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Recommendations Summary

GDM: Vitamins and Minerals 2016

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    GDM: Dietary Vitamin and Mineral Intake

    The registered dietitian nutritionist (RDN) should encourage women with gestational diabetes melliltus (GDM) to make healthy food choices and consume a variety of foods to meet the micronutrient needs of pregnancy. The micronutrient needs of women with GDM are the same as for pregnant women without diabetes (emphasis on dietary intake of iron, folate, calcium, vitamin D, choline and iodine). The consumption of more food to meet caloric needs and the increased absorption and efficiency of nutrient utilization that occurs in pregnancy, are generally adequate to meet the needs for most nutrients, when good food choices are consistently made.

    Rating: Consensus
    Imperative

    GDM: Vitamin and Mineral Supplementation

    The RDN should consider recommending dietary supplementation within the Dietary Reference Intakes (DRI) for pregnancy with a prenatal multivitamin/mineral or specific vitamin or mineral supplement(s) to address inadequate dietary vitamin and mineral intake (e.g.,  iron, folate, calcium, vitamin D, choline and iodine) or documented micronutrient deficiency. Dietary supplements may be indicated in pregnant women at high risk for inadequate micronutrient intake, such as food insecurity; alcohol, tobacco or other substance dependency; anemia; strict vegetarian (vegan) diet; or poor eating habits. 
     

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

      • Some individuals may not tolerate vitamin or mineral supplementation
      • In general, pregnant women should seek medical consultation before or while taking a non-prescribed over-the-counter (OTC) micronutrient supplement that exceeds the Tolerable Upper Limits (UL) for a particular vitamin or mineral (Kaiser & Campbell, 2014) or if taking herbal supplements.


       

    • Conditions of Application

      • Consideration should be given to the total intake of micronutrients from all sources in the diet, such as fortified foods and beverages (e.g., calcium-fortified juice; grains enriched with iron, folic acid and other B-vitamins) and prescribed or non-prescribed vitamin and mineral supplements
      • The RDN should use professional judgment when assessing nutrition status and determining the need for vitamin and mineral supplementation for those at high risk of nutrient deficiencies, including history of malabsorptive disorders (bariatric surgery), multi-fetal pregnancy, omission of food groups and eating disorders (Kaiser and Campbell, 2014; Shields and Tsay, 2015).

    • Potential Costs Associated with Application

      There is an increased cost for vitamin and mineral supplements.

    • Recommendation Narrative

      • The micronutrient needs of pregnant women with GDM are the same as for those without diabetes. Consuming sufficient calories to support recommended weight gain and eating a variety of foods to meet nutrient needs are beneficial for pregnant women (Marra and Boyar, 2009). As long as good food choices are made, the higher intake of calories, coupled with the increased absorption and efficiency of nutrient utilization that occurs in pregnancy are generally adequate to meet the needs for most nutrients (Kaiser and Campbell, 2014). However, vitamin and mineral supplementation may be warranted in pregnant women with multiple gestations, smoking and other substance dependency, poor quality diets,  food insecurity, anemia or who are strict vegetarians (vegans) (Kaiser and Campbell, 2014; Shields & Tsay, 2015). For example, a vegan may need to supplement her diet with Vitamin D and Vitamin B12 (Shields and Tsay, 2015). While adequate intake of all micronutrients is important for the health of the mother and baby, special attention should be paid to the following micronutrients.
      • Iron
        • The overall prevalence of iron deficiency is nearly 18% in pregnant women in the United States, with anemia at 5% of pregnant women. Rates of iron deficiency increase across trimesters from 6.9% to 14.3% to 28.4% (Siu, 2015) 
        • The risk for pre-term labor, low body weight (LBW), and infant mortality increase if there is iron deficiency anemia during the first two trimesters of pregnancy. Iron supplementation is needed to meet the increased maternal and fetal demand for iron throughout pregnancy (Procter & Campbell, 2014)
        • The Recommended Dietary Allowance (RDA) for iron is 27 mg/day [Institute of Medicine (IOM) 1997-2011]. Iron supplementation (30mg per day) is generally recommended starting at the first prenatal visit. However, while routine iron supplementation during pregnancy may improve maternal hematologic status and reduce the incidence of iron deficiency and iron deficiency anemia (IDA) in the short term, no clear or consistent evidence was found that prenatal iron supplementation has a beneficial clinical impact on maternal or infant health (Siu, 2015). Prenatal vitamins generally contain 30mg of iron. Women who have iron deficiency anemia during pregnancy should be prescribed 60mg to 120mg of elemental iron per day (Shields and Tsay, 2015). 
      • Folic Acid
        • Folic acid is recognized for preventing neural tube defects and is important before (pre-conception) and during pregnancy (Procter and Campbell, 2014). Pregnant women should consume 600mcg of dietary folate equivalents (DFE) daily from all food sources (IOM, 1997-2011; Procter and Campbell, 2014). One DFE is equal to 1.0mcg food folate or 0.6mcg of folic acid from fortified food or as a supplement consumed with food (or 0.5mcg if supplement is taken on an empty stomach) (IOM, 1997-2011). Most prenatal multi-vitamin and mineral supplements contain 600mcg of folic acid and can assist the woman in meeting folic acid requirements of pregnancy (Shields and Tsay, 2015).
        • Women with a previous infant with NTD should consult their physician regarding a 4, 000mcg folic acid daily before and throughout the first trimester of pregnancy (Procter and Campbell, 2014).
      • Calcium
        • The RDA for calcium is 1, 000mg per day for women ages 19 to 50 years. The DRI for calcium in pregnancy is the same as for women of the same age who are not pregnant, due to increased efficiency in calcium absorption and maternal bone calcium mobilization during pregnancy (Procter and Campbell, 2014). Women with calcium intakes under 500mg per day may need supplementation (Procter and Campbell, 2014).
      • Vitamin D
        • Vitamin D's function during pregnancy for both mother and fetus is not fully defined at this time and vitamin D supplementation during pregnancy remains controversial, althogh ongoing research suggests higher levels of supplementation appear to be safe and effective. The RDA for vitamin D is 600 IU (15mcg) per day (IOM 1997-2011) to meet the needs of most North American adults, including pregnant women (Procter and Campbell, 2014).
      • Choline
        • Because of its high rate of transport from mother to fetus, choline is considered an essential nutrient during pregnancy. A deficiency can interfere with normal fetal brain development (Procter and Campbell, 2014). The adequate intakes (AI) for choline is 450mg (IOM, 1997-2011). Most pregnant women do not consume the AI for choline, despite its presence in many foods (Procter and Campbell, 2014).
      • Iodine
        • Iodine is required for normal brain development and growth. Iodine requirements increase during pregnancy. Iodine deficiency is a growing concern and recent national surveys suggest a subset of pregnant women may have mild to moderately inadequate intake of iodine. The IOM recommends an iodine intake of 15mg per day before conception and 220mg per day for pregnant women (Procter and Campbell, 2014).

    • Recommendation Strength Rationale

      Consensus: This topic was not included in the EAL systematic review. The recommendations are based on consensus publications.

    • Minority Opinions

      None.

  • Supporting Evidence

    The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

    • References
    • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

      • Academy Quality Management Committee and Scope of Practice Subcommittee of Quality Management Committee. Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. J Acad Nutr Diet. 2013 Jun;113 (6 Suppl):S17-S28. doi: 10.1016/j.jand.2012.12.008. PMID: 23454020.
      • Institute of Medicine (IOM). Dietary Reference Intakes: Estimated Average Requirements, Recommended Intakes, Acceptable Macronutrient Distribution Ranges, and Tolerable Upper Intake Levels. NAS. Food and Nutrition Board. 1997-2011. Accessed November 1, 2016: https://fnic.nal.usda.gov/sites/fnic.nal.usda.gov/files/uploads/recommended_intakes_individuals.pdf
      • Kaiser LL, Campbell CG; Academy Positions Committee Workgroup. Practice paper of the Academy of Nutrition and Dietetics abstract: nutrition and lifestyle for a healthy pregnancy outcome. J Acad Nutr Diet. 2014 Sep; 114 (9): 1, 447. PMID: 25699300.
      • Marra MV, Boyar AP. Position of the American Dietetic Association: nutrient supplementation. J Am Diet Assoc. 2009 Dec; 109 (12): 2, 073-2, 085. PMID: 19957415.
      • Procter SB, Campbell CG. Position of the Academy of Nutrition and Dietetics: nutrition and lifestyle for a healthy pregnancy outcome. J Acad Nutr Diet. 2014 Jul; 114 (7): 1, 099-1, 103. PMID: 24956993.
      • Shields, L and Tsay, GS. Editors, California Diabetes and Pregnancy Program Sweet Success Guidelines for Care. Developed with California Department of Public Health; Maternal Child and Adolescent Health Division; revised edition, updated September 2015. Accessed August 9, 2016: http://www.cdappsweetsuccess.org/Portals/0/2015Guidelines/2015__CDAPPSweetSuccessGuidelinesforCare.pdf.
      • Siu AL; U.S. Preventive Services Task Force. Screening for Iron Deficiency Anemia and Iron Supplementation in Pregnant Women to Improve Maternal Health and Birth Outcomes: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2015 Oct 6;163(7): 529-36. doi: 10.7326/M15-1707. PMID: 26344176.