Medical Nutrition Therapy for Gestational Diabetes MellitusManual of Clinical Nutrition Management C- 17 Copyright © 20 13 Compass Group, Inc.
Table C-5: Recommended Daily Energy Intake for Pregnant Diabetic Women
Prepregnancy Weight Status Energy (kcal/kg per day) Energy (kcal/lb per day)
Desirable body weight 30 13.6
120% of desirable body weight, BMI >30 kg/m^2 25 10.9
<90% of desirable body weight 36 - 40 16.3-18.2
Sources: American Diabetes Association. Gestational diabetes mellitus: position statement. Diabetes Care. 2004;27(suppl 1):88S-90S.
Medical Management of Pregnancy Complicated by Diabetes. 2nd ed. Alexandria, Va: American Diabetes Association; 1995.
Managing Ketosis
The prevention of ketosis is a primary outcome of medical nutrition therapy in GDM (5). Case-control and
cohort studies have found an association between ketonemia and ketonuria during GDM and a lower
intelligence quotient in offspring (Grade II) (6). Ketone testing is an important part of self-monitoring and aids in
adjusting the energy intake level, carbohydrate distribution, and physical activity level (Grade II) (6). To prevent
ketosis, adequate energy intake and the appropriate distribution of meals and snacks is important. An
evening snack may be needed to prevent accelerated ketosis overnight (4). Low-energy diets in obese women
with GDM can result in ketonemia and ketonuria (4). Randomized controlled trials have shown that
restricting energy intake to 1,200 kcal/day in obese women (BMI >30 kg/m^2 ) with GDM results in ketonemia
or ketonuria, whereas restricting the daily energy intake to a more liberal amount of ~1,800 kcal (25 kcal/kg
of actual weight) does not result in ketonemia or ketonuria (Grade I) (6). Moderate energy restriction, defined as
a 30% reduction in estimated energy needs, in obese women with GDM may improve glycemic control and
reduce excessive maternal weight gain without the development of ketonemia; however, insufficient data are
available to determine the effect of such diets on perinatal outcomes (4). Daily food records, weekly weight
checks, and ketone testing remain paramount in assessing the adequacy of a patient’s energy intake (4).
Carbohydrate Intake
The amount and kind of carbohydrate in meals and snacks are key to maintaining optimal blood glucose
levels and reducing the need for insulin while controlling maternal weight gain and infant birth weight (Grade II)
(4,6,11). The amount and distribution of carbohydrate intake should be based on the clinical outcome measures
of hunger, plasma glucose levels, weight gain, and ketone levels (4). A minimum of 175 g of carbohydrate
should be provided on a daily basis (Grade II) (3,4,6). A diet comprised of 42% to 45% carbohydrate distributed
among six to eight meals and snacks throughout the day with smaller amounts of carbohydrate (15 to 45 g) at
breakfast and snacks promotes normal blood glucose levels (Grade II) (6). Lower carbohydrate intake is
suggested at breakfast, because carbohydrate is generally less well tolerated at breakfast than at other meals
during pregnancy (4). It has been suggested that nonnutritive sweeteners may be used in moderation as a
means to control total energy intake and promote blood glucose control in GDM (5). While there are
recognizable benefits of the use of nonnutritive sweeteners with maintenance of blood glucose control, there
is limited evidence to support the use or nonuse of nonnutritive sweeteners in pregnancy and even less
evidence addressing this issue specifically in GDM (Grade IV) (6). Refer to Section IA: Nutrition Management
During Pregnancy and Lactation for additional information about the nutrient requirements and use of
nonnutritive sweeteners during pregnancy.
Self-Monitoring of Blood Glucose Goals
Self-monitoring of blood glucose levels is an essential component of maintaining desirable blood glucose
levels in women with GDM. Studies have shown that the best outcomes are achieved when both fasting and
1 - or 2-hour postprandial blood glucose levels are monitored three to eight times per day and used to modify
food intake or meal patterns and physical activity levels (Grade I) (6). The American Diabetes Association
recommends that people with type 1 diabetes and pregnant women who take insulin check their blood
glucose levels three or more times daily so that they can adjust their food intake, physical activity level,
and/or insulin dosage to meet blood glucose goals (1). Evidence has shown that mean serum glucose levels of
86 mg/dL increase the risk for small for gestational age infants and that mean glucose levels of 105 mg/dL
increase the risk for macrosomia (Grade I) (6). The following are glucose goals established for GDM by the
American Diabetes Association based on capillary glucose concentrations (1):