Program Objectives. Managing Gestational Diabetes

Transcription

1 Managing Gestational Diabetes Joslin Diabetes Center MDA Nutrition Convention & Exposition March 29, 2013 Program Objectives Identify maternal and fetal risks Describe diagnostic criteria Determine therapeutic blood glucose targets Discuss role of obesity in fetal/maternal outcomes Describe tenets of medical nutrition therapy List medication options Defining Gestational Diabetes Any degree of glucose intolerance with onset or first recognition during pregnancy Pathophysiology Origin of BG elevation hormonal impact insulin resistance reduction in first phase insulin response alterations in insulin sensitivity, fat, CHO amino acid metabolism may occur Ketone production Statistics Prevalence in the U.S. ~ 4 % ( 1 14%) > 200,000 cases annually DM in pregnancy: 90% GDM Significance Future patients Practice opportunities: prevention intervention follow up Centers for Disease Control and Prevention. Diabetes Report Card Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; Risk Factors & Outcomes Curr Diab Rep 13:6 11, 2013 New Diagnostic Criteria The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study Address maternal glycemia and neonatal outcomes Assess hyperglycemia less severe than diabetes Inclusion of overt DM Standardize care Eliminate confusion MDA Nutrition Convention & Exposition 1

2 The HAPO Study Over 23,000 women in 9 countries over 7 years completed the study Primary outcomes: Cesarean delivery Macrosomia birth wt >90% Neonatal morbidity (hypoglycemia) Fetal hyperinsulinemia Cord c peptide >90% Screening Criteria: Old vs. New IADPSG Guidelines Oral Glucose Load (OGL) at wks 140 then OGTT 3 hr 100 gmogtt OGTT value limits 105 / 190 / 165 / abnormal values for diagnosis No OGL First trimester glucose evaluation 2 hr 75 gram OGTT OGTT value limits 92 / 180 / abnormal value for diagnosis Diabetes Care, vol. 30, supplement 2, pp. S251 S260, 2007 Diabetes Care, vol. 33, no. 3, pp , 2010 All HAPO Outcomes Normal vs. 1 Abnormal value Maternal Glucose vs. Primary Outcomes Copyright 2009 ADA. Published online at /DC1 Copyright 2009 ADA. Published online at /DC1 Obesity in Pregnancy Approximately 60% of women aged are overweight or obese in the US guidelines MDA Nutrition Convention & Exposition 2

3 Obesity in Pregnancy and Adverse Outcomes Risk of GDM 2 fold vs 8 fold in overweight vs obese Pre eclampsia rates Twice as prevalent in overweight Increase of 11.3% in cesarean section deliveries bet. BMI of <25 to BMI of >35 Post cesarean section complications Obesity in Pregnancy 400,000 patients followed: GDM risk 3.5 times in overweight 7.7 times in obese 11 times in severely obese Delivery complications blood loss, increased op time, increased post op wound infection Emergency C section Obstetrics & Gynecology 118: , 2011 Obstetrics & Gynecology 118: , 2011 Recommended Weight Gain During Pregnancy Underweight (< 18.5) 28 40lbs kcals/kg Pregravid wt Normal wt ( ) 25 35lbs 30 kcals/kg Pregravid wt Overweight ( ) 15 25lbs 24kcals/kg Pregravid wt Obese ( lbs 20kcals/kg Pregravid wt Weight Gain During Pregnancy: Reexamining the Guidelines. National Academy Sciences, Washington DC, May 2009 Calorie Needs Caloric restriction (~70% of the DRI for pregnant women) results in considerable slowing of maternal weight gain in obese women with GDM, without causing maternal or fetal compromise and/or ketonuria. Academy of Nutrition and Dietetics, Evidence Analysis Library Monitoring Targets Fasting and pre meal blood glucose mg/dl One hour post meal blood glucose mg/dl Fasting ketone measurement negative MDA Nutrition Convention & Exposition 3

4 Goals of Management Blood glucose at target ~ 100% Ketone absence Abdominal circumference of baby < 70 th %ile Appropriate weight gain relative to pre pregnancy BMI Absence of maternal and fetal abnormalities related to hyperglycemia Obstetrical Monitoring Fetal and maternal assessment Alpha fetoprotein (AFP) blood test Ultrasound testing Fetal echocardiogram Non stress testing Biophysical profile Hadlock Abdominal Circumference Meal Planning Carbohydrate Control Glycemic index DASH Diet? Artificial Sweeteners Diabetes Care 30: S 200, July 2007 Diabetes Care 34: (1) 39 43, 2011 Diabetes Care 30: S , July 2007 Carbohydrate Distribution Aim for a minimum175 grams carbohydrate (carb) per day; less than 45% of total energy grams for breakfast, lunch, and dinner grams snacks between meals High fiber, low glycemic index carbs Protein with meals and bedtime snack Methods of Teaching Carb & Healthy Eating Carb Counting Plate Method MDA Nutrition Convention & Exposition 4

5 Plate Method Sample Meal Plan Time Food Carb Grams Exchanges Total calories 7:00 1 scrambled egg, whole wheat toast, 1 cup milk, 1tsp spread 30 1MK, 1S, 1M, 1F 9:30 1 cup berries 15 1FR 12:30 Turkey sandwich w/l&t, 1 plain yogurt, carrot sticks, 2 tsp diet mayo 3:00 6 whole grain crackers, 1 TBSP peanut butter 6:30 4 ounces pork loin, 1 cup broccoli, 2/3 cup whole wheat pasta, ½ cup tomato sauce, 1 small peach 9:00 1 cheese stick, 1 small apple 45 2S, 1.5V, 3M, 1F, 1MK 15.5M 2F 1S 45 4M 2.5V,3S,1FR, 2F 15 1M, 1FR Approx 1800 Glycemic Effect of Foods Low vs. High GI Diets in GDM Study Low vs. High GI Outcomes Statistics Moses et al GI 38 vs. GI 56 More women started insulin Louie et al GI 50 vs.gi 60 No differences Grant et al GI 49 vs. GI 58 LGI fewer postprandial blood glucose above target. No other differences 29% vs. 59% p= % vs. 30.3% P=.003 Curr Diab Rep 13:6 11, 2013 What About DASH? Food Group Control Diet DASH Diet 45 55% carbohydrates 15 20% protein 25 30% total fat 2400mg Na+ Rich in whole grains, & low fat dairy Grains 12 9 Simple 3 1 Sugars Vegetables 3 5 Fruits 3 6 Dairy Prod 3 4 Meats, poultry, fish 3 5 Nuts, seeds, legumes 1 2 Fats & oils 7 8 British Journal of Nutrition Nov 13, 1 7, 2012 British Journal of Nutrition Nov 13, 1 7, 2012 MDA Nutrition Convention & Exposition 5

6 Artificial Sweeteners British Journal of Nutrition Nov. 13, 1 7, 2012 Academy Moderation is encouraged Benefit is post meal glucose levels FDA approves: Acesulfame K Neotame Aspartame Saccharin Sucralose Danish National Birth Cohort 59,334 women Food frequency questionnaire OR of pre term delivery higher greater intake OR 1.38 >= 1 serving OR 1.78 => 4 servings Am J Clin Nutr.92: , 2010 GDM Management Ongoing Nutrition counseling Monitor weight gain Use weight gain charts SMBG and ketone monitoring Weekly or bimonthly medical visits Communicate frequently: telephone, fax and Beyond MNT If blood glucose levels remain elevated despite MNT and exercise, medication is promptly initiated Indicated if 3 or > values are above goal in a week Dosing based on glucose results, activity and food intake? Oral meds vs. insulin Medication Choices Insulin vs. the Orals Oral Agents (metformin and glyburide) Insulin NPH category B Levemir category B (March 29, 2012) Humalog, Novolog category B MDA Nutrition Convention & Exposition 6

7 Insulin vs. the Orals Results of Meta Analysis of Orals vs. Insulin Fasting Blood Glucose Postprandial Blood Glucose Neonatal Hypoglycemia Birth weight LGA babies Congenital Abnormalities Maternal hypoglycemia Favors Insulin No difference; largest study favored insulin No difference; in studies using metformin there were fewer hypoglycemic episodes No difference; in studies using metformin statistically significant lower birth weight than insulin No difference No difference No difference Am J Obstet Gynecol 203:457.e1 9., 2010 Best Pract Res Clin Obstet Gynaecol 25:51 63, Conclusion Oral agents metformin and glyburide appear as viable alternatives to insulin in the shortterm and are often preferred by patients, but more studies are needed to ascertain longterm safety. Postpartum Management No insulin required (usually). Monitor pre breakfast and 2 hours post meal blood sugars for 24 hours. Six week post partum 75 gram 2 hour OGTT Discuss prognosis (50% after 7 10 years convert to DM) and prevention Annual fasting blood glucose Every 3 years 75 gram 2 hour OGTT Recommendations Lifestyle modifications Follow HSPH food guidelines vegetables, fruits, lean meats and whole grains, avoid sodas, juices, white breads and bakery items. Exercise 60 minutes of moderate or 30 to 45 minutes of vigorous exercise daily. Target weight > 7% below preconception weight (as long as BMI is not below normal) Cycle of obesity and diabetes from generation to generation Neonatal macrosomia Gestational diabetes + Type 2 DM Obesity in childhood And later life Concept by David Pettitt MDA Nutrition Convention & Exposition 7

8 Opportunities for Infants In most studies breast feeding reduces the risk of obesity in offspring. Improve the awareness of pediatricians regarding the increased risk of obesity, impaired glucose metabolism and diabetes in offspring of mothers with GDM/preexisting diabetes. Create early dietary and exercise interventions in high risk offspring. Case Study Case Study Jane presents at 28 wks gestation, G2P1 OGTT: 83, 185, 148 Pre pregnancy Wt 157lbs, Ht 5 3 BMI 27.8., AC: 25.1 cm 65% Age 35 She has gained 15lbs to date Does Jane have gestational diabetes? How much weight should Jane gain during her pregnancy? What should her glucose goals be? Jane s Weight Gain Pattern Diet History Breakfast Raisin bagel with cream cheese, 6 oz juice Lunch 2 slices pizza, 8 oz milk or Sandwich with baked lays, 8 oz milk Snack driving home Iced coffee and donut or nuts and fruit Dinner Chicken, or pork chops with potato or rice and broccoli/green beans/ pasta w meatballs Pad Thai or pizza, Chinese or weekends Nutrition Assessment Excessive >2300 Excessive 75 grams at breakfast, lunch Inadequate calcium MDA Nutrition Convention & Exposition 8

9 Jane s Prescription Carb Controlled Meal Plan of 30,45,45, and 3 15 gram snacks (approx kcals) Testing fasting and 1 hour post meals Goals <95mg/dl fasting and 130mg/dl 1 hour post meals Weight gain of 0.6 lbs per week Morning ketone testing Fasting 1 hour post Blood Glucose Numbers 1Week Post Education 1 hr post lunch 1 hr post dinner Ketones Neg Neg Trace Neg Weight 158lb 1ld Review of food records carb counts accurate Elevated fasting and post dinner Wt gain sl. rapid Begin NPH insulin 4 units at bedtime Walk post dinner One Month Follow Up Take Home Messages Fasting 1 1 hr Fasting 1 hour hour post p post lunch 1 hr post dinner Ketones Neg Neg Trace Neg Weight 163lb Started on Humalog 3 units at dinner Final Insulin NPH 6 units, Humalog 4 units Lunch and Dinner New diagnostic criteria Lower blood glucose targets Consideration of Hadlock A/C Immerging treatments (diet and medication) Type 2 DM prevention Follow up! MDA Nutrition Convention & Exposition 9