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Recommendations Summary

GDM: Calories 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: Calorie Prescription

    For women with gestational diabetes mellitus (GDM), the registered dietitian nutritionist (RDN) should individualize the calorie prescription based on a thorough nutrition assessment with guidance from relevant references [Dietary Reference Intakes (DRI), Institute of Medicine (IOM)] and encourage adequate caloric intake to promote fetal/neonatal and maternal health, achieve glycemic goals, and promote appropriate gestational weight gain (GWG). No definitive research suggests there is a specific optimal calorie intake for women with GDM or if calorie needs are different than pregnant women without GDM. Limited research in women with GDM whose pre-pregnancy weights ranged from normal to obese showed no significant differences in most fetal/neonatal and maternal outcomes with various reported calorie intakes. In a study of obese women only, GWG slowed after women with GDM reportedly consumed 30% below their caloric requirements, without adverse effects. 

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

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

    • Conditions of Application

      • Refer to the GDM: Nutrition Assessment and GDM: Nutrition Monitoring & Evaluation recommendations for factors to consider in determining and adjusting an individualized calorie prescription, such as pre-pregnancy weight and BMI, total and rate of GWG (IOM, 2009), single vs. multiple fetuses,  physical activity level, etc.
      • Individual caloric requirements during pregnancy vary among women and are dependent on several factors, including pre-pregnancy BMI and fat mass, and changes in physical activity (Ho et al, 2005).

    • Potential Costs Associated with Application

      Costs may include expenses related to medical nutrition therapy (MNT) visits from an RDN and higher food costs, if a caloric increase is needed (e.g., types and amounts of food).

       

    • Recommendation Narrative

      GDM: Calorie Prescription

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

      • One positive quality prospective cohort study (Ho et al, 2005)
      • One positive quality randomized controlled trial (RCT) (Rae et al, 2000)
      • One neutral quality prospective cohort study (Romon et al, 2001).
      Evidence Summary
      • Three international studies evaluated the impact of calorie intake on fetal/neonatal and maternal outcomes (glycemic control, maternal weight gain, fetal growth/birth weight and adverse outcomes), in women with GDM.
        • One positive quality prospective cohort study by Ho et al, 2005, evaluated a caloric prescription of 30kcal/kg body weight (BW) in 62 women with a non-obese pre-pregnancy weight (BMI range: 22.4±3.2 to 23.1±4.2kg/m2).
          • Caloric intake of the women was categorized into three tertiles (calculated kcal/kg values): 1, 863kcals; 33kcal/kg BW (highest tertile), 1, 692kcals; 30.4 kcal/kg BW (middle tertile) and 1, 384kcals; 25 kcal/kg BW (lowest tertile), noting the women had a tendency to over-restrict their calorie intake.
          • Women in the highest tertile had significantly higher post-dinner glucose concentration after controlling for pre-pregnancy weight and height. Total GWG was 20.2±7.9, 22±8.36, 22±9.5 pounds, respectively. 
          • There was no significant (NS) difference between caloric intake tertiles and either maternal GWG or neonatal outcomes [gestational age (GA), birth weight, crown heel length (CHL), Apgar scores at the first and fifth minute, incidence of large-for-gestational-age (LGA) or small-for-gestational-age (SGA) and placental weight].
          • There was NS correlation between the incidence of LGA and SGA infants and caloric intake. 
        • One neutral quality prospective cohort study by Romon et al, 2001,  evaluated a minimum caloric prescription of 1, 800kcals in 80 women with a pre-pregnancy BMI of 25.2±5.2kg/m2 (62%) and >36kg/m2 (38%).
          • Romon et al, 2001 found mild ketonuria was present in 45% of the women during week 1, but decreased to 16% in women who consumed an average of 1, 842±343kcals/day*.
          • No relationship between calorie intake and infant birth weight was found. 
        • One positive quality RCT by Rae et al, 2000, evaluated the effect of a 30% reduction in calorie intake (1, 590-1, 776kcal/day) vs. no calorie restriction (2, 010-2, 200kcal/day) in 117 women with an obese pre-pregnancy weight (BMI 37.9±0.7 and 38.0±0.7kg/m2 for the intervention and control, respectively). 
          • Rae et al, 2000,  found that the women consumed roughly the same caloric intake (~70% of the RDI for Australia) * [1, 560kcal intervention vs. 1, 630kcal control; NS], despite no prescriptive calorie restriction in the control group.
          • The mean rate of GWG slowed once dietary intervention started and 54.1% of the intervention vs. 40.7%of the control groups failed to gain or lost weight (NS). Women in both groups lost 1.68kg [SE 0.33, range 7.5-0.00 and SE 0.32, range 5.0-0.00 intervention vs. control, respectively]
          • Total GWG was 25.4 pounds in the intervention and 21.3 pounds in the control group (NS). 
          • There were no differences between the groups in maternal outcomes (anemia, pre-existing hypertension, pre-eclampsia,  premature rupture of membranes (PROM),  threatened preterm labor, percent requiring insulin, ketonuria (34.5 vs. 38.5% nondetectable ketones),  serum beta-hydroxybuterate, BG control,  HbA1c,  GWG) or neonatal outcomes (rates of delivery mode, labor induction, fetal distress birth trauma,  GA and incidence of macrosomia).
          • Intervention group infants had greater average abdominal skinfold thickness, but mean total skinfold measurements were similar between the two groups.
          • Control group infants had greater incidences of polycythemia and shoulder dystocia. 
        • More research is needed to elucidate the effect of caloric consumption (kcals/kg pre-pregnancy BW), independent of other factors, on fetal/neonatal and maternal outcomes. 
      *The kcal intake per kg of body weight for the Romon et al, 2001, and Rae et al, 2000, studies could not be calculated for the groups.

    • Recommendation Strength Rationale

      • Conclusion statement supporting GDM: Calorie Prescription is Grade III.
      • Results of the studies were confounded by use of reported vs. actual caloric intakes (possible underreporting), tendency of the women to over-restrict caloric intake vs. prescribed, inconsistent stratification by pre-pregnancy BMI, and pre-pregnancy weights not described, making comparison and synthesis of the research challenging. 

       

    • Minority Opinions

      None.