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Recommendations Summary

GDM: Medical Nutrition Therapy 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: Medical Nutrition Therapy (MNT)

    The registered dietitian nutritionist (RDN) should provide medical nutrition therapy (MNT) that includes an individual nutrition prescription and nutrition counseling for all women diagnosed with gestational diabetes mellitus (GDM). Research indicates that MNT provided by an RDN (or international equivalent) as part of a comprehensive nutrition intervention that includes individualization of MNT is effective in improving blood glucose control and neonatal and maternal outcomes in women with GDM. Improved outcomes included lower birth weight and a reduction in the following: Incidence of macrosomia (LGA),  need for insulin therapy, hypertensive disorders of pregnancy and maternal hospitalizations, neonatal intensive care unit (NICU) admissions and neonatal deaths, premature births and rate of shoulder dystocia, bone fracture and nerve palsy. 

    Rating: Strong
    Imperative

    GDM: Frequency and Duration of MNT

    The RDN should provide regular and frequent MNT visits to women with GDM to optimize outcomes. Visits should include an initial 60 to 90 minute MNT visit, followed by a second MNT visit (30 to 45 minutes) within one week, and a third MNT visit (15 to 45 minutes) within two to three weeks. Additional MNT visits should be scheduled every two to three weeks or as needed for the duration of the pregnancy. MNT assists the woman with GDM in meeting her blood glucose and weight gain targets, contribute to a well-balanced food intake and promote fetal and maternal well-being.

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

      There are no potential risks or harms associated with the application of these recommendations.

    • Conditions of Application

      For the recommendation GDM: Frequency and Duration of MNT,  barriers to attendance may include financial constraints,  scheduling conflicts,  inability to take time off work or school, lack of child care and lack of transportation. 

    • Potential Costs Associated with Application

      Costs of MNT sessions and reimbursement vary. However, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      GDM: MNT

      A total of five studies were included in the evidence supporting the recommendation:

      • Two positive quality randomized controlled trials (RCTs) (Landon et al, 2009; Reader et al, 2006)
      • One neutral quality RCT (Crowther et al, 2005)
      • One neutral quality prospective cohort study (Maher et al, 2013)
      • One neutral quality non-randomized controlled trial (Perichart-Perera et al, 2009).
      Evidence Summary
      • Five studies evaluated the effectiveness of MNT intervention, provided by an RDN (or international equivalent) (specifically, dietitian, registered dietitian or nutritionist) on GDM-related outcomes. Four studies (three RCTs, one non-randomized controlled trial) compared MNT intervention to standard or usual care in women with GDM. One prospective cohort study (Maher et al, 2013) evaluated early MNT during the subjects' first trimester (mean, 10.2 weeks gestation), as part of multi-disciplinary intervention in women with a history of insulin-requiring GDM. All studies found that the MNT intervention improved fetal/neonatal and maternal outcomes in women with GDM (Crowther et al, 2005; Landon et al 2009; Perichart-Perrera et al, 2009; Reader et al; 2006) or with women with a history of insulin-requiring GDM (Maher et al, 2013).  
      • The studies described MNT, provided by dietitians in a number of ways, including nutrition education or counseling (with nutrition assessment), diet therapy and dietary advice. All studies included individualization of MNT as part of a comprehensive intervention that included at least two of the following: education on diabetes, instructions in self-monitoring of blood glucose (SMBG),  regular follow up and monitoring with the physician, blood glucose (BG) monitoring and lifestyle (e.g., physical activity) counseling and advice. Insulin therapy was initiated, as required. Although the studies did not describe the actual number of MNT encounters during the intervention, all studies reported more than one MNT visit and one study (Reader et al, 2006) described a minimum of three MNT visits in the intervention. No studies described the frequency of MNT visits.
      • MNT, as part of a comprehensive intervention improved blood glucose control (Perichart-Perrera et al, 2009; Reader et al, 2006) and improved the following adverse outcomes:
        • Maternal outcomes: 
          • Fewer hypertensive disorders of pregnancy and pre-eclampsia (Landon et al, 2009; Perichart-Perrera et al, 2009)
          • Fewer maternal hospitalizations (Perichart-Perrera et al, 2009)
          • Fewer premature births (Perichart-Perrera et al, 2009)
          • Reduced need for insulin therapy (Reader et al, 2006).
          • Fewer caesarian deliveries (Landon et al, 2009)
        • Neonatal outcomes: 
          • Fewer neonatal deaths (Crowther et al, 2005; Perichart-Perrera et al, 2009)
          • Fewer NICU admissions (Perichart-Perrera et al, 2009)
          • Lower birth weight (Crowther et al, 2005; Perichart-Perrera et al, 2009) and reduced neonatal fat mass (Landon et al, 2009)
          • Fewer LGA (Crowther et al, 2005; Landon et al, 2009) and lower prevalence of macrosomia (Crowther et al, 2005; Landon et al, 2009; Maher et al, 2013; Perichart-Perrera et al, 2009)
          • Reduced rate of shoulder dystocia (Landon et al, 2009; Crowther et al, 2005),  bone fracture, and nerve palsy (Crowther et al, 2005).
      • Studies included: Crowther et al, 2005; Landon et al, 2009; Maher et al, 2013; Perichart-Perera et al, 2009; Reader et al, 2006.
      GDM: Frequency and Duration of MNT 
      • No evidence was identified to evaluate the optimal frequency and duration of MNT visits by an RDN (or international equivalent) to improve fetal and maternal outcomes. However, the following guidance from Joslin Diabetes Center & Joslin Clinic (2011) provides support for the recommendation:
        • A minimum of three encounters with a Certified Diabetes Educator (CDE) (RDN, RN) for assessment and meal plan modification (and SMBG instruction, if RDN is adequately trained) are recommended as follows.
          • Visit One (60 to 90 minutes) individual or group visit
          • Visit Two (30 to 45 minutes) one week after initial visit 
          • Visit Three (15 to 45 minutes) in one to three weeks. 
          • Additional visits every two to three weeks and as needed until delivery.

    • Recommendation Strength Rationale

      • Conclusion statement supporting the recommendation GDM: MNT is Grade II
      • Consensus: The recommendation GDM: Frequency and Duration of MNT is based on consensus publications. This topic was included in the EAL systematic review. However, no evidence was found to answer the research question. 

    • Minority Opinions

      None.