Presented

by: Melanie Wheeland,

Sodexo Dietetic Intern

Learning Objec-ves
! Learners will be able to state the recommendation for

carbohydrate intake in patients diagnosed with

Gestational Diabetes Mellitus

! Learners will be able to describe the components of

the Low GI diet

! Learners will be able to list the 4 main take home

messages the dietitian should give the patient

Gesta-onal Diabetes Mellitus

Put Yourself in Her Shoes

! Gestational Diabetes: Poke, Pee, and Eat your Carbs

by Carmen Lavoie, PhD from Canadian Family

Physician

Background Informa-on
! The most prevalent medical complication in

pregnancy is diabetes mellitus

! Pre existing Type 1 or Type 2

! Gestational Diabetes Mellitus (GDM)

! GDM is dened as any degree of glucose intolerance

with onset or rst recognition during pregnancy

! Aects about 7% of all pregnancies
! Associated with risk factors that are similar to the risk

of developing type 2 diabetes

Background Informa-on
! GDM primarily develops during the second half of

pregnancy

! Hyperglycemia in the second trimester is associated

with:

! An increased risk for macrosomia

! C-section
! Traumatic delivery
! Neonatal hypoglycemia

Background Informa-on
! There are 3 main strategies to improve outcomes for

pregnant women with pre-existing and gestational

diabetes and their ospring

Preconception counseling for women with preexisting

diabetes
2. Timely diagnosis and treatment of gestational
diabetes
3. Euglycemia throughout pregnancy
1.

The Clinical Die--an

A new consult came
through the printer. A
diet education for a
woman in LDRP with
Gestational Diabetes!

The Glycemic Index

! The Glycemic Index (GI) is a system of ranking

carbohydrate foods according to their eect on

postprandial glycemia
! They glycemic eect of 50gm of digestible CHO from a

single food measured over a 2 hour period

! The food is then assigned a value compared with the

response of a reference food

!
!

Glucose
White Bread

The Glycemic Index

The Glycemic Index

! Misconception: High-GI food peaks very rapidly and

a low-GI food peaks more gradually ! Incorrect!

The Glycemic Index

! The GI is not always an indicator of healthy food or

meal choices

! Low GI diets are associated with signicantly higher

sugar intakes than high-GI diets

! Many high sugar foods fall into the moderate or low-GI
categories
!
!

Coke (GI=58)
Snickers (GI=56)

! Sugars have moderate-low GI values because they are

only 50% glucose (the other 50% being fructose or

lactose)

Glycemic Load
! The glucose response to a food is inuenced not only

by the glycemic response, but also by the amount of

CHO in the food

! The Glycemic Load (GL) of foods takes into account

both the quantity of the food consumed and the GI

value of the food
! GL = GI x gm CHO per serving

Glycemic Load
Example:
! Carrots (GI = 92)
! cup carrots has a GL of 5 (92 x 5g CHO/100 = 5)

! Watermelon (GI = 72)

! 1 cup watermelon has a GL of 8 (72 x 12g CHO/100 = 8)
! Pizza (GI = 60)
! 10 oz pizza has a GL of 42 (60 x 70/100g CHO = 42)

Research Study #1
Can a Low-Glycemic Index Diet Reduce the Need
for Insulin in Gestational Diabetes Mellitus?
March 11, 2009. Diabetes Care.

! Location
! Wollongong, New South Wales, Australia, a coastal city with a

population of ~280,000 people situated about 50 miles south of

Sydney

! Purpose
! The purpose of this study was to determine whether prescribing a

low-glycemic index diet for women with GDM could reduce the #
of women requiring insulin without compromise of pregnancy
outcomes

Research Study #1
! Research and Design Methods
! All women with GDM seen over a 12-month period were considered
for inclusion in the study. 63 women were randomly assigned to
receive either
! a lowglycemic index diet
! or a conventional high-ber (and higher glycemic index) diet.
! Results
! Of the 31 women randomly assigned to a lowglycemic index diet, 9
(29%) required insulin.
! Of the women randomly assigned to a higherglycemic index diet, a
signicantly higher proportion, 19 of 32 (59%), met the criteria to
commence insulin treatment.
! However, 9 of these 19 women were able to avoid insulin use by
changing to a lowglycemic index diet. Key obstetric and fetal
outcomes were not signicantly dierent.

Research Study #1
! Conclusions
! Using a lowglycemic index diet for women with GDM
eectively halved the number needing to use insulin,
with no compromise of obstetric or fetal outcomes.

! but WAIT A MINUTE! Look at the footnotes!

Research Study #1
! The publication costs of this article were defrayed in

part by page charge payments. This article must hereby

be marked advertisement in accordance with 18 U.S.C.
1734 solely to indicate this fact.
! J.B.M. is a coauthor of The New Glucose Revolution
book series (Hodder and Stoughton, London; Marlowe
and Co, New York; and Hodder Headline, Sydney and
elsewhere); President of the GI Foundation, a nonprot
glycemic indexbased food endorsement program in
Australia; and Director of the University of Sydney
glycemic index testing service.

Research Study #2
A randomized controlled trial investigating the
eects of a low-glycemic index diet on pregnancy
outcomes in gestational diabetes mellitus
Diabetes Care 2011 Nov
! Location

! This study was a two-arm parallel randomized controlled trial

based at the Diabetes Antenatal Clinic of the Royal Prince Alfred

Hospital, Camperdown, Australia.

! Purpose
! The authors aimed to investigate the eect of a low-glycemic index

(LGI) versus a conventional high-ber diet on pregnancy

outcomes, neonatal anthropometry, and maternal metabolic
prole in GDM.

Research Study #2
! Research and Design Methods
! Ninety-nine women (age 26-42 years; mean prepregnancy
BMI 24 5) diagnosed with GDM at 20-32 weeks' gestation
were randomized to follow either
!
!

an LGI (n = 50; target glycemic index [GI] ~50)

or a high-ber moderate-GI diet (HF) (n = 49; target GI ~60).

! Dietary intake was assessed by 3-day food records (including

2 weekdays and 1 weekend day) at baseline and again at 36

37 weeks gestation.

! Pregnancy outcomes were collected from medical records.

Research Study #2
! Results
! The LGI group achieved a modestly lower GI than the HF
group.
! At birth, there was no signicant dierence in birth weight,
birth weight centile , prevalence of macrosomia, insulin
treatment, or adverse pregnancy outcomes.
! Conclusion
! In intensively monitored women with GDM, an LGI diet and
a conventional HF diet produce similar pregnancy outcomes.
An LGI diet appears to be a safe alternative to the traditional
pregnancy diet for women with GDM and expands the range
of dietary strategies that can be oered.

Research Study #3
! Low Glycemic Index Carbohydrates versus All

Types of Carbohydrates for Treating Diabetes in

Pregnancy: A Randomized Clinical Trial to
Evaluate the Eect of Glycemic Control Int J
Endocrinol. 2012; 2012
! Population
!

The research was done in the Nutrition Research Department,

Instituto Nacional de Perinatologa Isidro Espinosa de los Reyes,
Montes Urales 800, Lomas de Virreyes, 11000 Mexico City,
Mexico
Women were included if they had a gestational age 29 weeks,
had GDM or pregestational type 2 DM, and planned to attend
their pregnancy in the institution where the authors were
associated.

Research Study #3
! Purpose
! Compare the eect of including only low glycemic
index carbohydrates against all types of CHO on
maternal glycemic control and on the maternal and
newborn's nutritional status of women with type 2 DM
and gestational diabetes mellitus
! Research and Design Methods
! 107 women at 29 weeks of gestation were randomly
assigned to one of two nutrition intervention groups:
moderate energy and CHO restriction (Group 1: all
types of CHO, Group 2: low GI foods).

Research Study #3
! Results
! No baseline dierences in clinical data were observed.
! Capillary glucose concentrations throughout
pregnancy were similar between groups.
! Fewer women in Group 2 exceeded weight gain
recommendations.
! Higher risk of prematurity was observed in women in
Group 2.
! No dierences in glycemic control were observed
between women with type 2 DM and those with GDM.

Research Study #3
! Conclusions
! Inclusion of low GI CHO as part of a comprehensive
nutrition intervention is equally eective in improving
glycemic control as compared to all types of CHO. This
strategy had a positive eect in preventing excessive
maternal weight gain but increased the risk of
prematurity.

Research Study #4
Low Carbohydrate Diet for the Treatment of
Gestational Diabetes Mellitus Diabetes Care April 2013
! Population
! Participation in the trial was oered to all women diagnosed with

GDM in the only diabetes and pregnancy outpatient clinic of the

reference hospital of the Public Health System of the province of
Lleida (Catalonia, northeastern Spain) between November 2008
and July 2011.

! Purpose
! The purpose of this study was to test the hypothesis that a low-

CHO diet for the treatment of GDM would lead to a lower rate of
insulin treatment with similar pregnancy outcomes compared with
a control diet.

Research Study #4
! Research and Design Methods
! A total of 152 women with GDM were included in this
open, randomized controlled trial and assigned to
follow either a diet with
!

low-CHO content (40% of the total diet energy content as

CHO)
or a control diet (55% of the total diet energy content as
CHO).

! CHO intake was assessed by 3-day food records

! The main pregnancy outcomes were also assessed.

Research Study #4
! Results
! The rate of women requiring insulin was not signicantly
dierent between the treatment groups (low CHO 54.7% vs.
control 54.7%).
! Daily food records conrmed a dierence in the amount of
CHO consumed between the groups.
! No dierences were found in the obstetric and perinatal
outcomes between the treatment groups.
! Conclusions
! Treatment of women with GDM using a low-CHO diet did
not reduce the number of women needing insulin and
produced similar pregnancy outcomes. In GDM, CHO
amount (40 vs. 55% of calories) did not inuence insulin
need or pregnancy outcomes.

Comparisons of Results
! Study #1 - Low GI Diet may result in reduced need

for insulin use but can the author be trusted?

! Study #2 and #3 A low GI diet cant hurt

! Study #4 - Using a low-CHO diet did not reduce the
number of women needing insulin and produced similar
pregnancy outcomes
!

What about the limitations of the studies?

!

Reliance upon the honesty of the participants

Current Recommenda-ons
! American Diabetes Association
! Monitoring CHO intake, whether by CHO counting,
exchanges, or experience based estimation, remains a key
strategy in achieving glycemic control.
! The use of the GI and GL may provide additional benet for
glycemic control over that observed when total carbohydrate
alone is considered
! Determine individual glycemic response to various
carbohydrate foods by monitoring preprandial and
postprandial BG levels.
! Staying within a target amount of carbohydrate for meals
and choosing less processed foods that are high in ber can
help to lower the glycemic response of foods.

Carbohydrate Requirements
! In persons with specically GDM, the DRI for CHO in

pregnant women ages 19-50 is minimum of 175g per

day

! This amount of CHO provides an adequate source of

glucose for fetal growth and for the maternal brain.

! The ANDs Evidence Based GDM Nutrition Practice

Guidelines suggest splitting CHO intake into 3 small

to moderate meals with 2-4 snacks.

Example of Daily CHO Intake

! Breakfast: 15-45g CHO
! Lunch and Dinner: 45-75g each
! Snacks: 15-45g

**The most dicult BG level to manage is the post-

breakfast value, due to higher hormonal levels in the
morning.
**Controlling the amount of rice, potato, and starches is
very important

Promote a Well Balanced Diet

! As women with GDM learn about controlling their

CHO intake to manage their BG levels, they may

unintentionally cut back on nutrient-rich CHO such
as fruit, milk or dairy, and starches
! Reinforce the message that adequate intake of these
foods is still critical, and that there are strategies to
include them in a CHO controlled diet without
negatively impacting BG levels.
! It is a common practice to shift milk and fruit to
snack time so that a more normal portion of starch
can be consumed during meals.

Take Home Messages for the Pa-ent

! Use your diabetes team
! Glucose control is important for a healthy

pregnancy

! Insulin is good medicine

! Guard your own health after delivery - knowing

you had GDM is a clear signal you are at risk of

developing diabetes

Pop Quiz
! In persons with specically GDM, the DRI for CHO in

pregnant women ages 19-50 is minimum of _______

per day?

! Why?

Any Ques-ons?
Thank you!

References
! Mensing, Carol, Sue McLaughlin, and Cindy Halstenson. The Art and Science of

Diabetes Self-management Education Desk Reference. Second ed. Chicago: American

Association of Diabetes Educators, 2011. Print.

! Moses RG, Barker M, Winter M, Petocz P, Brand-Miller JC. Can a low-glycemic index

diet reduce the need for insulin in gestational diabetes mellitus? A randomized trial.
Diabetes Care 2009;32:9961000 http://care.diabetesjournals.org/content/32/6/996.full

! Louie, J. C. Y., T. P. Markovic, N. Perera, D. Foote, P. Petocz, G. P. Ross, and J. C. Brand-

Miller. "A Randomized Controlled Trial Investigating the Eects of a Low-Glycemic

Index Diet on Pregnancy Outcomes in Gestational Diabetes Mellitus." Diabetes Care
34.11 (2011): 2341-346. Web. http://www.ncbi.nlm.nih.gov/pubmed/21900148

! Otilia Perichart-Perera, Margie Balas-Nakash, Ameyalli Rodrguez-Cano, Jennifer

Legorreta-Legorreta, Adalberto Parra-Covarrubias, and Felipe Vadillo-Ortega, Low

Glycemic Index Carbohydrates versus All Types of Carbohydrates for Treating Diabetes
in Pregnancy: A Randomized Clinical Trial to Evaluate the Eect of Glycemic Control,
International Journal of Endocrinology, vol. 2012, Article ID 296017, 10 pages, 2012. doi:
10.1155/2012/296017 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3517846/

References Con-nued
! Moreno-Castilla C. Hernandez M, Bergua M,et al. Low-carbohydrate diet for the treatment of

gestational diabetes mellitus: a randomized controlled trial.Diabetes Care 2013;36:22332238

http://care.diabetesjournals.org/content/36/8/2233.full.pdf+html

! Han S, Crowther CA, Middleton P, Heatley E. Dierent types of dietary advice for women with

gestational diabetes mellitus. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.:
CD009275. DOI: 10.1002/14651858.CD009275.pub2.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009275.pub2/abstract

! Lavoie, Carmen. "Gestational Diabetes: Poke, Pee, and Eat Your Carbs."Canadian Family Physician.

College of Family Physicians of Canada, July 2011. Web. 04 Apr. 2015.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135431/

! Walsh Jennifer M, McGowan Ciara A, MahonyRhona, Foley Michael E, McAulie Fionnuala M.Low

glycaemic index diet in pregnancy to prevent macrosomia (ROLO study): randomised control trial
BMJ 2012; 345 :e5605
http://www.bmj.com/content/345/bmj.e5605.abstract?
ijkey=30edc3cf85eaed00df6260c26a1687a475c8534b&keytype2=tf_ipsecsha

! American Diabetes Association. Standards of medical care in diabetes2014.Diabetes Care

2014;37(Suppl 1):S1480. doi:10.2337/dc14-S014 http://care.diabetesjournals.org/content/37/

Supplement_1/S14.extract