Our aim is to alleviate human suffering related to diabetes and its complications among those least able to withstand the burden of the disease. From 2002 to March 2017, the World Diabetes Foundation provided USD 130 million in funding to 511 projects in 115 countries. For every dollar spent, the Foundation raises approximately 2 dollars in cash or as in-kind donations from other sources. The total value of the WDF project portfolio reached USD 377 million, excluding WDF’s own advocacy and strategic platforms. The WDF mission:

1. Nutrition Therapy In
Gestational Diabetes
PART 1 – ASSESSMENT
PART 2 – RECOMMENDATIONS
PART 3 – EDUCATION

2. Objectives
• Discuss factors that should be considered when doing a nutritional
assessment
• Discuss appropriate balance of meals/snacks through the day
• Discuss appropriate weight gain based on preconception weight
• Discuss the value of a late night snack to prevent early morning
ketosis
• Evaluate the importance of folic acid supplementation before and
during pregnancy
• Discuss the value of multivitamin supplementation during pregnancy
2

3. Goals for MNT in GDM
•Optimal nutrition and weight gain for fetus and mother
•Maternal euglycemia
•Reduce the risk of diabetes related complications for
the mother and child
•Minimize the maternal and infant morbidity and
mortality rates
•Integrate diet, activity and pharmalogic therapy
•Introducing healthy habits that can prevent or delay
onset of type 2 DM
3

4. Assessing from an Interview
• Age
• Obstetric history
• Weight History
• Significant medical history (co-morbidities)
• Food preferences and eating habits
• Food Allergies
• Individual psychological, social and physical
status
• Lifestyle, culture, and socio-economic status
• Oral health
• Readiness to change
4

5. Assessing from Clinical Information
Laboratory tests to determine clinical status
 OGTT, fasting glucose, HbA1c level
 SMBG
 Urine ketones and proteins
 lipid profile (cholesterol — HDL, LDL)
 Haemoglobin, creatinine, thyroid function
 Blood pressure
Anthropometric Data
 Height , Weight and BMI
Current medications and nutrition supplements
5

6. Use pre pregnancy weight for calculations
Weight and height measurements to calculate BMI:
BMI = weight in kg/(height in m)2
Standard BMI normograms:
Body Mass Index (BMI)
6
Asian ADA norms
Underweight <18.5 kg/m2
Normal BMI 18.0-22.9 kg/m2 18.5-24.9 kg/m2
Overweight 23.0-24.9 kg/m2 25.0-29.9 kg/m2
Obesity >25 kg/m2 > 30 kg/m2

7. Weight Gain Chart
•Plot weight on a prenatal weight
gain grid to obtain an accurate
assessment of total pregnancy
weight gain and rate of weight
gain.
•Determine if weight gain is
above, at or below the
recommended range.
•If weight gain has already
exceeded the recommended
range, slow weight gain in order
to prevent further excess gain.
7

8. Nutrition Assessment
Nutrition history
 usual food intake recorded through interview
Dietary recall
 food and drink consumed in previous 24
hours (24-hour recall)
8

9. Activity –
Think of things to check for
when doing a dietary history.
9

10. •Based on memory
•Based on willingness to disclose the truth to a
healthcare provider
•Nutrient intake and long-term habits are not
represented
•Accurate estimations of food quantities/ingredients
are difficult
Issues with Dietary Recalls
10

11. Nutrition Therapy In
Gestational Diabetes
PART 1 – ASSESSMENT
PART 2 – RECOMMENDATIONS
PART 3 – EDUCATION

12. Composition of Food and Drinks
Macro-nutrients
 protein
 carbohydrates
 fats
Micro-nutrients
 vitamins
 minerals
12

13. Recommendations for Weight Gain
Singleton pregnancy
• Where possible a dietitian should develop a
meal plan.
• At about the 4th month of the pregnancy about
350 calories should be added daily. This should
mean the woman is eating about 1900-2000
calories a day.
• Overweight women (BMI 23 and over before
pregnancy) should increase less.
• Underweight women (BMI less than 18 before
pregnancy) could add more.
13
Institute of Medicine : 2009

14. Dietary Recommendations for GDM
Macronutrient composition
Nutrient % of daily calorie
intake
Carbohydrates 45-65%
Fats 20-35%
Protein 10-35%
Dietary fibre 28g/day
Institute Of Medicine 2002
14

15. Fluids
•Essential for all body functions
•40-60% of body weight is water
•Important to drink adequate amounts
of fluid
•Restrictions may be required in case
of pedal edema
15

16. Proteins
• Provide amino acids
• Help to build muscle mass
• Animal sources
• Plant sources
• 1 g of protein gives 4 kcal energy
16

17. Protein Recommendations
•1.1 g protein per kg bodyweight per day
•10-35% of total energy per day
•Animal protein often high in fat,
especially saturated.
•Attention must be paid to meeting the
protein requirements of women who are
vegetarians or vegans
17

18. Carbohydrates
• Provide main source of energy for
the body (45-65%) – individualized
• Nutrient that most influences blood
glucose levels
• Source of simple sugars – glucose,
fructose
• 1 g of carbohydrate provides 4 kcal
18

19. Name some of the common
carbohydrates and staple foods
in your region.
Activity
19

20. Carbohydrates And Meal Planning
•Amount and source of carbohydrates is
considered when planning meals
•Recommended source of carbohydrates is
mainly from
- whole grains: wheat, rice, pasta, bread, rice,
wheat, barley, oats, maize and corn
- legumes, beans, pulses (bengal gram, black gram,
rajma)
- fruit and vegetables
- milk
20

21. Carbohydrate (CHO) content of common foods
Food Amount Serving CHO (g)
Bread, whole wheat 28 g 1 slice 11
Rice (cooked) 75 g 0.3 cup 13
Pasta 125 mL 0.5 cup 16
Chappati 44 g 1 small 19
Corn meal 45 mL 3 tbsps 16
Potato 84 g 1 small 15
Couscous, cooked 125 mL 0.5 cup 17
Lentils 250 mL 1 cup 15
Banana 101 g 1 small 20
(Canadian Diabetes Association, 2006)
21
M

22. Benefits of Fibre
A high-fibre diet is healthy
Mixture of soluble and insoluble fibre
- slows absorption of glucose
- reduces absorption of dietary fats
- retains water to soften stool
- may reduce the risk of colon cancer
- may reduce the risk of heart disease
22

23. Fibre Recommendations
Recommended amounts of total fibre : 28
g per day
Sources of insoluble fibre include: wheat
bran, whole grains, seeds, fruits and
vegetables
Sources of soluble fibre: legumes (beans),
oat bran, barley, apples, citrus fruits
CDA, 2013
23

24. Glycaemic Index (GI)
Ranks carbohydrate-rich foods
according to the increase in blood
glucose levels they cause in
comparison with a standard food (white
bread/glucose).
24

25. Glycaemic Response of Glucose
and Lentils
Bloodglucoselevel
Glucose Lentils
Reprinted with permission from CDA, 2004
25

26. Type of sugar
- glucose, fructose, galactose
Nature of starch
- amylose, amylopectin
Starch-nutrient interactions
- resistant starch
Cooking/food processing
Factors Affecting the Glycaemic Index
26

27. Processing/form of the food
- gelatinization
- particle size
- cellular structure
Presence of other food components
- fat and protein
- dietary fibre
Factors Affecting The Glycaemic Index
Kalergis, De Grandpre, Andersons, 2005
27

28. Glycaemic Index of Foods
Low glycaemic
index foods
Intermediate
glycaemic index
High glycaemic
index
Oats Multigrain bread White Bread
Lentils/dhal Some rice (long
grain)
White Rice
Yogurt Pasta Processed
breakfast cereal
Milk Bananas Glucose
Most Fruits and
vegetables
Grapes Mashed and
baked potatoes
CDA , 2006
28

29. Promotes healthy eating
Increases fibre intake
Helps control
- appetite
- blood glucose levels
- blood lipid levels
Low GI - Advantages
29

30. Fats
• The most concentrated source of
energy
• Foods may contain fat naturally or
have it added during cooking
• 1 g fat provides 9 kcal
30

31. Fat Recommendations
• Low in polyunsaturated fats (up to 10% of
total daily energy)
• High in monounsaturated fats (>10%)
• Low in saturated fats (<10%)
• Trans or hydrogenated fat should be
avoided
IoM 2002
31

32. Fats
• Common sources of different fats
• Polyunsaturated – safflower oil, sunflower oil,
corn oil
• Monounsaturated – olive oil, canola oil, rape
seed oil, groundnut oil, mustard oil, sesame oil
• Saturated – red meats, butter, cheese,
margarine, ghee (clarified butter), whole milk,
cream, lard
• Trans fats – baked products, biscuits, cakes
32

33. Identify major sources of fats in
foods in your region.
Activity
33

34. Vitamins
• Organic substances present in very
small amounts in food
• Essential to good health
• A balanced meal automatically
provides all necessary vitamins
• Either fat-soluble or water-soluble
• In some countries foods are
“fortified” with vitamins and minerals
34

35. Vitamin Recommendations
Daily multivitamin supplement should be added
as they are often not met by diet alone.
Multivitamin content varies depending on the
product used.
Women at higher risk for dietary deficiencies
include multiple gestation, heavy smokers,
adolescents, complete vegetarians, substance
abusers, and women with lactase deficiency.
35

36. Minerals
•Substance present in bones, teeth, soft
tissue, muscle, blood and nerve cells
•Help maintain physiological processes,
strengthen skeletal structures, preserve heart
and brain function and muscle and nerve
systems
•Act as a catalyst to essential enzymatic
reactions
•Low levels of minerals puts stress on
essential life functions
36

37. Minerals And Trace Elements
• A balanced diet supplies minerals and
trace elements
• Supplements are important as
requirements are higher during
pregnancy
 Calcium supplementation
 Iron supplementation
 Folic acid supplementation 0.4mg (should
be started three months prior to conception)
CDA , 2013
37

38. Sodium Recommendations
•Most people consume too much salt
•Sodium restriction may be advised in case of
uncontrolled hypertension and edema
•Targets for daily sodium intake
Age Adequate
Intake
(mg/day)
Upper limit
(mg/day)
14-50 1500 2300
51-70 1300 2300
over 70 1200 2300
Health Canada, 2005
38

39. Lowering Salt Intake
• Sodium content is often high in restaurant foods
• Encourage meal plans with
• more fresh foods – fruits and vegetable
• less processed, fast, convenience or canned foods
• herbs and spices used when cooking instead of salt.
• Teach people to read food labels.
• Choose salt free, reduced or low in sodium foods
39

40. Substance Use
The following substances should be avoided completely once
the woman plans a pregnancy
 Tobacco in any form
 Alcohol
 Drugs (street, illegal)
40

41. Sweeteners
Sweeteners that increase blood glucose
 Sugar, honey
 Polydextrose & Sugar alcohols – maltitol, sorbitol, Xylitol
Sweeteners that do not increase blood glucose
 Acesulfame potassium
 Aspartame
 Cyclamate*
 Saccharin*
 Sucralose
*Must be avoided during
pregnancy
CDA, 2006
To check with Health care team
prior to starting use of sweeteners
41

42. Food Labels
•Nutrition facts
•Serving size (if available)
•Nutrient content
•Ingredients
•Nutrition information
42

43. Food labels
M
43
Food labels may look
different in different countries,
but the same information is
usually available
Nutrition Facts
Per 1 cup (250g)
Amount % Daily Value
Calories 100
Fat 0g 0 %
Saturated 0 g
+ Trans 0 g
0 %
Cholesterol 0 mg
Sodium 3 mg 0 %
Carbohydrate 26 g 8 %
Fibre 1 g 4 %
Sugars 23 g
Protein 2 g
Vitamin A 20 % Vitamin C 170 %
Calcium 2 % Iron 2 %

44. Practice reading a food label
Calculate the following:
 Serving size
 Number of calories in one serving
 Number of carbohydrates in one serving
 Amount of fat in one serving
Activity
44

45. Summary of Dietary Recommendations
•Carbohydrates: 45-65%
•Dietary fibre: 28 g / day
•Fats: 20-35%
•Protein: 10-35% (1.1 g/kg/day)
•Sodium: 1500 - 2300 mg/day
45

46. Nutrition Therapy in
Gestational Diabetes
PART 1 – ASSESSMENT
PART 2 – RECOMMENDATIONS
PART 3 – EDUCATION

47. Approach To Meal Planning
A uniform approach to meal planning does
not work for everyone
A flexible plan or a variety of approaches is
necessary to address different needs
47

48. Meal Planning
Before deciding on the content of meal plans,
consider:
• Food preferences and eating habits
• Previous experience, knowledge and skills
• Current clinical, psychological and dietary status
• Appropriate clinical and nutrition goals
• Lifestyle factors
48

49. What to teach and when?
Basic
• Basic information about nutrition
• Nutrient requirements
• Healthy eating guidelines
• Making healthy food choices
• Self-management training and use
of educational tools
49

50. Nutrition Education: Tools
•Awareness of the basics of healthy
eating/balance of good health
•Food Pyramid
•The plate model
50

51. Food Guides
•Australian Food Guide
M
51

52. Healthy eating
•Eating Well with
Canada’s Food Guide
M52
Recommended Number of Food Guide Servings per Day
Children Teens Adults
Age In Years 2-3 4-8 9-13 14-18 19-50 51+
Sex Girls and Boys Females Males Females Males Females Males
Vegetables
and fruits
4 5 6 7 8 7-8 8-10 7 7
Grain
Products
3 4 6 6 7 6-7 8 6 7
Milk and
Alternatives
2 2 3-4 3-4 3-4 2 2 3 3
Meat and
Alternatives
1 1 1-2 2 3 2 3 2 3
The chart above shows how many Food Guide Servings you need
from each of the four food groups every day.
Having the amount and tyoe of food recommended and following the
tips in Canada’s Food Guide will help:
 Meet your needs for vitamins, minerals and other nutrients.
 Reduce your risk of obesity, type 2 diabetes, heart disease,
certain types of cancer and osteoporosis.
 Contribute to your overall health and vitality.

53. Food pyramid – India
Diabetes India, 2005
53

54. Balance of good health - UK eat well plate
M
54
Bread, cereals
and potatoes
Milk and
dairy products
Foods rich in
sugars and fat
Meat, fish and
protein alternatives
Fruits and
vegetables
(Reproduced with kind permission of the Food Standards Agency)

55. Example of Healthy food plate with
South-Asian foods
Healthy food plate
(Source: Diabetes Education Modules 2011)
55
These graphics will change
to be the same as the new
ones going in the booklets

56. Draw on a paper plate either:
The recommended proportions of foods
from your region
The proportions of what you ate last night
Activity
56

57. Practical Advice/ 1
• Make healthy food choices
• Avoid fatty foods
• Use low-fat cooking methods
• Substitute high fat foods with low fat options;
e.g use low fat milk
• Minimize consumption of sugar and salt
• Use fresh foods instead of preserved or
canned foods
57

58. Practical Advice/ 2
•At least five servings of fruit and vegetables per day
- Choose colourful fruits and vegetables
- Choose whole fruits over juices
•Replace high calorie beverages with water
•Eat small frequent meals that are well spaced
•Do not skip meals
•Calories should be restricted especially if overweight
•Eat free foods as desired, include in between major
meals
58

59. Practical Advice/ 3
•One low GI food at each meal
•Mix high and low GI food = intermediate GI
meal
•Substitute high GI cereals/breads/rice with low
GI cereals/bread/rice
•Eat low GI snacks instead of high GI snacks
(remember to choose lower fat snacks)
59

60. References
• American Diabetes Association. (2013). Clinical Practice Recommendations. Diabetes Care, 36, (supple 1).
• Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2013). Canadian Diabetes
Association 2013. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.
Canadian Journal of Diabetes, 37(suppl 1).
• Canadian Diabetes Association. (2006). Beyond the Basics. Toronto ON: Canadian Diabetes Association
• Diabetes India. (2005). Diet Charts. Retreived September 13, 2010.
http://www.diabetesindia.com/diabetes/diet_chart.htm
• Franz MJ, Evert AB (Eds.) American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2nd Ed. 1012
• Health Canada. Food and Nutrition. Sodium. It’s Your Health. Available from: http://www.hc-sc.gc.ca/hl-
vs/iyh-vsv/food-aliment/sodium-eng.php
• Health Canada. (2005). Food and Nutrition. The Issue of sodium. (Retrieved September 13, 2010)
http://www.hc-sc.gc.ca/fn-an/nutrition/reference/table/ref_elements_tbl-eng.php
• Institute of Medicine 2002
http://www.iom.edu/Global/News%20Announcements/~/media/C5CD2DD7840544979A549EC47E56A02B.a
shx
• Institute Of Medicine 2009
http://www.ncbi.nlm.nih.gov/books/NBK32799/table/summary.t1/?report=objectonly
• Kalergis, M., De Grandpre, E., Andersons, C. (2005). The Role of Glycemic Index in the Prevention and
Management of Diabetes: A Review and Discussion. Can J of Diab, 29(1), 27-38.
• Misra A, Chowbey P, Makkar PM, Vikram NK, Wasir JS, Chadha D, et al. Consensus Statement for
Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians and
Recommendations for Physical Activity, Medical and Surgical Management. JAPI 2009;57.
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