Dietary manipulation as a primary treatment strategy for pregnancies complicated by diabetes.

Abstract

The mainstay of management for gestational diabetic women (GDM) has been dietary. If it is inadequate to sustain normoglycemia, insulin therapy must be initiated. We studied whether we could prevent macrosomia by insulin therapy based on four daily self blood glucose levels (SBG). Fifty GDM, ages 28-39 years were, recruited to the study. They were divided based on fasting glucose (FBS) level on the glucose tolerance test (GTT): those with FBS less than 90 mg/dl were managed by diet alone; those with FBS greater than 90 mg/dl were immediately started on insulin. The four SBG checks [FBS and 1 hour after each meal (lhpc)] correlated with the continuous glucose monitor with r = 0.91. The women were asked to perform a dipstick for ketones on their urine upon awakening and whenever a meal or snack had been missed. Insulin was initiated when the SBG monitoring indicated that: (1) the FBS was 80 mg/dl whole blood from fingerstick (WBG) or the plasma glucose (PG) greater than 90 mg/dl and/or (2) the lhpc was greater than 140 mg/dl WBG and/or (3) the patient had persistent ketonuria on the prescribed diet which cleared only when the caloric intake was increased to a point which precipitated postprandial hyperglycemia. The prescribed diet was calculated based on body weight to be 30 kcal/kg if the women were between 80 and 120% ideal body weight; or was calculated to be 24 kcal/kg if their weight was greater than 120% ideal body weight. The calories were divided such that 40% was carbohydrate, 20% protein, and 40% fat.(ABSTRACT TRUNCATED AT 250 WORDS)

Gestational diabetes and nutritional recommendations

“…Peterson and Jovanovic-Peterson [46] reported a positive correlation between the glycemic response to a mixed meal and the percent of calories from carbohydrate [46]. In clinical practice, Jovanovic-Peterson and Peterson [29,30] reported that 50% of women required insulin therapy consuming a diet composed of 50% to 60% of energy from carbohydrate, but carbohydrate restriction to 30% to 40% of total kcal reduced insulin use by one half, to 26%. Major et al [44] nonrandomly allocated two clinics of diet-controlled patients with GDM to either carbohydrate restriction (< 42% of kcal) or high carbohydrate (45% to 50% of total kcal).…”

“…In 2002, the ADA also recommended modest carbohydrate restriction (35% to 40% of kilocalories [kcal]) for GDM [4•]. This recommendation was based on limited observational evidence that high carbohydrate levels (55% compared to 40% of total energy) may be associated with deterioration in glycemic control, and accentuation of hyperinsulinemia among persons with type 2 diabetes [28] as well as pregnant women with GDM [29,30]. (7) BMI-body mass index.…”

Development of early-onset type 2 diabetes in the young: Implications for child bearing

“…There is at least theoretic concern with caloric restriction specifically in regard to the potential adverse fetal effect of maternal ketonuria. However, studies in overweight and obese pregnant women with diabetes have shown improved pregnancy outcomes with moderate caloric restriction [27][28][29]. It is generally believed that overweight women with diabetes do not need to gain as much weight as their counterparts with type 1 diabetes, owing to their existing adipose tissue.…”

Tratamento do diabetes melito gestacional

“…Com a introdução da insulina na terapêu-tica, a taxa de carboidratos na dieta manteve-se entre 35% a 65% das calorias 17 , e objetivou-se restrição calórica e de carboidratos para melhor controle glicêmico. Entretanto, é importante a manutenção da oferta protéica na gestação, tanto para o crescimento fetal adequado, quanto para garantir o aumento da produção de insulina necessário na gestação 18 .…”

“…Estudos demonstram bons resultados em relação ao crescimento fetal com a restrição calórica baseada no peso da paciente, com 30 Kcal/Kg/dia em mulheres com 80% a 120% do peso ideal, 24 kcal/Kg/dia em pacientes acima de 120%, e 40 Kcal/Kg/dia naquelas com menos de 80% do peso ideal. O total de calorias ingeridas deve ser dividido em várias refeições, sendo recomendado: apenas 10% do total de calorias no café da manhã, já que neste horário ocorrem os picos de hormônio do crescimento e cortisol, gerando maior hiperglicemia pós-prandial; 60% divididos entre almoço e jantar; e os 30% restantes divididos entre dois ou três lanches no decorrer do dia 17,20,21 . O tempo necessário para observar o efeito da dieta sobre o controle do DMG ainda é questionado.…”