Objectives. What Is Diabetes? 1/26/2015. Carbs & Meds & Meters, Oh My!: Diabetes in Pregnancy

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1 Carbs & Meds & Meters, Oh My!: Diabetes in Pregnancy Jan Tisdale RD, MPH, CDE Nutritionist / Certified Diabetes Educator UAB School of Medicine OB/GYN Maternal-Fetal Medicine 02/2015 Objectives Review definitions, screening & diagnostic criteria of pregestational diabetes and gestational diabetes Discuss carbohydrate counting or carb counting as a management tool for diabetes in pregnancy Describe blood glucose lowering medications used in management of diabetes in pregnancy Identify monitoring modalities useful in diabetes self management education (DSME) What Is Diabetes? A metabolic disease in which the body s inability to produce any or enough insulin causes elevated levels of glucose in the blood. This disease is characterized by hyperglycemia. Carbohydrate is the Nutrient in Food that raises blood glucose the most 1

2 Diabetes Statistics Currently 9 % of total population has Diabetes Estimated that over 14 million Women aged 20 years & over have diabetes CDC National Diabetes Statistic Report, 2014 Diabetes Classifications Type 1 ( B-cell destruction, Insulin Deficient) o5-10% of all Diabetes Type 2 ( Insulin Resistance ) o 90-95% of all Diabetes Gestational Diabetes (Diagnosed in pregnancy & is not clearly overt DM) Other Cystic Fibrosis Related Dm, Drug Induced ADA Standards of Medicaid care in Diabetes-2014 Diabetes care vol 37, supplement 1, January 2014 Diabetes Diagnostic Criteria (Non-Pregnant ) HgA1c >6.5 Fasting Blood Sugar >126 Random Blood Sugar >200 ADA Standards of Medicaid care in Diabetes-2014 Diabetes care vol 37, supplement 1, January 2014 ADA Standards of Medicaid care in Diabetes-2014 Diabetes care vol 37, supplement 1, January

3 Diabetes in Pregnancy 5-10 % of all Pregnancies Pregestational Diabetes (Type 1 & Type 2) Complicates 1-2 % of all pregnancies Gestational Diabetes Complicates 6-% of all pregnancies (7-14% in obese) (Fong, ACOG 2014) White s Classification of Diabetes in Pregnancy Age of onset > 20 y y <10 y* Duration < 10 yr yr. > 20 yr. * or any background non-proliferative retinopathy Nephropathy Ischemic cardiovascular disease Proliferative Retinopathy Screening for GDM Risk factor based strategy May miss up to 50% of patients Universal screening recommended for simplicity Identifies population at risk: Pregnancy complications Overt diabetes in later life Other Considerations A1C ( ) (>6.4) Fasting BG (>126) 3

4 Different Approaches to GDM Screening 2 Tiered ACOG 50 gm 100 gm (95 / 10/ 155/ 140) 2 abnormal # s needed for diagnosis 1 Tiered WHO 75 gm (92/10/153) 1 abnormal needed for diagnosis Diabetes in Pregnancy Plan of Care includes: Medical Nutrition Therapy (MNT) Diabetes Self Management Education (DSME)- including SMBG /Meds Activity as tolerated Role of CDEs in Medical Nutrition Therapy in Diabetes Care Diabetes self-management education (DSME) can improve patient knowledge, behavior, and glycemic control Medical Nutrition Therapy is an essential part of DSME Addressing carbohydrates as a nutritional strategy is endorsed by the ADA and the AADE Clinical trials have shown that MNT can improve A1C by 1-2% Facilitating positive behavior as well as transferring knowledge is a priority 12 4

5 Carbohydrate Counting Amount of carbohydrate eaten determines how high blood glucose will rise after a meal Carbohydrate begins to raise blood glucose within 15 minutes of eating 15 g Carb will BG mg/dl Flexible meal planning tool for consistent meals and snacks Starches Starch Group Each amount listed below=15 g carbohydrate 1 ounce (oz) of bagel, bread, or roll (1 slice of bread or one fourth of a bagel) ¾ cup (C) unsweetened cereal (Cheerios, Rice Krispies, or cornflakes) ⅓ C higher carbohydrate cereals (raisin bran) One half of an English muffin ⅓ C cooked pasta, spaghetti, or macaroni and cheese ⅓ C cooked brown or white rice ½ C mashed potatoes ½ C corn, beans, chickpeas, or peas 1 small baked potato (3 oz) 5

6 Fruit and Fruit Juices Fruit Group Each amount listed below=15 g carbohydrate 1 small fresh fruit (4 oz) ½ C canned fruit (in natural juice) 2 tablespoons (Tbsp) raisins 17 grapes ½ C fruit juice 1 C fresh fruit (cut up) Milk and Yogurt 6

7 Milk Group Each amount listed below=approximately 12 g carbohydrate fluid ounces (fl oz) of skim, 1%, 2%, or whole milk 1 C plain yogurt 1 C plain or vanilla soy milk Carbohydrate and Noncarbohydrate Categories Groups/Lists CHO Protein Fat Calories Starch Fruit Milk: Skim Low fat Whole Other carbohydrates 12 varies varies varies Vegetables Meat and substitute group: Very lean Lean Medium fat High fat Fat group Food Labels Total carbohydrate includes grams of sugar, sugar alcohol, starch, and dietary fiber Total grams of carbohydrate to determine amount of carbohydrate eaten, multiply grams of total carbohydrates on the label by the number of servings eaten 7

8 When Diet Fails 20-40% Insulin vs oral agents Controversial Anomalies, macrosomia, hypoglycemia Sulfonyurea or Metformin Insulin Regimens Once daily Twice daily (2/3 am & 1/3 pm) N:R ratio of 2:1 am 1:1 pm Self mix Premix Multiple Daily Injections (MDI)-Intensive basal / bolus (basal 50% bolus 50%) Continuous Subcutaneous Insulin Injection (CSII) pump therapy Insulin Injection Devices Insulin pens Faster and easier than syringes Improve patient attitude and adherence Have accurate dosing mechanisms, but inadequate mixing may be a problem

9 Advantages Of Pumps Over MDI More reliable insulin action Fewer missed/skipped doses Precision 0.05 u versus 0.5 u Automatic dose calculations Less insulin stacking DSME: Diabetes Self- Management Education Prepare patients to make informed decisions, engage in effective diabetes selfmanagement and implement self care behaviors that allow individuals to maximize well being. Self-monitored Blood Glucose (SMBG) The most important parameter used to determine the level of metabolic control is evaluation of SMBG levels. Professional organizations have yet to agree on glycemic thresholds and timing and frequency of testing. 9

10 Goals of therapy- ACOG Timing Fasting <95 Value (mg/dl) Preprandial <100 1 hr postprandial <140 2 hr postprandial <120 During the night >60 HgbA1C < 6.0 Intensive monitoring associated with improved perinatal outcomes Record Keeping Accurate records of blood-glucose levels, urineketone testing, dietary intake, timing and dosage of insulin, and activity level allow for appropriate adjustment of the diabetes regimen. To detect falsification or over- or underreporting, the nurse periodically correlates logged values to the meter memory. Summary Diabetes is a common medical complication of pregnancy Pregestational diabetics are at increased risk for maternal and fetal complications that are best addressed in the preconception period Universal Testing for Gestational diabetes should occur. The options for treatment of diabetes have increased Glycemic Control determines outcomes 10

11 References ACOG Practice Bulletin (2013, August). Gestational diabetes mellitus. 122(2), Coustan, D. (2013). Gestational diabetes mellitus. Clinical Chemistry, 59 (9), Mathiesen, E., Ringholm, L, Damm, P. (2011). Pregnancy management of women with pregestational diabetes. Endocrinol Metab Clin North Am, 40(4), MyPlate Information retrieved from Vargas, R., Repke, J., Ural, S. (2010). Type 1 diabetes mellitus and pregnancy. Reviews in Obstetrics & Gynecology, 3(3), White, P. (1949). Pregnancy complicating diabetes. Am J Med, 7,

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