Diabetes & Pregnancy

During pregnancy the increased glucose level in the blood has a bad effect on the development of the foetus. Therefore it is important that glucose level remains in control throughout pregnancy.

Pregnancy is safe in diabetic patients provided some precautions are followed. Before the discovery of insulin pregnancy in diabetes was dangerous for both mother and foetus.

Most important thing to remember is that no oral drug should be given in a diabetic pregnant lady. The ideal method of controlling diabetes in a pregnant lady is by insulin hormone.

The availability of insulin has made it possible to have a safe pregnancy outcome.

Two types of Diabetes can occur in pregnancy:

1. Normal female without history of diabetes before pregnancy:

If a normal female develops diabetes during pregnancy (generally after 24 weeks of pregnancy), it is known as Gestational Diabetes Mellitus (GDM).

This is more common in females above the age of 30, overweight and those who have positive family history of diabetes.

During pregnancy many hormonal changes take place in the body which decrease the efficiency of insulin. This increases the requirement of insulin. Females in whom this extra insulin is not produced go on to have Gestational Diabetes. This condition occurs in 3% of the females.

Here it is important to know that Gestational Diabetes is different from Pre-Gestational Diabetes. If a female who is already diabetic, becomes pregnant then such a condition is called Pre-Gestational Diabetes.

Diagnosis of GDM:

Around 24th week of pregnancy blood glucose level in fasting state and one hour, two hour, three hour post 75 gm oral glucose is tested. Following table shows the upper limit of normal value for blood glucose:

If two of the above four reports are above the normal value the patient is diagnosed as a case of GDM.

In GDM initially patient is advised to make dietary changes and if glucose level does not come down with diet alone then insulin treatment is started.

2. Females with Pre-existing Diabetes and Pregnancy:

Patients with diabetes willing for pregnancy should consider this option in a planned manner.

It is important to note that if a diabetic female patient suffers from any of the following serious disorders, she should not opt for pregnancy.

• Severe heart disease.
• High blood pressure
• Diabetic Retinopathy (Severe NPDR or Proliferative DR)
• Diabetic Nephropathy

Advise before Conception:

• If diabetes is under control by diet and exercise alone then pregnancy can be planned. If glucose is on the higher side then it has to be controlled by insulin before planning pregnancy.
• If patient is taking oral drugs for diabetes then this has to be modified and patient has to be put on insulin. . Insulin treatment is the safest option in diabetes with pregnancy.
• If patient is on insulin before pregnancy then blood glucose should be controlled before conception. During pregnancy only Human Insulin should be used.

Target glucose level during pregnancy:while on treatment

Precautions during pregnancy:

• Avoid artificial sweeteners.
• Do not consume alcohol.
• Do not smoke.
• Divide daily meals in 6-8 parts.
• Regular Kidney and Eye checkup.

Expectations from Pregnant Diabetic Patients:

• Follow diet instruction sincerely.
• Glucose self monitoring with help of Glucometer.
• Insulin self injection.
• Should be able to identify and manage hypoglycemia.
• maintain food diary (daily / weekly )

Breast Feeding:

• Mother’s milk is most important for the new born. All diabetic mothers can breast feed their babies

how to monitor sugars after delivery (those who has normalise sugars after delivery )

• sugar monitoring fbs,ppbs after one month of delivery and then check 3 monthly fbs,ppbs,hba1c and than yearly monitoring sugar level.
• GDM resolves after pregnancy in majority of cases.
• recurrent gdm in subsequent pregnancy
• history of gdm were tested for type 2 dm after delivery 40%of time.

General instruction and dietary management in GDM

(Gestational diabetes mellitus = Diabetes in pregnancy)

it is advise to consult your doctor / gynecologist / dietician for customization of dietary changes according to your health / fitness.

High blood sugar levels during pregnancy may be harmful to both the woman and the growing fetus. It is important to monitor how many carbohydrates are present in the diet — including the type of carbohydrate and the frequency of consumption — to help manage blood sugar levels.

Keeping a food diary may make this easier. It is also important for women with gestational diabetes to monitor and log their blood sugar levels according to a doctor’s directions. Most women will need to check these levels in the morning and between meals. The results can indicate the amount and type of food that is safe for them to eat.

Monitoring carbohydrates

It can help to space meals and snacks that contain carbohydrates evenly throughout the day. Doing this can reduce the size of blood sugar spikes after eating.

The National Institute of Child Health and Human Development recommend that women with gestational diabetes consume at least three small-to-medium meals and between two and four snacks per day.

Other ways to help regulate blood sugar include:

• refraining from eating too many carbohydrates at one time
• sticking to foods that contain complex carbohydrates, such as fiber
• combining carbohydrates with protein or healthful fats
• avoiding skipping meals
• eating a protein-rich and high fiber breakfast

Eating low glycemic index foods

Eating foods that have a low glycemic index (GI) is another crucial factor in a gestational diabetes diet.

GI measures how rapidly a particular food increases blood sugar levels. The body breaks down foods with a low GI more slowly than those with a high GI.

The index classifies foods with a score of 55 or below as low GI. These foods are ideal for women with gestational diabetes who are trying to manage their blood sugar levels.

Low GI foodsTrusted Source to eat include:

nonstarchy vegetables

some starchy vegetables, such as peas and carrots

• some fruit, such as apples, oranges, kiwi, grapefruit, peaches, and pears
• beans
• lentils
• chickpeas

All of these low GI foods release sugar into the blood slowly, which helps keep blood sugar levels stable.

Eating more protein

Eating protein alongside carbohydrates or choosing carbohydrate-rich foods that also provide protein helps balance blood sugar levels. Women with gestational diabetes should try to eat nutritious, protein-rich foods, such as:

• tofu
• beans : soybean, chickpeas, lentils
• nuts : almond, cashews, pistachios, walnuts
• seeds : hempseed, chia seed, flex seed, pumpkin seed
• qunioa
• legumes
• soya milk
• oats
• peanut butter
• fish, chicken, turky
• eggs

Choosing unsaturated fats

Unsaturated fats are also part of any healthful diet.

• Go easy on butter, margarine, salad dressing, cooking oil, and desserts.
• Avoid fats high in saturated fat such as hamburger, cheese, bacon, and butter.
• Don't cut fats and oils from your diet entirely. They provide energy for growth and are essential for baby's brain development.
• Choose healthy oils, such as canola oil, olive oil, peanut oil, and safflower oil. Include nuts, avocados, and olives.

Foods to avoid

Avoiding foods that may excessively raise blood sugar levels is essential if a person is following a gestational diabetes diet.

Avoiding sugary foods

Blood sugar levels increase when people eat sugary foods, particularly those that have undergone refinement or processing. Women with gestational diabetes should avoid or limit sugary foods as much as possible.

Sugary foods to avoid include the following:

• cakes
• cookies
• candy
• desserts
• sweet pastries
• soda
• ice cream
• fruit juice with added sugar

Women with gestational diabetes can enjoy milk and fruits in moderation, even though they contain natural sugars.

Avoiding highly starchy foods

Starchy foods are high in carbohydrates and can have a significant effect on blood sugar, so it is important to eat them only in small portions. It is best to avoid or limit very starchy foods, including:

• white potatoes
• white bread
• white rice
• white pasta

Although whole grains, such as whole wheat pasta and brown rice, are more nutritious, they are still high in carbohydrates. As a result, these foods may also be best in moderation.

Avoiding hidden sugars and carbohydrates

as consuming more salt can lead to water retention and further increase swelling during pregnancy and can also lead to gestational hypertension, which along with gestational diabetes can be very risky for both the mother and the baby

Avoiding highly starchy foods

Some foods and drinks are not obviously sources of sugar or carbohydrates. However, they may still contain potentially harmful levels of both. Examples of these products include:

• highly processed foods
• some condiments, such as dressings and ketchup
• fast foods
• alcohol

MEDICAL NUTRITION THERAPY IN GESTATIONAL DIABETES MELLITUS

Women with GDM should be counselled by a dietitian once the diagnosis is made to initiate MNT which is the mainstay of any management plan. The aim is to attain normal glycemic control without ketosis and fetal compromise along with adequate weight gain based on prenatal BMI. MNT should allow sufficient calories for the mother and the developing fetus while avoiding excess weight gain and prandial hyperglycemia. The calorie requirement depends on factors such as pre-pregnancy weight, stage of pregnancy, activity levels and blood glucose levels. No incremental calorie intake is recommended during the first trimester. approximately 350 kcal/day additional (only in the second and third trimester) is regarded as adequate. Pre-pregnancy body mass index-adjustment calorie requirement during pregnancy

Calorie intake may be reduced (if overweight/obese), but should not be below 1600-1800 kcal/day Monitoring weight changes is important to ensure the adequacy of MNT and to gain weight within the recommended limits. It is very important to avoid skipping meals. This is because nutritional needs are increased for optimal growth and development of the foetus.

Ways to reduce post-meal glucose spikes

1. MNT comprising of three meals and mid-meal snacks (low in carbohydrates and moderate amounts of protein at regular intervals is recommended to allow even distribution of carbohydrates throughout the day. A minimum of 175 g/day carbohydrates should be ensured.

2. including fibre aids in improving safety, prevents constipation and helps in stabilizing blood glucose levels. The recommended fibre intake for women is 25-40 g/day. Consumption of adequate fibre in the form of whole grains, millets, legumes and whole fruits and vegetables should be advised.

3. Carbohydrates are generally not as well tolerated at breakfast as in other meals. This is because during pregnancy in most cases dawn phenomenon appears to contribute to morning glucose intolerance. Hence, it is advised to split the breakfast in to two parts with a 2hr gap.