What is gestational diabetes? - ESPEN · Gestational Diabetes Doctor Gary Frost And Doctor Anne...

© ESPEN 2003 - For personal use only. 1

ESPEN Congress Cannes2003

Organised by the Israel Society for ClinicalNutrition

Session: Dietitian Symposium: Nutrition throughout the woman life cycle

An Update in the Nutritional Management ofGestational Diabetes

Doctor Gary Frost And Doctor Anne DornhorstLondon, United Kingdom

email [email protected]

Education and Clinical Practice Programme

What is gestational diabetes?• Find definition

– WHO– This is based on risk if type 2 diabetes

• Not clear what level of glucose causes problems for thefetus– HAPO Study (hyperglycaemic adverse pregnancy outcome study)

– 25,000 pregnant women with lesser degrees of glucose tolerancewill answer this.

• Detrimental maternal effects– Type 2 diabetes– CHD


General Dietary Recommendation

• Poor evidence base– Cochrane systematic review – 4 studies reached

the quality for consideration– No relationship between dietary intervention

and final birth weight, risk of LGA infant ormethod of delivery

– Poorly designed– Small underpowered studies

General nutrition adviceapplies

• Folate• Iron• Vitamin C• Calcium and Vitamin D• Alcohol


Hyperglycaemia and the Fetus

1st trimester congenital malformations

2nd trimester fetal cell programming

3rd trimester fetal growth & stillbirth

Extra-uterine Sequelle of IntrauterineHyperglycaemia

Neonate transient hypoglycaemia; hypocalcaemia, cardiomyopathy

Adolescent obesity, IGT and insulin resistance

Adulthood obesity, type 2 DM and ?CVD


Fetal Fuels

• Metabolic changes occur throughout pregnancy to ensureoptimal fetal growth.

• Metabolic changes occur to maximise the maternal-fetaltransfer of glucose.

• Maternal glucose is the primary fetal oxidative substrateand, by late pregnancy, 17- 26g glucose are metabolisedper day.

• The maternal respiratory quotient rises during pregnancyas fetal carbohydrate metabolism increases .

Barker in reverse: High birth weightand Adult disease

• Lasting structural and functional adaptation to excess fetalnutrient supply

• Fetal insulin a key fetal growth factor, determines fat andmuscle mass at birth

• Fuel-mediated teratogenesis that effects the adipoinsularaxis, leading to insulin resistance, childhood obesity andfuture diabetes

• There is a ‘U’ shape relationship between birth weight andfuture type 2 diabetes


Diagnosed Type 2 Diabetes USA Prevalence Data

Per

son

s W

ith

Dia

gn

ose

dD

iab

etes

(m

illio

ns)

Diabetes Overview. October 1995 (updated 1996). NIDDK publication NIH 96-1468.Kenny SJ et al. In: Diabetes in America. 2nd ed. 1995:47-67.

Year

8

7

6

5

4

3

2

0

1

1958 1963 1968 1979 1984 1989 1994

8,000,000

5X increase

Obesity – Past and Future


Disease Risk and Body Mass

Increasing US Prevalence of Type 2 Diabetes in1990-1998

Diagnosed type 2 Diabetes È 4.9% - 6.5%

40-49 yr. È 40%

30-39 yr. È 70%

Type 2 diabetes is increasing USA teenagers

Mokdad et al, Diabetes trends in the U.S.: 1990-1998. Diabetes Care, 2000. 23: p. 1278.


Pima Indian in Arizona

Maintained traditionallifestyle up until 1900 whenwater supply was diverted bywhite farmers and theybecome dependent on U.S.government supply of food -lard, sugar,white flour

Pima Indian Woman 1902

Pima Indiansenvironment verses genes

•The Pima Indians from Arizona have changed from a subsistence existence to Western lifestyle

•Pima Indian ancestors live in a mountainous remote undeveloped area of NW-Mexico

Ravussin et al Diabetes Care 1994 17:1067-1074


Increasing Prevalence of Type 2 DM inPima Indian Girls

0

1

2

3

4

5

6

Prav

elen

ce %

1967-1976

1977-1986

1989-1996

5-9yrs 10-14yrs 15-19yrs

5274 children examined over 30years. The prevalence hasincreased 2-3 fold over this time

Dabelea et al. J Matern-Fetal Med 2000;9:83-88

Prevalence of Type 2 DM Accordingto Maternal Diabetic Status

Dabelea et al. J Matern-Fetal Med 2000;9:83-88

0

10

20

30

40

50

60

70

80

Prav

elenc

e %

5-9. 10-14. 15-19. 20-24. 25-29. 30-34.

years

Non-DM Pre-DM DM


The Lasting Legacy of MaternalHyperglycaemia

• Maternal hyperglycaemia accounts for 40% of Type 2 DMin the Pima children <19-yrs.

• There is an increased risk of Type 2 DM in children ofType 1 mothers, and the risk appears dependent onglycaemic control in pregnancy.

• Likely to explain the higher maternal than paternal familyhistory of DM.

Obesity management

• Population based:– Obesity is a major public health problem

– To prevent GDM need to prevent obesity


-8

-6

-4

-2

0

0 1 2 3 4

Years from Randomization

Weig

ht

Ch

an

ge (

kg

)

Placebo

Metformin

Lifestyle

Mean Weight Change

The DPP Research Group, NEJM 346:393-403, 2002

0 1 2 3 4

0

10

20

30

40Placebo (n=1082)Metformin (n=1073, p<0.001 vs. Plac)Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )

Percent developing diabetes

All participants

All participants

Years from randomization

Cu

mu

lativ

e in

cid

en

ce (

%)

Placebo (n=1082)

Metformin (n=1073, p<0.001 vs. Placebo)Lifestyle (n=1079, p<0.001 vs. Metformin , p<0.001 vs. Placebo)

Incidence of DiabetesIncidence of Diabetes

Risk reductionRisk reduction31% by 31% by metforminmetformin58% by lifestyle58% by lifestyle

The DPP Research Group, NEJM 346:393-403, 2002


Obesity management

In pregnancy• Dutch famine (800kcal/day) thin babies, more

diabetes• Maternal ketosis effects fetal neuro-physiological

and cognative development• Moderate energy restriction 25kcal/kg/day from 24th

week, limits weight gain, LGA reduced. Womenonly gained half weight of controls (Dornhorst 1991,Knopp 1991)

Long chain polyunsaturates

Hammersmith HospitalsNHS Trust ©


Long chainpolyunsaturates (LCPs)

• Man cannot insert double bonds atthe n3 and n6 positions in fattyacids

• therefore……….


Long chainpolyunsaturates (LCPs)

• Linoleic acid (double bonds at the n6 position)

• and

• Alpha linolenic acid (double bonds at the n3 position)

• are ESSETIAL FATTY ACIDS and are the precursorsof LCPs



Long chain polyunsaturates (LCPs)

Arachidonic acid (n6) : Docosahexaenoic acid (n3)

Ratio in brain

2:1


Development of the cortex24 weeks to term

Hammersmith HospitalsNHS Trust

©


Fish oils and gestational diabetes

• Insulin resistance & altered maternal metabolismin gestational diabetes impairs arachidonic acidand DHA.– Low levels in cord blood

• Impairment of accretion may effect fetal accretionof DHA and AA

• Maternal supplements effect IQ• Low consumption in many countries is a problem

Fish consumption

• Recent evidence suggested an increasespontaneous abortion rate in low fishconsuming countries

• Is this due to DHA?• Does a maternal background of abnormal

glucose tolerance decrease levels further?• Role in hypertensive crisis? Small study

evidence.


What is What is Glycaemic Glycaemic IndexIndex

Incremental area under the bloodglucose response curve for food

Corresponding area after equi-carbohydrate portion of glucose

X 100

Glycaemic response of carbohydrates

0

2

4

6

8

10

12

0 30 60 90 120

Time (minutes)

De

lta

ch

an

ge

in

glu

co

se

(m

mo

l/l)

White Bread Wholemeal Bead White pasta Kidney beans


Glycaemic Glycaemic indexindexFOOD

White bread

Wholemeal bred

Brown rice

White rice

Boiled potato

Pasta

YamGreen banana

Sucrose

Baked beans

Chickpeas

GI100

100

81

81

98

65

7465

83

70

60

Glycaemic index

• Potential of decreasing risk of developingtype 2 diabetes

• Potential of decreasing risk of CHD• Potential effect of decreasing body weight• Mechanism

– Improving insulin sensitivity• Adipose tissue

Summerbell and Frost. Systematic Review of glyceamic index, Cochrane Reviews 2003


Feto-placental growthregulation

Rate of substrate delivery to the placental site

Release of placental growth or suppressive peptides into the umbilical circulation

Production of IGF and IGFBP by the liver and othertissues

Rate of feto-placental growth

Clapp etal 1991

Glycaemic index in GDM

• Low GI meal causes a lower post-prandialinsulin and glucose response

• Low GI diet blunt the mid and late pregancyinsulin resistance

• High GI larger infants• Low GI limited energy intake, and weight

gain in the motherClapp Proc Nutr Soc 2003


Glycaemic index in GDM

• Low blood glucose measurement• Reduction in hypos• Improved fasting blood glucose

Gestational Diabetes:Potential Relevance of Diet

A important factor fuelling the current rise inadolescent obesity & type 2 DM

We need evidence of effective interventionsPotential areas of interest are:

Fish oilsCarbohydates


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What is gestational diabetes? - ESPEN · Gestational Diabetes Doctor Gary Frost And Doctor Anne...

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