Recommendations Summary

GDM: Meal and Snack Distribution 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: Meal and Snack Distribution

  In women with gestational diabetes mellitus (GDM), the registered dietitian nutritionist (RDN) should distribute the total calories and carbohydrate (CHO) into smaller meals and multiple snacks per day. The distribution should be individualized, based on blood glucose levels, physical activity and medication, if any (e.g., insulin) and adjusted as needed. Three meals and two or more snacks helps to distribute CHO intake and reduce post-prandial blood glucose fluctuations. 

  Rating: Consensus
  Imperative

  • Risks/Harms of Implementing This Recommendation

    There are no risks or harms associated with the application of this recommendation.

  • Conditions of Application

    • The RDN should consider the following when individualizing the distribution of meals and snacks: Usual food intake, food preferences, pharmacotherapy, blood glucose levels (hypo- or hyperglycemia), activity level, sleep pattern, treatment goals, work schedule (e.g., shift work, night schedule), food insecurity and access, and cultural/religious beliefs and practices (e.g., fasting), etc.
    • The RDN should encourage regular and timely consumption of meals and snacks and avoid fasting beyond 10 to 12 hours (e.g., skipping the evening snack at bedtime or skipping breakfast) to promote blood glucose control (Buchanan et al, 1990; Metger et al, 1982; Mills et al, 1998)
    • Pregnant women who opt to fast beyond 12 hours, due to cultural or religious reasons (e.g., Ramadan), should be medically evaluated prior to the fasting period for intensive management, self-management instruction,  appropriate diet and insulin adjustment, if prescribed (Al-Arouj et al, 2010).

  • Potential Costs Associated with Application

    Costs may include expenses related to medical nutrition therapy (MNT) visits from an RDN,  blood glucose monitoring and associated medical follow-up.

  • Recommendation Narrative

    No evidence was found to evaluate the impact of meal and snack distribution for women with gestational diabetes mellitus (GDM). However, the following provide support for the consensus recommendation:

    • Six to eight small meals and snacks are suggested to decrease post-prandial hyperglycemia in women with GDM. The distribution of calories should be individualized and based on usual intake, preferences and medication regimen [Joslin Diabetes Center & Joslin Clinic (Joslin), 2011] 
    • Three meals and two to three snacks is suggested to distribute glucose intake and reduce fluctuations in post-prandial glucose in women with GDM [American College of Obstetricians and Gynecologists (ACOG), 2013]
    • Three meals and several snacks is recommended to prevent hypoglycemia, particularly for women with GDM who are taking glyburide or multiple insulin injections. The food distribution should be individualized to tolerance and preference (Shields and Tsay, 2015)
    • In pregnancy, decreased insulin sensitivity occurs as hormonal production increases (Shields and Tsay, 2015). Although no evidence was found to support a specific or range of CHO distribution at meals or snacks, customary practice suggests limiting the amount and type of CHOs at breakfast (Joslin, 2011). The CHO intake is reassessed at subsequent visits for possible adjustment according to the blood glucose records (Shields and Tsay, 2015). See the recommendation GDM: Macronutrients (GDM: Carbohydrate and Post Prandial Breakfast Glycemia).

  • Recommendation Strength Rationale

    Consensus: This topic was included in the EAL systematic review. However, no evidence was found to answer the research question. The recommendation is 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

    • Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for Management of Diabetes During Ramadan: Update 2010. Diabetes Care. 2010;33(8): 1, 895-1, 902. 
    • American College of Obstetricians and Gynecologists (ACOG). Committee on Practice Bulletins--Obstetrics. Practice Bulletin No. 137: Gestational diabetes mellitus. Obstet Gynecol. 2013 Aug;122 (2 Pt 1): 406-416. PMID: 23969827.
    • Buchanan TA, Metzger BE, Freinkel N. Accelerated starvation in late pregnancy: a comparison between obese women with and without gestational diabetes mellitus. Am J Obstet Gynecol. 1990 Apr;162(4): 1, 015-1, 020. PMID: 2327442.
    • Joslin Diabetes Center and Joslin Clinic Guideline for Detection and Management of Diabetes in Pregnancy. 9/10/2010: Revised 06-15-11 Accessed Aug 5, 2016: http://www.joslin.org/info/joslin-clinical-guidelines.html.
    • Metzger BE, Ravnikar V, Vileisis RA, Freinkel N. "Accelerated starvation" and the skipped breakfast in late normal pregnancy. Lancet. 1982 Mar 13;1(8272):588-592. PMID: 6121184.
    • Mills JL, Jovanovic L, Knopp R, Aarons J, Conley M, Park E, Lee YJ, Holmes L, Simpson JL, Metzger B. Physiological reduction in fasting plasma glucose concentration in the first trimester of normal pregnancy: the diabetes in early pregnancy study. Metabolism. 1998 Sep;47(9):1, 140-1, 144. PMID: 9751245.
    • 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.