|Year : 2021 | Volume
| Issue : 5 | Page : 52-58
Management of gestational diabetes mellitus with medical nutrition therapy: A comprehensive review
Sheryl Salis1, Natasha Vora1, Shefa Syed1, Uma Ram2, Viswanathan Mohan3
1 Nurture Health Solutions, Mumbai, Maharashtra, India
2 Seethapathy Clinic and Hospital, Chennai, Tamil Nadu, India
3 Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
|Date of Submission||09-Apr-2021|
|Date of Decision||19-Apr-2021|
|Date of Acceptance||03-May-2021|
|Date of Web Publication||20-Jul-2021|
Ms. Sheryl Salis
504, Navsmruti, Kalina, Mumbai 400098, Maharashtra.
Source of Support: None, Conflict of Interest: None
Gestational diabetes mellitus (GDM) also referred to as hyperglycemia during pregnancy is posing to be a big health concern for women and is emerging as a major public health problem in India. Early diagnosis and tight glycemic control during pregnancy play a pivotal role in improving pregnancy outcomes in women with GDM. Once diagnosis is made, lifestyle behavioral changes with medical nutrition therapy (MNT) and physical activity form the first choice of therapy for the management of GDM. Failure to meet glycemic goals with these requires the addition of medication/insulin. Regular blood glucose monitoring and record keeping must be encouraged to improve adherence and review treatment efficacy. MNT for GDM is defined as a “carbohydrate-controlled” meal plan that provides adequate nutrition along with appropriate weight gain and fetal well-being to meet increased requirements of energy, protein, and micronutrients, achieve normoglycemia, and prevent nutritional ketosis. Choosing nutrient-dense carbohydrate sources which are low to moderate in glycemic index and glycemic load with focus on the correct amount and distribution of carbohydrates at meals helps control postprandial glucose excursions which is the biggest challenge in GDM. Blood glucose levels can be difficult to control in the morning due to increased insulin resistance secondary to dawn phenomenon seen in women with GDM. Splitting meals at breakfast has shown to improve post-breakfast blood glucose levels. This article is a comprehensive review of guidelines and scientific literature for the dietary management of GDM aimed at achieving normoglycemia, ensuring fetal and maternal wellbeing, and preventing adverse outcomes in pregnancy. The literature has been retrieved from various databases such as “Google Scholar,” “PubMed,” and “Cochrane Database of Systematic Reviews” using relevant keywords related to the topics discussed in this manuscript.
Keywords: Fetal growth and development, gestational diabetes, glucose monitoring, medical nutrition therapy, postpartum, pregnancy outcomes
|How to cite this article:|
Salis S, Vora N, Syed S, Ram U, Mohan V. Management of gestational diabetes mellitus with medical nutrition therapy: A comprehensive review. J Diabetol 2021;12, Suppl S1:52-8
| Introduction|| |
Gestational diabetes mellitus (GDM) also referred to as hyperglycemia in pregnancy (HIP) is defined as “glucose intolerance with onset or first recognition during pregnancy.”
The International Diabetes Federation (IDF) Atlas More Details, ninth edition, 2019, revealed an alarming increase in the global prevalence of HIP with women having some form of it, of which GDM amounted to 83.6%.
There is an exceptionally high estimated prevalence of GDM in India, and it is emerging as a major public health problem. The prevalence of GDM in different parts of India varies from 3.8% to 17.9% which is much higher than the west.
The Women in India with GDM Strategy (WINGS) project of the IDF study carried out in the city of Chennai and rural antenatal clinics in Tamil Nadu in southern India between January 2013 and December 2014 showed that there were no urban–rural differences, suggesting that GDM prevalence rate in the rural areas in South India is also rising. Thus, it is recommended that all women be screened for GDM even if they do not show symptoms. Emphasis must be on increasing awareness and taking steps to prevent GDM.,
| Glycemic Goals|| |
Management of blood glucose levels plays a pivotal role in reducing the risk of complications that may occur during pregnancy. The aim should be to target the infant’s birth weight appropriate for gestational age to prevent the offspring developing non-communicable diseases in the future. Early diagnosis and stringent maternal blood glucose control during pregnancy similar to glycemic level in a normal pregnancy are therefore necessary to reduce risk of adverse pregnancy outcomes. Glycemic goals are HbA1c ≤6% achieved without significant hypoglycemia, fasting plasma glucose ≤90 mg/dL (5.0 mmol/dL), 1-h postprandial glucose ≤140 mg/dL (7.8 mmol/dL), and 2-h postprandial plasma glucose ≤120 mg/dL (6.7 mmol/dL). Women with GDM must monitor their blood glucose levels at least four times each day: fasting and either 1 or 2 h after each meal.,,
Continuous glucose monitoring (CGM) when used in addition to self-monitoring of blood glucose (SMBG) can help achieve HbA1c targets in pregnancy associated with diabetes. Recent data suggest that even more stringent targets may be necessary to improve outcomes in women with GDM. The goal in pregnancy is to safely increase time in range as quickly as possible, while reducing glycemic variability and time above range [Figure 1]. However, as shown in [Table 1], evidence is lacking on CGM targets and percentages of time spent in range for women with GDM.
| Medical Nutrition Therapy (MNT) in GDM|| |
According to American Diabetes Association (ADA) 2021 guidelines, lifestyle behavioral change is an essential component in the management of GDM.
All national and international guidelines suggest MNT, together with weight management and physical activity (PA), as the initial mainstay for the management of GDM.,
An overview of Cochrane systematic reviews elucidated that lifestyle changes (MNT, PA) and SMBG were the only interventions that showed positive health outcomes for women and their offspring.
Counseling by a qualified dietitian familiar with the management of GDM must be done to initiate MNT once diagnosis of GDM is confirmed. PA of 30 min a day is recommended.,, Evidence has shown that lifestyle modification alone is sufficient to control blood glucose in 70–85% of the women who are diagnosed with GDM. Failure to meet glycemic goals with appropriate MNT and PA requires the addition of medication/insulin.,
The WINGS Model of Care (MOC) has shown that following a structured program with focussed counseling and regular follow-up helps achieve good pregnancy outcomes in women with GDM. The management protocol includes MNT to be followed for 2 weeks after diagnosis with GDM, following which screening for fasting blood glucose (FBG) and postprandial blood glucose (PPBG) testing is done. If FBG is <5.5 mmol/L (<90 mg/dL) or 1-h PPBG <7.7 mmol/L (<140 mg/dL) or 2-h PPBG <6.6 mmol/L (<120 mg/dL) in the follow-up visit, then MNT can be continued. If blood glucose levels are not in the desired range after 2 weeks, then insulin is indicated.
MNT for GDM is defined as a “carbohydrate-controlled” meal plan which provides adequate nutrition with appropriate weight gain and fetal well-being, keeping cultural preferences in mind to achieve normoglycemia and prevent nutritional ketosis.,,,
Monitoring weight changes is important to ensure adequacy of MNT and to gain weight within the recommended limits as shown in [Table 2].
For twin pregnancy, a gestational weight gain of 16.8–24.5 kg for women of normal weight, 14.1–22.7 kg for overweight women, and 11.3–19.1 kg for obese women is recommended by the Institute of Medicine (IOM).
Interventions need to begin in the first trimester for women at high risk for excessive weight gain.
| Energy Recommendations|| |
MNT should allow sufficient calories for optimum growth and development of the fetus, while avoiding postprandial hyperglycemia and excessive weight gain in the mother. The energy requirement depends on factors such as preconception weight, stage of pregnancy, PA levels, and blood glucose levels.
As per the ICMR-National Institute of Nutrition (ICMR-NIN) 2020 guidelines, there should be no increase in calorie intake in the first trimester and an average recommendation of an additional 350 kcal/day through the second and third trimesters. Pre-pregnancy BMI adjustment calorie requirements during pregnancy are detailed in [Table 3].
|Table 3: Prepregnancy BMI adjustment calorie requirements during pregnancy|
Click here to view
Restricting calories has been a strategy for controlling weight gain in obese women, or women who have already achieved the recommended weight gain to control glucose levels and avoid macrosomia in babies of women with GDM. A modest calorie restriction of 30–33% or between 1600 and 1800 kcal/day may be advisable to help control weight gain and glucose levels in obese women without leading to ketosis.,
Calorie restriction of <1500 calories/day or 50% restriction is not recommended as it may increase the chances of ketosis. Ketosis has been associated with lower mental or motor function in the offspring and hence should be avoided.
For twin pregnancy, an increased energy intake with an average of 700 kcal/day in the second and third trimesters in comparison to the first trimester is necessary to support rise in energy expenditure and gestational weight gain of twin pregnancy. Luke et al.,, suggested 20% of energy intake derived from protein, 40% from low glycemic index (GI) carbohydrates, and 40% from fat. Adequate protein intake is emphasized as essential to normal fetal growth in twin gestations.
| Carbohydrate Recommendations|| |
Since the biggest challenge in GDM is management of high PPBG levels, carbohydrates become a vital macronutrient as they have the greatest impact on post-meal blood glucose levels. Post-meal blood glucose concentrations are directly dependent on the amount, type, digestion, and absorption of the carbohydrate content of the meal or snack.,
The quantity and distribution of carbohydrates will vary depending on the caloric requirement, glycemic targets, and pre-meal blood glucose levels. The ICMR NIN 2020 guidelines suggest that the estimated average requirements (EARs) for carbohydrate for pregnant women should be 135 g/day plus the additional requirement of 35 g/day for the fetus during the last trimester. The recommended dietary allowance (RDA) for carbohydrate for pregnant women is set at a minimum of 175 g/day for appropriate fetal growth and cerebral development and function.,,
Most guidelines recommend carbohydrate intake of 33–45% of the total energy. This should be distributed over three main meals and 2–4 snacks/day. This will help suppress hunger pangs, control postprandial glucose excursions, and improve pregnancy outcomes in GDM.,,,,,,,
Nutrient-dense carbohydrate sources which are low to moderate in GI and glycemic load (GL) such as non-starchy vegetables, whole fruits, dairy products, whole pulses and sprouts, whole grain cereals such as barley, rolled/steel cut oats, millets should be preferred over high GI and GL foods such as polished rice, bread, refined flour and its products, cornflakes, potato, sugar, fruit juices, etc.,,,,,,,
Several studies have shown that including fiber in the diet aids in improving satiety, stabilizing blood glucose levels, and preventing constipation which is commonly observed in pregnancy. Most guidelines recommend fiber intake of 25–40 g/day.,,,,
The WINGS-MOC project, which was one of the first studies to show the beneficial effect of a low-cost, well-structured dietary intervention on neonatal outcomes, showed that women with a higher healthy “dietary score” derived from higher intake of whole grains, dairy, and dietary fiber had beneficial effects on neonatal outcomes in women with GDM. This type of dietary intervention therefore has a huge potential in public health applications in low-resource settings.
| Splitting Meals at breakfast|| |
Blood glucose levels can be difficult to control in the morning due to increased insulin resistance secondary to dawn phenomenon seen in women with GDM. As the pregnancy progresses, insulin resistance increases. Refined cereals and breads may lead to rise in blood glucose levels and hence may not be a good option for breakfast. A decreased carbohydrate load, high protein breakfast is recommended to prevent undue spikes in post-breakfast blood glucose levels. An egg/paneer whole wheat wrap or a pesarrattu/dal dosa (adai)/chilla are an ideal choice at breakfast.
Studies have shown that distribution of carbohydrates especially at breakfast helps to improve post-meal excursions. The suggested recommendation is 10–20% carbohydrates of total calories at breakfast divided into two meals and taken 2 h apart, 30% carbohydrates of total calories at lunch, 30% carbohydrates of total calories at dinner with two small meals comprising 10% carbohydrates of total calories at each meal. Eating in portioned amounts at timely intervals makes the carbohydrates easier for the body to process, thus requiring lesser insulin. A bedtime high-protein snack may be recommended to prevent accelerated ketosis overnight.,,,
| Meal Planning for Women with GDM on Insulin Therapy|| |
If post-meal blood glucose levels continue to rise, then bolus insulin (rapid-acting or regular insulin) should be started before that meal. If both fasting and postprandial glucose levels are elevated, multiple daily injection insulin therapy which is bolus insulin at mealtimes and basal insulin once or twice a day needs to be started.
Indian data on insulin therapy in women with pregestational type 2 diabetes mellitus revealed that insulin requirement was highest at dinner time which was further co-related significantly with higher calorie intake at dinner versus breakfast and lunch.
Women with GDM should be trained in carbohydrate counting, hypoglycemia management, and advised to keep a record of food intake, activity, and insulin dosage.,
| Protein Recommendations|| |
During pregnancy, protein requirement increases due to its role in the synthesis of placental, maternal, and fetal tissues.
Most guidelines suggest that protein intake should be 20% of the total calories. Protein intake with every meal is recommended as it flattens the glycemic response of food helping control postprandial glucose spikes.,,,,, As per the ICMR-NIN 2020 guidelines, the suggested EAR for protein for pregnant women is an additional protein of 7.6 g/day in the second trimester and 17.6 g/day in the third trimester. The RDA for protein for pregnant women is an additional 9.5 g protein/day in the second trimester and 22 g protein/day in the third trimester.
On an average, 1.1 g protein/kg ideal body weight is needed which is 60–70 g of protein/day. Protein sources such as curd/yogurt, paneer, egg, pulses, sprouts, soybean, nuts, lean-meat (fish and chicken breast), etc. are recommended. Whole pulses provide both protein and fiber, thus blunting the post-meal blood glucose spikes. Change in the pulse: cereal ratio from 1:7 in the standard diet to about 1:5 and 1:3 in the 2nd and 3rd trimesters, respectively, helps improve the protein quality.,, The recipes of traditional Indian foods can be modified to increase the fiber and protein content of the meal and lower the GI, e.g., adding a pulse flour to the chapatti flour can help improve the protein and fiber content while reducing the GI of the chapati.
Studies have shown that a meal with low GI not only lowers the postprandial glycemic response after the first meal but also lowers the glycemic response after a standardized second meal. Hence, adding a low GI, low carbohydrate protein source like egg, nuts, curd, yogurt, paneer in the morning at breakfast may help in reducing post-meal glucose spikes and improve satiety.
Studies have shown that if protein and fiber are consumed first followed by carbohydrates or starch, the post-meal blood glucose spikes are lower. For example, if you have chicken, fish, paneer, or dal with vegetables first followed by rice or chapatti, the post-meal blood glucose level spike is blunted.,
| Fat Recommendations|| |
Most guidelines suggest that the fat intake should be 35–40% of the total calories.,,,,, As per the ICMR-NIN 2020 guidelines, the minimum level of total fat should be 20% of energy, of which 30 g can be visible fat. It is recommended to increase proportion of polyunsaturated fats including n-3 and monounsaturated fats (MUFA), limit proportion of saturated fats (SFA), and avoid trans fats. It is recommended to choose lean meat and low fat dairy products to limit SFA consumption. Bakery products, margarine, vanaspati/dalda, ready-to-eat foods, deep fried foods, high fat sweets, and takeaway foods should be avoided as they are sources of trans fat.
Co-relation between low levels of n-3 and n-6 during pregnancy and preterm birth or fetal growth retardation have been observed. The recommendations by IOM are 5–10 E% n-6 and 0.6–1.2 E% n-3 with a minimum of 13 g/day of n-6 fatty acids. Emphasis should be on ensuring sufficient intake of n-3 fatty acids with a minimum of 1.4 g/day and up to 2.7 g/day. About 200 mg/day of DHA is recommended for optimal adult health, fetal, and infant development and to prevent preeclampsia.,
Walnuts, chia seeds, and fish are good sources of omega 3 fatty acids. A minimum intake of 350 g of fish/week is recommended of which 200 g should be fatty fish. Low mercury fishes such as Indian salmon, anchovy, catfish, pomphret, etc. can be consumed.
Nuts while being low in carbohydrates are a good source of MUFA, protein, fiber, and antioxidants. Studies have shown that when a snack containing carbohydrate and SFA are replaced with raw unsalted nuts, it helps improve glycemic control in individuals with T2DM. This may also hold true in women with GDM.,
| Sugar Substitutes|| |
The use of sugar substitutes during pregnancy has increased in the recent decades with approximately 30% of the pregnant women reporting intentional sugar substitute consumption.
Sucralose and stevia are safest for consumption in pregnant women. There is limited research on the safety of acesulfame-K and polyols during pregnancy. Saccharin is not recommended for pregnant women as placenta concentrates saccharin avidly. Aspartame must be restricted in pregnant women with hyperphenylalaninemia.
In the recent times, there are growing concerns that sugar substitutes cause gut dysbiosis. While there is some evidence, further studies are needed to elucidate the potential impact of sugar substitutes on intestinal microbiota.,
Since data concerning the use of sugar substitutes during pregnancy are limited, caution must be exercised for their use well within the recommended acceptable daily intake standards.
| Probiotics|| |
Studies have shown that the use of probiotics is associated with improved lipid and glucose metabolism in pregnant women and could reduce the risk of GDM. A meta-analysis showed that probiotic supplementation reduced fasting serum insulin levels and insulin resistance (HOMA-IR) significantly in women with GDM when compared with women with normal pregnancy. Effectiveness of probiotic food supplements is dependent on various factors such as anaerobic storage conditions, temperature, initial dose of the strain, and its quality.,
Whether modification of gut microbiota is an effective tool in improving glycemic outcomes is inconclusive.
| Micronutrients|| |
Kozlowska et al. found no statistically significant differences for most of the vitamin and mineral intakes among women with normal pregnancy, pregnant women with GDM, and pregnant women with pregestational T1DM.
Increased calcium needs may be met by MNT alone (1.2 g/day recommended); however, in women with low dietary calcium intake (<1 g/day), supplementation of 0.3–2.0 g/day is advised to preserve bone density, maternal calcium balance, and support fetal development.
Evidence supporting vitamin D supplementation for improving pregnancy outcomes is limited.
The demand for iron increases in pregnancy, from 0.8 to up to 7.5 mg/day of absorbed ferritin. The risk of developing iron deficiency anemia increases in pregnancy; hence, supplementation with 30–60 mg/day of elemental iron is recommended.
Zhang and Rawal reviewed that there is a potential link between increased risk of GDM with higher iron status. As iron supplementation is often prescribed to prevent or treat iron deficiency anemia, the potential association of a higher GDM risk with higher iron status warrants more research.
Total intake of ~600 μg/day of folic acid is recommended for all reproductive age women from at least 1 month prior to conception until at least 12 weeks of gestation.
Plows et al. found limited evidence for nutritional supplementation of myo-inositol, vitamins D and B6, magnesium, selenium, zinc, fatty acids, and probiotics in improvement of glycemic control or to prevent GDM.
| Physical Activity|| |
The WINGS-MOC study by Anjana et al. showed that PA levels are inadequate among pregnant women with and without GDM. The study indicated that a low-cost, culturally appropriate MOC can result in significant improvements in PA in women with GDM and is associated with improved glycemic control and pregnancy outcomes.
In women with GDM who have no medical or obstetric contraindications to PA, most guidelines suggest planned PA of moderate intensity for at least 30 min per day or 150 min weekly, as this may contribute to improved glycemic control. Brisk walking, recumbent bicycling, or 10 min of seated arm exercises after each meal can be advised to accomplish this goal. Women are advised to refrain from overexerting and monitor fetal activity and blood glucose levels before and after exercise.,,,
| Postpartum Care|| |
Although most women with GDM revert to normal glucose tolerance postpartum, they are at increased risk of developing GDM in subsequent pregnancies and a 10-fold risk of type 2 diabetes in the future. GDM is therefore a perfect window of opportunity for prevention of diabetes in the future. Postpartum follow-up for diabetes screening is seen to be low globally. Most scientific bodies recommend that women with a history of GDM should undergo the 2-h 75 g OGTT at 6–12 weeks postpartum and regular screening for the development of prediabetes or type 2 diabetes every 1–3 years lifelong. The WINGS-MOC project which adopted several strategies like follow-up and reminders for testing through telephone calls, WhatsApp, and e-mail showed a 95.8% postpartum follow-up rate.
The study emphasized the use of proactive reminder systems using mobile health technology as a key strategy to achieve adherence to postpartum follow-up. Intensive lifestyle intervention has shown to prevent or delay progression to diabetes in women with prediabetes and those with a history of GDM.,,,
| Conclusion|| |
Structured counseling by a qualified dietitian must be offered to all women with GDM. Lifestyle behavioral intervention is the cornerstone in the management of GDM. To ensure that the metabolic needs of pregnancy are met while achieving normoglycemia and preventing nutritional ketosis, the meal plan must provide adequate energy and nutrients. Emphasis should be on choosing the right type, amount, and distribution of carbohydrates at meals to control postprandial glucose excursions. In addition, women with GDM are encouraged to indulge in moderate intensity PA for at least 30 min daily, perform regular SMBG, and maintain records to help improve adherence and pregnancy outcomes. Postpartum follow-up for diabetes testing and lifestyle modification is crucial to prevent or delay progression to diabetes in the future.
“It is time to focus on the fetus of the future.”
Financial support and sponsorship
This review was not supported by any funding.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]