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NUTRITIONAL MANAGEMENT OF DIABETES & PREGNANCYBY RITA A. CHRIVIA, RD, CSP, LDWith the rising rates of obesity in the United States and theresulting rise in diabetes, chances are you are seeing moremothers and infants affected by diabetes in pregnancy.Reported rates of diabetes in pregnancy range from 2-10%of all pregnancies with 88% of those due to gestationaldiabetes, another 8% due to Type 2 and 4% due to Type1. (1) Poorly controlled diabetes beforeconception and during the first trimestercan cause major birth defects in5-10% of pregnancies andcan result in spontaneousabortions in 15-20% ofpregnancies. Poorlycontrolled diabetesin the second andthird trimestersof pregnancycan result inexcessively largebabies, posinga risk to bothmother and childduring laborand delivery.Gestationaldiabetes is a riskfactor for Type2 diabetes in themother; 5-10% ofwomen diagnosedwith gestational diabetesare found to have diabetesimmediately after the pregnancy.An estimated 15-50% will developdiabetes in the decades following theaffected pregnancy. (2)The good news is that intensive treatment of diabetes inpregnancy is associated with outcomes similar to thosein control populations. (3) For all types of diabetes inpregnancy, this involves medical nutrition therapy. Takinginto account the total calories per day, the number of mealsper day and the composition of those meals is important forreaching the goals of euglycemia, appropriate weight gain,and a healthy outcome for mother and child.Although the carbohydrate content of the diet is the firstpriority, total nutrient content and total calorie intake cannotbe ignored. A well balanced diet containing importantsources of vitamins and minerals, and promoting appropriateweight gain, is the goal for any pregnancy.Total calories per day should be based on the prepregnancyweight as a percent of ideal bodyweight. Women who are 80-120%of their ideal body weight arerecommended to have intakesof 30 calories per kg or 14calories per pound. Forobese women (120-150% of ideal bodyweight or with aBMI greater than27 kg/m2), 25calories per kgor 11 caloriesper pound is therecommendedintake. Womenwho are greaterthan 150% oftheir ideal weightare recommendedto have intakes of12-15 calories per kgand limit weight gain tono more than 8kg (17-18pounds). (3) While weightloss during pregnancy is notrecommended, a modest energyand carbohydrate restriction may beappropriate. (4) Avoidance of ketosis is importantto allow adequate provision of glucose to the fetal brain.The diet should be culturally appropriate, containing 1-1.2 gprotein per kg and at least 175 g carbohydrates per day. Totalcarbohydrates should be less than 45% of energy in womenwith gestational diabetes to prevent hyperglycemia. (5) Thecarbohydrates should be from complex sources with simplesugars and high glycemic index foods limited. Fiber intakeof 25-30 g per day is recommended as is a low saturated fatintake of less than 10% total calories. (6)VOL. 27 NO. 1 | MARCH 2013
Normal hormonal changes in pregnancy lead todecreased insulin sensitivity and increased insulinresistance. This can result in transient hyperglycemiaafter meals. Hypoglycemia between meals and atnight can occur due to the continuous fetal draw ofglucose. Women with preexisting diabetes should beencouraged to maintain consistency in the timing oftheir meals and to include at least a bedtime snack toprevent hypoglycemia. The recommended distribution ofcarbohydrates to prevent hyperglycemia or hypoglycemiais 10-20% at breakfast, 20-30% at lunch, 30-40% atdinner with up to 30% for snacks. Insulin resistance ishighest in the morning due to increased cortisol levels.Adding protein to the morning meals and snacks mayhelp combat hunger. Smaller, more frequent mealsmay also help combat hunger, reduce the mealtimecarbohydrate load, reduce nausea and heartburn, andmaintain a more stable postprandial blood glucose level.Unless contraindicated, the pregnant woman should beencouraged to participate in physical activity 30 minutesper day for a minimum of 3 times per week to improveglycemic control and general health. (5,6)Involving a registered dietitian who is familiar with thecomponents of medical nutrition therapy of diabetesduring pregnancy will allow for an individualized mealplan that reflects treatment goals and takes the woman’slifestyle into account. Barriers to compliance can also beaddressed and the meal plan modified as needed for thebest outcome for mother and infant.Breastfeeding is recommended for women withpreexisting diabetes and some data suggests it maydecrease the risk of Type 1 diabetes in the infant. Thewoman with Type 1 diabetes who breastfeeds mayexperience hypoglycemia and should be encouraged tohave a meal or snack available before or during feeds.Women diagnosed with gestational diabetes whobreastfeed appear to have a lesser chance of developingType 2 diabetes. Their children also have a decreasedrisk of childhood obesity and impaired glucose tolerance.(6) Postnatal follow up should include adapting the mealplan for breastfeeding and for achieving a more optimalweight if needed to minimize the risk of developinggestational diabetes in future pregnancies. ●REFERENCES1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet:national estimates and general information on diabetes and prediabetes inthe United States,2011.Atlanta,GA:U.S. Department of Health and HumanServices, Centers for Disease control and Prevention,2011.2. Division of Reproductive Health. National Center for Chronic DiseasePrevention and Health Promotion. Pregnancy Complications,2012.http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PregComplications.htm3. Meltzer S. Management of Diabetes in Pregnancy: Challenges and trends.Canadian Journal of Diabetes. 2005:29(3):246-256.4. American Diabetes Association. Bantle JP, Wylie-Rosett J, Albright AL,et al. Nutrition recommendations and interventions for diabetes: aposition statement of the American Diabetes Association. Diabetes Care.2008:Jan;Suppl1:S61-78.5. American Dietetic Association(ADA). Gestational diabetes mellitus (GDM).Evidence based nutrition practice guideline. Chicago,IL;American DieteticAssociation (ADA);2008.6. Barbour LA, Friedman JE. Management of Diabetes in Pregnancy,2010.http://diabetesmanager.pbworks.com/w/page/17680258/Management%20of%20Diabetes%20in%20PregnancyABOUT THE AUTHORRita Chrivia is a Clinical Dietician at SSM Cardinal Glennon Children’s Medical Center inSt. Louis, MO.THE PERINATAL TIMES | 9
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