Nutrition Therapy In

Gestational Diabetes

PART 1 ASSESSMENT
PART 2 RECOMMENDATIONS
PART 3 EDUCATION
Objectives

Discuss factors that should be considered when doing a nutritional

assessment

Discuss appropriate balance of meals/snacks through the day

Discuss appropriate weight gain based on preconception weight

Discuss the value of a late night snack to prevent early morning

ketosis

Evaluate the importance of folic acid supplementation before and

during pregnancy

Discuss the value of multivitamin supplementation during pregnancy

2
Goals for MNT in GDM

Optimal nutrition and weight gain for fetus and mother

Maternal euglycemia
Reduce the risk of diabetes related complications for
the mother and child
Minimize the maternal and infant morbidity and
mortality rates
Integrate diet, activity and pharmalogic therapy
Introducing healthy habits that can prevent or delay
onset of type 2 DM

3
Assessing from an Interview
Age
Obstetric history
Weight History
Significant medical history (co-morbidities)
Food preferences and eating habits
Food Allergies
Individual psychological, social and physical
status
Lifestyle, culture, and socio-economic status
Oral health
Readiness to change

4
Assessing from Clinical Information

Laboratory tests to determine clinical status

OGTT, fasting glucose, HbA1c level
SMBG
Urine ketones and proteins
lipid profile (cholesterol HDL, LDL)
Haemoglobin, creatinine, thyroid function
Blood pressure

Anthropometric Data
Height , Weight and BMI

Current medications and nutrition supplements

5
Body Mass Index (BMI)
Use pre pregnancy weight for calculations
Weight and height measurements to calculate BMI:
BMI = weight in kg/(height in m)2

Standard BMI normograms:

Asian ADA norms
Underweight <18.5 kg/m2
Normal BMI 18.0-22.9 kg/m2 18.5-24.9 kg/m2
Overweight 23.0-24.9 kg/m2 25.0-29.9 kg/m2
Obesity >25 kg/m2 > 30 kg/m2

6
Weight Gain Chart

Plot weight on a prenatal weight

gain grid to obtain an accurate
assessment of total pregnancy
weight gain and rate of weight
gain.

Determine if weight gain is

above, at or below the
recommended range.

If weight gain has already

exceeded the recommended
range, slow weight gain in order
to prevent further excess gain.

7
Nutrition Assessment

Nutrition history
usual food intake recorded through interview

Dietary recall
food and drink consumed in previous 24
hours (24-hour recall)

8
Activity
Think of things to check for
when doing a dietary history.

9
Issues with Dietary Recalls
Based on memory

Based on willingness to disclose the truth to a

healthcare provider

Nutrient intake and long-term habits are not

represented

Accurate estimations of food quantities/ingredients

are difficult

10
Nutrition Therapy In
Gestational Diabetes
PART 1 ASSESSMENT
PART 2 RECOMMENDATIONS
PART 3 EDUCATION
Composition of Food and Drinks

Macro-nutrients
protein
carbohydrates
fats
Micro-nutrients
vitamins
minerals

12
Recommendations for Weight Gain
Singleton pregnancy
Where possible a dietitian should develop a
meal plan.
At about the 4th month of the pregnancy about
350 calories should be added daily. This should
mean the woman is eating about 1900-2000
calories a day.
Overweight women (BMI 23 and over before
pregnancy) should increase less.
Underweight women (BMI less than 18 before
pregnancy) could add more.
Institute of Medicine : 2009

13
Dietary Recommendations for GDM

Macronutrient composition

Nutrient % of daily calorie

intake
Carbohydrates 45-65%
Fats 20-35%
Protein 10-35%

Dietary fibre 28g/day

Institute Of Medicine 2002

14
Fluids

Essential for all body functions

40-60% of body weight is water

Important to drink adequate amounts

of fluid

Restrictions may be required in case

of pedal edema

15
Proteins

Provide amino acids

Help to build muscle mass
Animal sources
Plant sources

1 g of protein gives 4 kcal energy

16
Protein Recommendations

1.1 g protein per kg bodyweight per day

10-35% of total energy per day
Animal protein often high in fat,
especially saturated.
Attention must be paid to meeting the
protein requirements of women who are
vegetarians or vegans

17
Carbohydrates

Provide main source of energy for

the body (45-65%) individualized
Nutrient that most influences blood
glucose levels
Source of simple sugars glucose,
fructose
1 g of carbohydrate provides 4 kcal

18
Activity

Name some of the common

carbohydrates and staple foods
in your region.

19
Carbohydrates And Meal Planning

Amount and source of carbohydrates is

considered when planning meals
Recommended source of carbohydrates is
mainly from
- whole grains: wheat, rice, pasta, bread, rice,
wheat, barley, oats, maize and corn
- legumes, beans, pulses (bengal gram, black gram,
rajma)
- fruit and vegetables
- milk

20
Carbohydrate (CHO) content of common foods
Food Amount Serving CHO (g)
Bread, whole wheat 28 g 1 slice 11
Rice (cooked) 75 g 0.3 cup 13
Pasta 125 mL 0.5 cup 16
Chappati 44 g 1 small 19
Corn meal 45 mL 3 tbsps 16
Potato 84 g 1 small 15
Couscous, cooked 125 mL 0.5 cup 17

Lentils 250 mL 1 cup 15

Banana 101 g 1 small 20
(Canadian Diabetes Association, 2006)

21
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Benefits of Fibre

A high-fibre diet is healthy

Mixture of soluble and insoluble fibre
- slows absorption of glucose
- reduces absorption of dietary fats
- retains water to soften stool
- may reduce the risk of colon cancer
- may reduce the risk of heart disease

22
Fibre Recommendations

Recommended amounts of total fibre : 28

g per day
Sources of insoluble fibre include: wheat
bran, whole grains, seeds, fruits and
vegetables
Sources of soluble fibre: legumes (beans),
oat bran, barley, apples, citrus fruits

CDA, 2013
23
Glycaemic Index (GI)

Ranks carbohydrate-rich foods

according to the increase in blood
glucose levels they cause in
comparison with a standard food (white
bread/glucose).

24
Glycaemic Response of Glucose
and Lentils

Blood glucose level

Glucose Lentils

Reprinted with permission from CDA, 2004

25
Factors Affecting the Glycaemic Index

Type of sugar
- glucose, fructose, galactose
Nature of starch
- amylose, amylopectin
Starch-nutrient interactions
- resistant starch
Cooking/food processing

26
Factors Affecting The Glycaemic Index

Processing/form of the food

- gelatinization
- particle size
- cellular structure

Presence of other food components

- fat and protein
- dietary fibre

Kalergis, De Grandpre, Andersons, 2005

27
Glycaemic Index of Foods

Low glycaemic Intermediate High glycaemic

index foods glycaemic index index

Oats Multigrain bread White Bread

Lentils/dhal Some rice (long White Rice
grain)
Yogurt Pasta Processed
breakfast cereal
Milk Bananas Glucose
Most Fruits and Grapes Mashed and
vegetables baked potatoes

CDA , 2006

28
Low GI - Advantages

Promotes healthy eating

Increases fibre intake
Helps control
- appetite
- blood glucose levels
- blood lipid levels

29
Fats

The most concentrated source of

energy

Foods may contain fat naturally or

have it added during cooking

1 g fat provides 9 kcal

30
Fat Recommendations

Low in polyunsaturated fats (up to 10% of

total daily energy)
High in monounsaturated fats (>10%)
Low in saturated fats (<10%)
Trans or hydrogenated fat should be
avoided

IoM 2002
31
Fats

Common sources of different fats

Polyunsaturated safflower oil, sunflower oil,
corn oil
Monounsaturated olive oil, canola oil, rape
seed oil, groundnut oil, mustard oil, sesame oil
Saturated red meats, butter, cheese,
margarine, ghee (clarified butter), whole milk,
cream, lard
Trans fats baked products, biscuits, cakes

32
Activity
Identify major sources of fats in
foods in your region.

33
Vitamins

Organic substances present in very

small amounts in food
Essential to good health
A balanced meal automatically
provides all necessary vitamins
Either fat-soluble or water-soluble
In some countries foods are
fortified with vitamins and minerals

34
Vitamin Recommendations

Daily multivitamin supplement should be added

as they are often not met by diet alone.

Multivitamin content varies depending on the

product used.

Women at higher risk for dietary deficiencies

include multiple gestation, heavy smokers,
adolescents, complete vegetarians, substance
abusers, and women with lactase deficiency.

35
Minerals

Substance present in bones, teeth, soft

tissue, muscle, blood and nerve cells
Help maintain physiological processes,
strengthen skeletal structures, preserve heart
and brain function and muscle and nerve
systems
Act as a catalyst to essential enzymatic
reactions
Low levels of minerals puts stress on
essential life functions

36
Minerals And Trace Elements

A balanced diet supplies minerals and

trace elements
Supplements are important as
requirements are higher during
pregnancy
Calcium supplementation
Iron supplementation
Folic acid supplementation 0.4mg (should
be started three months prior to conception)

CDA , 2013
37
Sodium Recommendations

Most people consume too much salt

Sodium restriction may be advised in case of
uncontrolled hypertension and edema

Targets for daily sodium intake

Age Adequate Upper limit
Intake (mg/day)
(mg/day)
14-50 1500 2300
51-70 1300 2300
over 70 1200 2300

Health Canada, 2005

38
Lowering Salt Intake

Sodium content is often high in restaurant foods

Encourage meal plans with

more fresh foods fruits and vegetable
less processed, fast, convenience or canned foods
herbs and spices used when cooking instead of salt.

Teach people to read food labels.

Choose salt free, reduced or low in sodium foods

39
Substance Use

The following substances should be avoided completely once

the woman plans a pregnancy

Tobacco in any form

Alcohol
Drugs (street, illegal)

40
Sweeteners

Sweeteners that increase blood glucose

Sugar, honey
Polydextrose & Sugar alcohols maltitol, sorbitol, Xylitol

Sweeteners that do not increase blood glucose

Acesulfame potassium
Aspartame *Must be avoided during
Cyclamate* pregnancy
Saccharin*
Sucralose To check with Health care team
prior to starting use of sweeteners

CDA, 2006
41
Food Labels

Nutrition facts
Serving size (if available)
Nutrient content
Ingredients
Nutrition information

42
Food labels

Nutrition Facts
Per 1 cup (250g)
Amount % Daily Value
Calories 100
Fat 0g 0%
Saturated 0 g
0%
+ Trans 0 g
Cholesterol 0 mg
Sodium 3 mg 0%
Carbohydrate 26 g 8%
Fibre 1 g 4%
Food labels may look
Sugars 23 g
Protein 2 g
different in different countries,
Vitamin A 20 % Vitamin C 170 % but the same information is
Calcium 2% Iron 2% usually available

43
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Activity

Practice reading a food label

Calculate the following:
Serving size
Number of calories in one serving
Number of carbohydrates in one serving
Amount of fat in one serving

44
Summary of Dietary Recommendations

Carbohydrates: 45-65%
Dietary fibre: 28 g / day
Fats: 20-35%
Protein: 10-35% (1.1 g/kg/day)
Sodium: 1500 - 2300 mg/day

45
Nutrition Therapy in
Gestational Diabetes
PART 1 ASSESSMENT
PART 2 RECOMMENDATIONS
PART 3 EDUCATION
Approach To Meal Planning

A uniform approach to meal planning does

not work for everyone

A flexible plan or a variety of approaches is

necessary to address different needs

47
Meal Planning

Before deciding on the content of meal plans,

consider:

Food preferences and eating habits

Previous experience, knowledge and skills
Current clinical, psychological and dietary status
Appropriate clinical and nutrition goals
Lifestyle factors

48
What to teach and when?
Basic
Basic information about nutrition
Nutrient requirements
Healthy eating guidelines
Making healthy food choices
Self-management training and use
of educational tools

49
Nutrition Education: Tools

Awareness of the basics of healthy

eating/balance of good health
Food Pyramid
The plate model

50
Food Guides

Australian Food Guide

51
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Healthy eating
Recommended Number of Food Guide Servings per Day
Eating Well with Age In Years 2-3
Children
4-8 9-13
Teens
14-18 19-50
Adults
51+

Canadas Food Guide Sex Girls and Boys Females Males Females Males Females Males

Vegetables
and fruits
4 5 6 7 8 7-8 8-10 7 7

Grain
Products
3 4 6 6 7 6-7 8 6 7

Milk and
Alternatives
2 2 3-4 3-4 3-4 2 2 3 3

Meat and
Alternatives
1 1 1-2 2 3 2 3 2 3

The chart above shows how many Food Guide Servings you need
from each of the four food groups every day.

Having the amount and tyoe of food recommended and following the
tips in Canadas Food Guide will help:

Meet your needs for vitamins, minerals and other nutrients.

Reduce your risk of obesity, type 2 diabetes, heart disease,
certain types of cancer and osteoporosis.
Contribute to your overall health and vitality.

52
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Food pyramid India

Diabetes India, 2005

53
Balance of good health - UK eat well plate
Bread, cereals
Fruits and
and potatoes
vegetables

Meat, fish and Milk and

protein alternatives dairy products
Foods rich in
sugars and fat

(Reproduced with kind permission of the Food Standards Agency)

54
M
 These graphics will change
to be the same as the new
ones going in the booklets

Healthy food plate Example of Healthy food plate with

(Source: Diabetes Education Modules 2011) South-Asian foods

55
Activity
Draw on a paper plate either:
The recommended proportions of foods
from your region
The proportions of what you ate last night

56
Practical Advice/ 1

Make healthy food choices

Avoid fatty foods
Use low-fat cooking methods
Substitute high fat foods with low fat options;
e.g use low fat milk
Minimize consumption of sugar and salt
Use fresh foods instead of preserved or
canned foods

57
Practical Advice/ 2

At least five servings of fruit and vegetables per day

- Choose colourful fruits and vegetables
- Choose whole fruits over juices

Replace high calorie beverages with water

Eat small frequent meals that are well spaced
Do not skip meals
Calories should be restricted especially if overweight
Eat free foods as desired, include in between major
meals

58
Practical Advice/ 3

One low GI food at each meal

Mix high and low GI food = intermediate GI
meal
Substitute high GI cereals/breads/rice with low
GI cereals/bread/rice
Eat low GI snacks instead of high GI snacks
(remember to choose lower fat snacks)

59
References
American Diabetes Association. (2013). Clinical Practice Recommendations. Diabetes Care, 36, (supple 1).
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2013). Canadian Diabetes
Association 2013. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.
Canadian Journal of Diabetes, 37(suppl 1).
Canadian Diabetes Association. (2006). Beyond the Basics. Toronto ON: Canadian Diabetes Association
Diabetes India. (2005). Diet Charts. Retreived September 13, 2010.
http://www.diabetesindia.com/diabetes/diet_chart.htm
Franz MJ, Evert AB (Eds.) American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2 nd Ed. 1012
Health Canada. Food and Nutrition. Sodium. Its Your Health. Available from: http://www.hc-sc.gc.ca/hl-
vs/iyh-vsv/food-aliment/sodium-eng.php
Health Canada. (2005). Food and Nutrition. The Issue of sodium. (Retrieved September 13, 2010)
http://www.hc-sc.gc.ca/fn-an/nutrition/reference/table/ref_elements_tbl-eng.php
Institute of Medicine 2002
http://www.iom.edu/Global/News%20Announcements/~/media/C5CD2DD7840544979A549EC47E56A02B.a
shx
Institute Of Medicine 2009
http://www.ncbi.nlm.nih.gov/books/NBK32799/table/summary.t1/?report=objectonly

Kalergis, M., De Grandpre, E., Andersons, C. (2005). The Role of Glycemic Index in the Prevention and
Management of Diabetes: A Review and Discussion. Can J of Diab, 29(1), 27-38.
Misra A, Chowbey P, Makkar PM, Vikram NK, Wasir JS, Chadha D, et al. Consensus Statement for
Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians and
Recommendations for Physical Activity, Medical and Surgical Management. JAPI 2009;57.

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