Pat Sonnenstuhl,RN, CNM

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Gestational Diabetes Mellitus

• Helping Your ClientMake Healthy Lifestyle
  Choices

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Introduction

• Following appropriate screening guidelines,
  understanding causation and associated
  conditions, and effectively managing the client
  with GDM can improve both short term and long
  term health conditions associated with GDM

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Definitions

• Gestational Diabetes (GDM)
• Insulin Resistance (IR)
• Glycemic Index (GI)
• Syndrome X
• Body Mass Index (BMI)
• euglycemia

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Gestational Diabetes (GDM)

• A carbohydrate intolerance of varying degrees and
  severity with onset or first recognition during
  pregnancy with a probable resolution after the
  end of pregnancy. Diabetes, glucose intolerance
  or insulin resistance may have existed before the
  pregnancy. GDM is not the same as Type 1 or Type
  2 Diabetes

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Insulin Resistance (IR)

• Insulin resistance is the resistance of the
  skeletal muscles and adipose to the affects of
  insulin. The pancreas produces more insulin, and
  over time cells become more and more resistant to
  the actions of insulin. As blood sugars and
  insulin increase, eventually the pancreas fails
  to produce enough insulin and diabetes occurs.

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Glycemic Index (GI)

• The glycemic index ranks foods on how they affect
  our blood sugar levels. This index measures how
  quickly an individual's blood sugar increases in
  the two or three hours after eating.
• http//www.mendosa.com/gi.htm

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euglycemia Normal concentration of glucose
in the blood. Also called normoglycemia.
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Factors That Affect the GI

• The GI of a food is influenced by the
  characteristics of the food or meal.
• Processing, preparation, storage, physical form,
  and ripeness of foods affect the GI.
• The GI varies within the same individual and
  between individuals.

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Value of the GI

• Each client can determine how she reacts to
  certain foods by monitoring food intake and
  postprandial blood glucose levels
• The primary goal of GDM management is to achieve
  and maintain euglycemia throughout pregnancy to
  improve the outcomes for both mother and fetus

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Syndrome X

• The loss of responsiveness of the body to insulin
  is associated with a clustering of
  cardiovascular risk factors that includes
  abdominal obesity, hypertension, dyslipidemia,
  glucose intolerance and hyperinsulinemia.
• This association is referred to as the insulin
  resistance syndrome, which is also known as
  Syndrome X.

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Body Mass Index (BMI)

• A commonly used measure to differentiate
  underweight, normal weight, overweight and
  obesity. Obtained by dividing the weight of the
  subject (in kilos) by the square of his (her)
  height in meters.
• A BMI of approximately 25 kg/m2 corresponds to
  about 10 percent over ideal body weight.
• http//www.americanheart.org/Heart_and_Stroke_A_Z_
  Guide/body.html

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Body Mass Index Definitions
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Body Mass Index and Recommended Weigh Gain
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How These Conditions Are Related

• Women with a history of GDM are metabolically
  vulnerable with insufficient ß-cell reserve, and
  many are insulin resistant.

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How These Conditions Are Related
Approximately 50 of women who are diagnosed
with gestational diabetes during pregnancy will
develop it in future pregnancies, and are at a
much greater risk of developing type 2 diabetes
in later life.
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How These Conditions Are Related
The insulin resistance is the factor that exists
in the woman with GDM. The aim of the lifestyle
changes to be discussed here are to decrease
insulin resistance.
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Pregnancy Pathophysiology

• Insulin resistance occurs because the hormonal
  changes associated with pregnancy partially block
  the effects of insulin.
• Insulin resistance causes glucose to be shunted
  from the mother to the fetus to facilitate fetal
  growth and development.

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Pregnancy Pathophysiology

• During the third trimester of pregnancy, insulin
  resistance increases by 50.
• Maternal pancreatic beta cells increase insulin
  secretion almost threefold to compensate for
  increased insulin resistance.

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Pregnancy Pathophysiology

• The subsequent increase in insulin secretion
  causes the maternal glucose levels to increase
  80 of the blood levels of non-pregnant women
• If the mothers pancreas is unable to produce
  sufficient insulin to overcome insulin
  resistance, maternal glucose levels increase and
  GDM occurs

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Pregnancy Pathophysiology

• GDM complicates pregnancy by further increasing
  insulin resistance
• GDM disappears after pregnancy because the
  hormonal changes that caused insulin resistance
  are no longer present
• Useful physiologic process out of balance

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Action Plan for Prevention

• Approximately 60 to 80 of the women with GDM
  are obese and experience insulin resistance
  associated with both obesity and GDM.
• A decrease in caloric intake and caloric
  redistribution of foods may help decrease
  abnormally high blood glucose levels by improving
  target-organ insulin sensitivity.

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Laboratory Screening for GDM

• Demographics
• Who to Screen
• Screening

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Demographics of GDM

• Most common medical complication of pregnancy
• Occurs in 4 of all pregnancies (all ethnicities)
  
• Changes in diagnostic criteria will increase
  incidence of this metabolic complication
  (involves a recognition of a lower level of blood
  glucose)

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Who Should Be Screened

• Women over 25
• Women who are obese
• Women with a family history of diabetes
• Women of ethnic/racial high risk groups
• Women who have had a 9 baby

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Value of Screening During the Current Pregnancy

• Increased screening, identification and treatment
  can decrease the morbidity and mortality of GDM
• Decreased macrosomia, cesarean birth and birth
  trauma due to a 4000g infant
• Decreased neonatal hypoglycemia, hypocalcaemia,
  hyperbilirubinemia, polycythemia
• Identify women at future risk for diabetes and
  those with insulin resistance

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Routine Screening (ACOG,1994)
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Screening and Diagnosis of GDM(ACOG, 1994)

• Nearly 25 of women will have a 1hr GTT, and
  will need a 3 hour GTT.
• A GTT is considered diagnostic for GDM when 2 or
  more values are met or exceeded.

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Determination of GDM (ACOG, 1994)
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Retesting (32-34 Weeks) When?

• Negative initial test, risk factors present
• Obesity
• 33 years of age
• Positive 1 hour screen followed by a negative
  OGGT
• 3/4 glucosuria

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Factors That Influence the Development of Type 2
Diabetes Mellitus
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Factors That Influence the Development of Type 2
Diabetes Mellitus
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Factors That Influence the Development of Type 2
Diabetes Mellitus
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Teachable Moments

• Women with GDM and/or IR present an ideal group
  for diabetes prevention and education because
  they are teachable and usually more motivated to
  change behaviors and improve their long range
  health and the health of their families.

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Teachable Moments

• Seen as a positive thing, the diagnosis of GDM
  during pregnancy identifies these women at risk
  and this awareness can encourage healthy
  lifestyle changes

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Management of GDM During Pregnancy and Post Partum

• Healthy food Choices
• Encouraging Lifestyle changes
• Education and support
• Laboratory follow-up
• Post Partum and Beyond
• Teachable Moments

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Healthy Food Choices

• Various Options
• Medical Nutritional Therapy
• Nutritional Prescription

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Making Healthy Food Choices

• What are healthy choices ?
• Goals of medical nutrition therapy respect the
  needs of the pregnant woman and her developing
  fetus
• Food combination options encourage maternal
  euglycemia

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What Are Healthy Choices ?

• Nutritional management is understudied, with no
  randomized control studies looking specifically
  at optimal medical nutrition for GDM, lean or
  obese.

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What Are Healthy Choices ?

• Distribution of Macronutrients
• Optimal distribution of calories is unknown
  (little consensus, wide variability, not adequate
  research).

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What Are Healthy Choices ?

• The ideal caloric recommendations for GDM are
  unknown or have not been well studied. Factors
  such as maternal height, pregravid wt, maternal
  age, physical activity and smoking all need to be
  considered.

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What Are Healthy Choices ?

• The majority of women should eat 2200-2400
  calories. Moderate calorie restrictions (to
  1800) have been shown to reduce macrosomia and
  its associated morbidity and maternal ketonuria

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Goals of Medical Nutrition Therapy
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Goals of Medical Nutrition Therapy
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Goal of Medical Nutrition Therapy

• Deborah Thomas-Dobersen suggests three reasonable
  options which seem to accomplish this goal

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Option ITraditional Food Pyramid

• High Carb/low fat 55 carbohydrate,
• 25 protein,
• 20 fat

Http//www.mjbovo.Com/PregWt.Html
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Option II Balanced

• Discuss with your client the effect of high GI
  carb foods versus low GI-carb foods

35-40 carbohydrates,
20--25 protein
35-40 fat
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Option III Low Glycemic Carbohydrates

• More Protein
• Low GI Carbs
• Appropriate Fats

http//www.enteract.com/jldavid/lowcarb/pyramid.h
tml
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Nutritional Prescription

• For GDM, the nutritional prescription should
  satisfy the minimum requirements for pregnant
  women
• Minimal caloric intake for those with GDM is
  debated
• There is little risk of ketonuria when diets
  provide 25kcal/kg, which is based on the womans
  actual body weight

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Nutritional Recommendations

• Distribution of total calories is
• 35-45 carbohydrates
• 20-25 protein
• 35-40 fat

Tolstoi Jusmovich
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ADA Clinical Guidelines

• Restriction of carbohydrates to 3540 of
  calories has been shown to decrease maternal
  glucose levels and improve maternal and fetal
  outcomes
• American Diabetes AssociationClinical Practice
  Recommendations 2001

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Limiting Carbohydrate Intake

• When starchy carbohydrate intake is limited,
  postparandial blood glucose levels are lower
  compared with diets higher in carbohydrate
  content.

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Factors That Affect Blood Glucose Levels

• Stress physical and psychological
• Time of day
• Exercise
• Amount of carbohydrate consumed
• Lifestyle choices such as smoking

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Goals of Nutritional Therapy

• Encourage euglycemia
• Prevent Ketosis
• Decrease maternal hyperglycemia

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Making Healthy Lifestyle Choices

• Modifying Eating Behavior
• Daily Exercise
• Lifestyle Management

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Healthy Lifestyle Choices

• "Lifestyle changeis the central determinant of
  whether people will lose weight and maintain
  loss' Kelly D. Brownell.
• Lifestyle management is the systematic change of
  behavior and thinking patterns that
  affect weight.

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Healthy Lifestyle Choices

• Brownell cites helping with the modification of
  eating behavior, physical activity, and a change
  in attitude, goals and emotions as specific ways
  practitioners can help women make these lifestyle
  changes.

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Healthy Lifestyle Choices

• Practitioners can help individuals acquire skills
  to change the ways they think and act that affect
  their eating habits.

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Healthy Lifestyle Choices

• Simply giving the advice to 'eat better' and
  'exercise more' will work in only a small handful
  of patients. Health professionals commonly ask
  their clients to lose weight without providing
  the ways to ensure success. "We must give
  patients the best chance of success."

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Exercise !

• Moderate regular exercise such as walking,
  cycling or swimming are excellent forms of
  exercise for pregnant women. Keeping
  well-hydrated and well-nourished is essential

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Exercises to Encourage

• Brisk walking, cycling and swimming are often
  done safely by pregnant women. Staying balanced
  and avoiding falls is important

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Benefits of Exercise

• Exercising for 15-20 minutes after a meal may
  help to keep blood glucose levels within the
  target range for women with GDM.
• Individualized programs can start with 20
  minutes/day, gradually increasing to 45-60
  minutes/day.

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Education and Support

• Food Journals
• Ongoing Support
• Ongoing Education

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Food Journals

• Provide a tool for ongoing evaluation and
  discussion, and increasing your clients awareness
  of the effects specific foods and activities.

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Food Journals

• Keeping a record of all foods and beverages
  consumed can motivate women to alter caloric
  intake and learn the affect of specific foods and
  activates on blood sugar.

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Viewpoints About Food Journals

• Journals reinforce the expectation of
  improvement.
• Approach your clients food choices carefully, as
  she needs affirmation, not criticism for long
  term support. Encourage the food record to be a
  learning tool, not a rigid diet to follow.

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Supportive Communities

• Have available resources of support groups in
  your community that can be helpful for your
  client.
• Be familiar with the many on line resources
  available for women who are gestational
  diabetics, or who want to make these lifestyle
  changes.

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Ongoing Education

• Keep current with available educational resources
  available that might be helpful for your client.
• Involve your client in her own learning as much
  as possible.
• Take the time to explain her progress to her.

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Laboratory Follow-up

• Self-monitoring Blood Glucose
• Checking for Ketonuria
• FBS and 2 Hour PP

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Self-monitoring of Blood Glucose (SMBG)

• SMBG can improve outcomes in pregnancies by early
  recognition of abnormal blood sugar levels. New
  meters and lancing devices make the process of
  obtaining blood almost painless.
• SMBG empowers women with GDM to become active
  participants in their care. Women can readily see
  the impact of their choices.

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SMBG

• Self-monitoring will give women immediate
  feedback about portion size, particular foods
  that cause hyperglycemia, and the impact of
  exercise on blood sugar
• Newer and more appealing tools will improve
  clients willingness to monitor their blood glucose

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SMBG Promotes Empowerment

• Studies have shown that SMBG helps clients follow
  goals of treatment and learn about the impact of
  specific food and activity choices.
• Clients are more likely to believe the advice
  they receive when they can see high blood glucose
  levels 2 hours after eating, or see a level
  decrease after walking.

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Acceptable SMBG Values

• Postprandial glucose levels are more closely
  related to fetal risks than fasting levels.
  Taking a fasting level and then 1 or 2 hour
  postprandial levels are recommended.
• FPG
• 2hr PG

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Checking for Ketonuria

• Clients who are following a hypocaloric or
  carbohydrate restricted diet might benefit from
  testing ketones before breakfast.
• The persistence of small to moderate ketones can
  signal inadequate calories, a misunderstanding of
  the meal plan, or a woman secretly restricting
  food to avoid the addition of insulin.

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Checking for Ketones

• Recommended for women on a hypo caloric or
  carbohydrate restricted diet.
• Small to moderate ketones can signal inadequate
  calories or identify women who are restricting
  food.

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FBS and 2 Hour PP

• Considered the follow-up test to determine
  effectiveness of management
• HgA1c also might provide insights to ongoing
  blood glucose levels

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Blood Glucose Values for Pregnancy
Normal blood glucose range 60-120 mg/dl
Rubin, A. L. Diabetes for Dummies, p 95
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HG A 1 C is a test that measures the amount of
glycosylated hemoglobin in your blood.
Glycosylated hemoglobin is a molecule in red
blood cells that attaches to glucose (blood
sugar). You have more glycosylated hemoglobin if
you have more glucose in your blood. A truly
normal A1c is 4.6 or less. That is the level
that corresponds to a blood sugar kept under
100 mg/dl (5.6 mmol/L) at all times.
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Post Partum and Beyond

• Breastfeeding
• Follow-up Labs
• Follow-up Education
• Healthy Lifestyle Choices

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Breastfeeding

• Extensive research documents the superiority of
  human milk for infant feeding
• Breastfeeding in the postpartum period is
  associated with better maternal weight loss,
  improved fasting blood glucose levels, glucose
  tolerance and lipid levels

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Postpartum and Beyond

• Follow-up labs at 6-12 week postpartum a 75g GTT
  can help determine a woman's risk of developing
  diabetes.
• Subsequent annual screening for diabetes and CV
  risk factors (Lipid profile).
• Discuss prevention of a diabetic pregnancy in
  subsequent pregnancies.

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Postpartum Fasting and 2 Hour Screening and
Diagnosis Criteria
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Additional Definitions

• FPG Fasting Plasma Glucose.
• IFG Impaired fasting glycemia a fasting glucose
  concentration lower than those required to
  diagnose diabetes but higher than the 'normal'
  reference range.

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Additional Definitions

• IGT Impaired Glucose Tolerance a stage in the
  natural history if disordered carbohydrate
  metabolism. This marker serves as an indicator or
  marker along with the other elements of Metabolic
  Syndrome. Individuals with IGT manifest glucose
  intolerance only when challenged with an oral
  glucose load.

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Significance of GDM and Insulin Resistance Post
Partum

• Up to 60 of women will develop type 2 diabetes
  during their lifetime
• Recurrence rate in subsequent pregnancies is up
  to 65

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Postpartum Monitoring

• A FBG 125 mg/dl on two occasions denotes DM
• A FPG of 110-125 mg/dl impaired fasting glucose
• 2HR PG 140-199 Impaired FBG
• A level 200mg/dl DM

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Post Partum and Beyond

• "All women with GDM history should be counseled
  on the modifiable risk factors, such as the
  importance of healthy weight maintenance and
  daily exercise and the risk of postpartum weight
  gain to the development of subsequent GDM and
  type 2 diabetes.

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Post Partum and Beyond

• Women should receive medical nutrition therapy to
  decrease dietary fat. If they can achieve a 10-lb
  weight loss postpartum, they can decrease the
  risk of subsequent diabetes by one-half"
• Deborah Thomas-Doberson

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A Woman With a History of GDM

• Is metabolically vulnerable with insufficient
  ß-cell reserve, and many are insulin resistant
• If type 2 diabetes is delayed by 6 years the risk
  of developing sight-threatening retinopathy would
  be reduced by 65

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Women With a History of GDM

• Often are not followed intensively for modifiable
  lifestyle changes that may prevent type 2
  diabetes
• Need to be identified before pregnancy because,
  the incidence of fetal structural anomalies
  increases during the first 2 months of gestation

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Recommendations Postpartum

• All women with a history of GDM should be
  screened annually for diabetes and heart disease
  risk factors.

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Significance of GDM and Insulin Resistance Post
Partum

• Offspring of women with GDM have an increased
  risk for developing obesity and glucose
  intolerance as they grow and mature.

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Teachable Moments

• Preconception
• Postpartum
• Previous Pregnancy

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Preconception Counseling

• Strict glucose control greatly reduces the
  incidence of structural defects which occur in
  the first two months of gestation
• Preconception counseling and monitoring becomes a
  major objective in the care of these women

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Postpartum

• Women with a history of GDM present an ideal
  group for diabetes prevention, not only in
  preventing diabetes in themselves, bur for their
  family, for whom they are often the gatekeepers
  for nutrition and exercise.
• Pregnancy a teachable moment when women are
  usually very focused on their own health and the
  health of their baby.

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The Value of ExerciseContinues !
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Dietary Recommendations

• A high dietary fat intake between pregnancies can
  be a predictor for the recurrence of GDM.
• A diet with a high glycemic index and low fiber
  count appears to increase the relative risk of
  developing type 2 diabetes.

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Modifiable Nutritional and Non-nutritional
Factors for Diabetes Prevention
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Modifiable Nutritional and Non-nutritional
Factors for Diabetes Prevention.
Source Deborah Thomas-Doersen
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Concerns and Questions

• Is lowering carbs better than initiating insulin?
• Will increasing fat increase CV risk?
• How can a woman be encouraged to make food
  choices, and how rigid must she be?
• Does a reduction to 35 total carbs lead to
  nutrient deficiencies ?

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In Conclusion

• Strive for an accurate diagnosis and
  identification of the woman with IR and GDM
• Consult and refer as indicated should lab
  values persist outside of the range of euglycemia

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In Conclusion

• Help your client establish Healthy Lifestyle
  Changes in Pregnancy
• Encourage continuing Healthy Lifestyle Choices
  Postpartum
• Offer ongoing support and follow-up

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Long Term Goals of Management

• Primary prevention of type 2 diabetes
• Improvement of existing IR or obesity
• Permanent lifestyle changes

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The End