Gestational Diabetes

GDM: Executive Summary of Recommendations (2008)

Executive Summary of Recommendations

Below are the major recommendations and ratings for the Academy of Nutrition and Dietetics Gestational Diabetes Mellitus (GDM) Evidence-Based Nutrition Practice Guideline. View the Guideline Overview from the Introduction tab.. More detail (including the evidence analysis supporting these recommendations) is available on this website to Academy members and EAL subscribers under Major Recommendations.

To see a description of the Academy Recommendation Rating Scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence), click here.

The GDM Recommendations are listed below. [Note: If you mouseover underlined acronyms and terms, a definition will pop-up.]

Executive Summary of Recommendations

• Screening and Referral
  GDM: Risk Assessment and Screening for Gestational Diabetes Mellitus

  All pregnant women should be assessed for risk of gestational diabetes mellitus (GDM) at the first prenatal visit.  Depending on level of risk, timing of screening for gestational diabetes mellitus (GDM) and/or impaired glucose tolerance (IGT) will differ.  Most women are screened between 24 - 28 weeks of gestation.  Research indicates the similarities between gestational diabetes mellitus (GDM) and impaired glucose tolerance (IGT), and both are associated with increased risks of poor maternal/neonatal outcomes if left untreated.     

  Strong

  Imperative
  GDM: Pregnant Women At Risk for GDM

  For pregnant women at average or high risk for gestational diabetes mellitus (GDM), the RD should monitor weight gain, nutritional intake and physical activity.  Research indicates that obesity, excessive weight gain prior to pregnancy and increased saturated fat intake are associated with the development of glucose abnormalities in pregnancy and increased risk of gestational diabetes.  In addition, regular physical activity during pregnancy reduces the risk of gestational diabetes mellitus (GDM).

  Weak

  Conditional
  GDM: MNT for Women with GDM

  The Registered Dietitian (RD) should initiate Medical Nutrition Therapy (MNT) within one week after diagnosis of gestational diabetes mellitus (GDM), and include a minimum of three nutrition visits.  Research indicates that MNT results in improved maternal and neonatal outcomes, especially when diagnosed and treated early.    

  Strong

  Imperative
  GDM: MNT for Pregnant Women with IGT

  For women with impaired glucose tolerance (IGT) during pregnancy, the Registered Dietitian (RD) should initiate the same recommendations of Medical Nutrition Therapy (MNT) as those for gestational diabetes mellitus (GDM).  Research indicates that impaired glucose tolerance (IGT) and gestational diabetes mellitus (GDM) carry similar risks of adverse outcomes.

  Strong

  Imperative
• Nutrition Assessment
  GDM: Assess Food Intake, Physical Activity and Medications

  The Registered Dietitian (RD) should assess food intake, physical activity and medications of pregnant women, including those with gestational diabetes mellitus (GDM).  Evaluation of a pregnant woman's dietary pattern, augmented by questions about medications, special concerns, conditions, and/or food preferences that might affect her nutritional adequacy or needs, provides the basis for Medical Nutrition Therapy (MNT).

  Consensus

  Imperative
  GDM: Assessment of BMI and Weight Gain

  The Registered Dietitian (RD) should assess body mass index (based on actual or estimated prepregnancy weight) as a baseline to determine recommended weight gain in pregnant women, including those with gestational diabetes mellitus (GDM).  Body mass index (BMI) is a better indicator of maternal nutritional status than is weight alone.   

  Consensus

  Imperative
• Nutrition Intervention
  GDM: Caloric Intake for Normal and Underweight Women

  The Registered Dietitian (RD) should encourage normal and underweight pregnant women, including those with gestational diabetes mellitus (GDM), to consume adequate calories to promote appropriate weight gain, with guidance from the Dietary Reference Intakes (DRI) for pregnant women.  Research indicates that low or inadequate weight gain during pregnancy is associated with an increased risk of preterm delivery, regardless of prepregnancy BMI levels.

  Fair

  Conditional
  GDM: Caloric Intake for Overweight/Obese Women with GDM

  Since weight loss in pregnancy is not recommended, the Registered Dietitian (RD) should encourage a modest energy restriction to slow weight gain in women with gestational diabetes mellitus (GDM) who are also overweight/obese.  Caloric restriction [~70% of the Dietary Reference Intakes (DRI) for pregnant women] results in considerable slowing of maternal weight gain in obese women with gestational diabetes mellitus (GDM), without causing maternal or fetal compromise and/or ketonuria.

  Fair

  Conditional
  GDM: Carbohydrate Intake

  The Registered Dietitian (RD) should encourage pregnant women, including those with gestational diabetes mellitus (GDM), to consume a minimum of 175 grams of carbohydrate per day based on the Dietary Reference Intake (DRI) for pregnant women for provision of glucose to the fetal brain and to prevent ketosis.  Total carbohydrate intake should be less than 45% of energy to prevent hyperglycemia in women with GDM.  Carbohydrate intake affects postprandial blood glucose levels; increased postprandial blood glucose levels are associated with increased incidence of large-for-gestational age infants and increased rate of Cesarean sections.  Research is limited regarding fiber intake and glycemic index in women with gestational diabetes mellitus (GDM).

  Fair

  Imperative
  GDM: Protein and Fat Intake

  The Registered Dietitian (RD) should encourage pregnant women, including those with gestational diabetes mellitus (GDM), to consume adequate protein and fat based on the Dietary Reference Intakes (DRI) for pregnant women.  Research is limited regarding protein and fat intake in women with gestational diabetes mellitus (GDM).

  Fair

  Imperative
  GDM: Vitamin and Mineral Supplementation

  If usual dietary intake does not meet the Dietary Reference Intakes (DRI) for pregnant women, including those with gestational diabetes mellitus (GDM), the Registered Dietitian (RD) should encourage vitamin and mineral supplementation to prevent nutritional deficiencies.

  Consensus

  Conditional
  GDM: Physical Activity

  Unless contraindicated, the Registered Dietitian (RD) should encourage pregnant women, including those with gestational diabetes mellitus (GDM), to participate in physical activity for 30 minutes per day for a minimum of three times per week.  Research indicates that regular physical activity during pregnancy reduces the common discomforts of pregnancy without a negative effect on maternal or neonatal outcomes, and improves glycemic control in those with gestational diabetes mellitus (GDM). 

  Fair

  Conditional
  GDM: Blood Glucose Monitoring

  The Registered Dietitian (RD) should advise women with gestational diabetes mellitus (GDM) to monitor their blood glucose, including fasting and postprandial levels.  Several studies report a correlation between elevated fasting and postprandial blood glucose values with poor maternal and neonatal outcomes.

  Fair

  Imperative
  GDM: Use of Non-Nutritive Sweeteners

  If pregnant women, including those with gestational diabetes mellitus (GDM), choose to consume products containing non-nutritive sweeteners, the Registered Dietitian (RD) should inform them that only FDA-approved non-nutritive sweeteners should be consumed and that moderation is encouraged.  Research in this area is extremely limited.    

  Consensus

  Conditional
  GDM: Promotion of Breastfeeding

  Unless contraindicated, the Registered Dietitian (RD) should encourage breastfeeding in pregnant women, including those with gestational diabetes mellitus (GDM).   Research indicates that even short duration of breastfeeding results in long-term improvements in glucose metabolism and may also reduce the risk of type 2 diabetes in children. 

  Fair

  Conditional
  GDM: Alcohol Consumption

  The Registered Dietitian (RD) should advise pregnant women, including those with gestational diabetes mellitus (GDM), to avoid the consumption of alcohol, including alcohol used in cooking.  No amount of alcohol consumption can be considered safe during pregnancy.  Alcohol use during pregnancy increases the risk of alcohol-related birth defects, including growth deficiencies, facial abnormalities, central nervous system impairment, behavioral disorders, and impaired intellectual development. 

  Consensus

  Imperative
  GDM: Pharmacological Therapy for Treatment of GDM

  When optimal blood glucose levels have not been maintained with medical nutrition therapy (MNT) and/or the rate of fetal growth is excessive, the Registered Dietitian (RD) should recommend the initiation of pharmacological therapy for treatment of women with gestational diabetes mellitus (GDM).  Research indicates that pharmacological therapy, such as the use of insulin, insulin analogs and glyburide, improves glycemic control and reduces the incidence of poor maternal and neonatal outcomes.

  Strong

  Conditional
  GDM: Ketone Testing

  The Registered Dietitian (RD) should recommend ketone testing for women with gestational diabetes melltius (GDM) who have insufficient calorie and/or carbohydrate intake and/or weight loss.  Two of three studies regarding ketonemia and ketonuria with poor metabolic control during a diabetic pregnancy report a positive association with lower IQ in offspring.

  Fair

  Conditional
• Nutrition Monitoring and Evaluation
  GDM: Monitor and Evaluate MNT Effectiveness

  The Registered Dietitian (RD) should monitor and evaluate blood glucose levels, weight change, food intake, physical activity and pharmacological therapy (if indicated) in women with gestational diabetes mellitus (GDM) at each visit.   Research indicates that Medical Nutrition Therapy (MNT) results in improved maternal and neonatal outcomes.

  Strong

  Imperative
• Outcomes Management
  GDM: Weight Loss After Delivery

  For women with gestational diabetes mellitus (GDM) who are overweight/obese or with above recommended weight gain during pregnancy, the Registered Dietitian (RD) should advise weight loss after delivery which includes a combination of diet modification and physical activity. Research indicates that the risks of recurrent gestational diabetes (GDM) or development of type 2 diabetes can be reduced with weight loss.

  Strong

  Conditional