabetes Linked to multiple inherited predisposition Environmental triggers such as: –Excess body fat –Unhealthful diets –Low physical activity levels

6. Risk Factors for Gestational Diabetes

7. Diagnosis of Gestational Diabetes All pregnant women should be screened at first prenatal visit for regular diabetes by the standard criteria used for those who are not pregnant. –One confirmed positive result for any of following would be the basis for diagnosis of diabetes: Hemoglobin A1c (A1c) >6.5% Fasting plasma glucose >126 mg/dL (7.0 mmol/L) 2-hour glucose >200 mg/dL after 75 g oral load Classic symptoms of hyperglycemia present Random plasma glucose >200 mg/dL

8. Diagnosis of Gestational Diabetes All pregnant women without diabetes should be tested for GDM by a 75-gm oral glucose tolerance test at 24-28 weeks. –Diagnosis cutpoints: Women with one* of these elevated plasma glucose levels are diagnosed with GDM: Fasting plasma glucose >92 mg/dL 1-hr plasma glucose >180 mg/dL 2-hr plasma glucose >153 mg/dL *Note this difference from 4th edition of the textbook.

9. Management of Gestational Diabetes First approach is medical nutrition therapy to normalize blood glucose levels with diet & exercise –Blood glucose levels can be brought down with low calorie intake – avoid elevated ketones –Oral medication metformin (glyburide) used to decrease insulin resistance

11. Exercise Benefits & Recommendations Regular aerobic exercise decreases insulin resistance & blood glucose in gestational diabetes –Recumbent bicycle at moderate intensity 45 min 3 x week –Weight lifting with arms 20 min 3 x week –Brisk walking 30 minutes every day –Exercise to make women slightly sweaty but not overheated, dehydrated or exhausted

12. Nutritional Management of Women with Gestational Diabetes Assess dietary & exercise habits Develop individualized diet & exercise plan Monitor weight gain Interpret blood glucose & urinary ketone results Ensure follow-up during & after pregnancy

13. THE DIET PLAN –Whole-grain breads & cereals, vegetables, fruits, & high-fiber foods –Limited intake of simple sugars –Low-GI foods, or carbohydrate foods that do not greatly raise glucose levels –Unsaturated fats –Three regular meals & snacks –Based around calculated level of calories

14. Estimating Levels of Caloric Need in Women with Gestational Diabetes Distribute calories among 3 meals & several snacks Caloric levels & meal/snack plans are starting points and my need modifications. See Table 5.11 for menu examples

15. Consumption of Foods with Low Glycemic Index Low GI carbohydrate foods help sustain modest improvement in blood glucose levels Blood glucose response with diabetes from meals of white bread or spaghetti is shown in graph

16. Gestational Diabetes Postpartum Follow-Up –15% will remain glucose intolerant postpartum –10-15% will develop Type 2 diabetes in 2-5 yrs Prevention of Gestational Diabetes –Reduce excessive weight and obesity –Increase physical activity –Decrease insulin resistance prior to pregnancy