Blood Glucose Control O If blood glucose levels are in the 140 range, baby may not be harmed, but he or she may be larger at delivery O If values are in the 160-180 range, it puts stress on baby s pancreas as it is developing Susan B Dopart, MS, RD, CDE 1
Important! OInsulin does not cross the placenta but glucose does! Susan B Dopart, MS, RD, CDE 2
CONTROL: Factors Affecting Glucose Levels O Level of insulin resistance O Macronutrient Balance O Level of Activity O Amount of Sleep O Stress and the Weather Susan B Dopart, MS, RD, CDE 3
Other Factors Affecting BG O Women who consumed less than 70 mg/day of dietary Vitamin C experienced a 3.7 fold increase in GDM O Take Home: increase intake of vitamin C rich foods strawberries, kiwi, red bell peppers, oranges, etc. Susan B Dopart, MS, RD, CDE 4
Supplements/Vitamins O Prenatals O Omega 3 fats ALA, DHA, EPA O Vitamin D3 O Additional folic acid (or active form: 5-MTHF or L-methylfolate)) Susan B Dopart, MS, RD, CDE 5
Omega 3 Fats O Higher levels of omega 3 fats can lower maternal triglycerides by 10% O This lowering of triglycerides decreases accumulation of fetal fat Susan B Dopart, MS, RD, CDE 6
Omega-3 Fats O ALA found in the highest concentration in ground flax seed 1 tablespoon per day helps achieve needs (and assist with constipation common in pregnancy) O DHA, EPA helps with lowering insulin resistance at cellular level at least 500 mg. each recommended Susan B Dopart, MS, RD, CDE 7
Vitamin D O There is a high prevalence of Vitamin D deficiency with GDM O Without supplementation, exclusively breastfed babies will be Vitamin D deficient 8 weeks after birth Susan B Dopart, MS, RD, CDE 8
Vitamin D O D3 is a pre-pro-hormone made in the skin O At least 37 different tissues require Vit D O Needed for bone metabolism, as well as other systems such as cardiovascular health, neurodevelopment, insulin secretion and regulation of cell growth Susan B Dopart, MS, RD, CDE 9
Vitamin D O Vitamin D deficiency is associated with a 2.6 fold increased risk of GDM O Supplementation may be necessary during pregnancy and lactation O Check levels twice during pregnancy- supp. accordingly (critical 1 st trimester) Susan B Dopart, MS, RD, CDE 10
Bruce Hollis, PhD At no point in human nature is it more critical to ensure adequate nutrient intake than during the state of pregnancy. Susan B Dopart, MS, RD, CDE 11
Bruce Hollis, PhD Vitamin D in essential in pregnancy since: O It is an immune modulator O Lower vitamin D in 1 st trimester associated with higher risk of developing GDM (Laxroix, et al, 2014 Acta Diabetol) O Low levels of D are an independent risk factor for developing GDM and IR in 2 nd trimester Vitamin D in Pregnancy: Diabetes and other Adverse Outcomes Susan B Dopart, MS, RD, CDE American Diabetes 74 th Scientific Sessions June 2014 12
Bruce Hollis, PhD Vitamin D in essential in pregnancy since: O It has beneficial effects on glycemia and total LDL cholesterol in women with GDM O Recommendations: Daily vitamin D vs. large dose (large dose only good for skeletal needs vs. other systems) O From his data recommend 4000 IU/day during pregnancy with a minimum of 40 ng/ml. Susan B Dopart, MS, RD, CDE 13 Vitamin D in Pregnancy: Diabetes and other Adverse Outcomes American Diabetes 74 th Scientific Sessions June 2014
Vitamin D O According to researchers from the University of Toronto: The period from pre-pregnancy to 24 months of a child s life offers an important developmental window during which vitamin D exposure can have profound effects on human health. Inadequate concentrations of vitamin D during perinatal life can adversely affect Susan B Dopart, MS, RD, CDE 14
Vitamin D O Continued. O bone health, brain development, heart disease, type one diabetes, and cancer. To achieve optimal health at adulthood, it is imperative that pregnant mothers and their newborn babies receive sufficient amounts of vitamin D during critical developmental windows. Susan B Dopart, MS, RD, CDE 15
Vitamin D O Pregnant women may need at least 4,000-5,000 IU of vitamin D per day both during pregnancy and lactation O Having adequate vitamin D levels helps prevent complications during pregnancy such as preeclampsia and increased levels of insulin resistance leading to high blood glucose levels Susan B Dopart, MS, RD, CDE 16
Vitamin D and GDM O 1,25 (OH) 2 D regulates insulin secretion by pancreatic beta-cells O Low 25(OH)D is a risk factor for glucose intolerance and insulin resistance O Early pregnancy Vit D deficiency significantly increases risk for GDM Nov 2013 PloS One 2008; L. Nichols, Sweet Success Conf Susan B Dopart, MS, RD, CDE 17
Vitamin D and GDM Risk of GDM increases 40% for each standard deviation decrease in 25 (OH) D independent of adiposity, age, or a season of blood sampling European Association for the Stud of Diabetes (EASD) 48 th Annual Meeting 2012 L. Nichols Sweet Success Nov 2013 Susan B Dopart, MS, RD, CDE 18
Folic Acid O Abnormalities in the fetus can occur at week 5 and 8, making pregnancy planning with diabetes essential so blood glucose values can be controlled prior to conception O Controversy whether obese women need more folic acid (about 350 mcg.) since women with GDM/DM have babies with higher rates of NTD s Susan B Dopart, MS, RD, CDE 19
Type of Folic Acid Some GDM experts speculating whether high risk pregnancies in need of L-methylfolate or 5- MTHF which is the active form of folic acid since some of the population are poor metabolizers of this vitamin impairing conversion of the normal 4-step process Susan B Dopart, MS, RD, CDE 20
Fiber O Over 10 grams/day can lower GDM by 26% O Can reduce the chance of a baby being overweight by 33 percent O Stressing low glycemic foods high in fiber helpful in reduction of blood glucose levels Susan B Dopart, MS, RD, CDE 21
How do we bridge the gap for the reward? Susan B Dopart, MS, RD, CDE 22
Exercise and Blood Glucose Susan B Dopart, MS, RD, CDE 23
Pregnancy and Exercise O Only 16% of pregnant women meet guidelines for physical activity for pregnancy O Pregnant women are half as likely to be active when pregnant than not pregnant Susan B Dopart, MS, RD, CDE 24
ACOG Guidelines O Show physical activity and exercise have very favorable effects on: O Birth weight of the infant O Preterm birth O Risk of GDM lowered by 40% O Pre-eclampsia Susan B Dopart, MS, RD, CDE 25
Exercise O Dr. Raul Artal: O Pregnant women should walk after each meal to help their insulin work more effectively or walk at least 30 minutes per day. Within 10 days of initiating an exercise program, 60 percent of women with GDM will attain normal blood sugars. Susan B Dopart, MS, RD, CDE 26
The Profound Effects of Exercise with GDM O Beta cells are a bank you can only make withdrawals, not deposits O Glucose transporter type 4 (Glut 4) is a protein found in adipose tissue and striated muscle cells that is responsible for insulin regulated glucose transport into the cell during muscle contraction Susan B Dopart, MS, RD, CDE 27
The Profound Effects of Exercise with GDM O The glut -4 translocates from intracellular storage depot to the plasma membrane and T-tubules O Glucose enters the muscle cell via diffusion O Translation: exercise training is the most potent stimulus to stimulate glut-4 expression Susan B Dopart, MS, RD, CDE 28
The Magic of Exercise O Allows women to be able to use glucose and spare insulin (which rests the beta-cells) and lowers blood glucose values O Walking: using gluts, quads and hamstrings, which is constantly engaging muscles thus utilizing the glucose, sparing the insulin and resting the beta cells Susan B Dopart, MS, RD, CDE 29
Benefits of Exercise in GDM O Regular participation and sufficient intensity are important for: O O O O Control of blood glucose levels Skeletal muscle uptake Enhanced insulin action Uses muscle glycogen O Weight maintenance and loss of visceral fat O Lack of postpartum weight loss and exercise are strong predictors of increased incidence of type 2 diabetes Susan B Dopart, MS, RD, CDE 30
Exercise Gives the Beta- Cells A Much needed NAP Susan B Dopart, MS, RD, CDE 31
Benefits of Exercise O Mood benefits and stress relief O Less incidence of depression O Increased self-image O Sleep benefits O Over-all sense of increased wellbeing Susan B Dopart, MS, RD, CDE 32
Benefits of Exercise O Mood benefits and stress relief O Less incidence of depression O Increased self-image O Sleep benefits O Over-all sense of increased wellbeing Susan B Dopart, MS, RD, CDE 33
Exercise Duration O Usually not more than 45-60 minutes due to risk of overheating and potential for dehydration, and hypoglycemia especially if taking insulin O ACSM/CDC suggest 30 minutes on most days, if not all days, of the week O Especially encourage 30 minutes, 6 days a week if exercising for blood glucose control Melissa Ortiz, Exercise in Diabetes During Pregnancy, 2014 Sweet Success Susan B Dopart, MS, RD, CDE 34
Movement Throughout the Day Susan B Dopart, MS, RD, CDE 35
Fetal Benefits of Exercise O Short and long term benefits for the offspring of women who exercise during pregnancy O Decreased risk of O Childhood obesity O Childhood type 2 diabetes O Childhood metabolic syndrome O Advanced cerebral maturation Melissa Ortiz, Exercise in Diabetes During Pregnancy, 2014 Sweet Success Susan B Dopart, MS, RD, CDE 36
Considerations with Pregnancy and GDM O Increased blood glucose is testing is essential O Carry a snack at all times O Meal and snack planning is essential Susan B Dopart, MS, RD, CDE 37
Considerations with Pregnancy and GDM O Planned exercise may require insulin adjustment O Knowledge of signs/symptoms of hypoglycemia O Watch injecting insulin into working muscle and exercise when BG is on the rise, not falling Susan B Dopart, MS, RD, CDE 38
Medications O Two issues with meds during pregnancy: O Safety? O Efficacy? Susan B Dopart, MS, RD, CDE 39
Oral Meds O Glyburide and Metformin O Both cross the placenta O Is one preferable to the other? Susan B Dopart, MS, RD, CDE 40
Glyburide O An older diabetes medication known as an oral-hypoglycemic agent O It triggers the pancreas to release more insulin to help with normalizing blood sugars O Increases risk for hypoglycemia Susan B Dopart, MS, RD, CDE 41
Metformin O A medication used in type 2 diabetes, known as an insulin sensitizer O Lowers the blood sugar by lowering the amount of glucose produced by the liver, increasing body s response to its own insulin, thus lowering the amount of glucose absorbed from food O Level of insulin resistance is decreased Susan B Dopart, MS, RD, CDE 42
Metformin Crossing the placenta which is advantageous since it can lower insulin resistance in both the Mom and fetus which can alter the course of future risk for diabetes in both Susan B Dopart, MS, RD, CDE 43
Glyburide or Metformin? O Glyburide easy to use, given once or twice a day depending on blood glucose values, but can cause hypoglycemia and drive betacells O Metformin can cause gas, bloating, nausea at first, dosing 1-3x/day, improves insulin sensitivity and fat mass in both the Mom and fetus Susan B Dopart, MS, RD, CDE 44
Approved Insulins O Lispro, Aspart short acting insulins O Long acting insulins- NPH and Determir O For each week of pregnancy need approximately 2 more units insulin/day Susan B Dopart, MS, RD, CDE 45
Price of Medications for 12 weeks for GDM O Insulin $1990 O Rapid acting insulin 8 units TID O Basal Insulin 36 units/day O Metformin 500 mg. BID $72 O Glyburide 5 mg. BID $93 74 th Scientific Sessions June 2014 Susan B Dopart, MS, RD, CDE 46
Added Lifestyle Time Taking a pill 3x/day Time to learn insulin administration and balancing that with other ADL s Susan B Dopart, MS, RD, CDE 47
Is One Better than the Other? O Studies show oral meds are equally as effective in as insulin in achieving good glycemic control O Oral meds are not associated with adverse pregnancy outcomes O Oral meds are a significant cost savings and patients prefer them O Further studies required to determine LT effects Susan B Dopart, MS, RD, CDE 48
No Clear Answer O Although benefits are based on blood glucose values, lifestyle of the Mom, level of insulin resistance research is not clear which is actually better and more research is needed O Treatments should be individual and tailored to each woman based on above criteria Susan B Dopart, MS, RD, CDE 49
Our Goal as Practitioners O Early diagnosis if possible O Early treatment with individualized diet balance and meds if needed and coordinating with physician O Encourage regular after meals and/or daily exercise O Monitor throughout pregnancy for adjustments Susan B Dopart, MS, RD, CDE 50
Your Healthy Reward Susan B Dopart, MS, RD, CDE 51
Postpartum O Monitor blood sugars for 6 weeks postpartum O Check glycosylated hemoglobin A1C every 3 months O Risk of type 2 diabetes strong with conversion within 5-10 years Susan B Dopart, MS, RD, CDE 52
Our Ultimate Goal Susan B Dopart, MS, RD, CDE 53
Healthy You, Healthy Baby: A Mother s Guide to Gestational Diabetes Susan B Dopart, MS, RD, CDE 54
References O Healthy You, Healthy Baby: A Mother s Guide to Gestational Diabetes O http://susandopart.com/store O Webinar Special: Free shipping for GDM book for 5 days after webinar (use code: baby) Susan B Dopart, MS, RD, CDE 55
References O A Recipe for Life by the Doctor s Dietitian (free shipping 5 days use code: baby) Susan B Dopart, MS, RD, CDE 56
References O A Recipe for Life plus Teaching Tools 18 reproducible handouts for RD s (free shipping for 5 days use code: baby) Susan B Dopart, MS, RD, CDE 57
Webinar Special OAll 3 Webinar Special: O Buy all 3 together free shipping (use code: baby) Susan B Dopart, MS, RD, CDE 58
Researchers O Patrick Catalano, MD: O http://www.prnewswire.com/newsreleases/march-of-dimes-honors-researcherwho-linked- ob-diabetes-and-obesity-to-a- newborns-long-term-health- 132899293.html Susan B Dopart, MS, RD, CDE 59
Researchers O Lynn Barbour, MD, MSPH O http://www.ucdenver.edu/academics/colleg es/medicalschool/departments/medicine/e ndocrinologymetabolismdiabetes/faculty_st aff/pages/barbour.aspx Susan B Dopart, MS, RD, CDE 60
Research O Dr. Sylvie Haugel-de Mouzon O http://www.ncbi.nlm.nih.gov/pubmed/2207 1058 O http://www.ncbi.nlm.nih.gov/pubmed/2185 2675 O http://www.ncbi.nlm.nih.gov/pubmed/2167 5877 O http://www.ncbi.nlm.nih.gov/pubmed/1946 0915 Susan B Dopart, MS, RD, CDE 61
Research O Alicia Jawerbaum, PhD: O http://edrv.endojournals.org/content/31/5/ 680.abstract O Mary Loeken, PhD: O http://www.ncbi.nlm.nih.gov/pubmed?term =Loeken%20MR%5BAuthor%5D&cmd=Deta ilssearch&log$=details Susan B Dopart, MS, RD, CDE 62
Research O Michelle Williams O Chair of Epidemiology O Harvard School of Public Health O http://www.hsph.harvard.edu/faculty/miche lle-williams/ Susan B Dopart, MS, RD, CDE 63
Research O Lois Jovanovic, MD. O O Churchill JA, Berendes HW, Nemore J: Neuropsychological deficits in children of diabetic mother. Am J Obst Gynecol 105: 257-268, 1969 Stehbens JA, Baker GL, Kitchell M. Am J Obstet Gynecol. 1977 Feb 15;127(4):408-13. Outcome at ages 1, 3, and 5 years of children born to diabetic women. O Jovanovic L, et al. Am J Obstet Gynecol. 1991;164:103. Susan B Dopart, MS, RD, CDE 64
Research O Lois Jovanovic, MD. O O Jovanovic L et al. Diabetes Care. 1998 Nov;21(11):1978-84. The Diabetes in Early Pregnancy Study: beta-hydroxybutyrate levels in type 1 diabetic pregnancy compared with normal pregnancy. NICHD-Diabetes in Early Pregnancy Study Group (DIEP). National Institute of Child Health and Development Major CA, Henry MJ, De Veciana M, Morgan MA. Obstet Gynecol. 1998 Apr;91(4):600-4. The effects of carbohydrate restriction in patients with diet-controlled gestational diabetes. Susan B Dopart, MS, RD, CDE 65
Research O Lois Jovanovic, MD. O O O Rizzo T, Metzger BE, Burns WJ, Burns K. N Engl J Med. 1991 Sep 26;325(13):911-6. Correlations between antepartum maternal metabolism and child intelligence. Jovanovic L. Sweet success, but an acid aftertaste? N Engl J Med 325:959-960, 1991. Jovanovic L. Am J Clin Nutr. 1999 Jul;70(1):3-4. Comment on: Am J Clin Nutr. 1999 Jul;70(1):53-61. Susan B Dopart, MS, RD, CDE 66
Research O http://keck.usc.edu/en/education/academi c_department_and_divisions/department_ of_medicine/our_divisions/divsion_of_end ocrinology/research.aspx Susan B Dopart, MS, RD, CDE 67
Research O Janet Rowan, M.D. research on metformin O http://www.ncbi.nlm.nih.gov/pubmed?term =janet%20rowan O Obed Langer, M.D. research on meds O http://www.ncbi.nlm.nih.gov/pubmed?term =obed%20langer Susan B Dopart, MS, RD, CDE 68
Research O Raul Artal, MD research on weight and exercise with GDM O http://www.ncbi.nlm.nih.gov/pubmed?term =raul%20artal Susan B Dopart, MS, RD, CDE 69