GDM: Pharmacologic Therapy (2008)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
This technical review discusses research related to nutrition and diabetes.
Inclusion Criteria:

Article inclusion methods not described.

Exclusion Criteria:

Not described.

Description of Study Protocol:

Recruitment

Article selection methodology not described.  323 references used.

Design

Consensus Report.

Blinding Used (if applicable):

Not applicable.

Intervention (if applicable):

Not applicable.

Statistical Analysis:

Not applicable.

Data Collection Summary:

Timing of Measurements:

Not applicable.

Dependent Variables:

Not applicable.

Independent Variables:

Not applicable.

Control Variables:

Not applicable.

Description of Actual Data Sample:

Initial N:  323 references cited.

Attrition (Final N):  323 references 

Age:  not applicable

Ethnicity:  not applicable

Other Relevant Demographics: 

Anthropometrics:

Location:  Worldwide studies

 

Summary of Results:

Pregnancy and Diabetes:

The goals of nutrition during pregnancy are:

  1. to provide adequate maternal and fetal nutrition
  2. to assist in appropriate maternal weight gain
  3. to assist with normalization of maternal blood glucose

A favorable pregnancy outcome has been defined as a gestational duration of 39-41 wk and a live birth weight of 6.6-8.8 lb. (3-4 kg).

Prepregnancy weight as well as weight gain during pregnancy are know to influence birthweight, maternal morbidity, and perinatal mortality.

Weight gain/calorie requirements:

To promote a favorable outcome the National Academy of Sciences recommends that the total weight gain be based on prepregnancy BMI

Weight for height             

Weight Gain

Low(BMI<19.8)  18-40 lb.
Normal (BMI 19.8-26) 25-35 lb
High (BMI 26-29) 15-25 lb.
Obese (BMI >29) 15      lb.

Obese women often have significantly heavier babies independent of weight gain from 0-30 lbs.

Longitudinal studies of well-nourished pregnant women generally show a slight increase in energy intake of 70-240 kcal/d.

An additional 300 kcal are recommended during the 2nd and 3rd trimesters.

Maternal 3rd trimester ketonemia has been associated with lower IQ scores at 2-5 yr in offspring so every attempt should be made to avoid ketonemia in all pregnant women.

Gestational Diabetes

Goals for treatment of GDM are to provide adequate calories and optimal nutrition during pregnancy without hyperglycemia or ketonemia through nutrition therapy, exercise and insulin if necessary.

For obese women (BMI >30) with GDM a  30-33% kcal restriction (~1,800 kcal;/d)reduces hyperglycemia without an increase in ketones.

 Individualization of the meal plan is recommended.

Breakfast: <30 g carbohydrate and frequent small feedings throughout the day.

 Monitoring blood glucose, urine ketones, appetite, and weight gain can guide in developing an appropriate individualized meal plan and in making adjustments as necessary throughout the pregnancy.

Exercise can assist in overcoming insulin resistance and lower postprandial glucose elevations.  Appropriate exercises are those that use the upper body muscles or place little mechanical stress on leg and trunk regions during exercise.

97% of all women with GDM return to normal glycemia but have a 60% chance of developing type 2 diabetes melliltus. This prevalence rate can be reduced to 25% with maintenance of a desirable body weight after delivery.

Breast feeding should be encouraged in women with preexisting diabetes or GDM; however women with Type I diabetes mellitus may experience an increased incidence of hypoglycemia within 20-40 minutes after breast feeding.

Author Conclusion:

There are still unanswered questions regarding GDM and the meal composition/frequency for best outcomes. However, the best nutrition advice begins with a nutrition assessment, modification of lifestyle factors based on the primary problem and desired outcomes, implementing nutrition therapy principles and monitoring metabolic consequences. The goal of nutrition therapy is to provide adequate calories and optimal nutrition during pregnancy without hyperglycemia or kentonemia.

Funding Source:
Not-for-profit
0
Foundation associated with industry:
Reviewer Comments:

The recommendations for a healthy pregnancy are the same as for a women without diabetes plus self-glucose and ketone monitoring and nutrition intervention by a diabetes educator and RD.

Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? Yes
 
Validity Questions
  1. Was the question for the review clearly focused and appropriate? Yes
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? ???
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? ???
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? ???
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? ???
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? No
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? Yes
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? Yes
  10. Was bias due to the review's funding or sponsorship unlikely? Yes