Manual of Clinical Nutrition

Medical Nutrition Therapy for Gestational Diabetes Mellitus

Manual of Clinical Nutrition Management C- 19 Copyright © 20 13 Compass Group, Inc.

gain during pregnancy (Grade II) (6). Persons should frequently monitor their blood glucose levels before and
after physical activity. Persons who do exercise should be aware that prolonged exercise (> 60 minutes) is
more likely to cause hypoglycemia in pregnancy (Grade II) (6).

Follow-up Evaluation and Monitoring
The recurrence rate of GDM in subsequent pregnancies is 30% to 65% (Grade I) (6). The American Diabetes
Association recommends a follow-up evaluation of each woman diagnosed with gestational diabetes (1,4),
because these women may be prone to the development of type 2 diabetes later in life (Grade I) (4).
Reclassification of maternal glycemic status should be performed 6 to 12 weeks after delivery (1). If
postpartum glucose levels are normal, then glycemia should be reassessed at a minimum of 3-year intervals
(1). Women with impaired fasting glucose or impaired glucose tolerance in the postpartum period should be
annually tested for diabetes (1,5). See Section II: Diagnostic Criteria for Diabetes Mellitus. It is prudent to
provide nutrition counseling and guidance to these women after the birth of their children. Lifestyle
modifications aimed at reducing weight or preventing weight gain and increasing physical activity after
pregnancy are recommended to reduce the risk of developing type 2 diabetes mellitus (1).

Dietary Recommendations for Pregnant Women With Preexisting Diabetes
Preconception care is a key factor in successful pregnancy outcomes for persons with preexisting diabetes
(type 1 or type 2). All women with diabetes should be educated regarding the need for good blood glucose
control before pregnancy and should participate in family planning (1). A woman’s A1C level should be as
close to normal as possible (<6.5%) before conception is attempted (1). Medication use should be evaluated
before conception because drugs commonly used to treat diabetes and its complications may be
contraindicated or not recommended in pregnancy (1). Nutrient requirements during pregnancy and lactation
are similar for women with and without diabetes (4). For pregnancy complicated by diabetes, nutrition
therapy should attempt to achieve and sustain optimal maternal blood glucose control. A favorable
pregnancy outcome is defined as a gestational duration of 39 to 41 weeks and the birth of a live infant
weighing 6.8-7.9 lb (3.1-3.6) (8). During pregnancy with prior onset of type 1 or type 2 diabetes, the
distribution of energy intake and carbohydrates in the meal plan should be based on the woman’s eating
habits, blood glucose records, and stage of pregnancy. Regular meals and snacks are important to avoid
hypoglycemia due to the continuous fetal draw of glucose from the mother (4). An evening snack is usually
necessary to decrease the potential for overnight hypoglycemia and fasting ketosis (4). Energy intake to
achieve appropriate weight gain may be estimated based on the percent of desirable body weight before the
pregnancy (4,5). Pregravid BMI may be used to estimate a goal for weight gain during pregnancy (7-9).

Lactation
Breast-feeding is recommended for infants of women with preexisting diabetes or GDM. Research indicates
that even short duration of breastfeeding results in long-term improvements in glucose metabolism and may also
reduce the risk of type 2 diabetes in children (Grade III) (6). Successful lactation requires planning and coordination
of care (12). In most situations, breast-feeding mothers require less insulin because of the energy expended by
nursing. Lactating women have reported fluctuations in blood glucose levels related to nursing sessions, and
they often require a carbohydrate-containing snack before or during nursing sessions (12).

*The Academy of Nutrition and Dietetics has assigned grades, ranging from Grade I (good/strong) to Grade V (insufficient evidence), to
evidence and conclusion statements. The grading system is described in Section III: Clinical Nutrition Management A Reference Guide,
page III-1.

References

1. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1): 11S-66S


2. American Diabetes Association. Diagnosis and classification of diabetes mellitus: position statement. Diabetes Care.
   2013;36(suppl 1): 67S-74S.


3. Gestational Diabetes. In: The Nutrition Care Manual. The Academy of Nutrition and Dietetics. Updated annually. Available at:
   nutritioncaremanual.org. Accessed January 23, 2013.


4. American Diabetes Association. Nutrition recommendations and interventions for diabetes: position statement. Diabetes Care.
   2008;31 (suppl 1):61S- 7 8S.


5. American Diabetes Association. Gestational diabetes mellitus: position statement. Diabetes Care. 2004;27(suppl 1):88S-90S.


6. Gestational Diabetes Evidence-Based Nutrition Practice Guideline. Academy of Nutrition and Dietetics Evidence Analysis Library.
   Academy of Nutrition Dietetics; 2008. Available at: http://www.andevidencelibrary.com. Accessed January 23, 2013..


7. Food and Nutrition Board. Nutrition During Pregnancy. Part I: Weight Gain. Part 2: Nutrient Supplements. Washington, DC:
   Institute of Medicine, National Academy of Sciences; 1990.


8. Butte NF, King JC. Energy requirements during pregnancy and lactation. Public Health Nutr. 2005;8:1010-1027.


9. Brown JE, Carlson M. Nutrition and multifetal pregnancy. J Am Diet Assoc. 2000;100:343-348.


10. Medical Management of Pregnancy Complicated by Diabetes. 2nd ed. Alexandria, Va: American Diabetes Association; 1995.


11. Major CA, Henry MJ, De Veciana M, Morgan MA. The effects of carbohydrate restriction in patients with diet-controlled gestational
    diabetes. Obstet Gynecol. 1998;91:600-604.


12. Reader D, Franz MJ. Lactation, diabetes, and nutrition recommendations. Curr Diab Rep. 2004;4:370-376.