Diabetes Institute in india

1. Nutrition Therapy In Gestational DiabetesPart 1 – AssessmentPart 2 – RecommendationsPart 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

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

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

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

6. Body Mass Index (BMI) Use pre pregnancy weight for calculations Weight and height measurements to calculate BMI: BMI = weight in kg/(height in m)2 Standard BMI normograms:

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.

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

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

10. Issues with Dietary Recalls • 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

11. Nutrition Therapy In Gestational DiabetesPart 1 – AssessmentPart 2 – RecommendationsPart 3 – Education

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

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. Institute of Medicine : 2009

14. Dietary Recommendations for GDM Macronutrient composition Dietary fibre 28g/day Institute Of Medicine 2002

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

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

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

18. 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 Carbohydrates

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

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

21. Module 2-2B Nutrition therapy - Recommendations Carbohydrate (CHO) content of common foods (Canadian Diabetes Association, 2006)

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

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

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).

25. Glycaemic Response of Glucose and Lentils Blood glucose level Glucose Lentils Reprinted with permission from CDA, 2004

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

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

28. Glycaemic Index of Foods CDA , 2006

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

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

31. Fat Recommendations • Low in polyunsaturated fats (up to10% of total daily energy) • High in monounsaturated fats (>10%) • Low in saturated fats (<10%) • Trans or hydrogenated fat should be avoided IoM 2002

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

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

34. 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 Vitamins

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.

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

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

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 Health Canada, 2005

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

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

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 To check with Health care team prior to starting use of sweeteners CDA, 2006

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

43. Module 2-2B Nutrition therapy - Recommendations Food labels Food labels may look different in different countries, but the same information is usually available

44. Activity 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

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

46. Nutrition Therapy in Gestational DiabetesPart 1 – AssessmentPart 2 – RecommendationsPart 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

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

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

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