Gestational Diabetes Mellitus in a Hispanic Female
Sonia Esparza
Dr. Susan Hewlings
FNS 672 Advanced Clinical Nutrition
Case Study
March 28, 2017
Introduction:
Prevalence data
A pregnancy can be the most life-changing experience for both mother and father. Unfortunately, due to the elevated incidence of obesity with more than two-thirds of the US population have increased the risk for gestational diabetes in women.1 The Center for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire estimates the prevalence of gestational diabetes in the United States may have been as high as 9.2% between 2007-2010.2 According to the Centers for Disease Control and Prevention (CDC), Hispanics rank as the second highest age-adjusted rates of obesity at 42.5%. 3 In 2011, Georgia reported the rate of GDM among Hispanic women to be the greatest at 37.2%. 4 In New York City, the incidence of GDM rose to 46% from 1990 to 2002 in Hispanic women.5 Colorado reported an increase of 95% GDM incidence from 1994 to 2002 with the highest among Hispanic women.5
History
The first description of diabetes in pregnancy was in Germany by Bennewitz in 1824. 6 Diabetes in pregnancy resulted in poor pregnancy outcomes such as fetal death and stillborn.7,8,9 In 1909, J. W. Williams advised to follow up with all pregnancies that presented with glycosuria for possible complications of diabetes. 10 He advised if the glycosuria appeared late in gestation, which was about 2% of asymptomatic cases, it was most likely transient and should be monitored for the remainder of pregnancy.10 Per J.W. Williams, diabetes can manifest during gestation suggesting if the amount of glycosuria was large and uncontrolled, induction of abortion or premature labor should be indicated, even with women reporting minimal symptoms.10 In 1926, Lambie in Edinburgh concluded when diabetes manifests in pregnancy, it’s usually in the fifth or sixth month with few cases manifesting before the fourth or after the eight months of gestation. He suggested that a 50gram oral glucose challenge test (OGCT) should be obtained in all pregnancies with diabetes to calculate the ketogenic-antiketogenic balance.11 There were many disagreements for the best way to screen and diagnose diabetes in pregnancy in the 1900’s. Norbet Freinkel in Chicago organized the First International Workshop on Gestational Diabetes Mellitus (GDM) in October 1979. 12,13,14 GDM was defined as “carbohydrate intolerance of variable severity recognized for the first time in pregnancy.” 12,13,14 The GDM management instructions were on limiting intake of sucrose, monitoring gestational weight and a caloric intake recommendation as of a non-diabetic woman of normal weight without restricting calories.15
Gestational diabetes is a very delicate condition that can affect the maternal and fetal outcome if uncontrolled. Timely interventions are essential to help reduce pregnancy complications. Effective treatment methods using medications such as insulin have been essential for severe insulin resistance during gestation. Nutrition and exercise continue to be an integral part of gestational diabetes management. 16
Background:
Pathophysiology
During early stages of pregnancy, estrogen and progesterone increase and lead to pancreatic ß-cell hyperplasia releasing extra insulin.17 Glucose is increasingly utilized peripherally and glycogen storage with less hepatic glucose production lowers maternal fasting glucose levels.18 In the second and third trimester, increased amount of human chorionic somatomammotropin (hCS), cortisol, prolactin, progesterone, and estrogen causes increased insulin resistance in peripheral tissues, a diabetogenic state.19 The insulin sensitivity is reduced by 80%.20 The pancreas compensates by secreting 1.5-2.5 times the usual insulin.21 In gestational diabetes, women have a much greater severity of insulin resistance.20 The insulin release is impaired possibly due to some degree of decreased beta-cell function, particularly in the first-phase response.22 A 67% reduction of beta-cell compensation is seen in gestational diabetes compared to a normal pregnancy.23
Etiology
Genetic factors, sedentary lifestyle, older age, obesity, environmental factors are etiologic reasons that contribute to the development of insulin resistance.24 According to the CDC, women are at high risk for developing gestational diabetes if they present with the following:
• History of gestational diabetes
• Had a baby born weighing over 9 pounds
• Overweight or obese
• More than 25 years old
• Family history of diabetes
• African American, Hispanic American Indian, Alaska Native, Native Hawaiian, or Pacific Islander
• Treated for HIV.25
Screening
Gestational Diabetes Mellitus is usually diagnosed in the 24th-28th week of gestational age.26,27 There are two types of strategies for GDM diagnosis.26,27 The first is the “one-step” 75-grams Oral Glucose Tolerance Test (OGTT) and the second is the “two-step” approach using 50-grams (non-fasting) screen followed by a 100-gram OGTT if screened as positive.26,27 In 2011 Standards of Care, the American Diabetes Association (ADA) recommended to follow the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) that all pregnant women should undergo the “one-step” 75-g at the 24-28th week gestation age.26 It was predicted that by following the 2011 ADA recommendation, the number of diagnosed gestational diabetes would increase from 5-6% to 15-20% because only one abnormal value is sufficient for diagnosis.26
Complications
Complications arise from uncontrolled gestational diabetes. Maternal hyperglycemia can cause risks for both the mother and the developing fetus. GDM can increase chances of developing pre-eclampsia and the need for a cesarean section.26, 27 By having a history of GDM, chances of developing type 2 diabetes increase at 35-60% in the next 10-20 years. 26, 27 The fetus is greatly affected under maternal hyperglycemic conditions increasing the risk of macrosomia, fetal anomalies, intrauterine fetal demise, hypoglycemia, hyperbilirubinemia, shoulder dystocia and respiratory distress syndrome.26, 27 The baby, as it progresses through its lifecycle, would be at increased risk of obesity and type 2 diabetes by adulthood.26, 27
A1c Target
In pregnancy, an A1c of 6% minimizes the risk for a large-for-gestational-age infant while an A1c of 6.5% increases chances of adverse outcomes.27 The target A1c during gestation is 6-6.5% with a desired 6% for an optimal pregnancy outcome.27 It’s important that the target A1c is achieved with minimal incidences of hypoglycemia to reduce the risk of low birth weight infant.27 Due to the rapid turnover rate of red blood cell during pregnancy and other physiologic changes in glycemic parameters, an A1c level can be monitored monthly.27
Blood Glucose Targets
To achieve an A1c of 6-6.5%, optimal glucose control is ideal to help minimize both maternal and fetal risks. Self-blood glucose monitoring is recommended at least four times a day at fasting and 1 or 2 hours postprandial. The recommendations from the Fifth International Workshop-Conference are:
• Preprandial ≤ 95mg/dL
• 1 hour post meal ≤ 140 mg/dL
• 2 hours post meal ≤ 120 mg/dL
The recommendations from the American College of Obstetricians and Gynecologists (ACOG) are:
• Fasting < 90mg/dL
• Preprandial < 105mg/dL
• 1 hour post meal < 130-140 mg/dL
• 2 hours post meal < 120 mg/dL
Gestational Weight Gain
Weight management during gestation is important to ensure adequate development of the fetus and reduce maternal complication. The following are the recommended weight gain by The American College of Obstetrician and Gynecologists, 2013:
Pre-Pregnancy Weight During Gestation 2nd & 3rd Trimester/Week
Underweight at 18.5 BMI 28-40 lbs. weight gain 1 lb.
Normal weight at 18.5-24.9 BMI 25-35 lbs. weight gain 1 lb.
Overweight at 25-29.9 BMI 28-40 lbs. weight gain 0.6 lb.
Obese at ≥30 BMI 11-20 lbs. weight gain 0.5 lb.
In Salmenhaara M et al. study, women with GDM had a higher BMI (mean 28.1kg/m2) at initial antenatal visit than women without GDM (mean 24.1kg/m2). 28 Women affected by GDM gained less weight (P<0.001 with a mean of 9.4kg, SD 5.1) than the women without GDM (mean 12.6kg/m2). 28 The mean weight gain for GDM women was 0.34kg/week and in women without GDM had a mean weight gain was 0.43kg/week (P<0.001). 28 These results may be the result after being diagnosed with GDM, women made dietary changes that caused less weight gain such as limiting carbohydrates.
Clinical Presentation:
AV was a 40 year old Hispanic, morbidly obese female that presented with a diagnosis of GDM based on the 1hr screen result of 197mg/dl. The patient had an excessive weight gain of 22 pounds from pre-prandial weight (PPW) at 27 weeks and 2 days gestational age (GA).
Figure 1. Lab Results
11/18/16 01/04/17 02/03/17
Gestational Diabetes
1 hr screen 197mg/dl — —
Hgb A1c 6.3% 7.2% 6.1%
Figure 2. Weight Chart
Office visits with RD —– 12/09/16
Initial 12/20/16
follow up 01/03/17
follow up 01/24/17
follow up 01/31/17
follow up 02/03/17 OB appt.
GA PPW 30 1/7 32 0/7 34 0/7 37 0/7 38 0/7 38 3/7
Weight (lbs.) 186 208 211 211.4 214.8 216.4 217
Weight change from prior visit —– +22 in 30 weeks +3 in 1 ½ weeks +0.4 in 2 weeks +3.4 in 3 weeks +1.6 in 1 week +0.6 in 3 days
Figure 3. Patient BG log
Date RBG (mg/dl) FBG (mg/dl) 1hr PP B(mg/dl) 1hr PP L (mg/dl) 1hr PP D (mg/dl) Comments # of low BGs? Treated low?
12/09/16 91 — — — — During glucometer instruction —
12/20/16 — 73-110 88-120 86-120 102-146 No meter only BG log —
01/03/17 131 — — — — Meter doesn’t match BG log —
01/24/17 — 59 Lo-88 96-134 94-106 104-176 Hi Meter matches BG log 1 time; drank 4 oz. orange juice
01/31/17 — 56 Lo-87 97-134 88-149 Hi 111-177 Hi Meter matches BG log 1 time; drank 4 oz. orange juice
*RBG – Random Blood Glucose, FBG – Fasting Blood Glucose, PP – Post Prandial, B – Breakfast, L – Lunch, D – Dinner, Lo – Low, Hi – High
Figure 4. 24-hour Recall Day Analysis
12/20/16 01/03/17 01/24/17 01/31/17
Total Carb servings consumed/day 11-12 8-9 14 16
Whole grain servings 4.5 0 6 5
Non-starchy vegetable servings 2 2 3 3
Dairy servings 1 2 2 ¾ 3
Protein servings 8 oz. 7 oz. 10 oz. 14 oz.
Healthy fat source consumed Peanut butter Eggs Eggs, walnuts, avocado, peanut butter Eggs, pecans, peanut butter
Water intake 60-72 oz./ 1.77-2L 84 oz./2.5L 84 oz./2.5L 72-84 oz./ 2-2.5L
Exercised? 15 min. walk post meals (45min total/d) 15 min. walk post meals (45min total/d) 10-15 min. walk post meals (30-45min. total/d) 10-15 min. walk post meals (30-45min. total/d)
Visit 1 on 12/09/16 at 30 1/7 GA
The patient came in for an initial RD consultation. The topics covered were on general GDM information, maternal/fetal risks, nutrition & exercise plan, instructed on glucometer use and blood glucose daily logging. The patient was instructed to perform self-blood glucose monitoring (SMBG) four times a day at fasting and 1hr postprandial. The entire visit was about 2 hours long.
Visit 1- 12/09/16 Anthropometrics & Labs:
Height 61”
Pre-Pregnancy Weight (PPW):
186#
Current Body Weight (CBW): 12/09/17- 208# (+22# gain from PPW at 30 1/7 GA)
Pre-Pregnancy Body Mass Index (PPBMI): 35.27, Morbidly Obese
Estimated Due Date (EDD): 02/14/2017
RBG: 91mg/dL during glucometer teaching
11/18/2016 HgbA1c: 6.3% at 27 2/7 GA
12/20/16 F/U visit at 32 0/7 GA
The patient reported with reduced weight gain and brought BG log but didn’t bring the glucometer to compare readings. The BG readings in the BG log all appeared to be within desired range. We discussed AV’s last 24hr food recall. She was inconsistent with carbohydrate intake and was not consuming sufficient variety of food groups. Her fluid intake was not sufficient, based on her calculated needs. AV’s exercise routine was consistent with a daily walking routine of about 30-45 minutes. The personal meal plan was developed and reviewed. We reviewed the food groups, serving sizes and consistent carbohydrate intake. It was emphasized to AV to drink more fluids and to adhere to meal plan. Refer to Figure 2,3 and 4 for weight, BG log, 24-hour food intake.
Estimated Daily Caloric Needs: 2,446kcal/28g fiber/93g protein/54g fat/ (40% of kcal) 244g carbohydrates (16CHO total/day)
Meal Plan Carbohydrate distribution:
2 Carbohydrate servings at Breakfast
2 Carbohydrate servings at Morning Snack
4 Carbohydrate servings at Lunch
2 Carbohydrate servings at Midafternoon Snack
4 Carbohydrate servings at Dinner
2 Carbohydrate servings at Bedtime Snack
Estimated Daily Fluid Needs: 3L
F/U Visit 2 on 01/03/2017 at 34 0/7 GA
AV brought in her BG log and glucometer. When comparing BG log to the glucometer, the readings did not match. We discussed with AV the importance of SMBG. It was emphasized to have AV start checking BG four times a day. She reported with only +0.4 pound weight gain in the past 2 weeks. Based on the 24hr-food recall, she was not consuming sufficient carbohydrates and not consistent with carbohydrate intake. AV was lacking sufficient intake of important food groups. AV was drinking more fluids and had been consistent with her walking routine. Refer to Figure 2,3 and 4 for weight, BG log, 24-hour food intake.
F/U Visit 3 on 01/24/17 at 37 0/7 GA
AV had an elevated A1c at 7.2% about 3 weeks ago and was started on an insulin regimen. AV reported to be adherent to her insulin regimen and had been helped improve BG reading. She had been able to eat more. She brought in her glucometer and BG log for review. AV did experience one episode of hypoglycemia and treated appropriately. Her weight increased at a little over a pound a week. Her 24hr-food recall revealed improved intake of a variety of food groups and had increased her carbohydrate intake towards estimated needs (from 8-9 carbs/day to 14 carbs/day). She continued to drink more fluids and was consistent with her walking routine. We reviewed how to treat low blood glucose appropriately. Refer to Figure 1, 2,3 and 4 for A1c, weight, BG log, 24-hour food intake.
Was placed on insulin regimen:
Humalog 18 units before breakfast
NPH 36 units before breakfast
Humalog 14 units before dinner
NPH 14 units before bedtime
F/U Visit on 01/31/17 at 38 0/7 GA
AV reported being adherent to insulin regimen and no recent dose changes made. She brought in her glucometer and BG log for review. AV did experience one episode of hypoglycemia and treated appropriately. She gained about a pound and a half in 1 week. AV continued to improve her eating pattern consuming sufficient carbohydrates and a variety of recommended food groups to meet needs. She continued to drink more fluids and was consistent with her walking routine. Refer to Figure 2,3 and 4 for weight, BG log, 24-hour food intake.
Last Office Visit with OB 02/03/17 at 38 0/7 GA
AV had only about half a pound weight gain in 3 days. Her total weight gain from PPW was 31 pounds. Her urinalysis for protein was negative and glucose was also negative. Her new A1c dropped to 6.1%, which was within the recommended range (6.0-6.5% A1c). Refer to Figure 1 for A1c lab results.
Phone Call for Post Partum Update
On February 6th, 2017, AV had a C-section and delivered a 9.7-pound baby. She reported that her newborn was not treated for hypoglycemia. Her insulin regimen was discontinued. A follow-up visit with the RD was scheduled to talk about the postpartum care that includes type 2 diabetes risk and prevention.
Treatment and Outcomes:
The first line of intervention is lifestyle changes in diet to improve glycemic control and adequate weight gain (no weight loss) during pregnancy. The 2002 Dietary Reference Intake made the following recommendations in calculating the energy requirements during gestation:
• No increase in calories is recommended during the first trimester.29
• During the second and third trimester, total energy expenditure (TEE) of a non-pregnancy state is calculated, and then add 8 kcal multiplied by weeks of gestation for extra TEE during gestation. Another 180kcal is added per day for energy deposition during gestation.29
As far as calculating the percentage caloric distribution, the general composition is 40% carbohydrate, 15-20% protein, and 40-45% fat.30 This has come into question due to lack of sufficient evidence.30 In 2011, the American Diabetes Association (ADA) emitted the recommendation for specific diet or carbohydrate percentage from its practice guidelines.30 The ACOG continues to recommend a low-carbohydrate diet of 35-40% carbohydrate.30 Based on the Daily Recommended Intake (DRI) for pregnancy, at least 175 gram of carbohydrate per day is advised during gestation for fetal brain development and to prevent ketosis.24,31 If intake of vitamins and minerals from food is inadequate, a supplement such as a prenatal vitamin is encouraged.32
The combination of diet intervention and exercise helps reduce excessive weight gain and helps preserve fat-free mass.37 The U.S. Department of Health and Human Services issued guidelines for physical activity in 2008. It has been advised that for healthy pregnant and postpartum women, 30 minutes per day for at least 3 times a week of moderate-intensity aerobic activity such as brisk walking and should be spread throughout the week.31,32 The recommendation can be modified if medically indicated.
According to the Nutrition Care Manual of the Academy of Nutrition and Dietetics, implementing nutrition interventions involve the following:
• Consulting the Academy of Nutrition and Dietetics Evidence Analysis Library Gestational Diabetes Mellitus Evidence-Based Nutrition Practice Guideline.
• Determining patient goals for glucose, eating, weight, and physical activity.
• Prescribing the nutrition care plan.
• Reviewing Eating Plan rationale and guidelines.
• Teaching food and meal-planning skills
• Teaching and/or fine-tuning gestational diabetes mellitus (GDM) self-management skills.
• Promoting problem-solving skills.
• Encouraging blood glucose monitoring and ketone monitoring.
• Encouraging 30 minutes of moderate-intensity physical activity during most days of the week.
• Developing a schedule for follow-up.
Taken from the Nutrition Care Manual, 2017.32
Other important interventions are self-blood glucose monitoring at least four times a day at fasting and postprandial on a daily basis while keeping a log. 32 As health professionals, it’s important to monitor and evaluate blood glucose levels, any weight changes, food intake pattern, and physical activity, pharmacological therapy that includes medication adherence at every visit. 32
Due to higher circulating hormone levels in the early morning hours, breakfast is the most difficult post-prandial blood glucose reading to manage. 32 Choosing whole grains, protein, healthy fats, and low glycemic foods help reduce blood glucose elevations in the mornings with breakfast and bedtime snack. Breakfast should be restricted to 15-30 grams of carbohydrates. 32 Evening snacks are recommended to include 1ounce of protein and 15-30 grams of carbohydrates to prevent accelerated ketosis overnight. 32 In a study, A low-glycemic-index diet had indicated a 29% decrease need for insulin without adverse fetal outcomes.34, 35 While another study compared a high complex carbohydrate diet of 60% carbohydrates to a low carbohydrate diet of 40% carbohydrates, only modest improvements were found in the 1 hour and 2hour postprandial for the high complex carbohydrate diet.36
The following is the suggested carbohydrate distribution:
• 15-30 grams of carbohydrates at breakfast
• 45-60 grams of carbohydrates at lunch and dinner
• 15-30 grams of carbohydrates for snacks. 32
It’s important to instruct the patient once initiating insulin on how to treat low blood glucose (less than 70 mg/dL). 33 The best fast-acting carbohydrate recommended for pregnancy is 8 ounce of skim milk to help meet daily needs. Another fast-acting carbohydrate could be used such as 4 ounces of juice if skim milk is not available.
The use of the most up-to-date medical nutrition therapy and personalized interventions taking into account any pharmacological treatment can help to achieve euglycemia during gestation. Ensuring intake of whole grains, non-starchy vegetables, fruits, dairy, lean protein, poly- and mono-unsaturated fats can help with fetal development. The combination of these treatments mentioned will help reduce the possibility of maternal and fetal complications. It also helps the patient to make lifestyle changes that could potentially develop into new lifestyle habits postpartum. Adequate prenatal weight gain, good blood glucose management, and A1c are the desired outcomes from these interventions.
Prevention:
Early interventions can be the solution to decrease the incidence of developing gestational diabetes by focusing on educating during childbearing years. Due to many pregnancies that are unplanned, bringing awareness to the possibility in high-risk population is vital. For women who are overweight or obese, weight loss would be the ideal goal to help improve fertility and decrease possible maternal and fetal complications when pregnant.37 Hieronymus L, et al. found that Hispanic women who participated in an Education Intervention program for at-risk women reported having improved birth outcomes when compared to women who received traditional care.38 A preconception risk assessment and counseling could potentially improve pregnancy outcomes.39
White S et al. used a variety of clinical and biomarker variables to develop prediction tools for obese women who are at higher risk for GDM.40 The candidate biomarkers are the HbA1C, random glucose, fructosamine, SHBG, adiponectin, and triglycerides. 40 They identified a model that does not require a blood sample, which could be useful in low and middle-income communities where the prevalence of obesity and GDM are known.40 The age, history of GDM, first-degree relative T2DM, sum of skinfold thicknesses, waist: height ratio, neck: thigh ratio, systolic BP, mid-arm circumference, subscapular skinfold thickness and waist circumference were effectively used for GDM prediction.40 These newer predictive tools can be used at first antenatal visits for intervention.40
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