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| REVIEW ARTICLE |
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| Year : 2017 | Volume
: 15
| Issue : 3 | Page : 222-226 |
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Diet in a pregnant mother with diabetes mellitus
Mini Joseph, Sahana Shetty, Nihal Thomas
Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| Date of Web Publication | 7-Aug-2017 |
Correspondence Address:
Mini Joseph
Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_45_17
Gestational diabetes mellitus (GDM) is a severe threat to maternal and child health. It is associated complications adversely affect the mother and the child. One in seven births is affected by gestational diabetes. Lifestyle intervention has a positive impact on glycemic control and pregnancy outcomes of GDM. Adequate nutrition during pregnancy ensures good health for the mother and the growing fetus. There is an increased need for calories, proteins and vitamins, and minerals to meet the demands of increased metabolic activity during this period. The composition of each meal is crucial in attaining glycemic control. A low-carbohydrate diet (60%–65%) with adequate proteins (15%) and fats (20%–25%) is beneficial in attaining acceptable postprandial sugars. “My Plate Planner” is a simple method for remembering the type and quantity of food to be consumed with each meal. Regularity of meals with frequent snacking of healthy foods ensures acceptable glucose homeostasis throughout the day.
Keywords: Diabetes mellitus, diet in diabetes, diet in pregnancy
How to cite this article:
Joseph M, Shetty S, Thomas N. Diet in a pregnant mother with diabetes mellitus. Curr Med Issues 2017;15:222-6 |
| Introduction | |  |
Diabetes is the most common disease condition in pregnancy and its prevalence is on the increase. The worldwide prevalence of hyperglycemia in pregnant women (20–49 years) is 16.9% or 21.4 million live births 2013.[1] More than 90% of the cases occur in low- and middle-income countries. Majority of these patients have gestational diabetes mellitus (GDM). The rest have preexisting diabetes (pre-GDM) which includes mostly Type 1 and Type 2 diabetes mellitus.[2]
GDM is a severe and neglected threat to maternal and child health. Uncontrolled GDM is also associated with pregnancy related complications including high blood pressure, fetal macrosomia, neonatal hypoglycemia, and obstructed labor.[3],[4]
The diabetes atlas (7th edition; 2015) of the International Diabetes Federation defines GDM as a glucose intolerance of varying degrees of severity which starts or is first recognized during pregnancy. One in seven births is affected by gestational diabetes.[5] The major risk factors for GDM include higher parity, advanced maternal age, family history of diabetes mellitus, nonwhite race, overweight, and obesity.[6]
Prevention of blood glucose fluctuations during pregnancy has several medical and economic benefits for the mother and infant on a long-term basis. Studies from worldwide have shown that lifestyle intervention has a positive impact on glycemic control and pregnancy outcomes of GDM. Diet, exercise, and nutrient composition play a significant role in reducing rates of adverse pregnancy outcomes.[7],[8]
| Nutritional Requirements for a Pregnant Mother With Gestational Diabetes Mellitus and Preexisting Diabetes | | |
Pregnancy is a state of increased metabolic activity. Adequate nutrition during pregnancy ensures good health for the mother and the growing fetus. To attain maximum potential in terms of physical and mental development for the mother and the growing fetus, appropriate nourishment in terms of quality and quantity of the diet is crucial. There is an increased need for macro- and micro-nutrients during pregnancy.[9] The nutritional requirements for a woman with and without diabetes are the same; however, the composition of each meal should be tweaked to attain good glycemic control. This is tabulated in [Table 1].[10] | Table 1: Recommended daily allowances during pregnancy (with/without diabetes)
Click here to view |
Key points: Dietary Tips to Healthy Eating in Pregnancy
- Eat meals at regular times, never skip any meals
- Follow the 3 meal + 3 snack pattern,
- Avoid long gaps - not be more than 2 ½–3 h' time gap between meals
- Choose a low glycemic food for breakfast
- Reintroduce millets in the daily diet
- Fill half your plate with vegetables and quarter with proteins and carbohydrates
- Grow your own organic vegetables in your own backyard/terrace!
- Non-vegetarians should choose leaner cuts of the meat
- Drink 2–3 L of water daily and more if you work outdoors
- Be active; do 15–20 min of walking after each meal.
The pregnant woman with diabetes should take special care to ensure that it is adequate in macro- and micro-nutrients. There is an increased need for calories (+ 350 cal/day from the 2nd trimester) to meet the demands of growth and physical activity of the fetus, growth of the placenta, normal maternal size and for the additional task of carrying the weight of the fetus and maternal tissues and the increased rate of basal metabolism.
The protein requirement during pregnancy is an additional 23 g/day (i.e., 55 + 23 = 78 g/day). This is required for meeting the growth needs of the enlargement of the uterus, mammary glands, placenta, growth of fetus, increase in circulating blood volume, plasma proteins, amniotic fluid synthesis, and transfer of amino acids from the mother to fetus.[9]
There is a subsequent increase in the need for Vitamin D for enhancing maternal calcium absorption. Vitamin K is necessary to prevent neonatal hemorrhage. There is an increase in the requirements for thiamine (+0.2 mg/day), riboflavin (+0.3 mg/day), niacin (+2 mg/day), Vitamin C (+20 mg/day), folic acid (+300 mg/day), and Vitamin B12 (0.2 mcg/day). The need for calcium increases to 1000 mg/day to provide for the calcification of fetal bones and teeth and to protect the calcium reserves of the mother to meet the high demands of lactation. The increased iron needs is to meet the growth of the fetus, placenta, and for production of fetal hemoglobin.[9]
| Nutrient Composition of Each Meal | | |
The composition of each meal is crucial in attaining glycemic control. A low-carbohydrate diet (60%–65%) with adequate proteins (15%) and fats (20%–25%) is beneficial in attaining acceptable postprandial sugars.
The Indian population living in Asia consumes a high-carbohydrate diet. Each meal is composed of 75%–80% of carbohydrates with low-protein content. This is more evident in the lower socioeconomic groups where carbohydrate-rich foods are more cheaply available compared to other foods. There has been a paradigm shift in our eating habits from a traditional diet of millets and whole grains to the present day highly processed refined fast food culture. The subsidized availability of polished rice in our public distribution system has contributed to this high intake of refined cereals. Reintroduction of the old food habits (millet-based) will definitely improve the intake of fiber and micronutrients in our diet. The “My Plate Planner”[11] vividly illustrates how the meal of a woman with diabetes should resemble [Figure 1]. This meal pattern is advisable for any pregnant woman; with or without diabetes. | Figure 1: My Plate Planner is a simple method for remembering the type and quantity of food to be consumed with each meal (modified from https:// www1.nyc.gov/assets/doh/downloads/pdf/csi/obesity-plate-planner-13.pdf).
Click here to view |
The picture clearly depicts that in a nine-inch plate, half the plate should be filled with vegetables, quarter with carbohydrates and the other quarter is for protein-rich food.
| Vegetables | | |
Half a plate of vegetables can be expensive, especially to a daily wage laborer. Emphasis should be placed on selecting locally grown vegetables as it will be cheaper and fresher. Kitchen gardens should be encouraged wherever possible. Many individuals have the misconception that expensive foods are more nutritious. Home-grown drumstick leaves are several times more nutritious than the exotic vegetables from distant places. Including green leafy vegetables on alternate days will ensure adequate intake of fiber, B-complex vitamins and minerals. Working mothers with time constraints particularly during the rush morning hours should be encouraged to include vegetables in the form of raw salads. A fruit per day is advised, but it is preferable that it be taken between meals so as not to increase the meal carbohydrate load. Fruit juices should be discouraged as it is devoid of fiber.
| Carbohydrates | | |
Carbohydrates should occupy only quarter of the plate at each meal. It is advised to consume complex carbohydrates since they retain the fiber-rich bran layer. Fiber has an important role in maintaining glucose homeostasis. Millets and small grains are rich in fiber and are considered as nutri-rich cereals. Each meal should contain complex carbohydrates like millet/whole grains foods in place of refined cereals. However, our Indian diet consisting of polished rice, idlis, dosa, upma, white bread, parottas, maida (refined flours), etc., is carbohydrate-rich foods and should be restricted. These foods have very little fiber content as the processing methods (machine milling) remove the fiber rich outer bran layer. Sugars and sweet foods are simple carbohydrates and are best avoided as they cause a spike in the postprandial blood sugars. Artificial sweeteners can be used as sugar substitutes in moderation (3–4 servings per day).
| Proteins | | |
Protein foods consist of milk and milk products, flesh foods, sea foods, eggs, poultry, and pulses and legumes. These are relatively more expensive and hence consumed in smaller amounts. It is important that a pregnant woman include one protein food in each meal as it flattens the glycemic response in the postprandial state. Milk is commonly consumed and it is recommended that they consume 750–800 ml/day, especially from the 2nd trimester onward. Protein-rich snacks like groundnuts and roasted pulses like bengal gram are excellent low-cost sources of fiber and micronutrients.
| Fats | | |
It is best to avoid fried foods and oily foods as there are caloric dense items and causes a spike in the postprandial sugars. The amount of oil a person requires daily is 15–20 g/day (3–4 teaspoon of oil daily) and in a month this is approximately 500 ml/month/person. This includes refined oil, ghee, butter etc., Hence, a family of 4 members requires 2 kg of cooking oil/fats in the whole month. Palm oil and animal fats like lard are high in saturated fat and are best avoided.
| Regularity of Meal Timings | | |
Eating meals on time is vital for maintaining glucose homeostasis. Long-time periods between meals can result in low blood sugars. There should not be more than 2½–3 h' time gap between meals. This is, especially, true for patients who are on insulin. The food intake should correspond to the diabetes medication. The daily meal plan-breakfast, midmorning snack, lunch, tea-time snack, predinner snack (in case of late dinner due to work schedule), dinner, and a late night snack is helpful in preventing hypoglycemic attacks. Skipping meals/snacks has to be strongly discouraged.
3 meal +3 snack pattern
The meal pattern of a pregnant woman with diabetes requires special attention. It is important to take 3 meals and have 3 protein-rich snacks between meals [Figure 2] and [Figure 3]. The composition of each meal should resemble My Plate Planner. Including vegetables at all meals will reduce postprandial sugars. Our clinical practice has shown that the first meal consisting of pulses (boiled/sprouts) and milk is helpful in regulating the morning hyperglycemias that are normally seen during pregnancy. This is because of its low glycemic index (GI).
Bedtime snack
The bedtime snack (should be taken 2 h after dinner, that is just before going to bed) is very important to prevent a hypoglycemia in the early morning hours followed by high fasting sugars (Somogyi effect). Groundnuts, fruits, sprouts, whole gram pulses, nuts, and milk are good bedtime snack options.
Glycemic index and glycemic load
GI is a measure in the rise of blood sugar after the consumption of a particular carbohydrate (50 g) as compared to the reference foods (glucose or white bread). Glycemic load (GL) refers to the rise in blood sugar after the consumption of a particular food (100 g) as compared to the reference foods. Both these measures give an idea about the suitability of a food for diabetes patients. Low GI/GL foods are preferred. These include whole gram pulses, whole grain cereals, vegetables, milk, and milk products. They flatten the glycemic response of the food following a meal. Foods such as potato, sugar, cornflakes, and white bread have a high GI and are best avoided.[12]
It is advised that the pregnant mother with diabetes should choose at least one low GI food at each meal, combine a high GI and low GI food (rice and pulses) and choose whole grain cereals over refined foods and include vegetables at all meals.
| Conclusion | | |
The gestational period should be viewed as a window of opportunity to modify dietary patterns and introduce healthy lifestyle practices for the woman and her family. Adequate intake of micro- and macro-nutrients will not only facilitate glycemic control during pregnancy but also influence the metabolic health of the mother and the child.
Financial support and sponsorship
Nil.
Conflicts of interets
There are no conflicts of interest.
| References | | |
| 1. | Goldenberg RL, McClure EM, Harrison MS, Miodovnik M. Diabetes during pregnancy in low- and middle-income countries. Am J Perinatol 2016;33:1227-35.  [ PUBMED] |
| 2. | American Diabetes Association. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002;25:202-12. [ PUBMED] |
| 3. | American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2006;29:S43-8. [ PUBMED] |
| 4. | Wong T, Ross GP, Jalaludin BB, Flack JR. The clinical significance of overt diabetes in pregnancy. Diabet Med 2013;30:468-74. [ PUBMED] |
| 5. | |
| 6. | Moosazadeh M, Asemi Z, Lankarani KB, Tabrizi R, Maharlouei N, Naghibzadeh-Tahami A, et al. Family history of diabetes and the risk of gestational diabetes mellitus in Iran: A systematic review and meta-analysis. Diabetes Metab Syndr 2016. pii: S1871-4021(16)30239-9. |
| 7. | Agha-Jaffar R, Oliver N, Johnston D, Robinson S. Gestational diabetes mellitus: Does an effective prevention strategy exist? Nat Rev Endocrinol 2016;12:533-46. [ PUBMED] |
| 8. | Carolan-OIah MC. Educational and intervention programmes for gestational diabetes mellitus (GDM) management: An integrative review. Collegian 2016;23:103-14. [ PUBMED] |
| 9. | Srilakshmi B. Dietetics. 5 th ed. New Delhi: New Age International Pvt. Ltd. Publishers; 2005. |
| 10. | |
| 11. | |
| 12. | Thomas N, Kapoor N, Velavan J, Senthil Vasan K. A Practical Guide to Diabetes Mellitus. New Delhi: Jaypee; 2012. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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