CME INDIA Presentation by Dr. R. Bhavatharini Aruyerchelvan, Jt. Sec, DIPSI, TN RSSDI, Founder member, TAPI – Tamil Nadu chapter API, DFSI, SRC Diabetes Care Centre, Erode, Tamil Nadu.

Based on ICDM – Baroda talk in July 2023.

Principles of Guidance:

• For all pregnant women who receive their first positive GDM diagnosis, the initial course of action involves commencing Medical Nutrition Therapy (MNT) and engaging in regular physical exercise for a duration of two weeks. During this period, it is recommended that the woman participates in a daily 30-minute walk or exercise routine.
• Following the two-week period of adhering to MNT and engaging in physical activity, a 2-hour Post-Prandial Blood Sugar (PPBS) test should be conducted.

Principles of GDM (Gestational Diabetes Mellitus) management

• 90% of GDM require only MNT (Medical nutrition therapy) and only remaining 10% require insulin.
• Modify & titrate diet till 2 weeks before adding Insulin in case of minimal raise.
• If BS >200 don’t wait. Straight away Insulin + MNT.

Under-nutrition

• The focus previously and even now in some rural areas inadequate weight gain in pregnancy due to under nutrition leading to IUGR/SGA fetus and related neonatal complications.

Table TOP is education – and with 4 legs becomes a complete table

Caloric Intake and GDM:

• When determining calorie requirements for individuals with GDM, it’s essential to tailor the approach based on their specific needs. Adjustments should be made considering patterns of weight change over time.
• The energy requirement during pregnancy encompasses the standard energy needs of an adult, along with an additional requirement for fetal growth, as well as accounting for the increased body weight of the pregnant woman. It’s worth noting that during the first trimester, energy requirements typically remain stable unless the woman is underweight.
• Energy needs begin to rise during the second and third trimesters to support the growing fetus and maternal weight gain. The goal is to ensure that energy intake is sufficient to promote healthy weight gain throughout pregnancy.
• According to Indian ICMR guidelines, to facilitate an average weight gain of 10-12 kg, an additional intake of 350 kcal per day above the standard adult requirement is recommended during the second and third trimesters. It’s crucial to avoid severe caloric restriction, as this can lead to ketonemia and ketonuria, potentially impairing the physical and mental development of the offspring.
• To calculate the adult energy requirement, you can utilize the equations proposed by the ICMR expert group, which are as follows:

Energy Requirement (kcal/day) = Basal Metabolic Rate (BMR) × Physical Activity Level (PAL).

• Please note that BMR represents the basal metabolic rate, while PAL indicates the level of physical activity. These equations serve as valuable tools for determining the appropriate energy intake to support a healthy pregnancy in women with GDM.

Split Meals

• Three major meals (small to moderate size).
• In between allow 3 Small meals.
• Split breakfast into two parts, give 2-1/2 hrs. interval total 6 parts.

Breakdown of Macronutrients

• Total carbohydrate: 45 -50% of total calories.
• Total Protein: 25-30% of total calories.
• Total fat: 25-30% of total calories.

Medical Nutrition Therapy

(MNT)

• Carbohydrate-controlled meal plan that promotes adequate nutrition with appropriate weight gain, normoglycemia, and the absence of ketosis.
• Interventions during pregnancy should ensure that the growing fetus is not deprived of essential nutrients.
• Carbohydrate rich foods besides being an important dietary source of energy also provide vitamins, minerals, and fiber content.
• Ideally in pregnancy wt. gain of 7 -12 kg weight gain depending on the initial weight.
• IBW – 35-40 Kcal/Kg à2100 to 2400 Cals.
• Obese – 25-30 Kcal/Kg à1500 to 1800 Cals.
• If not daily calories +300 kcal as pregnancy allowance.
• Each visit according to weight loss initially later weight gain, calories should be distributed thought the day.

Energy Needs in Pregnancy

• 1st Trimester: No increased needs.
• 2nd Trimester: Additional 340 kcal/day.
• 3rd Trimester: Additional 452 kcal/day.
• Simple way…

Breakfast

• Insulin resistance max in morning.
• Breakfast CHO load low (15-30 gm).
• Let the proteins satisfy the morning hunger!
• Complex CHO, with low G.I to improve the insulin sensitivity & normalize BS in all 3 meals.

Carbohydrate requirement

• A minimum carbohydrate level of 130 g/day for non-pregnant.
• But 175g carbohydrate per day for pregnant.
• This additional carbohydrate is for fetal brain development and functioning.

Meal plan

• Dietary advice has to be individualized, and should not be a complete deviation from what she is taking.
• Better be flexible and modifiable.

• Carbohydrate-rich foods play a crucial role in maintaining the health of both the mother and baby during pregnancy. Once consumed, these foods are broken down into glucose, which enters the bloodstream. The type, quantity, and frequency of carbohydrate consumption significantly impact blood sugar levels.
• Carbohydrate sources encompass a wide range of options, including cereals (such as wheat, bajra, ragi, corn, and rice) and their products (like suji, refined flour, bread, pasta, and noodles), pulses (including green gram, Bengal gram, black gram, etc.), starchy vegetables (potatoes, sweet potatoes, corn, tapioca, etc.), fruits, sweets, and juices.
• It’s important to avoid consuming large quantities of carbohydrate-rich foods in a single sitting, as this can lead to elevated blood sugar levels. Instead, it is advisable to distribute carbohydrate intake throughout the day. Opting for three small meals and incorporating 2-3 snacks into your daily routine is preferable to having three large meals.
• Complex carbohydrates, found in whole-grain cereals like oats, bajra, jowar, ragi, whole pulses, and fruits and vegetables with skins, are the preferred choice over simple carbohydrates. Simple carbohydrates include foods with high levels of added sugars or honey, as well as products made from refined white flour. Examples of simple carbohydrates are sweets, cakes, puddings, sweet biscuits, pastry, juice, soft drinks, chips, white bread, naan, and pizza.
• To monitor carbohydrate intake effectively, mothers can count the number of carbohydrates serves they consume throughout the day. A helpful guideline is to aim for 2-3 carbohydrate serves at each major meal and 1-2 carbohydrate serves at each snack.
• For reference, one serve equals approximately 15 grams of carbohydrate. This approach assists in ensuring that carbohydrate intake remains at an appropriate level to manage blood sugar effectively during pregnancy.

Food Mapping

Understanding Fat, Protein, and Fiber Intake during Pregnancy:

1. Saturated Fat and Cholesterol: It’s important to limit saturated fat intake during pregnancy to less than 10% of total daily calories. Sources of saturated fat include ghee, butter, coconut oil, palm oil, red meat, organ meat, and full cream milk. Additionally, dietary cholesterol should be kept under 300 mg per day. In cases of obesity or overweight, reducing overall fat consumption can help slow the rate of weight gain.
2. Reducing Fat in Your Diet:
   • Use less fat in cooking and avoid frying foods.
   • Opt for low-fat dairy products instead of whole milk or full cream options.
   • Choose low-fat snacks, such as fresh fruits, salads, and baked or steamed foods, over high-fat snacks like cakes, biscuits, chocolates, pastries, samosas, and pakoras.
3. Protein: During pregnancy, the requirement for protein increases by an additional 23 grams per day to support fetal growth. Aim for at least three servings of protein-rich foods daily. Good sources of protein include milk and dairy products, eggs, fish, chicken, pulses (dal), and nuts.
4. Fiber: Including high-fiber foods in your diet, especially those containing soluble fiber, can help control blood sugar levels by slowing down gastric emptying, delaying the release of glucose into the bloodstream, and reducing the post-meal increase in blood sugar. Sources of soluble fiber include flax seeds, psyllium husk, oat bran, legumes (such as beans, peas, and lentils), pectin (found in fruits like apples), and certain root vegetables (like carrots). Incorporating these foods into your diet can be beneficial during pregnancy.

Recent Findings

• Diet is also a powerful modulator of the gut microbiota, insulin resistance and the inflammatory response in the host.
• Gut-microbiota modulation aids in the management of undernutrition and overnutrition.

Pregnancy physical activity

• Weight management program during pregnancy should be based on increasing physical activity not reducing the intake.

Exercise during GDM reduce the therapy and aids in normal labour

How to prime the body for exercise in HIP

• Drink fluids whenever feel, during and after exercise to prevent dehydration.
• Wear supportive shoes when needed.
• Limit activities to shorter interval.
• Exercise for 10-15min rest for 2-3min then exercise for another 10-15min.
• Decrease exercise level as pregnancy progresses.
• Take your pulse every 10-15min.
• if it is more than 140 beats per min slow down until it reaches to the maximum 90bpm.
• Rest in left lateral position for 10 min after the exercise.

What you should, should not & when to report to doctor in HIP(Hyperglycemia in Pregnancy)?

• Always rise slowly from lying to sitting position to prevent orthostatic hypotension.
• Don’t risk activities such as surfing, mountain climbing and sky diving.
• Don’t do activities that requires holding breath and bearing down.
• Do not continue the exercise if you experience shortness of breath, pain, undue cramping, vaginal bleeding or nausea. Report to the doctor/ if it is happening
• Don’t become over heated for extended period.

Lying exercise how to do in HIP

• Avoid exercise by lying flat in the later 2nd and 3rd trimester because of the danger of supine hypotension and decreased placental/fetal circulation.
• Instead, a half lying position with back raised to an angle of approximately 35 can be used.
• Never exercise to a point of fatigue.

CME INDIA Tail-Piece:

Sugar Substitutes and GDM:

• Pregnant women diagnosed with GDM can include sugar substitutes in their diet, as long as they adhere to the limits established by the FDA (Food and Drug Administration). The keyword in their case is moderation. The following sugar substitutes are considered safe options:
  • Aspartame (except for women with phenylketonuria)
  • Sucralose
  • Neotame
  • Advantame
  • Xylitol
  • Sorbitol (with possible gastrointestinal side effects)
  • Stevia
  • However, when it comes to saccharine, there are some considerations. While the FDA deems saccharine safe for consumption in the general population, some countries have banned it due to concerns that it may pass through the placenta and accumulate in fetal tissues for extended periods. The potential side effects on the fetus remain largely unknown.
• As a general guideline, pregnant women with GDM should exercise caution and consult with their healthcare provider or a registered dietitian when using sugar substitutes to ensure they stay within recommended limits and make choices that align with their specific health needs during pregnancy.

References:

1. Mahajan A, Donovan LE, Vallee R, Yamamoto JM⁴.Curr Diab Rep. 2019 Aug 31;19(10):94. doi: 10.1007/s11892-019-1208-4. Evidenced-Based Nutrition for Gestational Diabetes Mellitus.
2. Vasile FC, Preda A, Ștefan AG, Vladu MI, Forțofoiu MC, Clenciu D, Gheorghe IO, Forțofoiu M, Moța M. An Update of Medical Nutrition Therapy in Gestational Diabetes Mellitus. J Diabetes Res. 2021 Nov 18;2021:5266919. doi: 10.1155/2021/5266919. PMID: 34840988; PMCID: PMC8616668.
3. Jovanovic-Peterson L., Peterson C. M. Dietary manipulation as a primary treatment strategy for pregnancies complicated by diabetes. Journal of the American College of Nutrition . 1990;9(4):320–325. doi: 10.1080/07315724.1990.10720387. 
4.  Yamamoto J. M., Kellett J. E., Balsells M., et al. Gestational diabetes mellitus and diet: a systematic review and meta-analysis of randomized controlled trials examining the impact of modified dietary interventions on maternal glucose control and neonatal birth weight. Diabetes Care . 2018;41(7):1346–1361. doi: 10.2337/dc18-0102.
5.  US Food and Drug Administration. Additional information about high-intensity sweeteners permitted for use in food in the United States, February . 2018.
6. National_Guidelines_for_Diagnosis_&_Management_of_Gestational_Diabetes_Mellitus.pdf (nhm.gov.in)

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