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Acknow ledgm ents Gestational This webcast is made possible by the support of the Colorado Diabetes Prevention and Control Program (CDPCP), which is working to improve access to quality care for women with Gestational Diabetes in Colorado. Diabetes The CDPCP is supported by Cooperative Agreement U32/ CCU800342- 21-02 from the Centers for Disease Control and Prevention. NUTRITION MESSAGES Co-Sponsored By: YOU NEED TO KNOW February 27 th , 2009 Web page: www.diabetesedu.org Web page: http://www.cdphe.state.co.us/pp/diabetes/index.html Presenter Colorado Nutrition Guidelines for Gestational Diabetes Presentation by Mandy McCulloch, RD Developed by the Diabetes Prevention and Control Program Prenatal Program Director - Women’s Health Nutrition Consultant - Diabetes Prevention and at the Colorado Department of Public Health and Environment Control Program June 2007 Colorado Department of Public Health and Environment http://www.coloradoguidelines.org/guidelines/gestationaldiabetes.asp Objectives Definition of GDM � Discuss nutrition-based GDM prevention messages for preconception and early prenatal care � List at least 3 Nutrition Guidelines for GDM for � Gestational Diabetes Mellitus (GDM) is clients glucose intolerance recognized for the � Recognize client challenges and barriers to m aking first time during pregnancy. diet changes during pregnancy � List common food selections for different ethnic � This does not currently recognize the populations and describe how to appropriately difference between pre-existing adjust nutrition messaging diabetes identified for the first time � List educational tools & resources available for use during pregnancy and diabetes that with clients develops due to the pregnancy � Discuss important postpartum nutrition messages to help prevent future development of type 2 diabetes for mother and child

Long Term Concerns Preconception and � Mom : ~ 5 0 % risk of developing Early Prevention type 2 Diabetes in 5 -1 0 years!! Nutrition Messages � Baby: ↑ risk for developing childhood obesity and type 2 “adult onset” diabetes Risk of Pre-Pregnancy Early I ntervention Overw eight and Obesity � Complete universal risk assessment � Increasing evidence points to the importance of a at first prenatal visit healthy weight prior to becom ing pregnant � If client meets “High Risk” criteria: � Maternal obesity prior to conception is the strongest predictor for large for gestational age � Early glucose screening (LGA) and increased fat mass in the infant, even � Tell her about the risk of GDM more so than weight gain during pregnancy or treated Gestational Diabetes 1 � Track weight gain � A 5-10% decrease in pre-pregnancy weight can � Educate on healthy eating improve insulin sensitivity and the risk of & exercise diabetes and hypertension 1 Catalano OM, Ehrenberg HM, BJOG. 2006 Oct; 113 (10): 1126-33. Healthy Eating & Discuss W eight Gain Exercise Tips � Determine BMI based on pre- � Ask about eating habits and give a pregnancy weight and height few quick suggestions about nutrition � Inform client of � Increase water, decrease soda intake � Increase fruit & vegetable intake weight gain goal � Decrease high cal/ high sugar foods � Track weight � Decrease fast food frequency � Provide tips according � Encourage exercise (½ hour walk each to weight gain status day)

Goal of MNT Medical Nutrition � To control blood glucose levels by controlling intake of carbohydrates Therapy for GDM and saturated fats while ensuring adequate nutrition without excessive weight gain ASSESS Medical Nutrition Therapy � Assess � Weight History � Individualize plan based on client’s � Weight Gain & Calorie caloric needs and weight gain to date Recommendations � Instruct � Physical Activity � Teach carbohydrate counting, healthy � Current Food Habits & Preferences food choices, appropriate weight gain � Evaluate � Comprehension Level � Review food and blood glucose records to assess compliance W eight Gain and Calorie W eight History Recom m endations Recommended Estimated calorie intake BMI (kg/m 2 ) weight gain � Previous pregnancies (kcal/kg/day PPW) (lbs.) � Weight fluctuations Underweight (< 19.8) 28 - 40 36 – 40 � During pregnancy Normal weight (19.8 – 26) 25 – 35 30 � Prior to pregnancy � Dieting habits Overweight (26.1 – 29) 15 – 25 24 � Include history of anorexia or bulemia Obese (>29) 15 12 - 18 Add an extra 500 kcal/day Twin Gestation 35-45 to the above recommendations * Adopted from National Academy of Sciences Institute of Medicine Guidelines for Pregnancy

Physical Activity Diet Assessm ent Assessm ent � Ask about prenatal vitamin intake � Ask about current activity level � Ask about food allergies or � Determine willingness to increase intolerances activity, if not already active � Use a diet assessment tool to � Benefits include � insulin resistance, determine trends & preferences � postprandial hyperglycemia and � Discuss cooking ability prevention of excessive weight gain � Determine food availability Com prehension I NSTRUCT � Assess ability to understand written � Carbohydrates and verbal instructions � Meal Planning � Consider: � Healthy Eating Tips � Reading level � Portion Sizes � Preferred learning style � Weight Gain � Preferred language � Physical Activity Understanding Choosing Carbohydrates Carbohydrate Foods � Review client’s typical foods and � Explain that carbohydrate foods are their carbohydrate content converted to glucose in the body and � Choose higher fiber foods cause blood glucose levels to rise � Emphasize appropriate portion sizes � Balance amount of carbohydrate � Avoid confusing terminology foods eaten throughout the day � i.e. starch vs. carbohydrate � Discuss types of carbohydrates

Serving Size: Counting Carbohydrates Be sure to base calculations on # of servings eaten – take Saturated Fat: note of serving � Carbohydrates can be tracked either size Choose foods low in saturated fat by counting grams or “choices” (< 5% DV) Total Carbohydrate: � 15 grams of carbohydrate = 1 Be sure to count total, not just carbohydrate choice sugars. It is the total amount that will affect blood glucose levels. Developing a Meal Plan The Breakfast Meal � Start with 175 grams of carbohydrate, about 12 carbohydrate � Blood glucose elevated in the AM choices � Carbohydrate foods less tolerated � Distribute evenly throughout the day � Limit to 15-30 g (1-2 carb choices) � Smaller, more frequent meals � Choose items that contain protein � Consider client’s eating habits & over high-carb foods preferences � May need to avoid or limit fruit juice � Watch timing � Monitor response to other typical � 2 hours between meals breakfast foods � No more than 10-12 hours between last evening meal and morning meal Fat I ntake Tips for Decreasing Fat � Saturated fats contribute to higher � Bake, roast, grill or broil meats instead of levels of maternal triglycerides, frying which have been associated with � Choose low-fat or nonfat cheese, milk and macrosomia in the baby yogurt � Limit saturated fat to less than 10% � Avoid sauces or gravies of calories and avoid trans fats � Use minimal amounts of butter or � Do not replace carbohydrates with margarine high fat foods � Choose vegetable oils if needed for cooking, use small amounts � Choose foods with unsaturated fat in � Check food labels moderation

Additional Estim ating Portion Sizes Healthy Eating Tips � Know which low- � Choose high-fiber � The 9-inch Plate calorie sweeteners foods � Visual are safe for � Include additional � Can be an activity done together using pregnancy protein at meals paper plates � Limit caffeine � Take a prenatal � Keep in mind that milk and fruit are � Monitor intake of vitamin every day represented outside the plate, but are mercury-containing � Drink adequate counted in total carbohydrate fish water � Avoid exposure to � Include adequate listeriosis sources of calcium Estim ating Portion Sizes 9 ” Plate ( cont.) Milk Fruit � Common Item Visualization � Provide portion size card Non-Starchy � Explain portions compared to common Vegetables household items Grains, Meat and Beans, Meat Starchy Substitutes Vegetables Physical Activity EVALUATE � Aim for 30 minutes/ day, � Self Monitoring Blood Glucose 5 days/ week, if no contraindications � Food Record � Encourage exercising within one to two hours after a meal to improve glucose control � Weight Gain � Develop an individualized plan � Ensure adequate hydration and avoid overheating