Nutrition Therapy In Gestational Diabetes PART 1 ASSESSMENT

Nutrition Therapy In Gestational Diabetes PART 1 – ASSESSMENT PART 2 – RECOMMENDATIONS PART 3 – EDUCATION

Objectives • Discuss factors that should be considered when doing a nutritional assessment • Discuss appropriate balance of meals/snacks through the day • Discuss appropriate weight gain based on preconception weight • Discuss the value of a late night snack to prevent early morning ketosis • Evaluate the importance of folic acid supplementation before and during pregnancy • Discuss the value of multivitamin supplementation during pregnancy 2

Goals for MNT in GDM • Optimal nutrition and weight gain for fetus and mother • Maternal euglycemia • Reduce the risk of diabetes related complications for the mother and child • Minimize the maternal and infant morbidity and mortality rates • Integrate diet, activity and pharmalogic therapy • Introducing healthy habits that can prevent or delay onset of type 2 DM 3

Assessing from an Interview • • • Age Obstetric history Weight History Significant medical history (co-morbidities) Food preferences and eating habits Food Allergies Individual psychological, social and physical status Lifestyle, culture, and socio-economic status Oral health Readiness to change 4

Assessing from Clinical Information Laboratory tests to determine clinical status § OGTT, fasting glucose, Hb. A 1 c level § SMBG § Urine ketones and proteins § lipid profile (cholesterol — HDL, LDL) § Haemoglobin, creatinine, thyroid function § Blood pressure Anthropometric Data § Height , Weight and BMI Current medications and nutrition supplements 5

Body Mass Index (BMI) Use pregnancy weight for calculations Weight and height measurements to calculate BMI: BMI = weight in kg/(height in m)2 Standard BMI normograms: Asian Underweight ADA norms <18. 5 kg/m 2 Normal BMI 18. 0 -22. 9 kg/m 2 18. 5 -24. 9 kg/m 2 Overweight 23. 0 -24. 9 kg/m 2 25. 0 -29. 9 kg/m 2 Obesity >25 kg/m 2 > 30 kg/m 2 6

Weight Gain Chart • Plot weight on a prenatal weight gain grid to obtain an accurate assessment of total pregnancy weight gain and rate of weight gain. • Determine if weight gain is above, at or below the recommended range. • If weight gain has already exceeded the recommended range, slow weight gain in order to prevent further excess gain. 7

Nutrition Assessment Nutrition history § usual food intake recorded through interview Dietary recall § food and drink consumed in previous 24 hours (24 -hour recall) 8

Activity – Think of things to check for when doing a dietary history. 9

Issues with Dietary Recalls • Based on memory • Based on willingness to disclose the truth to a healthcare provider • Nutrient intake and long-term habits are not represented • Accurate estimations of food quantities/ingredients are difficult 10

Nutrition Therapy In Gestational Diabetes PART 1 – ASSESSMENT PART 2 – RECOMMENDATIONS PART 3 – EDUCATION

Composition of Food and Drinks Macro-nutrients § protein § carbohydrates § fats Micro-nutrients § vitamins § minerals 12

Recommendations for Weight Gain Singleton pregnancy • Where possible a dietitian should develop a meal plan. • At about the 4 th month of the pregnancy about 350 calories should be added daily. This should mean the woman is eating about 1900 -2000 calories a day. • Overweight women (BMI 23 and over before pregnancy) should increase less. • Underweight women (BMI less than 18 before pregnancy) could add more. Institute of Medicine : 2009 13

Dietary Recommendations for GDM Macronutrient composition Nutrient Carbohydrates % of daily calorie intake 45 -65% Fats 20 -35% Protein 10 -35% Dietary fibre 28 g/day Institute Of Medicine 2002 14

Fluids • Essential for all body functions • 40 -60% of body weight is water • Important to drink adequate amounts of fluid • Restrictions may be required in case of pedal edema 15

Proteins • Provide amino acids • Help to build muscle mass • Animal sources • Plant sources • 1 g of protein gives 4 kcal energy 16

Protein Recommendations • 1. 1 g protein per kg bodyweight per day • 10 -35% of total energy per day • Animal protein often high in fat, especially saturated. • Attention must be paid to meeting the protein requirements of women who are vegetarians or vegans 17

Carbohydrates • Provide main source of energy for the body (45 -65%) – individualized • Nutrient that most influences blood glucose levels • Source of simple sugars – glucose, fructose • 1 g of carbohydrate provides 4 kcal 18

Activity Name some of the common carbohydrates and staple foods in your region. 19

Carbohydrates And Meal Planning • Amount and source of carbohydrates is considered when planning meals • Recommended source of carbohydrates is mainly from - whole grains: wheat, rice, pasta, bread, rice, wheat, barley, oats, maize and corn - legumes, beans, pulses (bengal gram, black gram, rajma) - fruit and vegetables - milk 20

Carbohydrate (CHO) content of common foods Food Amount Serving CHO (g) Bread, whole wheat 28 g 1 slice 11 Rice (cooked) 75 g 0. 3 cup 13 125 m. L 0. 5 cup 16 44 g 1 small 19 45 m. L 3 tbsps 16 84 g 1 small 15 Couscous, cooked 125 m. L 0. 5 cup 17 Lentils 250 m. L 1 cup 15 Banana 101 g 1 small 20 Pasta Chappati Corn meal Potato (Canadian Diabetes Association, 2006) 21 M

Benefits of Fibre A high-fibre diet is healthy Mixture of soluble and insoluble fibre - slows absorption of glucose - reduces absorption of dietary fats - retains water to soften stool - may reduce the risk of colon cancer - may reduce the risk of heart disease 22

Fibre Recommendations Recommended amounts of total fibre : 28 g per day Sources of insoluble fibre include: wheat bran, whole grains, seeds, fruits and vegetables Sources of soluble fibre: legumes (beans), oat bran, barley, apples, citrus fruits CDA, 2013 23

Glycaemic Index (GI) Ranks carbohydrate-rich foods according to the increase in blood glucose levels they cause in comparison with a standard food (white bread/glucose). 24

Blood glucose level Glycaemic Response of Glucose and Lentils Glucose Lentils Reprinted with permission from CDA, 2004 25

Factors Affecting the Glycaemic Index Type of sugar - glucose, fructose, galactose Nature of starch - amylose, amylopectin Starch-nutrient interactions - resistant starch Cooking/food processing 26

Factors Affecting The Glycaemic Index Processing/form of the food - gelatinization - particle size - cellular structure Presence of other food components - fat and protein - dietary fibre Kalergis, De Grandpre, Andersons, 2005 27

Glycaemic Index of Foods Low glycaemic index foods Intermediate High glycaemic index Oats Multigrain bread White Bread Lentils/dhal Some rice (long grain) White Rice Yogurt Pasta Processed breakfast cereal Milk Bananas Glucose Most Fruits and vegetables Grapes Mashed and baked potatoes CDA , 2006 28

Low GI - Advantages Promotes healthy eating Increases fibre intake Helps control - appetite - blood glucose levels - blood lipid levels 29

Fats • The most concentrated source of energy • Foods may contain fat naturally or have it added during cooking • 1 g fat provides 9 kcal 30

Fat Recommendations • Low in polyunsaturated fats (up to 10% of total daily energy) • High in monounsaturated fats (>10%) • Low in saturated fats (<10%) • Trans or hydrogenated fat should be avoided Io. M 2002 31

Fats • Common sources of different fats • Polyunsaturated – safflower oil, sunflower oil, corn oil • Monounsaturated – olive oil, canola oil, rape seed oil, groundnut oil, mustard oil, sesame oil • Saturated – red meats, butter, cheese, margarine, ghee (clarified butter), whole milk, cream, lard • Trans fats – baked products, biscuits, cakes 32

Activity Identify major sources of fats in foods in your region. 33

Vitamins • Organic substances present in very small amounts in food • Essential to good health • A balanced meal automatically provides all necessary vitamins • Either fat-soluble or water-soluble • In some countries foods are “fortified” with vitamins and minerals 34

Vitamin Recommendations Daily multivitamin supplement should be added as they are often not met by diet alone. Multivitamin content varies depending on the product used. Women at higher risk for dietary deficiencies include multiple gestation, heavy smokers, adolescents, complete vegetarians, substance abusers, and women with lactase deficiency. 35

Minerals • Substance present in bones, teeth, soft tissue, muscle, blood and nerve cells • Help maintain physiological processes, strengthen skeletal structures, preserve heart and brain function and muscle and nerve systems • Act as a catalyst to essential enzymatic reactions • Low levels of minerals puts stress on essential life functions 36

Minerals And Trace Elements • A balanced diet supplies minerals and trace elements • Supplements are important as requirements are higher during pregnancy § Calcium supplementation § Iron supplementation § Folic acid supplementation 0. 4 mg (should be started three months prior to conception) CDA , 2013 37

Sodium Recommendations • Most people consume too much salt • Sodium restriction may be advised in case of uncontrolled hypertension and edema • Targets for daily sodium intake Age Adequate Intake (mg/day) Upper limit (mg/day) 14 -50 51 -70 over 70 1500 1300 1200 2300 Health Canada, 2005 38

Lowering Salt Intake • Sodium content is often high in restaurant foods • Encourage meal plans with • more fresh foods – fruits and vegetable • less processed, fast, convenience or canned foods • herbs and spices used when cooking instead of salt. • Teach people to read food labels. • Choose salt free, reduced or low in sodium foods 39

Substance Use The following substances should be avoided completely once the woman plans a pregnancy § Tobacco in any form § Alcohol § Drugs (street, illegal) 40

Sweeteners that increase blood glucose § Sugar, honey § Polydextrose & Sugar alcohols – maltitol, sorbitol, Xylitol Sweeteners that do not increase blood glucose § § § Acesulfame potassium Aspartame *Must be avoided during Cyclamate* pregnancy Saccharin* Sucralose To check with Health care team prior to starting use of sweeteners CDA, 2006 41

Food Labels • Nutrition facts • Serving size (if available) • Nutrient content • Ingredients • Nutrition information 42

Food labels Nutrition Facts Per 1 cup (250 g) Amount % Daily Value Calories 100 Fat 0 g Saturated 0 g + Trans 0 g Cholesterol 0 mg 0% Sodium 3 mg 0% Carbohydrate 26 g 8% 0% Fibre 1 g 4% Sugars 23 g Protein 2 g Vitamin A Calcium 20 % 2% Vitamin C Iron 170 % 2% Food labels may look different in different countries, but the same information is usually available 43 M

Activity Practice reading a food label Calculate the following: § § Serving size Number of calories in one serving Number of carbohydrates in one serving Amount of fat in one serving 44

Summary of Dietary Recommendations • Carbohydrates: 45 -65% • Dietary fibre: 28 g / day • Fats: 20 -35% • Protein: 10 -35% (1. 1 g/kg/day) • Sodium: 1500 - 2300 mg/day 45

Nutrition Therapy in Gestational Diabetes PART 1 – ASSESSMENT PART 2 – RECOMMENDATIONS PART 3 – EDUCATION

Approach To Meal Planning A uniform approach to meal planning does not work for everyone A flexible plan or a variety of approaches is necessary to address different needs 47

Meal Planning Before deciding on the content of meal plans, consider: • • • Food preferences and eating habits Previous experience, knowledge and skills Current clinical, psychological and dietary status Appropriate clinical and nutrition goals Lifestyle factors 48

What to teach and when? Basic • Basic information about nutrition • Nutrient requirements • Healthy eating guidelines • Making healthy food choices • Self-management training and use of educational tools 49

Nutrition Education: Tools • Awareness of the basics of healthy eating/balance of good health • Food Pyramid • The plate model 50

Food Guides • Australian Food Guide 51 M

Healthy eating • Eating Well with Canada’s Food Guide Recommended Number of Food Guide Servings per Day Children Age In Years 2 -3 Sex 4 -8 Teens 9 -13 Adults 14 -18 19 -50 51+ Girls and Boys Females Males Vegetables and fruits 4 5 6 7 8 7 -8 8 -10 7 7 Grain Products 3 4 6 6 7 6 -7 8 6 7 Milk and Alternative s 2 2 3 -4 3 -4 2 2 3 3 Meat and Alternative s 1 1 1 -2 2 3 2 3 The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canada’s Food Guide will help: § Meet your needs for vitamins, minerals and other nutrients. § Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. § Contribute to your overall health and vitality. 52 M

Food pyramid – India Diabetes India, 2005 53

Balance of good health - UK eat well plate Bread, cereals and potatoes Fruits and vegetables Meat, fish and protein alternatives Foods rich in sugars and fat Milk and dairy products (Reproduced with kind permission of the Food Standards Agency) 54 M

These graphics will change to be the same as the new ones going in the booklets Healthy food plate (Source: Diabetes Education Modules 2011) Example of Healthy food plate with South-Asian foods 55

Activity Draw on a paper plate either: The recommended proportions of foods from your region The proportions of what you ate last night 56

Practical Advice/ 1 • Make healthy food choices • Avoid fatty foods • Use low-fat cooking methods • Substitute high fat foods with low fat options; e. g use low fat milk • Minimize consumption of sugar and salt • Use fresh foods instead of preserved or canned foods 57

Practical Advice/ 2 • At least five servings of fruit and vegetables per day - Choose colourful fruits and vegetables - Choose whole fruits over juices • Replace high calorie beverages with water • Eat small frequent meals that are well spaced • Do not skip meals • Calories should be restricted especially if overweight • Eat free foods as desired, include in between major meals 58

Practical Advice/ 3 • One low GI food at each meal • Mix high and low GI food = intermediate GI meal • Substitute high GI cereals/breads/rice with low GI cereals/bread/rice • Eat low GI snacks instead of high GI snacks (remember to choose lower fat snacks) 59

References • American Diabetes Association. (2013). Clinical Practice Recommendations. Diabetes Care, 36, (supple 1). • Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2013). Canadian Diabetes Association 2013. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes, 37(suppl 1). • Canadian Diabetes Association. (2006). Beyond the Basics. Toronto ON: Canadian Diabetes Association • Diabetes India. (2005). Diet Charts. Retreived September 13, 2010. http: //www. diabetesindia. com/diabetes/diet_chart. htm • Franz MJ, Evert AB (Eds. ) American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2 nd Ed. 1012 • Health Canada. Food and Nutrition. Sodium. It’s Your Health. Available from: http: //www. hc-sc. gc. ca/hlvs/iyh-vsv/food-aliment/sodium-eng. php • Health Canada. (2005). Food and Nutrition. The Issue of sodium. (Retrieved September 13, 2010) http: //www. hc-sc. gc. ca/fn-an/nutrition/reference/table/ref_elements_tbl-eng. php • Institute of Medicine 2002 http: //www. iom. edu/Global/News%20 Announcements/~/media/C 5 CD 2 DD 7840544979 A 549 EC 47 E 56 A 02 B. a shx • Institute Of Medicine 2009 http: //www. ncbi. nlm. nih. gov/books/NBK 32799/table/summary. t 1/? report=objectonly • Kalergis, M. , De Grandpre, E. , Andersons, C. (2005). The Role of Glycemic Index in the Prevention and Management of Diabetes: A Review and Discussion. Can J of Diab, 29(1), 27 -38. • Misra A, Chowbey P, Makkar PM, Vikram NK, Wasir JS, Chadha D, et al. Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians and Recommendations for Physical Activity, Medical and Surgical Management. JAPI 2009; 57. 60