Medical Nutrition Therapy in Gestational Diabetes Mellitus Dr. Parvin Mirmiran Obesity Research...
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Transcript of Medical Nutrition Therapy in Gestational Diabetes Mellitus Dr. Parvin Mirmiran Obesity Research...
Medical Nutrition Therapy in Medical Nutrition Therapy in Gestational Diabetes MellitusGestational Diabetes Mellitus
Dr. Parvin MirmiranObesity Research Center, Research Institute for Endocrine
Department of Human Nutrition, Faculty and Institute of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences
M. Akhoundan
Dr. Mirmiran / SBMU 1
Definition & Worldwide Definition & Worldwide Prevalence of GDM Prevalence of GDM
• GDMGDM is defined as any degree of glucose
intolerance with onset or first recognition
during pregnancy
• Approximately 7%7% of all pregnancies are complicated by GDM
• ranging from 1 to 14% depending on the population studied the diagnostic tests
• more than 200,000 more than 200,000 cases annually
Diabetes care, 2009Dr. Mirmiran / SBMU 2
Prevalence of GDM in Prevalence of GDM in IranIran
• According to 14 studies from 1992-2007,
the prevalence of GDM ranged between
1.3% toto 10%% in different regions of Iran.
Khoshnniat, 2009Dr. Mirmiran / SBMU 3
Dr. Mirmiran / SBMU Slide 4
Khoshnniat N, Iranian Journal of Diabetes and Lipid Disorders; 2009
Risk factors for the development Risk factors for the development of GDMof GDM
marked obesityolder agepersonal history of GDM glycosuriastrong family history of diabetes ethnicity polycystic ovary syndrome hypertension
Cheung,2009Dr. Mirmiran / SBMU 5
GDM GDM Complication
• adverse pregnancy outcomesadverse pregnancy outcomes:
macrosomia shoulder dystocia Jaundice polycythemia respiratory distress hypocalcemia
Cheung,2009Dr. Mirmiran / SBMU 6
GDM GDM Complication (cont’)(cont’)
adverse pregnancy outcomes adverse pregnancy outcomes (cont’)
Increase fetal malformationmalformation and perinatalperinatal mortalitymortality
predispose the child to a diabete diabete phenotype in later life
Cheung,2009Dr. Mirmiran / SBMU 7
Maternal Maternal complicationcomplication :
• Weight gainWeight gain
• Maternal hypertensive disordershypertensive disorders
• Miscarriages
• Third trimester fetal deaths
• Cesarean delivery (due fetal growth disorders)
• Long term risk of type 2 diabetes mellitusrisk of type 2 diabetes mellitus
Dr. Mirmiran / SBMU 8
GDM GDM Complication (cont’)(cont’)
Medical Nutrition Therapy Medical Nutrition Therapy (MNT) in GDM(MNT) in GDM
Dr. Mirmiran / SBMU 9
Medical Nutrition Therapy (MNT)Medical Nutrition Therapy (MNT) in GDM in GDM
• MNT is the primary therapy for 30 –90% of women diagnosed with GDM
Reader,2007Dr. Mirmiran / SBMU 10
Medical Nutrition Therapy Medical Nutrition Therapy (cont’)(cont’)
Goals:
• Achieve normoglycemia normoglycemia
Recommended treatment targets
ADA,2004Dr. Mirmiran / SBMU 11
Test GestationalDiabetes (mg/dl)
Fasting plasmaglucose
65-95
I hr postprandial <140
2 hr postprandial <120
• Providing the required nutrients required nutrients for normalnormal fetal growthfetal growth and maternal healthmaternal health
• Prevent excessive maternal weight gainPrevent excessive maternal weight gain, particularly in women who are overweight or have gained excess weight in pregnancy.
• Prevent ketosisPrevent ketosis
Dr. Mirmiran / SBMU 12
Medical Nutrition Therapy Medical Nutrition Therapy (cont’)(cont’)
Medical Nutrition Therapy Medical Nutrition Therapy (cont’)(cont’)
Include:Include:
• Nutrition therapyNutrition therapy
• ExerciseExercise
• Self-monitoring of blood glucose (SMBG)Self-monitoring of blood glucose (SMBG)
• Pharmacologic therapyPharmacologic therapy
• EducationEducation
Dr. Mirmiran / SBMU 13
Dr. Mirmiran / SBMU 14
Nutrition therapyNutrition therapy
Efficacy of dietary therapy for GDMEfficacy of dietary therapy for GDM
Nutrition intervention for GDM has been recognized as the cornerstone of therapycornerstone of therapy
In patients receive diet therapy:In patients receive diet therapy:• Fewer patients require insulin therapy
• Decrease HbA1c
• lower serious perinatal complications among the infants: lower birth weight lower % large-for-gestational-age Less macrosomia
Crowther ,2005 , Reader,2006 , Cheung,2009Dr. Mirmiran / SBMU 15
Nutrition therapy Nutrition therapy (cont’)(cont’)
• All women should receive individualized counselingindividualized counseling
• Food plan Food plan should be individualized individualized & culturally appropriateculturally appropriate
Cheung,2009Dr. Mirmiran / SBMU 16
Nutrition therapy Nutrition therapy (cont’)(cont’)
Maternal weight-gain & Calorie intake for Maternal weight-gain & Calorie intake for women with GDMwomen with GDM
There is no indication that normal-weightnormal-weight and
underweightunderweight women with GDM should not follow
the IOM weight-gain guidelinesIOM weight-gain guidelines and calorie intakecalorie intake
Reader,2007Dr. Mirmiran / SBMU 17
weight-gain recommendations based on
prepregnancy BMI
(BMI (kg/m2 weight-gain
normal 19.819.8– – 26.026.0
11.411.4– – 15.915.9 kgkg
overweight26.1–29.0
6.8–11.4 kg
Obese>29
kg7
(Institute of Medicine’s Nutrition for Pregnancy 1990)
Nutrition therapy Nutrition therapy (cont’)
Dr. Mirmiran / SBMU 18
overweight and obese women:
Severe calorie restrictionSevere calorie restriction, increases
ketonuria and ketonemia
American Diabetes Association have suggested:
a 30–33% calorie restriction fora 30–33% calorie restriction forobese women with GDM,obese women with GDM,
noting a minimum 1600-1800 calorienoting a minimum 1600-1800 calorie
Ada,2000
Nutrition therapy Nutrition therapy (cont’)(cont’)
Dr. Mirmiran / SBMU 19
• Calorie formulas have been suggested in articles and guidelines for GDM:
35–40 kcal/kg for underweight
30 –35 kcal/kg for normal weight
25–30 kcal/kg for overweight
23–25 kcal/kg (pregravid weight) for obese
35–40 kcal/kg for underweight
30 –35 kcal/kg for normal weight
25–30 kcal/kg for overweight
23–25 kcal/kg (pregravid weight) for obese
Reader,2007
Nutrition therapy Nutrition therapy (cont’)(cont’)
Dr. Mirmiran / SBMU 20
Macronutrient intakeMacronutrient intake
CarbohydrateCarbohydrate (CHO) (CHO) :: 50 to 55% 50 to 55% kcal intake
ProteinProtein: 20-2520-25 %% kcal intake
FatFat: 25-30%25-30% kcal intake
Nutrition therapy Nutrition therapy (cont’)(cont’)
Cheung,2009Dr. Mirmiran / SBMU 21
• CHO are an important dietary source of energy, vitamins, minerals & fiber content.
• CHO is the main nutrient that affects postprandial glucose levels.
• CHOCHO intake can be manipulated by: intake can be manipulated by:
Nutrition therapy Nutrition therapy (cont’)(cont’)
controlling the total amount of amount of CHO CHO distribution of distribution of CHOCHO over several meals and snacks type of type of CHOCHO
Reader,2007 Dr. Mirmiran / SBMU 22
The ADA Standards of Medical Care state :
• the glycemic index (GI) glycemic index (GI) can provide additional benefit to total carbohydrate control
Foods with a low GI (<55)low GI (<55)
produce a lower postmeal glucose elevation
Foods with a high GI (>70) high GI (>70)
show higher postprandial glucose values
Nutrition therapy Nutrition therapy (cont’)(cont’)
Reader,2007Dr. Mirmiran / SBMU 23
FiberFiber :
• SolubleSoluble (legumes, oats, fruits)
• InsolubleInsoluble (whole grain breads, cereals and some vegetables)
Both: increase satietyincrease satiety slowing absorption time slowing absorption time lower glycemic indexlower glycemic index
Nutrition therapy Nutrition therapy (cont’)(cont’)
Reader,2007Dr. Mirmiran / SBMU 24
Carbohydrate CountingCarbohydrate Counting
Works as follows: a dietitian determines a person’s dietary needsdetermines a person’s dietary needs
the individual is given a daily CHO allowancedaily CHO allowance
divided into a pattern of meals & snacks meals & snacks according to individual preferences
the carbohydrate allowance can be expressed in grams or as the number of carbohydrate portions grams or as the number of carbohydrate portions
allowed allowed per mealsper meals
Nutrition therapy Nutrition therapy (cont’)(cont’)
Dr. Mirmiran / SBMU 25
Carbohydrate CountingCarbohydrate Counting
• Emphasis is given to spreading the dietary intake over six meals dailysix meals daily:
• 3 main meals
• 3 snacks
Distribution of CHO in daily mealsDistribution of CHO in daily meals
Nutrition therapy Nutrition therapy (cont’)(cont’)
mealsmeals BreakfastBreakfast Snack1Snack1 LunchLunch Snack2Snack2 DinnerDinner Snack3Snack3
CHOCHO%% 15%15% 10%10% 30%30% 10%10% 20%20% 15%15%
Dr. Mirmiran / SBMU 26
• Additional dietary components are usually based based upon the general recommendations for diabetes upon the general recommendations for diabetes mellitusmellitus..
• A reductionreduction in simple carbohydrates simple carbohydrates and fat fat intake intake is advisable
Nutrition therapy Nutrition therapy (cont’)(cont’)
Cheung,2009Dr. Mirmiran / SBMU 27
Fat intake:Fat intake:
• less than 10 % less than 10 % SFASFA
• up to 10 %up to 10 % PUFAPUFA
• the remainderremainder derived from MUFAMUFA
Nutrition therapy Nutrition therapy (cont’)(cont’)
Cheung,2009Dr. Mirmiran / SBMU 28
Nutrient needs
• There is no indication no indication that women with GDM
should not follow the same guidelines same guidelines for nutrient
intakes for all pregnant women for all pregnant women
(Dietary Reference Intakes for pregnancy 2001)Dietary Reference Intakes for pregnancy 2001)
Nutrition therapy Nutrition therapy (cont’)(cont’)
Reader,2007Dr. Mirmiran / SBMU 29
Nutrition therapy Nutrition therapy (con’t)(con’t)
30
• ExerciseExercise is an obvious adjunct therapyobvious adjunct therapy to MNT for women with GDM
• light and moderate light and moderate intensity activities intensity activities such as walking for 20–30 min/day:
can be safely encouragedsafely encouraged, modest improvements in glycemic control might be
achieved
ExerciseExercise
Reader,2007Dr. Mirmiran / SBMU 31
Criteria for adding pharmacological therapyCriteria for adding pharmacological therapy
such as insulin or glyburide:such as insulin or glyburide:
• One or more blood glucose values outside the target range within a designated time frame.
• Elevated fasting glucose values alone
Pharmacologic therapyPharmacologic therapy
Reader,2007Dr. Mirmiran / SBMU 32
CONCLUSIONSCONCLUSIONS
Nutrition recommendations for women with GDM, including:
• Management of gestational weight gainManagement of gestational weight gain
• Control of calorie intakeControl of calorie intake
• Modifying macronutrient composition & distributionModifying macronutrient composition & distribution
• Providing vitamins & minerals to meet pregnancy's Providing vitamins & minerals to meet pregnancy's
needneed
Dr. Mirmiran / SBMU33
The food plan should be designed to :
FulfillFulfill minimum nutrient requirements for pregnancyfor pregnancy
Achieve glycemic goals Achieve glycemic goals without weight loss and ketonemia
BeBe culturally appropriate andand individualized to take to take into account the into account the patient’s body habituspatient’s body habitus, , weight gainweight gain, and , and physical activityphysical activity
CONCLUSIONSCONCLUSIONS
Dr. Mirmiran / SBMU 34
Nutrition interventions for GDM emphasize
• healthy food choiceshealthy food choices
• portion controlportion control
• Cooking practicesCooking practices
that can be continued postpartumthat can be continued postpartum
and may help prevent later diabetes,and may help prevent later diabetes,
obesity, cardiovascular disease, andobesity, cardiovascular disease, and
cancercancer
CONCLUSIONSCONCLUSIONS
Dr. Mirmiran / SBMU 35
با تشكر از توجه با تشكر از توجه شماشما