Nutritional Management of Gestational

Diabetes: Counseling and Education

Interventions
Queens Hospital Center
1/31/22-3/18/22
Everly Saenz
Queens College Dietetic Internship
Gestational Diabetes Mellitus
(GDM): Disease Description1,2
– Spontaneous development of glucose intolerance
during pregnancy that was not clearly present
during 1st trimester or before pregnancy
– 1 in 6 live births worldwide
- After delivery
- 90% become normoglycemic
- ↑ risk of GDM in subsequent pregnancies
- 5-10% dx’d with T2DM
- 35-60% increased risk of developing DM in the
next 5-10 years
Gestational Diabetes
Mellitus (GDM):
Pathophysiology2,3

– In normal early pregnancy, insulin sensitivity

↑
– As pregnancy progresses, insulin resistance ↑
– insulin sensitivity ↓ 50% by 3rd
trimester
– Hormones promote a state of insulin
resistance
– Blood glucose ↑, crosses
placental membrane, fuels fetus
for growth
– Insulin production is sufficient
to keep normal BG levels
Gestational Diabetes Mellitus (GDM):
Pathophysiology2,3
In GDM, these metabolic adaptations are heightened
Causes of β-cell dysfunction not fully defined:
1. Autoimmune β-cell dysfunction
2. Genetic abnormalities that cause impaired insulin secretion
3. Underlying chronic insulin resistance (~80% of GDM cases)
• β-cells deterioration + insulin resistance over time exhausts cells, “unmasking” effect
Gestational Diabetes Mellitus (GDM):
Risk Factors, Signs, & Symptoms4

Risk factors include: Signs/Symptoms not typical

– but polyuria, polydipsia,
Hx of GDM, miscarriage/stillbirth,
polyphagia may occur
large baby > 9lbs
– Advanced maternal age
– Family hx of DM
– Lack of physical activity
– Overweight or Obesity
– ↑ BP, cholesterol, and/or heart disease
– Excessive gestational weight gain
– Other insulin resistance dz such as PCOS
– African American, Asian, Hispanic, Native American, & Pacific Islander ↑ rates
Gestational Diabetes
Mellitus (GDM):
Complications1

–Health Implications for fetus:

– Macrosomia = fetal overgrowth
– Puts baby at risk for
shoulder dystocia, cesarean
delivery
Gestational Diabetes Mellitus
(GDM): Complications1

–Health Implications for infant:

– Neonatal hypoglycemia
– May require IV glucose for ~24-48 hrs to
regulate blood glucose
– Respiratory distress syndrome, metabolic
complications
– ↑ risk of T2DM, CVD, obesity later in life
Gestational –Health Implications for mother:
– Associated with antenatal depression
Diabetes
– ↑ risk for T2DM, GDM, CVD preeclampsia, pre-term
Mellitus (GDM): birth
Complications1
–Screening ~6-12 weeks postpartum/every 3 years
 Gestational Diabetes Mellitus (GDM): Diagnosis1-3

–Two strategies to confirm GDM

–“One-Step” approach: Where any of the following values dx GDM
– FG >92 mg/dl
– Administer 2-hr 75-g OGTT
– 1 hr > 180 mg/dL
– 2 hr > 153 mg/dL
 Gestational Diabetes Mellitus (GDM): Diagnosis1-3

–“Two--Step” approach :
– If 1-hr-50-g (non-fasting) >140 mg/dl
– Then proceed to 3-hr 100-g OGTT in a fasting state. 2/4 values are dx of GDM.
– FG > 95
– 1 hr > 180 mg/dL
– 2 hr > 155 mg/dL
– 3 hr > 140 mg/dL
–Screening for GDM between 24th and 28th weeks of pregnancy
– Those with high risk factors screened for DM during 1 st visit using standard DM dx criteria
Gestational Diabetes Mellitus
(GDM): Treatment3
SMBG Goals:
– Fasting BG goal < 95 mg/dl
&
– 1 hr postprandial < 140 mg/dL
or
– 2 hr postprandial < 120 mg/dL

A1C Target Goal: <6% w/o hypoglycemia, otherwise relaxed to <7%

Gestational Diabetes Mellitus
(GDM): Treatment3
– MNT
– ~70-85% of women can control GDM with lifestyle modification alone
– Meet nutrient requirements for pregnancy w/o inducing weight loss or excessive
weight gain
– Overall healthy food choices, portion control, & cooking practices that can be
continued postpartum
– Physical activity
– 30 min/day as tolerated
Gestational Diabetes Mellitus
(GDM): Treatment3
2021 Standards of Medical Care in Diabetes for uncontrolled glucose in GDM:
– Insulin is 1st line agent
– Glyburide (sulfonylureas)
– ↑ risk of neonatal hypoglycemia, macrosomia, & hyperbilirubinemia

– Metformin
– ↓ risk of neonatal hypoglycemia and less maternal weight gain, crosses placenta
– ↑ in BMI, obesity, weight-to height ratios, waist circumference
 Counseling Case Presentation

– Pregnant female referred for new dx of GDM

– Gestational Age: 30 weeks, first pregnancy
– Received pregnancy nutrition-related education during 1st trimester
– No SMBG currently, newly dx’d today
Stages of Change Model: Preparation stage
– during initial assessment for GDM, pt states she is ready to make
changes for her baby’s health
 Assessment: Client History

PMHx:
– Moderate persistent asthma w/o complication, no
further personal hx
– No family hx of DM
 Assessment: Food/Nutrition
History
FH-1.2: Food and Beverage Intake
– 3 meals daily
– Large portions of CHO in meals (rice + roti + provisions)
– Frequent snacking of simple CHO foods (chocolate cake, ice-cream,
crackers)
– Small portions of fruits
– Frequent eating during AM hours when unable to sleep
– Consumption of sugary beverages (soda + Milo)
 Assessment: Food/Nutrition
History
FH- 3.1 Medications
– Prenatal MVI
– Ferrous Sulfate
Assessment: Anthropometric
Measurements
Height 4’ 11”

Pre-Pregnancy Wt 119 lbs

Pre-Pregnancy BMI 24.0

Pre-Pregnancy BMI Criteria Normal

Current Body Weight (CBW) 138 lbs

Weight Gain +19 lbs

Weight Gain Goal for Pregnancy 25-35 lbs

Assessment:
Anthropometric
Measurements
Assessment: Biochemical Data

LAB REFERENCE RANGE VALUE

Fasting Glucose 70-94 mg/dL 88 mg/dL

OGTT 1-Hr 70-179 mg/dL 216 mg/dL (H)

OGTT 2-Hr 70-154 mg/dL 200 mg/dL (H)

OGTT 3-Hr 70-139 mg/dL 137 mg/dL

A1C <6% 5.4%

HGB >11 g/dL 12.2 g/dL

 Estimated Daily Nutrient Needs

Calories 1802-2072 kcal/day based

on 25-30 kcal/kg/day of pre-
pregnancy wt + 452 kcal
(3rd trimester)
Protein 71 g/day

Fluids 1890-2160 ml/day based on

35-40 ml/kg pre-pregnancy
wt
 Nutrition Diagnosis

PES Statement:
NB-1.1 Food and Nutrition Related Knowledge Deficit R/T
limited prior GDM diet related knowledge education AEB
food recall and elevated OGTT lab results
NB-1.6 Limited Adherence to Nutrition Related
Recommendations R/T limited success in applying prior
pregnancy-related nutrition recommendations AEB food
recall and elevated OGTT lab results
 Nutrition Interventions

E-1 Nutrition Education

– Limiting consumption of simple CHO foods and sugary beverages
– Reviewed sources of CHO, including those in ethnic foods
– Reviewed food & nutrient needs during pregnancy
– Discussed and taught CHO portion control
– Explained GDM diet guideline and how to create healthy balanced meals
according to the plate method recommendations
– Provided healthy low CHO snack ideas
– Exercise at least 30 min/day as tolerated throughout pregnancy
 Nutrition Interventions

(C-2.1) Nutrition Counseling

– Open ended questions
– Reflective listening
– Summarizing
– Affirming
– Pt’s partner was very supportive & engaged in counseling session
– Confidence & Importance Scale: 10/10, pt reports placing her and her baby’s
health a priority for fear of health implications, ready to act and follow
recommendations
 Monitoring & Evaluation

Weight (AD-1.1.2)
Adherence (FH-5.1)
Food and Beverage Intake (FH-1.2)
Physical Activity (FH-7.3)
 Goals

– Adequate Kcal/Protein intake

– Weight gain remain within goal range
– No other nutrition related pregnancy complications
– No DM related complications

***Pt will be seen by RD at follow up visit as referred.

 References
1. Cox JT, Carney VH. Nutrition for reproductive health and lactation. In: Nelms M, Sucher
KP. Nutrition Therapy & Pathophysiology. 4th ed. Boston, MA: Cengage; 2019:266-268.
2. Plows JF, Stanley JL, Baker PN, Reynolds CM, Vickers MH. The pathophysiology of
gestational diabetes mellitus. Int J Mol Sci. 2018;19(11):3342. Published 2018 Oct 26.
doi:10.3390/ijms19113342
3. Metzger BE, Buchana TA, Coustan DR, de Leiva A, Dunger DB, et al. Dunger. Summary and
Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes
Mellitus. Diabetes Care 1 July 2007; 30 (Supplement_2): S251–S260. 
https://doi.org/10.2337/dc07-s225
4. Friel AL. Diabetes mellitus in pregnancy. Merck Manual Professional Version.
https://www.merckmanuals.com/professional/gynecology-and-obstetrics/pregnancy-complicat
ed-by-disease/diabetes-mellitus-in-pregnancy
. Updated October 2021.
Questions?

Thank you!