Dr Shelley Wilkinson - Diabetes Queensland

Report
Dr. Shelley Wilkinson
18th June 2014
Gestational Diabetes:
nutrition priorities
Dr Shelley Wilkinson
Advanced Accredited Practising Dietitian,
Mater Mothers’ Hospital, Brisbane, Australia
During pregnancy:
A window of opportunity
• health service contact
• more receptive to health messages
• intergenerational effects
Behaviours with demonstrated outcomes:
• diet/nutrition, healthy weight gain (+breastfeeding)
• sufficient physical activity
• smoking cessation
Guidelines:
• Australian dietary guidelines (incl. gestational weight gain, GWG)
• Gestational Diabetes Mellitus (GDM) Nutrition practice guidelines
• QHealth Obesity guidelines
Pregnancy
Nutritional Requirements
Acknowledgement:Food systems & Policy team, Victorian Dept of Health, 2013
Pregnancy nutrition – dietary guidelines
1.
Achieve and maintain a healthy weight, by
2.
Eat a wide variety of food every day –
3.
Limit your intake of food/drinks that contain added
sugar, salt and/or saturated fat (and of course,
being physically active and choosing amounts of
nutritious food and drinks to meet your energy needs
including vegetables; fruit; grain foods (preferably
wholegrain); protein foods (e.g. meat, fish, eggs, nuts,
legumes), and dairy (mostly reduced fat)
in pregnancy, avoid alcohol)
4.
Encourage, support and promote breastfeeding
5.
Prepare and store food safely.
Not eating for two, but having to eat twice as well…
Not eating for two, but having to eat twice as well…
Energy requirements
1st trimester = no additional requirements
2nd trimester = +1400kJ/d
3rd trimester = +1900kJ/d
Nutrient requirements
Protein
RDI: 60g/d (46g/d)
Iron
RDI: 27mg/d (8mg/d)
Iodine*
RDI: 220μg/d (150μg/d)
Folate*
RDI: 600μg/d (400μg/d) + 400μg/d
LC n3 fatty acids
AI: 115mg/d (90mg/d)
How do we apply this in everyday settings?
Not eating for two, but having to eat twice as well…
Gestational weight gain guidelines
If pre-pregnancy BMI was …
GWG goal…
Rate of gain in trimesters 2 & 3
<18.5 kg/m²
12 ½ - 18kg
0.45 kg/week
18.5-24.9 kg/m²
11 ½ - 16kg
0.45 kg/week
25-30 kg/m²
7-11½kg
0.28 kg/week
30+ kg/m²
5-9kg
0.22 kg/week
“Based on your weight
at the beginning of
pregnancy, this weight
gain is recommended for
the healthiest pregnancy
possible”
GDM + Medical Nutrition Therapy (MNT)
• primary intervention strategy for managing BGLs in GDM
• Improvements in important outcomes (e.g. insulin, BGL control),
documented in ADA Nutrition Practice Guidelines validation study
• MNT according to an evidence-based appointment schedule
• Minimum: one-hour ‘new’, two+ reviews, plus postnatal follow up
• 3rd trimester dietetic counselling following a GDM diagnosis can
slow weight gain and reduce the incidence of macrosomia
• Australian Carbohydrate Intolerance Study
• Routine care vs dietary advice, BGL monitoring, insulin
• Significant decrease in serious perinatal complications and improvements
in self-reported maternal health status
How do we measure up?
A key recommendation
from a Qld dietitian
managers’ report:
“a demonstration project
implementing and
evaluating the GDM
nutrition guidelines to
facilitate its dissemination
and adoption across
Queensland”
Pregnancy nutrition priorities
“MNT primarily involves a
carbohydrate- controlled meal plan
that:
• promotes optimal nutrition for maternal
and fetal health,
• with adequate energy for appropriate
gestational weight gain,
• and maintenance of normoglycaemia,
• and absence of ketosis”
American Diabetes Association 2008
Carbohydrate
Pregnancy nutrition priorities
•component of the diet that has the greatest influence on BGLs
•commonly proposed options for reducing the post-prandial response:
•
•
•
•
Reduce total CHO intake, if excessive (NB minimum 175g CHO)
Re-distribute CHO across the day (eg 3 meals, 3-4 snacks)
Lower glycaemic index CHO
Physical activity post meals
Even so, in pregnancy
. . . “there is little evidence for a recommended amount and type of CHO or its
distribution . . . . The best indicators at this time are the results of selfmonitoring of BGL, food records, and weight gain”
Know your carbohydrate foods
Carbohydrates are in many foods
Include carbohydrate in each meal and snack
Aim to eat every 2 ½ to 3 hours
Aim to eat similar amounts of carbohydrate across meals
A good way to measure carbohydrates is to think of them
as exchanges that you mix and match over meals
Better choices
Grain or rye bread
Crackers containing whole grains or seeds
Pasta or noodles
Basmati or Doongara rice
Sweet potato
Pregnancy nutrition priorities
The CHO Dilemma . . .
Excessive CHO
Suboptimal CHO
Risks:
•
Higher BGLs and assoc. risks
e.g. LGA baby
•
Excess GWG and associated
risks
•
Unnecessary use of insulin
Risks:
• High BGLs, if resulting hunger
leads to overeating
• Poor intake of associated
nutrients (vit, min, fibre etc)
• Suboptimal weight gain and
associated risks e.g. SGA
• Starvation ketosis
Used with permission.
www.greatideas.net.au
Continue a healthy lifestyle after your pregnancy
Repeat Oral Glucose Tolerance Test (OGTT)
6 – 12 weeks after delivery
Repeat OGTT every one to two years
Greater risk of
• developing gestational diabetes again
• developing Type 2 diabetes in later life
Reduce your risk by continuing a healthy lifestyle after your
pregnancy
How to prevent T2DM
Diabetes Prevention Program (DPP)
Aim: to reduce the incidence of T2DM in high risk populations
1. Participation in a lifestyle program
• Individualised counselling, multiple contacts (monitoring/support)
• Goals:
- Weight reduction > 5-7%
- Total fat intake <30% total energy
- Saturated fat intake <10% total energy
- Fibre intake >15g/1000kcal
- Moderate intensity physical activity > 150mins/week
2. Use of Metformin
3. Control group
•
•
•
Weight management
Physical activity
Breastfeeding
How to prevent T2DM
• Lifestyle intervention was more effective than Metformin in
reducing the risk of developing T2DM
• Sub-analysis: Compared women with Hx GDM vs No GDM
• Both lifestyle and Metformin intervention reduced the incidence of
diabetes by approximately 50% compared w/ control
• Intensive lifestyle intervention was more effective in the non-GDM
group, and the GDM group were not able to sustain the lifestyle
changes over time
The combination of increased risk, less physical activity and
consistent weight gain in the GDM group highlights the
importance of follow up and intervention for these women
Australian Dietary guideline
How to prevent T2DM
Women post-GDM:
- Are less likely to BF than women without GDM (~delayed lactogenesis II)
- Are twice as likely to develop T2DM if don’t BF
- Have a 15% decrease in risk of T2DM/yr of lactation
- That have a higher intensity of BF = improved fasting BGLs and lower insulin levels
Lowest postpartum T2DM risk in women who BF > 9/12 (improved glucose homeostasis)
Exclusive BF increases postpartum weight loss, reduced long term obesity and
lower prevalence of the metabolic syndrome
BF offers a safe, feasible and low–cost
intervention to reduce the risk of
subsequent T2DM
Weight management
 Physical activity
 Breastfeeding

NEMO Resources
Nutrition Education Materials Online
• Antenatal nutrition
• Gestational Diabetes and nutrition
http://www.health.qld.gov.au/nutrition/nemo_antenatal.asp

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