Nutrition FYI

Gestational Diabetes Education and Diabetes Prevention

Strategies
Alison B. Evert, RD, CDE, and Kathy Vande Hei, RN, CDE

More than 8 million women in the after a pregnancy that is complicated ed for individuals with special needs.
United States have gestational diabetes by GDM. If overweight, women with During the past 4 years, > 300 women
mellitus (GDM); it is observed in 7% a history of GDM should be coun- annually have participated in the
of all pregnancies.1 The American seled to reduce their risk for diabetes GDM programs at this site.
Diabetes Association (ADA) position through lifestyle changes and medica- Women referred to the GDM pro-
statement on the Diagnosis and tions if necessary. Children of women gram come from diverse ethnic and
Classification of Diabetes Mellitus lists with a history of GDM should also be socioeconomic backgrounds. The eth-
GDM or delivery of a baby weighing encouraged to establish and maintain nic populations receiving care include
> 9 lb as a risk factor for developing healthy lifestyles to avoid excess Southeast Asians, Pacific Islanders,
diabetes later in life.2 Women who weight gain and reduce their risk for Latinos/Hispanics, and African
have had a pregnancy complicated by type 2 diabetes. Americans. A majority of the women
GDM are 40–60% more likely to This article describes a program that enrolled in one-on-one GDM appoint-
develop diabetes within 15–20 years.3,4 addresses both the diabetes medical ments do not speak English as a first
Other risk factors for developing dia- nutrition therapy and diabetes self- language. These women are seen in
betes include a family history of type 2 management education (DSME) needs paired appointments with a registered
diabetes, the degree of abnormality of of women with GDM while integrating dietitian and a registered nurse, both
the glucose tolerance test, the degree of information about how to reduce the of whom are certified diabetes educa-
obesity, and certain ethnicities.5 Table risk of developing diabetes later in life. tors, along with a medically trained
1 lists risk factors for developing type 2 interpreter fluent in the woman’s
diabetes. It is important for health care Background native language.
providers to take a proactive approach The Joslin Diabetes Center (JDC), an Women enrolled in the GDM pro-
to create awareness in women with education affiliate at Swedish Medical gram offered at the center are, as a
GDM that their own and their child’s Center, is located in Seattle, Wash. group, highly motivated and eager to
lifelong risk for developing type 2 dia- This center has a referral base of learn how to manage the condition.
betes is increased. > 120 health care providers, many of The majority of women referred for
In addition to creating awareness, whom regularly refer women diag- GDM education receive education
regular follow-up, including testing nosed with GDM. The center offers within 1 week of diagnosis. Many
for pre-diabetes and diabetes, should two GDM group classes every week. attend the program with a significant
be promoted on an ongoing basis One-on-one appointments are provid- other or support person.

Table 1. ADA Risk Factors for Type 2 Diabetes20 Two-Part GDM Classes
The group GDM education classes are
• Age ≥ 45 years composed of a 2-hour introductory
• Overweight BMI ≥ 25 kg/m2* class and a 1-hour follow-up class
• Family history of diabetes (i.e., parents or siblings with diabetes) team taught by the dietitian and the
• Habitual physical inactivity nurse. The same curriculum is used
• Race/ethnicity (e.g., African Americans, Hispanic Americans, Native with women with special needs, who
Americans, Asian Americans, and Pacific Islanders) are seen on an individual basis. This
• Previously identified impaired fasting glucose or impaired glucose center uses blood glucose targets rec-
tolerance ommended by the American College of
• History of GDM or delivery of a baby weighing > 9 lb Obstetricians and Gynecologists
• Hypertension (≥ 140/90 mmHg in adults) (ACOG) and shown in Table 2.6
• HDL cholesterol ≤ 35 mg/dl or triglyceride level ≥ 250 mg/dl
• Polycystic ovary syndrome Introductory class
• History of vascular disease Topics covered during the class are
pertinent to managing GDM during
*May not be correct for all ethnic groups pregnancy (Table 3).
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 Nutrition FYI

Table 2. ACOG Blood pregnant women.9 Women who are • Prevention of type 2 diabetes
Glucose Targets6 not able to achieve the recommended Diabetes Prevention Program
postprandial blood glucose goals may (DPP) results
need to have insulin therapy initiated. Role of breastfeeding
Fasting: < 95 mg/dl At the completion of the initial 2- • Nutrition recommendations for
2-hour postprandial: < 120 mg/dl hour class, participants are counseled lactation
to call the nurse information phone • Effect of contraceptive medications
As part of the class, women are line if they have questions, if they are on blood glucose
counseled to use blood glucose self- spilling ketones, or if they are experi-
monitoring results to evaluate their encing elevated blood glucose levels. Women who are unable to achieve
ability to tolerate the amount of car- They are instructed to return for the desirable glycemic control even when
bohydrates recommended in the meal follow-up class the next week with following the prescribed GDM meal
plan. If they achieve postprandial their blood glucose monitors and log plan, as evidenced by their blood glu-
blood glucose results significantly books. cose records, stay for an additional 1-
lower than the ACOG goal of < 120 hour class. These women are instruct-
mg/dl 2 hours after eating, they are Follow-up class ed on how to use insulin to achieve
advised to increase the carbohydrate The 1-hour follow-up class includes a more desirable glycemic control
as tolerated. The meal plan should question-and-answer session and a throughout the remainder of their
not be more restrictive than it has to review of log book test results (i.e., pregnancy. Insulin orders are obtained
be. blood glucose and ketones). In addi- by the nurse from the women’s health
It is not uncommon for women tion, the following topics are care providers. The dietitian adjusts
who are unable to achieve desirable discussed. meal plans based on the insulin thera-
postprandial control to reduce their • Future risk of developing type 2 dia- py prescribed.
carbohydrate intake to suboptimal betes after diagnosis of GDM for
levels with the hope of avoiding themselves and their children Lactation
insulin therapy. The Dietary • Recommended follow-up care with The positive health affects of breast-
Reference Intakes (DRI) recommends their health care provider after birth feeding should be strongly encouraged
175 g of carbohydrate per day for of the child by health care professionals for all

Table 3. Curriculum for Introductory GDM Class

The 1st hour of the introductory class is taught by the nurse educator and has the following objectives:
At the end of the class the participant will be able to:
• Describe the physiological changes during pregnancy that can alter glucose homeostasis—role of insulin and pla-
cental hormones
• Describe how the OGTT is used to diagnose GDM
• Describe the effect of hyperglycemia on the mother and fetus
• Describe how to treat GDM with healthy eating, physical activity, and possibly the use of medication
• Assess the postprandial blood glucose response to a carbohydrate-controlled meal plan with blood glucose self-
monitoring results
• Demonstrate use and operation of home blood glucose monitor and ability to record test results in a log book
• Describe how to test urine for ketones and the role of ketone testing to evaluate adequacy of nutritional intake
• Understand their risk and the risk of their child for development of diabetes later in life

The 2nd hour of the introductory class is taught by the dietitian educator and has the following objectives:
At the end of the class the participant will be able to:
• Describe how food nutrients (carbohydrates, protein, fat, and fiber) affect blood glucose
• Identify the desired portion size of one carbohydrate choice of some common foods
• Demonstrate how to read Nutrition Facts food labels
• Describe the clinical treatment goals of the American Dietetic Association’s nutrition practice guidelines for the
treatment of GDM:7,8
To achieve and maintain normoglycemia
To consume adequate energy to promote appropriate gestational weight gain and avoid maternal ketosis
To consume food providing nutrients necessary for maternal and fetal health
• Develop a meal plan using carbohydrate choice guidelines
Breakfast: two carbohydrate choices
Morning snack: one to two carbohydrate choices
Lunch: three to four carbohydrate choices
Afternoon snack: one to two carbohydrate choices
Dinner: three to four carbohydrate choices
Bedtime snack: one to two carbohydrate choices
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 Nutrition FYI

women, especially those with a histo- blood glucose level be checked at least months, they should try to lose 7% of
ry of GDM. Breastfeeding is associat- every 3 years thereafter.1 Although their body weight slowly and then
ed with weight loss and reduced still considered controversial, more strive to maintain that weight loss.
insulin resistance.10 Research has aggressive guidelines may be pub- Weight loss and maintenance
revealed that women who breastfeed lished soon recommending yearly strategies could include some of the
may have a decreased risk of develop- screening with at least a fasting glu- following:
ing diabetes later in life.11 cose or glucose tolerance test. • Follow a balanced meal plan:
Lactose is the only carbohydrate Screening should occur more often in Try to include a carbohydrate
found in breast milk, and it requires individuals who are overweight and food and a heart-healthy pro-
glucose for synthesis.10 The estimated have one or more risk factors for dia- tein at each meal. Use the plate
mean concentration of lactose in 1 betes (Table 1). method to portion out meals.
liter of breast milk is 72 g.12 The esti- Women who are considering The plate method meal plan-
mated energy output in milk produc- another pregnancy should be screened ning approach does not require
tion is ~ 500 kcal/day in the first 6 for diabetes before conception.9 measurement of food and
months and 400 kcal/day in the sec- Suggested screening methods include a therefore is an easy way to
ond 6 months of lactation.9 fasting blood glucose test or a 75-g, 2- serve healthful portions of
Breastfeeding not only is an effec- hour OGTT. If women who have had starchy foods, protein, and
tive method for mothers to increase GDM become pregnant again, it is nonstarchy vegetables. The
their energy expenditure, but it also is recommended that they be screened concept is very simple: fill half
more economical and more conve- for GDM earlier than 24 weeks and the plate with nonstarchy veg-
nient than bottles and formula. repeatedly with a 50-g, 1-hour OGTT etables. On the other half of the
Breastfeeding has positive health ben- to evaluate their glucose tolerance.1,2 plate, serve a palm-sized por-
efits for children, such as boosting the If a primary care provider is assum- tion of heart healthy protein
immune system, promoting a leaner ing care after the pregnancy, be sure and fist-sized portion of starchy
body composition during infancy, and this provider receives information foods.
possibly reducing the risk of obesity regarding the history of GDM during Space meals throughout the
later in life. Breastfeeding also pregnancy. Women should be coun- day.
enhances bonding between mothers seled to be vigilant regarding their Use added fats in moderation.
and their children.13 blood glucose levels as they age. Choose monounsaturated fats,
Overall nutrition needs during lac- Blood pressure, cholesterol, and such as canola or olive oil,
tation are greater than during preg- triglyceride levels should also be instead of polyunsaturated fats.
nancy. The DRI caloric recommenda- observed. Elevation of these levels Small servings of nuts and all-
tion to support lactation during may indicate movement toward pre- natural nut butters can be
infants’ first 6 months is 500 kcal per diabetes or the metabolic syndrome, heart-healthy snacks or protein
day higher than for nonpregnant particularly for women who have a choices at mealtime. Try to
women, and 400 kcal per day after 6 family history of diabetes. limit foods that include trans
months. Adequate protein is also fats.
important while nursing. The DRI is Healthful Postpartum Lifestyle • Eat second helpings of nonstarchy
71 g per day, which is 15 g more than Strategies vegetables instead of starchy foods,
for nonpregnant women 19–50 years The prevalence of type 2 diabetes is such as rice, pasta, and potatoes.
of age.9 Nursing mothers should try to three to seven times higher in obese • Try to have two to three servings of
drink ~ 8 cups of water per day and at than in normal-weight adults. Weight calcium-rich foods each day: milk,
least 1 cup of water each time they gain during adulthood is also directly yogurt, cheese, cottage cheese, forti-
breastfeed their baby.14 Nursing correlated with an increased risk of fied soy milk or tofu, sardines,
mothers should also try to eat a wide type 2 diabetes.15 The DPP demon- dried fish, or 2 cups of dark leafy
variety of foods, such as whole grains, strated that intensive lifestyle interven- vegetables.
fruits, and vegetables, because low vit- tions (diet and exercise) reduced the • Drink water to reduce empty calo-
amin and mineral intake can affect the incidence of type 2 diabetes by ries. Other options include seltzer,
nutritional quality of breast milk. 58%.16,17 The goal of the intensive mineral water, and sugar-free, caf-
lifestyle group was to maintain a feine-free soft drinks. Try to use
Future Health Care weight reduction of at least 7% of ini- caffeinated beverages such as tea
As for any pregnancy, women with tial body weight through the use of a and coffee in moderation.
GDM should be advised to return to healthy low-calorie, low-fat diet and • Use small (4 oz) glasses for fruit
their health care provider for a 6- moderate exercise for at least 150 juice and other sugary beverages. If
week postpartum checkup. The ADA minutes per week (i.e., ~ 20 minutes still thirsty, drink water.
recommends evaluation for the devel- per day). • Increase the fiber in the food plan.
opment of diabetes by completing a Women with a history of GDM Choose whole-grain breads, cereals,
75-g, 2-hour oral glucose tolerance should try to achieve their prepreg- and crackers with at least 3 g of
test (OGTT) in the 6- to 12-week nancy weight within 6–12 months fiber per serving. Choose whole
period after the birth of the child. It is after delivery. If they are still over- fruits and fresh or frozen vegetables
also recommended that the fasting weight (BMI > 25 kg/m2) after 12 each day.
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 Nutrition FYI

• Check out the new food pyramid the “Small Steps. Big Rewards.
(www.mypyramid.gov). Use the Prevent Type 2 Diabetes.” campaign References
“Pyramid Plan” to create a food to promote the findings from the 1
plan that is right for everyone in the Diabetes Prevention Program to audi- American Diabetes Association: Gestational dia-
betes mellitus (Position Statement). Diabetes
family. ences at high risk. This campaign fea- Care 27 (Suppl. 1):S88–S90, 2004
• Be a role model for children. If par- tures messages and materials for mul- 2
American Diabetes Association: Diagnosis and
ents choose to eat healthful foods, ticultural audiences to help them classification of diabetes mellitus (Position
children will be more likely to eat make lifestyle changes to reduce their Statement). Diabetes Care 28 (Suppl. 1):S37–
them, too. risk for the disease. In April 2006, the S42, 2005
Moderate physical activity 5 days NDEP launched the “It’s Never Too 3
O’Sullivan JB: Diabetes after GDM. Diabetes 40
per week for at least 30 minutes is Early to Prevent Diabetes” campaign (Suppl. 2):131–135, 1991
also a very important risk-reduction to alert women with a history of 4
O’Sullivan JB: Subsequent morbidity among
behavior. In the DPP, the majority of GDM—and their children—about gestational diabetic women. In Carbohydrate
participants walked briskly to reduce their increased lifelong risk for devel- Metabolism in Pregnancy and the Newborn.
their risk of diabetes. Additional oping type 2 diabetes. The NDEP has Sutherland HW, Stowers JM, Eds. New York,
strategies to increase levels of physi- developed a new educational tip sheet, Churchill Livingstone, 1984, p.174–180
cal activity could include some of the available in English and Spanish, that 5
Ross TA, Boucher JL, O’Connell BS: American
following: alerts them to this risk and directs the Dietetic Association guide to diabetes medical
• Choose a physical activity that is audience to learn more by obtaining nutrition therapy. In Diabetes in Pregnancy and
enjoyable, perhaps one that the comprehensive diabetes prevention Lactation. Reader DM, Ed. Chicago, American
Dietetic Association, 2005, p. 189–197 .
whole family can do together. The materials and resources, including
6
best time to perform physical activi- “Your GAME PLAN to Prevent Type American College of Obstetrics and
Gynecology: Pregestational diabetes mellitus.
ty is when it fits into the individ- 2 Diabetes.” The tip sheets and out- ACOG Practice Bulletin – No. 60. Obstet
ual’s or family’s schedule. reach efforts complement campaign Gynecol 105:675–685, 2005
• Use a pedometer to keep track of materials that are tailored for other 7
Thomas AM, Gutierrez YM: American Dietetic
how many steps are taken each day. groups at risk for developing type 2 Association guide to gestational diabetes. In
The long-term goal is 10,000 steps diabetes. In addition, the NDEP is Medical Nutrition Therapy. Guiterrez YM,
per day or 5 miles. Initially, the developing materials targeting health Reader DM, Eds. Chicago, American Dietetic
pedometer can be worn to determine care providers to alert them to this Association, 2005, p. 45–64
the baseline number of steps taken new information to help them support 8
American Dietetic Association: Medical nutri-
each day. Then counsel patients to their patients. NDEP materials can be tion therapy evidence-based guides for practice:
gradually increase their steps. ordered online at www.ndep.nih.gov nutrition practice guidelines for gestational dia-
betes mellitus” [CD-ROM]. Chicago, American
• Limit sedentary activities. Try to (click on the logo for “Small Steps. Dietetic Association, 2001
limit television and computer to no Big Rewards. Prevent Type 2
9
more than 2 hours per day. Diabetes”) or by calling 800-438- Institute of Medicine: Dietary Reference Intakes
for Energy, Carbohydrate, Fiber, Fat, Fatty
• Set an example. If parents are phys- 5383. Acids, Cholesterol, Protein, and Amino Acids
ically active, children will be more (Macronutrients). Washington, D.C., National
likely to be active, too. Summary Academy Press, 2002
The incidence of GDM and subse- 10
Thomas AM, Gutierrez YM: Postpartum con-
Contraception Considerations quent type 2 diabetes is increasing as siderations. In American Dietetic Association
The goal of contraception is to be obesity and reduced levels of physical Guide to Gestational Diabetes. Gutierrez YM,
effective, yet decrease the risk of dia- activity increase. In the past, we Thomas AM, Eds. Chicago, American Dietetic
betes later in life. Estrogen has no informed participants in our GDM Association, 2005, p. 101–113
effect on carbohydrate metabolism.18 programs of their increased risk of 11
Stuebe AM, Rich-Edwards JW, Willett WC,
There is some evidence that progestin- developing diabetes later in life in one Manson JE, Michels KB: Duration of lactation
and incidence of type 2 diabetes. JAMA
only oral contraceptives may increase or two sentences. Women with GDM 294:2601–2610, 2005
a woman’s risk of developing diabetes must be fully and completely coun- 12
later in life, especially when used dur- seled about their risk; the need to McGanity WJ, Dawson EB, Van Hook JW:
Maternal nutrition. In Modern Nutrition in
ing the time the woman is breastfeed- monitor the risk, including regular Health and Disease. Shils ME, Olson JA, Shine
ing.19 Whenever oral contraceptive follow-up; and the need for preventive M, Ross AC, Eds. Baltimore, Md., Williams and
agents are used, they should be com- measures (e.g., weight loss and physi- Wilkins, 1998, p. 811–838
bination pills in the lowest dose for cal activity), while striving to preserve 13
Akers S, Groh-Wargo S: Normal nutrition dur-
the wanted effect. Intrauterine devices their excitement regarding the preg- ing infancy. In Handbook of Pediatric Nutrition.
are a safe and effective method of nancy and impending parenthood. 3rd ed. Queen Samour P, King K, Eds. Sudbury,
birth control that do not affect Mass., Jones and Bartlett, 2005, p. 75–106
glycemic control. 14
Insel P, Turner RE, Ross D: Discovering nutri-
Acknowledgments tion. In Life Cycle: Maternal and Infant
Educational Materials for Women The authors thank the staff of the Nutrition. Baer JT, Ed. Sudbury, Mass., Jones
Joslin Diabetes Center education affil- and Bartlett, 2003, p. 503
With a History of GDM
In 2003, the National Diabetes iate at Swedish Medical Center who 15
Klein S, Sheard NF, Pi-Sunyer X, Daly A,
Education Program (NDEP) launched created and support this program. Wylie-Rosett J, Kulkarni K, Clark NG: Weight
management through lifestyle modification for
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18
the prevention and management of type 2 dia- Damm P: Contraception after gestational dia-
betes: rationale and strategies. Diabetes Care betes (Abstract). Presented at the 5th Alison B. Evert, RD, CDE, is a dia-
27:2067–2073, 2004 International Workshop-Conference on betes nutrition educator at the
16
Diabetes Prevention Program Research Group: Gestational Diabetes, 2005, Chicago, Ill., A59 University of Washington Diabetes
The Diabetes Prevention Program (DPP): 19
Kjos Siri L: Postpartum care of the woman Care Center in Seattle, Wash., and
description of lifestyle intervention. Diabetes
Care 25:2165–2171, 2002
with diabetes. Clin Obstet Gynecol 43:75–86, Kathy Vande Hei, RN, CDE, is a dia-
2000 betes nurse educator at the Joslin
17
Diabetes Prevention Program Research Group: 20 Diabetes Center, an education affiliate
Reduction in the incidence of type 2 diabetes American Diabetes Association: Screening for
with lifestyle intervention or metformin. N Engl type 2 diabetes (Position Statement). Diabetes at Swedish Medical Center in Seattle,
J Med 346:393–403, 2002 Care 26 (Suppl. 1):S21–S24, 2003 Wash.

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