The Official Patient's Sourcebook on Gestational Diabetes

THE OFFICIAL PATIENT’S SOURCEBOOK

on

GESTATIONAL DIABETES J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

ii

ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright Ó2002 by ICON Group International, Inc. Copyright Ó2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher's note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your physician. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified physician. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The Official Patient’s Sourcebook on Gestational Diabetes: A Revised and Updated Directory for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83141-6 1. Gestational Diabetes-Popular works. I. Title.

iii

Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.

Copyright Notice If a physician wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this sourcebook.

iv

Dedication To the healthcare professionals dedicating their time and efforts to the study of gestational diabetes.

Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to gestational diabetes. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.

v

About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

vi

About ICON Health Publications In addition to gestational diabetes, Official Patient’s Sourcebooks are available for the following related topics: ·

The Official Patient's Sourcebook on Antenatal Corticosteroid Therapy

·

The Official Patient's Sourcebook on Endometriosis

·

The Official Patient's Sourcebook on Uterine Fibroids

·

The Official Patient's Sourcebook on Vaginitis

To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

Contents vii

Table of Contents INTRODUCTION...................................................................................... 1

Overview............................................................................................................... 1 Organization......................................................................................................... 3 Scope ..................................................................................................................... 3 Moving Forward................................................................................................... 4

PART I: THE ESSENTIALS ................................................. 7 CHAPTER 1. THE ESSENTIALS ON GESTATIONAL DIABETES: GUIDELINES ........................................................................................... 9

Overview............................................................................................................... 9 What Is Gestational Diabetes? What Causes It? ............................................... 10 How Does Gestational Diabetes Differ from Other Types of Diabetes? ............ 12 Who Is at Risk for Developing Gestational Diabetes? How Is It Detected? ...... 13 How Does Gestational Diabetes Affect Pregnancy? .......................................... 14 What Can Be Done to Reduce Problems Associated with Gestational Diabetes? ............................................................................................................................ 16 What Is Self Blood Glucose Monitoring?........................................................... 17 How Often and When Should I Test? ................................................................ 17 How Should I Record My Test Results? ............................................................ 18 Are There Any Other Tests I Should Know About?.......................................... 18 How Do I Test for Ketones? ............................................................................... 18 When Do I Test for Ketones?.............................................................................. 19 Is It Ever Necessary to Take Insulin?................................................................. 19 Will My Baby Be Healthy?................................................................................. 19 Does Gestational Diabetes Affect Labor and Delivery? ..................................... 22 Should I Expect My Baby to Have Any Problems? ........................................... 23 Will I Develop Diabetes in the Future?.............................................................. 23 Why Is a Special Diet Recommended? ............................................................... 24 How Much Weight Should I Gain?.................................................................... 24 How Should I Eat during My Pregnancy? ........................................................ 26 Other Nutritional and Non-Nutritional Considerations................................... 29 What Food Patterns Help Keep Blood Sugar Levels Normal? ........................... 30 How Do I Plan Meals? ....................................................................................... 33 What Can Be Done to Slow Weight Gain during Pregnancy?.......................... 34 Is Breast-Feeding Recommended? ...................................................................... 36 Should I Exercise? .............................................................................................. 37 What Happens If Diet and Exercise Fail to Control My Blood Sugars? ........... 39 Can My Blood Sugar Level Go Too Low? .......................................................... 39 More Guideline Sources ..................................................................................... 40 Vocabulary Builder............................................................................................. 50

CHAPTER 2. SEEKING GUIDANCE ....................................................... 55

viii Contents

Overview............................................................................................................. 55 Associations and Gestational Diabetes............................................................... 55 Finding More Associations................................................................................. 57 Finding Doctors.................................................................................................. 59 Finding an Obstetrician-Gynecologist ............................................................... 60 Selecting Your Doctor ........................................................................................ 61 Working with Your Doctor ................................................................................ 61 Broader Health-Related Resources ..................................................................... 63 Vocabulary Builder............................................................................................. 63

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL.................................................. 65 CHAPTER 3. STUDIES ON GESTATIONAL DIABETES ............................ 67

Overview............................................................................................................. 67 The Combined Health Information Database ..................................................... 67 Federally-Funded Research on Gestational Diabetes ......................................... 78 E-Journals: PubMed Central .............................................................................. 92 The National Library of Medicine: PubMed ...................................................... 92 Vocabulary Builder............................................................................................. 93

CHAPTER 4. PATENTS ON GESTATIONAL DIABETES ........................... 97

Overview............................................................................................................. 97 Patents on Gestational Diabetes ......................................................................... 98 Patent Applications on Gestational Diabetes ................................................... 100 Keeping Current ............................................................................................... 100

CHAPTER 5. BOOKS ON GESTATIONAL DIABETES ............................ 101

Overview........................................................................................................... 101 Book Summaries: Federal Agencies .................................................................. 101 Book Summaries: Online Booksellers ............................................................... 104 The National Library of Medicine Book Index ................................................. 104 Chapters on Gestational Diabetes..................................................................... 105 General Home References ................................................................................. 107 Vocabulary Builder........................................................................................... 108

CHAPTER 6. MULTIMEDIA ON GESTATIONAL DIABETES.................. 109

Overview........................................................................................................... 109 Video Recordings .............................................................................................. 109 Audio Recordings ............................................................................................. 112 Bibliography: Multimedia on Gestational Diabetes ......................................... 112 Vocabulary Builder........................................................................................... 113

CHAPTER 7. PHYSICIAN GUIDELINES AND DATABASES ................... 115

Overview........................................................................................................... 115 NIH Guidelines................................................................................................. 115 NIH Databases.................................................................................................. 116 Other Commercial Databases ........................................................................... 127

Contents

ix

The Genome Project and Gestational Diabetes................................................. 127 Specialized References....................................................................................... 132 Vocabulary Builder........................................................................................... 133

CHAPTER 8. DISSERTATIONS ON GESTATIONAL DIABETES .............. 135

Overview........................................................................................................... 135 Dissertations on Gestational Diabetes.............................................................. 135 Keeping Current ............................................................................................... 136

PART III. APPENDICES .................................................. 137 APPENDIX A. RESEARCHING YOUR MEDICATIONS.......................... 139

Overview........................................................................................................... 139 Your Medications: The Basics .......................................................................... 140 Learning More about Your Medications .......................................................... 142 Commercial Databases...................................................................................... 143 Contraindications and Interactions (Hidden Dangers) ................................... 144 A Final Warning .............................................................................................. 145 General References............................................................................................ 146

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ................... 149

Overview........................................................................................................... 149 What Is CAM? ................................................................................................. 149 What Are the Domains of Alternative Medicine?............................................ 150 Can Alternatives Affect My Treatment? ......................................................... 153 Finding CAM References on Gestational Diabetes .......................................... 154 Additional Web Resources................................................................................ 156 General References............................................................................................ 158 Vocabulary Builder........................................................................................... 159

APPENDIX C. RESEARCHING NUTRITION ......................................... 161

Overview........................................................................................................... 161 Food and Nutrition: General Principles........................................................... 162 Finding Studies on Gestational Diabetes ......................................................... 166 Federal Resources on Nutrition........................................................................ 172 Additional Web Resources................................................................................ 173 Vocabulary Builder........................................................................................... 174

APPENDIX D. FINDING MEDICAL LIBRARIES.................................... 177

Overview........................................................................................................... 177 Preparation ....................................................................................................... 177 Finding a Local Medical Library ...................................................................... 178 Medical Libraries Open to the Public............................................................... 178

APPENDIX E. YOUR RIGHTS AND INSURANCE ................................. 185

Overview........................................................................................................... 185 Your Rights as a Patient................................................................................... 185 Patient Responsibilities .................................................................................... 189 Choosing an Insurance Plan............................................................................. 190

x

Contents

Medicare and Medicaid .................................................................................... 192 NORD’s Medication Assistance Programs ..................................................... 195 Additional Resources ........................................................................................ 196

APPENDIX F. MORE ON GESTATIONAL DIABETES ............................ 199

Overview........................................................................................................... 199 Why Do Some Women Get Gestational Diabetes?........................................... 200 How Do I Know If I'm at Risk? ....................................................................... 200 Should I Get Tested?......................................................................................... 200 What Is Involved in Getting Tested? ............................................................... 201 What If I Don't Get Treated for Gestational Diabetes? ................................... 201 What Should I Do If I Have Gestational Diabetes? ......................................... 202

ONLINE GLOSSARIES.................................................... 203 Online Dictionary Directories.......................................................................... 206

GESTATIONAL DIABETES GLOSSARY.................... 207 General Dictionaries and Glossaries ................................................................ 218 INDEX

........................................................................................ 220

Introduction

1

INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don't know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many physicians and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3

Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1 2

2

Gestational Diabetes

Since the late 1990s, physicians have seen a general increase in patient Internet usage rates. Patients frequently enter their doctor's offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that doctors often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Gestational Diabetes has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to gestational diabetes, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on gestational diabetes. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on gestational diabetes should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique. Deciding on

Introduction

3

appropriate options is always up to the patient in consultation with their physician and healthcare providers.

Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching gestational diabetes (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to gestational diabetes. It also gives you sources of information that can help you find a doctor in your local area specializing in treating gestational diabetes. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with gestational diabetes. Part II moves on to advanced research dedicated to gestational diabetes. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on gestational diabetes. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “free-to-use” options. Part III provides appendices of useful background reading for all patients with gestational diabetes or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with gestational diabetes. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with gestational diabetes.

Scope While this sourcebook covers gestational diabetes, your doctor, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that gestational diabetes is often considered a synonym or a condition closely related to the following: ·

Glucose Intolerance during Pregnancy

·

Glucose Intolerance of Pregnancy

4

Gestational Diabetes

In addition to synonyms and related conditions, physicians may refer to gestational diabetes using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world's illnesses. Your physician may use this coding system as an administrative or tracking tool. The following classification is commonly used for gestational diabetes:4 ·

648.8 abnormal glucose tolerance - gestational diabetes

For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to gestational diabetes. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians.

Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses. Some are written by patients or their family members. These generally take a layperson's approach to understanding and coping with an illness or disorder. They can be uplifting, encouraging, and highly supportive. Other guides are authored by physicians or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian. Why “Internet age”? All too often, patients diagnosed with gestational diabetes will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with gestational diabetes is even indexed in search engines, a non-systematic 4 This list is based on the official version of the World Health Organization's 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”

Introduction

5

approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. While we focus on the more scientific aspects of gestational diabetes, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors

7

PART I: THE ESSENTIALS

ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on gestational diabetes. The essentials of a disease typically include the definition or description of the disease, a discussion of who it affects, the signs or symptoms associated with the disease, tests or diagnostic procedures that might be specific to the disease, and treatments for the disease. Your doctor or healthcare provider may have already explained the essentials of gestational diabetes to you or even given you a pamphlet or brochure describing gestational diabetes. Now you are searching for more in-depth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your doctor has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.

Guidelines

9

CHAPTER 1. THE ESSENTIALS ON GESTATIONAL DIABETES: GUIDELINES Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on gestational diabetes. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on gestational diabetes can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them.

The National Institutes of Health (NIH)5 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on gestational diabetes. Originally founded in 1887, the NIH is one of the world's foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years include the world's most illustrious scientists and physicians. Among them are 97 scientists who have won the Nobel Prize for achievement in medicine.

5

Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.

10 Gestational Diabetes

There is no guarantee that any one Institute will have a guideline on a specific disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare diseases. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with gestational diabetes and associated conditions: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Child Health and Human Development (NICHD); guidelines available at http://www.nichd.nih.gov/publications/pubskey.cfm

Among those listed above, the National Institute of Child Health and Human Development (NICHD) is especially noteworthy. The mission of the NICHD, a part of the National Institutes of Health (NIH), is to support and conduct research on topics related to the health of children, adults, families, and populations. NICHD research focuses on the idea that events that happen prior to and throughout pregnancy as well as during childhood have a great impact on the health and well-being of adults. The following guideline is one the NICHD provides concerning gestational diabetes.6

What Is Gestational Diabetes? What Causes It?7 Approximately 3 to 5 percent of all pregnant women in the United States are diagnosed as having gestational diabetes. These women and their families have many questions about this disorder. Some of the most frequently asked questions are: What is gestational diabetes and how did I get it? How does it differ from other kinds of diabetes? Will it hurt my baby? Will my baby have diabetes? What can I do to control gestational diabetes? Will I need a special diet? Will gestational diabetes change the way or the time my baby is delivered? Will I have diabetes in the future?

6 This and other passages have been adapted from the NIH and NICHD: http://www.nichd.nih.gov/default.htm. “Adapted” signifies that the text has been reproduced with attribution, with some or no editorial adjustments. 7 Adapted from the National Institute of Child Health and Human Development (NICHD): http://www.nichd.nih.gov/publications/pubs/gesttoc.htm.

Guidelines 11

This guideline will address these and many other questions about diet, exercise, measurement of blood sugar levels, and general medical and obstetric care of women with gestational diabetes. It must be emphasized that these are general guidelines and only your health care professional(s) can tailor a program specific to your needs. You should feel free to discuss any concerns you have with your doctor or other health care provider, as no one knows more about you and the condition of your pregnancy. Diabetes (actual name is diabetes mellitus) of any kind is a disorder that prevents the body from using food properly. Normally, the body gets its major source of energy from glucose, a simple sugar that comes from foods high in simple carbohydrates (e.g., table sugar or other sweeteners such as honey, molasses, jams, and jellies, soft drinks, and cookies), or from the breakdown of complex carbohydrates such as starches (e.g., bread, potatoes, and pasta). After sugars and starches are digested in the stomach, they enter the blood stream in the form of glucose.8 The glucose in the blood stream becomes a potential source of energy for the entire body, similar to the way in which gasoline in a service station pump is a potential source of energy for your car. But, just as someone must pump the gas into the car, the body requires some assistance to get glucose from the blood stream to the muscles and other tissues of the body. In the body, that assistance comes from a hormone called insulin. Insulin is manufactured by the pancreas, a gland that lies behind the stomach. Without insulin, glucose cannot get into the cells of the body where it is used as fuel. Instead, glucose accumulates in the blood to high levels and is excreted or “spilled” into the urine through the kidneys.

Insulin: The Key to Turning Food into Energy 8

For the purpose of this brochure the words sugar and glucose are used synonymously.

12 Gestational Diabetes

When the pancreas of a child or young adult produces little or no insulin we call this condition juvenile-onset diabetes or Type I diabetes (insulindependent). This is not the type of diabetes you have. Unlike women with Type I diabetes, women with gestational diabetes have plenty of insulin. In fact, they usually have more insulin in their blood than women who are not pregnant. However, the effect of their insulin is partially blocked by a variety of other hormones made in the placenta, a condition often called insulin resistance. The placenta performs the task of supplying the growing fetus with nutrients and water from the mother's circulation. It also produces a variety of hormones vital to the preservation of the pregnancy. Ironically, several of these hormones such as estrogen, cortisol, and human placental lactogen (HPL) have a blocking effect on insulin, a “contra-insulin” effect. This contrainsulin effect usually begins about midway (20 to 24 weeks) through pregnancy. The larger the placenta grows, the more these hormones are produced, and the greater the insulin resistance becomes. In most women the pancreas is able to make additional insulin to overcome the insulin resistance. When the pancreas makes all the insulin it can and there still isn't enough to overcome the effect of the placenta's hormones, gestational diabetes results. If we could somehow remove all the placenta's hormones from the mother's blood, the condition would be remedied. This, in fact, usually happens following delivery.

How Does Gestational Diabetes Differ from Other Types of Diabetes? There are several different types of diabetes. Gestational diabetes begins during pregnancy and disappears following delivery. Another type is referred to as juvenile-onset diabetes (in children) or Type I (in young adults). These individuals usually develop their disease before age 20. People with Type I diabetes must take insulin by injection every day. Approximately 10 percent of all people with diabetes have Type I (also called insulin-dependent diabetes). Type II diabetes or noninsulin-dependent diabetes (formerly called adultonset diabetes) is also characterized by high blood sugar levels, but these patients are often obese and usually lack the classic symptoms (fatigue, thirst, frequent urination, and sudden weight loss) associated with Type I diabetes. Many of these individuals can control their blood sugar levels by following a careful diet and exercise program, by losing excess weight, or by

Guidelines 13

taking oral medication. Some, but not all, need insulin. People with Type II diabetes account for roughly 90 percent of all diabetics.

Who Is at Risk for Developing Gestational Diabetes? How Is It Detected? Any woman might develop gestational diabetes during pregnancy. Some of the factors associated with women who have an increased risk are obesity; a family history of diabetes; having given birth previously to a very large infant, a stillbirth, or a child with a birth defect; or having too much amniotic fluid (polyhydramnios). Also, women who are older than 25 are at greater risk than younger individuals. Although a history of sugar in the urine is often included in the list of risk factors, this is not a reliable indicator of who will develop diabetes during pregnancy. Some pregnant women with perfectly normal blood sugar levels will occasionally have sugar detected in their urine. The Council on Diabetes in Pregnancy of the American Diabetes Association strongly recommends that all pregnant women be screened for gestational diabetes. Several methods of screening exist. The most common is the 50gram glucose screening test. No special preparation is necessary for this test, and there is no need to fast before the test. The test is performed by giving 50 grams of a glucose drink and then measuring the blood sugar level l hour later. A woman with a blood sugar level of less than 140 milligrams per deciliter (mg/dl) at l hour is presumed not to have gestational diabetes and requires no further testing. If the blood sugar level is greater than 140 mg/dl the test is considered abnormal or “positive:” Not all women with a positive screening test have diabetes. Consequently, a 3hour glucose tolerance test must be performed to establish the diagnosis of gestational diabetes. If your physician determines that you should take the complete 3hour glucose tolerance test, you will be asked to follow some special instructions in preparation for the test. For 3 days before the test, eat a diet that contains at least 150 grams of carbohydrates each day. This can be accomplished by including one cup of pasta, two servings of fruit, four slices of bread, and three glasses of milk every day. For 10 to 14 hours before the test you should not eat and not drink anything but water. The test is usually done in the morning in your physician's office or in a laboratory. First, a blood sample will be drawn to measure your fasting blood sugar level. Then you will be asked to drink a full bottle of a glucose drink (100 grams). This glucose drink is extremely sweet and occasionally makes some people feel nauseated.

14 Gestational Diabetes

Finally, blood samples will be drawn every hour for 3 hours after the glucose drink has been consumed. If two or more of your blood sugar levels are higher than the diagnostic criteria, you have gestational diabetes. This testing is usually performed at the end of the second or the beginning of the third trimester (between the 24th and 28th weeks of pregnancy) when insulin resistance usually begins. If you had gestational diabetes in a previous pregnancy or there is some reason why your physician is unusually concerned about your risk of developing gestational diabetes, you may be asked to take the 50gram glucose screening test as early as the first trimester (before the 13th week). Remember, merely having sugar in your urine or even having an abnormal blood sugar on the 50gram glucose screening test does not necessarily mean you have gestational diabetes. The 3hour glucose tolerance test must be abnormal before the diagnosis is made.

How Does Gestational Diabetes Affect Pregnancy? The complications of gestational diabetes are manageable and preventable. The key to prevention is careful control of blood sugar levels just as soon as the diagnosis of gestational diabetes is made. You should be reassured that there are certain things gestational diabetes does not usually cause. Unlike Type I diabetes, gestational diabetes generally does not cause birth defects. For the most part, birth defects originate sometime during the first trimester (before the 13th week) of pregnancy. The insulin resistance from the contra-insulin hormones produced by the placenta does not usually occur until approximately the 24th week. Therefore, women with gestational diabetes generally have normal blood sugar levels during the critical first trimester.

Guidelines 15

The Role of High Maternal Glucose in Fetal Macrosomia

One of the major problems a woman with gestational diabetes faces is a condition the baby may develop called “macrosomia.” Macrosomia means “large body” and refers to a baby that is considerably larger than normal. All of the nutrients the fetus receives come directly from the mother's blood. If the maternal blood has too much glucose, the pancreas of the fetus senses the high glucose levels and produces more insulin in an attempt to use the glucose. The fetus converts the extra glucose to fat. Even when the mother has gestational diabetes, the fetus is able to produce all the insulin it needs. The combination of high blood glucose levels from the mother and high insulin levels in the fetus results in large deposits of fat which causes the fetus to grow excessively large, a condition known as macrosomia. Occasionally, the baby grows too large to be delivered through the vagina and a cesarean delivery becomes necessary. The obstetrician can often determine if the fetus is macrosomic by doing a physical examination. However, in many cases a special test called an ultrasound is used to measure the size of the fetus. This and other special tests will be discussed later. In addition to macrosomia, gestational diabetes increases the risk of hypoglycemia (low blood sugar) in the baby immediately after delivery. This problem occurs if the mother's blood sugar levels have been consistently high causing the fetus to have a high level of insulin in its circulation. After delivery the baby continues to have a high insulin level, but it no longer has the high level of sugar from its mother, resulting in the newborn's blood sugar level becoming very low. Your baby's blood sugar level will be checked in the newborn nursery and if the level is too low, it may be necessary to give the baby glucose intravenously. Infants of mothers with

16 Gestational Diabetes

gestational diabetes are also vulnerable to several other chemical imbalances such as low serum calcium and low serum magnesium levels. All of these are manageable and preventable problems. The key to prevention is careful control of blood sugar levels in the mother just as soon as the diagnosis of gestational diabetes is made. By maintaining normal blood sugar levels, it is less likely that a fetus will develop macrosomia, hypoglycemia, or other chemical abnormalities.

What Can Be Done to Reduce Problems Associated with Gestational Diabetes? In addition to your obstetrician, there are other health professionals who specialize in the management of diabetes during pregnancy including internists or diabetologists, registered dietitians, qualified nutritionists, and diabetes educators. Your doctor may recommend that you see one or more of these specialists during your pregnancy. In addition, a neonatologist (a doctor who specializes in the care of newborn infants) should also be called in to manage any complications the baby might develop after delivery. One of the essential components in the care of a woman with gestational diabetes is a diet specifically tailored to provide adequate nutrition to meet the needs of the mother and the growing fetus. At the same time the diet has to be planned in such a way as to keep blood glucose levels in the normal range (60 to 120 mg/dl). Specific details about diet during pregnancy are discussed later. An obstetrician, diabetes educator, or other health care practitioner can teach you how to measure your own blood glucose levels at home to see if levels remain in an acceptable range on the prescribed diet. The ability of patients to determine their own blood sugar levels with easy-to-use equipment represents a major milestone in the management of diabetes, especially during pregnancy. The technique called “self blood glucose monitoring” (discussed in detail later) allows you to check your blood sugar levels at home or at work without costly and time-consuming visits to your doctor. The values of your blood sugar levels also determine if you need to begin insulin therapy sometime during pregnancy. Short of frequent trips to a laboratory, this is the only way to see if blood glucose levels remain under good control.

Guidelines 17

What Is Self Blood Glucose Monitoring? Once you are diagnosed as having gestational diabetes, you and your health care providers will want to know more about your day-to-day blood sugar levels. It is important to know how your exercise habits and eating patterns affect your blood sugars. Also, as your pregnancy progresses, the placenta will release more of the hormones that work against insulin. Testing your blood sugar level at important times during the day will help determine if proper diet and weight gain have kept blood sugar levels normal or if extra insulin is needed to help keep the fetus protected. Self blood glucose monitoring is done by using a special device to obtain a drop of your blood and test it for your blood sugar level. Your doctor or other health care provider will explain the procedure to you. Make sure that you are shown how to do the testing before attempting it on your own. Some items you may use to monitor your blood sugar levels are: ·

Lancet–a disposable, sharp needle-like sticker for pricking the finger to obtain a drop of blood.

·

Lancet device–a spring-loaded finger sticking device.

·

Test strip–a chemically treated strip to which a drop of blood is applied.

·

Color chart–a chart used to compare against the color on the test strip for blood sugar level.

·

Glucose meter–a device which “reads” the test strip and gives you a digital number value.

Your health care provider can advise you where to obtain the selfmonitoring equipment in your area. You may want to inquire if any places rent or loan glucose meters, since it is likely you won't be needing it after your baby is born.

How Often and When Should I Test? You may need to test your blood several times a day. Generally, these times are fasting (first thing in the morning before you eat) and 2 hours after each meal. Occasionally, you may be asked to test more frequently during the day or at night. As each person is an individual, your health care provider can advise the schedule best for you.

18 Gestational Diabetes

How Should I Record My Test Results? Most manufacturers of glucose testing products provide a record diary, although some health care providers may have their own version. A Self Blood Glucose Monitoring Diary is included at the end of this book. You should record any test result immediately because it's easy to forget what the reading was during the course of a busy day. You should always have this diary with you when you visit your doctor or other health care provider or when you contact them by phone. These results are very important in making decisions about your health care.

Are There Any Other Tests I Should Know About? In addition to blood testing, you may be asked to check your urine for ketones. Ketones are by-products of the breakdown of fat and may be found in the blood and urine as a result of inadequate insulin or from inadequate calories in your diet. Although it is not known whether or not small amounts of ketones can harm the fetus, when large amounts of ketones are present they are accompanied by a blood condition, acidosis, which is known to harm the fetus. To be on the safe side, you should watch for them in your urine and report any positive results to your doctor.

How Do I Test for Ketones? To test the urine for ketones, you can use a test strip similar to the one used for testing your blood. This test strip has a special chemically treated pad to detect ketones in the urine. Testing is done by passing the test strip through the stream of urine or dipping the strip in and out of urine in a container. As your pregnancy progresses, you might find it easier to use the container method. All test strips are disposable and can be used only once. This applies to blood sugar test strips also. You cannot use your blood sugar test strips for urine testing, and you cannot use your urine ketone test strips for blood sugar testing.

Guidelines 19

When Do I Test for Ketones? Overnight is the longest fasting period, so you should test your urine first thing in the morning every day and any time your blood sugar level goes over 240 mg/dl on the blood glucose test. It is also important to test if you become ill and are eating less food than normal. Your health care provider can advise what's best for you.

Is It Ever Necessary to Take Insulin? Yes, despite careful attention to diet some women's blood sugars do not stay within an acceptable range. A pregnant woman free of gestational diabetes rarely has a blood glucose level that exceeds 100 mg/dl in the morning before breakfast (fasting) or 2 hours after a meal. The optimum goal for a gestational diabetic is blood sugar levels that are the same as those of a woman without diabetes. There is no absolute blood sugar level that necessitates beginning insulin injections. However, many physicians begin insulin if the fasting sugar exceeds 105 mg/dl or if the level 2 hours after a meal exceeds 120 mg/dl on two separate occasions. Blood sugar levels measured by you at home will help your doctor know when it is necessary to begin insulin. The ability to perform self blood glucose monitoring has made it possible to begin insulin therapy at the earliest sign of high sugar levels, thereby preventing the fetus from being exposed to high levels of glucose from the mother's blood.

Will My Baby Be Healthy? The ultimate concern of any expectant mother is, “Will my baby be all right?” There is an array of simple, safe tests used to assess the condition of the fetus before birth and these can be particularly valuable during a pregnancy complicated by gestational diabetes. Tests that may be given during your pregnancy include:

Ultrasound Ultrasound uses short pulses of high-frequency, low-intensity sound waves to create images. Unlike x-rays, there is no radiation exposure to the fetus. First used during World War II to detect enemy submarines below the

20 Gestational Diabetes

surface of the water, ultrasound has since been used safely in obstetrics. Occasionally, the date of your last menstrual period is not sufficient to determine a due date. Ultrasound can provide an accurate gestational age and due date that may be very important if it is necessary to induce labor early or perform a cesarean delivery. Ultrasound can also be used to determine the position of the placenta if it is necessary to perform an amniocentesis (another test discussed later). Fetal Movement Records Recording fetal movement is a test you can do by yourself to help determine the condition of the baby. Fetal activity is generally a reassuring sign of wellbeing. Women are often asked to count fetal movements regularly during the last trimester of pregnancy. You may be asked to set aside specific times to lie down on your back or side and count the number of times the baby moves or kicks. Three or more movements in a 2-hour period is considered normal. Contact your obstetrician if you feel fewer than three movements to determine if other tests are needed.

Fetal Monitoring Modern instruments make it possible to monitor the baby's heart rate before delivery. Currently, there are two types of fetal monitors — internal and external. The internal monitor consists of a small wire electrode attached directly to the scalp of the fetus after the membranes have ruptured. The external monitor uses transducers secured to the mother's abdomen by an elastic belt. One transducer records the baby's heart rate by a sensitive microphone called a doppler. The other transducer measures the firmness of the abdomen during a contraction of the uterus. It is a crude measure of the strength and frequency of contractions. Fetal monitoring is the basis for the non-stress test and the oxytocin challenge test described below.

Non-Stress Test The “non-stress” test refers to the fact that no medication is given to the mother to cause movement of the fetus or contraction of the uterus. It is often used to confirm the well-being of the fetus based on the principle that a healthy fetus will demonstrate an acceleration in its heart rate following movement. Fetal activity may be spontaneous or induced by external manipulation such as rubbing the mother's abdomen or making a loud noise

Guidelines 21

above the abdomen with a special device. When movement of the fetus is noted, a recording of the fetal heart rate is made. If the heart rate goes up, the test is normal. If the heart rate does not accelerate, the fetus may merely be “sleeping”; if, after stimulation, the fetus still does not react, it may be necessary to perform a “stress test” (oxytocin challenge test).

Stress Test (Oxytocin Challenge Test) Labor represents a stress to the fetus. Every time the uterus contracts, the fetus is momentarily deprived of its usual blood supply and oxygen. This is not a problem for most babies. However, some babies are not healthy enough to handle the stress and demonstrate an abnormal heart rate pattern. This test is often done if the non-stress test is abnormal. It involves giving the hormone oxytocin (secreted by every mother when normal labor begins) to the mother to stimulate uterine contractions. The contractions are a challenge to the baby, similar to the challenge of normal labor. If the baby's heart rate slows down rather than speeds up after a contraction, the baby may be in jeopardy. The stress test is considered more accurate than the non-stress test. Nevertheless, it is not 100 percent foolproof and your obstetrician may want to repeat it on another occasion to ensure its accuracy. Most women describe this test as mildly uncomfortable but not painful.

Amniocentesis Amniocentesis is a method of removing a small amount of fluid from the amniotic sac for analysis. Either the fluid itself or the cells shed by the fetus into the fluid can be studied. In mid-pregnancy the cells in amniotic fluid can be analyzed for genetic abnormalities such as Down syndrome. Many women over the age of 35 have amniocentesis for just this reason. Another important use for amniocentesis late in pregnancy is to study the fluid itself to determine if the lungs of the fetus are mature and able to withstand early delivery This information can be very important in deciding the best time for a woman with Type I diabetes to deliver. It is not done as frequently to women with gestational diabetes. Amniocentesis can be performed in an obstetrician's office or on an outpatient basis in a hospital. For genetic testing, amniocentesis is usually performed around the 16th week when the placenta and fetus can be located easily with ultrasound and a needle can be inserted safely into the amniotic sac. The overall complication rate for amniocentesis is less than 1 percent.

22 Gestational Diabetes

The risk is even lower during the third trimester when the amniotic sac is larger and easily identifiable.

Does Gestational Diabetes Affect Labor and Delivery? Most women with gestational diabetes can complete pregnancy and begin labor naturally. Any pregnant woman has a slight chance (about 5 percent) of developing preclampsia (toxemia), a sudden onset of high blood pressure associated with protein in the urine, occurring late in pregnancy. If preclampsia develops, your obstetrician may recommend an early delivery. When an early delivery is anticipated, an amniocentesis is usually performed to assess the maturity of the baby's lungs. Gestational diabetes, by itself, is not an indication to perform a cesarean delivery, but sometimes there are other reasons your doctor may elect to do a cesarean. For example, the baby may be too large (macrosomic) to deliver vaginally, or the baby may be in distress and unable to withstand vaginal delivery. You should discuss the various possibilities for delivery with your obstetrician so there are no surprises. Careful control of blood sugar levels remains important even during labor. If a mother's blood sugar level becomes elevated during labor, the baby's blood sugar level will also become elevated. High blood sugars in the mother produce high insulin levels in the baby. Immediately after delivery high insulin levels in the baby can drive its blood sugar level very low since it will no longer have the high sugar concentration from its mother's blood. Women whose gestational diabetes does not require that they take insulin during their pregnancy, will not need to take insulin during their labor or delivery. On the other hand, a woman who does require insulin during pregnancy may be given insulin by injection on the morning labor begins, or in some instances, it may be given intravenously throughout labor. For most women with gestational diabetes there is no need for insulin after the baby is born and blood sugar level returns to normal immediately. The reason for this sudden return to normal lies in the fact that when the placenta is removed the hormones it was producing (which caused the insulin resistance) are also removed. Thus, the mother's insulin is permitted to work normally without resistance. Your doctor may want to check your blood sugar level the next morning, but it will most likely be normal.

Guidelines 23

Should I Expect My Baby to Have Any Problems? One of the most frequently asked questions is, “Will my baby have diabetes?” Almost universally the answer is no. However, the baby is at risk for developing Type II diabetes later in life, and of having other problems related to gestational diabetes, such as hypoglycemia (low blood sugar) mentioned earlier. If your blood sugars were not elevated during the 24 hours before delivery, there is a good chance that hypoglycemia will not be a problem for your baby. Nevertheless, a neonatologist (a doctor who specializes in the care of newborn infants) or other doctor should check your baby's blood sugar level and give extra glucose if necessary. Another problem that may develop in the infant of a mother with gestational diabetes is jaundice. Jaundice occurs when extra red blood cells in the baby's circulation are destroyed, releasing a substance called bilirubin. Bilirubin is a pigment that causes a yellow discoloration of the skin (jaundice). A minor degree of jaundice is common in many newborns. However, the presence of large amounts of bilirubin in the baby's system can be harmful and requires placing the baby under special lights which help get rid of the pigment. In extreme cases, blood transfusions may be necessary.

Will I Develop Diabetes in the Future? For most women gestational diabetes disappears immediately after delivery. However, you should have your blood sugars checked after your baby is born to make sure your levels have returned to normal. Women who had gestational diabetes during one pregnancy are at greater risk of developing it in a subsequent pregnancy. It is important that you have appropriate screening tests for gestational diabetes during future pregnancies as early as the first trimester. Pregnancy is a kind of “stress test” that often predicts future diabetic problems. In one large study more than onehalf of all women who had gestational diabetes developed overt Type II diabetes within 15 years of pregnancy. Because of the risk of developing Type II diabetes in the future, you should have your blood sugar level checked when you see your doctor for your routine checkups. There is a good chance you will be able to reduce the risk of developing diabetes later in life by maintaining an ideal body weight and exercising regularly.

24 Gestational Diabetes

Why Is a Special Diet Recommended? A nutritionally balanced diet is always essential to maintaining a healthy mother and successful pregnancy. The foods you choose become the nutrient building blocks for the growth of the fetus. For a woman with , gestational diabetes, proper diet alone often keeps blood sugar levels in the normal range and is generally the first step to follow before resorting to insulin injections. Careful attention should be paid to the total calories eaten daily, to avoid foods which increase blood sugar levels, and to emphasize the use of foods which help the body maintain a normal blood sugar. A registered dietitian is the best person to help you with meal planning to meet your individual needs. Your physician can help you find a dietitian if this service is not a part of his or her office or clinic. Your local chapter of the American Dietetic Association or the American Diabetes Association can also help you locate a registered dietitian.

How Much Weight Should I Gain? Of all questions asked by pregnant women, this is the most common. The answer is particularly important for women with gestational diabetes. The weight that you gain is a rough indication of how much nutrition is available to the fetus for growth. An inadequate weight gain may result in a small baby who lacks protective calorie reserves at birth. This baby may have more illness during the first year of life. An excessive weight gain during pregnancy, however, has an insulin-resistant effect, just like the hormones produced by the placenta, and will make your blood sugar level higher. The “optimal” weight to gain depends on the weight that you are before becoming pregnant. Your pre-pregnancy weight is also a rough indication of how well-nourished you are before becoming pregnant. If you are at a desirable weight for your body size before you become pregnant, a weight gain of 24 to 27 pounds is recommended. If you are approximately 20 pounds or more above your desirable weight before pregnancy, a weight gain of 24 pounds is recommended. Many overweight women, however, have healthy babies and gain only 20 pounds. If you become pregnant when you are underweight, you need to gain more weight during the pregnancy to give your baby the extra nutrition he or she needs for the first year. You should gain 28 to 36 pounds, depending on how underweight you are before becoming pregnant. Your nutrition advisor or health care provider can recommend an appropriate weight gain.

Guidelines 25

Total recommended weight gain is often not as helpful as a weekly rate of gain. Most women gain 3 to 5 pounds during the first trimester (first 3 months) of pregnancy. During the second and third trimesters, a good rate of weight gain is about three-quarters of a pound to one pound per week. Gaining too much weight (2 or more pounds per week) results in putting on too much body fat. This extra body fat produces an insulin-resistant effect which requires the body to produce more insulin to keep blood sugar levels normal. An inability to produce more insulin, as in gestational diabetes, causes your blood sugar levels to rise above acceptable levels. If weight gain has been excessive, often limiting weight gain to approximately threequarters of a pound per week (3 pounds per month) can return blood sugar levels to normal. Fetal growth and development depend on proper nourishment and will be placed at risk by drastically reducing calories. However, you can limit weight gain by cutting back on excessive calories and by eating a nutritionally-sound diet that meets your needs and the needs of your baby. Remember that dieting and severely cutting back on weight gain may increase the risk of delivering prematurely. If blood sugar levels continue to go up and you are not gaining excessive weight or eating improperly, the safest therapy for the well-being of the fetus is insulin. Occasionally, your weight may go up rapidly in the last trimester (after 28 weeks) and you may notice an increase in water retention, such as swelling in the feet, fingers, and face. If there is any question as to whether the rapid weight gain is due to eating too many calories or too much water retention, keeping records of how much food you eat and your exercise patterns at this time will be very helpful. A Food and Exercise Record Sheet is included at the end of this book. By examining your Food and Exercise Record Sheet, your nutrition advisor can help you determine which is causing the rapid weight gain. In addition, by examining your legs and body for signs of fluid retention, your physician can help you to determine the cause of your weight gain. If your weight gain is due to water retention, cutting back drastically on calories may actually cause more fluid retention. Bed rest and resting on your side will help you to lose the build-up of fluid. Limit your intake of salt (sodium chloride) and very salty foods, as they tend to contribute to water retention. Marked fluid retention when combined with an increase in blood pressure and possibly protein in the urine are the symptoms of preeclampsia. This is a disorder of pregnancy that can be harmful to both the mother and baby. Inform your obstetrician of any rapid weight gain, especially if you are eating moderately and gaining more than 2 pounds per week. Should you develop preeclampsia, be especially careful to eat a well-balanced diet with adequate calories.

26 Gestational Diabetes

After being diagnosed as having gestational diabetes, many women notice a slower weight gain as they start cutting the various sources of sugar out of their diet. This seems to be harmless and lasts only 1 or 2 weeks. It may be that sweets were contributing a substantial amount of calories to the diet.

How Should I Eat during My Pregnancy? As with any pregnancy, it is important to eat the proper foods to meet the nutritional needs of the mother and fetus. An additional goal for women with gestational diabetes is to maintain a proper diet to keep blood sugars as normal as possible.

Protein Equivalents Grams of Protein Food 1 cup milk 8 1 cup plain nonfat yogurt 8 1 ounce American processed cheese 7 1 ounce low-fat cheese 7 1 tbsp. peanut butter 7 1/4 cup cottage cheese 7 1/2 cup cooked dried beans 7 1 slice whole wheat bread 3 1/2 cup flaked cereal bran or corn 3

The daily need for calories increases by 300 calories during the second and third trimesters of pregnancy. If non-pregnant calorie intake was 1800 calories per day and weight gain was maintained, a calorie intake of 2100 calories per day is usual from 14 weeks until delivery. This is the equivalent of an additional 8 ounce glass of 2milk and one-half of a sandwich (1 slice of bread, approximately 1 ounce of meat, and I teaspoon of margarine, mayonnaise, etc.) per day. The need for protein also increases during pregnancy. Make sure your diet includes foods high in protein, but not high in fat. Most vitamins and minerals are also needed in larger amounts during pregnancy. This can be attained by increasing dairy products, especially those low in fat, and making sure you include whole grain cereals and breads, as well as fruits and vegetables in your diet each day. To make sure you get enough folate (a B vitamin critical during pregnancy) and iron, your obstetrician will probably recommend a prenatal vitamin. Prenatal vitamins do not replace a good diet; they merely help you to get the nutrients you

Guidelines 27

need. To absorb the most iron from your prenatal vitamin, take it at night before going to bed, or in the morning on an empty stomach. The Daily Food Guide serves as a guideline for food sources that provide important vitamins and minerals, as well as carbohydrates, protein, and fiber during pregnancy. The recommended minimal servings per day appear in parenthesis after each food group listed. This guide emphasizes foods that are low in fat and in sugar.

Daily Food Guide (Each Item Equals One Serving) Milk and Milk Products (4 servings per day; high protein, calcium, and Vitamin D): ·

1 cup milk, skim or low-fat

·

1/3 cup powdered non-fat milk

·

1 cup reconstituted powdered non-fat milk

·

1-1/2 oz. Low-fat cheese9

Meat, Poultry, Fish, and Meat Substitutes (5-6 servings per day; high protein, B vitamins, and iron): ·

1 oz. Cooked poultry, fish, or lean meat (beef, lamb, pork)

·

1 tbsp. peanut butter

·

1 egg

·

1/4 cup low-fat cottage cheese

·

1/2 cup cooked dried beans or lentils

Breads, Cereals, and Other Starches (5-6 servings per day; high complex carbohydrates; emphasize whole grams, or use fortified or enriched; a good source of protein, B-vitamins, fiber and minerals): ·

1 slice whole grain bread

·

5 crackers

·

1 muffin, biscuit, pancake or waffle

1 oz. low-fat cheese can also be used as 1 serving from the Meat, Poultry, Fish, and Meat Substitutes group if sufficient calcium is already being provided from 4 servings. 9

28 Gestational Diabetes

·

3/4 cup dry cereal, unsweetened

·

1/2 cup pasta (macaroni, spaghetti), rice, mashed potatoes, or cooked cereal

·

1/3 cup sweet potatoes or yams

·

1/2 cup cooked dried beans or lentils

·

1/2 bagel, 1/2 english muffin, or l/2 flour tortilla

·

1 small baked potato

·

2 taco shells

Fruit (2 servings per day; fresh fruit provides fiber; include one vitamin C source daily): ·

1/2 cup fresh fruit,

·

1/2 banana, or 1 medium-sized fruit (apple, orange)

·

1/2 cup, orange, grapefruit, or other juice fortified with vitamin C

·

1/2 medium-sized grapefruit

·

1 cup strawberries

·

1/2 cup fresh apricots, nectarines, purple plums, cantaloupe or 4 halves dried apricots (vitamin A source)

Vegetables10 (2 servings per day; include good vitamin A sources at least every other day): ·

1/2 cup cooked or 1 cup raw broccoli, spinach, and carrots (vitamin A source)

·

1/3 cup mixed vegetables

Fats: ·

1 tsp. butter or margarine

·

1 tsp. oil or mayonnaise

·

1 tbsp. regular salad dressing

·

2 tbsp. low-calorie salad dressing

Starchy vegetables such as corn, peas, and potatoes are included in Breads, Cereals, and Other Starches list.

10

Guidelines 29

·

1/4 cup nuts or seeds

The food guide is divided into six groups: milk and milk products; meat, poultry, fish, and meat substitutes; breads, cereals, and other starches; fruits; vegetables; and fats. Each group provides its own combination of vitamins, minerals, and other nutrients which play an important part in nutrition during pregnancy. Omitting the foods from one group will leave your diet inadequate in other nutrients. Plan your meals using a variety of foods within each food group, in the amounts recommended, and you'll be most likely to get all the vitamins, minerals, and other nutrients the fetus needs for growth and development.

Other Nutritional and Non-Nutritional Considerations Alcohol There is no known safe level of alcohol to allow during pregnancy. Daily heavy alcohol intake causes severe defects in development of the body and brain of the fetus, called Fetal Alcohol Syndrome. Even moderate drinking is associated with delayed fetal growth, spontaneous abortions, and lowered birth weight in babies. The Surgeon General's office warns: “Women who are pregnant or even considering pregnancy should avoid alcohol completely and should be aware of the alcohol content of food and drugs.”

Salt Salt restriction is no longer routinely advised during pregnancy. Recent research shows that during pregnancy the body needs salt to help provide the proper fluid balance. Your health care provider may recommend that you use salt in moderation.

Caffeine Studies conflict on the potential danger of caffeine to the fetus. Caffeine is found primarily in coffee, tea, and some sodas. Moderation is recommended. Talk to your doctor or other health professional about the maximum amount of caffeine recommended.

30 Gestational Diabetes

Caffeine Comparisons Food Regular coffee Instant coffee Decaffeinated coffee Tea Carbonated drinks e.g. colas Hot chocolate

Serving 8 oz. 8 oz. 8 oz. 8 oz. 12oz. 8 oz.

Amount of Caffeine 80-200 ma. 60-100 ma. 3-5 ma. 60-65 ma. 30-65 mg. 13 ma.

Megavitamins Megavitamins are defined as 10 times the Recommended Dietary Allowance11 of vitamins and minerals and are not recommended for pregnant women. Although it is possible to get all of the necessary nutrients from food alone, your doctor may prescribe some prenatal vitamins and minerals. If taken regularly, along with a balanced diet, you will be getting all the vitamins and minerals needed during your pregnancy.

Smoking Research has shown without question that smoking during pregnancy increases the risk of fetal death and pre-term delivery, impairs fetal growth, and can lead to low birth weight. It is best to stop smoking entirely and permanently, or at the very least, to cut back drastically on the number of cigarettes you smoke.

What Food Patterns Help Keep Blood Sugar Levels Normal? The following outlines food patterns which help to keep blood sugar levels within an acceptable range. Avoid sugar and foods high in sugar. Most women with gestational diabetes, just like those without diabetes, have a desire for something sweet in their diet. In pregnant women, sugar is rapidly absorbed into the blood and requires a larger release of insulin to maintain normal blood sugar levels.

Dietary allowances established by the National Academy of Sciences-National Research Council.

11

Guidelines 31

Without the larger release of insulin, blood sugar levels will increase excessively when you eat sugar-containing foods. There are many forms of sugar such as table sugar, honey, brown sugar, corn syrup, maple syrup, turbinado sugar, high fructose corn syrup, and molasses. Generally, food that ends in “ose” is a sugar (e.g., sucrose, dextrose, and glucose). Foods that usually contain high amounts of sugar include pies, cakes, cookies, ice cream, candy, soft drinks, fruit drinks, fruit packed in syrup, commercially fruited yogurt, jams, jelly, doughnuts, and sweet rolls. Many of these foods are high in fat as well. Be sure to check the list of ingredients on food products. Ingredients are listed in order of amount. If an ingredient is first on the list, it is present in the highest amount. If some type of sugar is listed first, second, or third on the list of ingredients, the product should be avoided. If sugar is further down, fourth, fifth, or sixth, it probably will not cause your blood sugar levels to go up excessively. Fruit juices should only be taken with a meal and limited to 6 ounces. Tomato juice is a good choice because it is low in sugar. Six ounces of most other juice (apple, grapefruit, orange) with no sugar added still contain approximately 4 to 5 teaspoons of sugar. However, these do not contain much of the fiber of a piece of fruit which normally would act to slow the absorption of sugar into the blood. If you drink juice frequently to quench your thirst during the day, a high blood sugar level may result. Use only whole fruit for snacks. To help with the occasional sweet tooth that we all have, artificial sweeteners may be used in foods. Aspartame has been extensively tested for safety. Use during pregnancy has been approved by the Food and Drug Administration and by the American Medical Association's Review Board. However, aspartame has not been tested for long-term safety and has not been on the market very long. It may be best to avoid its use until more tests have been done. Saccharin is not advised during pregnancy. Likewise, use of mannitol, xylitol, sorbitol, or other artificial sweeteners is not recommended until further research is done. Fructose is a special type of sugar that is slowly absorbed into the system. A small amount of fructose can be used if your blood sugar levels are within

32 Gestational Diabetes

normal range. However, fructose still has 4 calories per gram, as much as table sugar. High fructose corn syrup is part fructose and part corn syrup, making it very similar to table sugar in composition. It will raise blood sugar levels and should definitely be avoided. Emphasize the use of complex carbohydrates. These include vegetables, cereal, grains, beans, peas, and other starchy foods. A well-balanced diet with plenty of fiber provided by vegetables, dried beans, cereals, and other starchy foods decreases the amount of insulin your body needs to keep blood sugars within a normal range. Anything that decreases the need for insulin is beneficial The American Diabetes Association recommends that at least one-half of your calories come from complex carbohydrates. Starchy foods include pasta, rice, grains, cereals, crackers, bread, potatoes, dried beans, peas, and legumes. Also, contrary to popular belief, carbohydrates are not highly fattening when eaten in moderate amounts and without the rich sauces and toppings often added. Emphasize foods high in dietary fiber. Fiber is the edible portion of foods of plant origin that is not digested (e.g., skins, membranes, seeds, bran). Foods with a high fiber content include whole grain cereals and breads, fruits, vegetables, and legumes (dried peas and beans). Fiber aids digestion and helps prevent constipation. The fiber found in fruits, vegetables, and legumes also helps keep your blood sugar level from becoming too high without requiring extra insulin. Keep your diet low in fat. Some fat is needed to help with the absorption of certain vitamins and to provide the essential fatty acids necessary for fetal growth. A diet which is high in fat causes the insulin to react in a less efficient manner, necessitating more insulin to keep blood sugar levels within normal range. Foods high in saturated fats such as fatty meats, butter, bacon, cream (light, coffee, sour cream, etc.), and whole milk cheeses are likely to be high in total fat. Most foods with saturated fat are also high in cholesterol because they are fats from animal origin. However, foods such as crackers made with coconut, palm, or palm kernel oil can be high in saturated fats as well. Read labels carefully. Unsaturated fats are found in foods such as fish, margarine and vegetable oils. Keep your use of salad dressings to a minimum and whenever possible use those prepared with olive oil. To help keep the diet lower in fat, avoid adding extra fats such as rich sauces and creamy desserts, and bake or broil foods instead of frying them. Replacing fatty foods with those high in complex carbohydrates is also helpful.

Guidelines 33

Include a bedtime snack that is a good source of protein and complex carbohydrates. Women with gestational diabetes have a tendency toward lower than normal blood sugar levels during the night. This causes the body to increase its utilization of fats as a fuel source. As fat is used, ketones (discussed later) are produced as a byproduct of the breakdown of fats, and in large amounts, may be harmful to the fetus. This can be prevented by having a bedtime snack that provides protein and complex carbohydrates such as starchy foods. Starch will stabilize your blood sugar level in the early night, while protein acts as a long-acting stabilizer. Examples of a bedtime snack are: ·

1 oz. Americanprocessed cheese + 5 crackers

·

1/2 chicken sandwich on whole wheat bread

·

3 cups unbuttered popcorn + 1/4 cup nuts

If you need to take insulin, a bedtime snack is critical and you should not omit it. When taken by injection, insulin acts to lower blood sugar level, even during the night when meals are not eaten. A bedtime snack is protective against low blood sugars while sleeping or upon arising. If a bedtime snack causes heartburn, sleep with your head raised on pillows, and be careful that you are not eating too large a bedtime snack.

How Do I Plan Meals? A registered dietitian or qualified nutritionist can help you plan a meal pattern that is right for you. Most women with gestational diabetes need three meals and a bedtime snack each day. It is unwise for anyone who is pregnant to go long periods of time (greater than 5 hours) without eating, as this will produce ketones. Extra snacks are necessary if your schedule results in a long time between meals. Blood sugars will be easier to keep in the normal range if meal times and amounts (total calories) are evenly spaced. It's more likely that a higher blood sugar will result if the majority of calories are eaten at dinner) than if they are distributed more evenly throughout the day. If insulin injections prove necessary, the time at which meals are eaten and the amounts eaten should be approximately the same from day to day. Do not skip meals and snacks, as this often results in hypoglycemia (low blood sugar), which may be harmful to the fetus and makes you feel irritable, shaky, or may result in a headache.

34 Gestational Diabetes

Sample Menu — 2000 Calories This diet is planned for women whose normal non-pregnant weight should be 130135 lbs. For women who weigh less than 130 before pregnancy, the diet should contain fewer calories. Women who are overweight are at higher risk for gestational diabetes. Your health care provider can discuss this and help you make necessary changes. BREAKFAST 1/2 grapefruit 3/4 cup oatmeal, cooked 1 tsp. raisins 1 whole wheat English muffin I tsp. margarine

AFTERNOON SNACK 2 rice cakes 6 oz. low-fat yogurt, plain 1/2 cup blueberries

LUNCH Salad with: 1 cup romaine lettuce 1/2 cup kidney beans, cooked 1/2 fresh tomato 1 oz. part skim mozzarella cheese 2 tbsp. low-calorie Italian dressing 1 bran muffin 1/2 cup cantaloupe chunks

DINNER 3/4 cup vegetable soup with 1/4 cup cooked barley 3 oz. chicken, without skin 1 baked potato 1/2 cup cooked broccoli 1 piece whole wheat bread 1 tbsp. Margarine 1 fresh peach

BEDTIME SNACK 1 apple 2 cups popcorn, plain 1/4 cup peanuts

What Can Be Done to Slow Weight Gain during Pregnancy? Gaining too much weight during pregnancy will make blood sugar levels higher than normal for women with gestational diabetes. Yet, for many pregnant women it is very difficult to gain weight slowly and still get all of the recommended nutrients. Luckily, fat, which is high in calories (9 calories per gram), is needed in only small amounts during pregnancy. Carbohydrates and protein, in contrast to fat, provide only 4 calories per gram. To cut calories without depriving the fetus of any necessary nutritional factors, it is best to avoid fats and fatty foods. ·

Avoid high-fat meats. Choose lean cuts of beef, pork, and lamb. Emphasize more fish and poultry (without the skin).

Guidelines 35

·

Avoid frying meat, fish, or poultry in added oil, shortening, or lard. Bake, broil, or roast instead.

·

Avoid foods fried in oil such as chips, french fries, and doughnuts. Substitute pretzels, unbuttered popcorn, or breadsticks instead.

·

Avoid using cream sauces and butter sauces, as well as salt pork for seasoning on vegetables. Season with herbs instead.

·

Avoid using the fat drippings from meat or poultry for gravy. Use broth or bouillon instead and thicken with cornstarch.

·

Avoid using mayonnaise or oil for salads. Use vinegar, lemon juice, or low-calorie salad dressings instead.

To help reduce calories choose low-fat dairy products. During pregnancy you need 1200 mg calcium daily to build the fetal skeleton without drawing from maternal calcium stores. The difference between 600 calories and 340 calories is only 260 calories and may seem insignificant. Yet, if your diet is cut by 260 calories daily for 1 week, your weight gain slows down by approximately 1/2 pound per week. In other words, instead of gaining 1-1/2 pounds per week you will only gain 1 pound per week. If cheese is a part of your daily diet, use low-fat cheeses such as low-fat cottage cheese, Neufchatel, mozzarella, farmers, and pot cheese. Avoid using cream cheese, as it has little protein and most of its calories come from fat. Even though pregnancy can be a very hectic time, with little time for meal preparation, eat less and less often at “fast food” restaurants. Studies have shown that some foods from fast food restaurants average 40 to 60 percent of their calories from fat, and are quite high in calories.12 For example, chicken and fish that are coated with batter and deep-fried in fat may contain more fat and calories than a hamburger or roast beef sandwich.

Calorie Comparisons Food 4-8 oz. glasses whole milk 4-8 oz. glasses 2milk 4-8 oz. glasses skim milk

Calories 600 480 340

Fast Food Facts: Nutritive and Exchange Values for Fast Food Restaurants. Marion J. Franz, International Diabetes Center. Minneapolis, Minnesota, 1987. 54 pp.

12

36 Gestational Diabetes

2-8 oz. glasses whole milk plus 3 oz. American processed cheese 2-8 oz. glasses 2milk plus 3 oz. American processed cheese 2-8 oz. glasses skim milk plus 3 oz. American processed cheese

600 540 470

Go lightly when using butter and margarine. Adding only an extra three pats of butter or margarine (same calories) daily could add an extra pound of weight gain next month. It may be better to emphasize the use of foods rich in complex carbohydrates that don't use butter, margarine, or cream sauce to make them palatable. Many people find rice, noodles, and spaghetti tasty without a lot of butter. Use a variety of spices and herbs (such as curry, garlic, and parsley) to flavor rice and tomato sauce to flavor pasta without additional fats. It is also a good idea to eat small amounts frequently, thereby keeping the edge off your appetite. This will assist your “self-control” in avoiding large portions of food that you should not have. Avoid skipping meals or trying to cut back drastically on breakfast or lunch. It will leave you too hungry for the next meal to exercise any control. Your doctor or dietitian can help you determine how you can cut extra calories. You may find it helpful to keep food records of what you eat, as most of us tend to forget or not realize the extent of our snacking. Recording everything you eat or drink tends to be a sobering and instructive experience. A Food and Exercise Record Sheet is included at the end of this book. Be careful to maintain a weight gain of at least 1/2 pound per week, over several weeks, if you are in the second trimester (14 weeks or more of gestation). Cutting back more than this may increase the risk of having a low-birth-weight infant.

Is Breast-Feeding Recommended? Breast-feeding is strongly encouraged. For most women this represents the easiest way back to pre-pregnancy weight after delivery. The body draws on the calories stored during the first part of pregnancy to use in milk production. Approximately 800 calories per day are used during the first 3 months of milk production, and even more during the next 3 months. By 6

Guidelines 37

weeks after delivery, women who breast-feed usually have lost 4 pounds more than women who bottle-feed. This can be a very important factor, as it is strongly recommended that women with gestational diabetes return to their desirable body weight 4 to 5 months postpartum. As previously mentioned, maintaining a weight appropriate for your height and frame may reduce the risk of developing diabetes later in life. In addition, breast-feeding has many advantages for your baby. Protection from infection and allergies are transferred to the baby through breast milk. This milk is also easier to digest than formula, and its minerals are better absorbed than those in formula.

Should I Exercise? A daily exercise program is an important part of a healthy pregnancy. Daily exercise helps you feel better and reduces stress. In addition, being physically fit protects against back pain, and maintains muscle tone, strength, and endurance. For women with gestational diabetes, exercise is especially important. Regular exercise increases the efficiency or potency of your body's own insulin. This may allow you to keep your blood sugar levels in the normal range while using less insulin. Moderate exercise also helps blunt your appetite, helping you to keep your weight gain down to normal levels. Maintaining the correct weight gain is very important in preventing high blood sugar levels. Talk with your doctor about what exercise program is right for you. Your doctor can advise you about limitations, warning signs, and any special considerations. Generally, you can continue any exercise program or sport you participated in prior to pregnancy. Use caution, however, and avoid sports or exercises where you might fall, or that involve jolting. Prepregnancy bicycling, jogging, and cross-country skiing are good exercises to continue during pregnancy. If you plan to start an exercise program during pregnancy, talk to your doctor before beginning and start slowly. Vigorous walking is good for women who need to start exercising and have not been active before pregnancy.

38 Gestational Diabetes

Exercising frequently, 4 to 5 days per week, is necessary to get the “blood sugar lowering” advantages of an exercise program. Don't omit a warm-up period of 5 to 10 minutes and a cool-down period of 5 to 10 minutes. Always stop exercising if you feel pain, dizziness, shortness of breath, faintness, palpitations, back or pelvic pain, or experience vaginal bleeding. Also, avoid vigorous exercise in hot, humid weather or if you have a fever. It is important to prevent dehydration during exercise, especially during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) recommends drinking fluids prior to and after exercise, and if necessary, during the activity to prevent dehydration. An ACOG report13 issued in 1985, warned that target heart rates for pregnant and postpartum women should be set approximately 25 to 30 percent lower than rates for non-pregnant women. It may be that exercising too vigorously will direct blood flow away from the uterus and fetus. ACOG recommends that pregnant women measure their heart rate during activity and that maternal heart rate not exceed 140 beats per minute. If you need to be on insulin during your pregnancy, take a few precautions. Because both insulin and exercise lower blood sugar levels, the combination can result in hypoglycemia or low blood sugar You need to be aware that this is a potential problem, and you should be familiar with the symptoms of hypoglycemia (confusion, extreme hunger, blurry vision, shakiness, sweating). When exercising, take along sugar in the form of hard, sugarsweetened candies just in case your blood sugar becomes too low. When on insulin, you should always carry some form of sugar for potential episodes of hypoglycemia. It may be necessary for you to eat small snacks between meals if the exercise results in low blood sugar levels: ·

One serving of fruit will keep blood sugars normal for most short-term activities (approximately 30 minutes).

·

One serving of fruit plus a serving of starch will be enough for activities that last longer (60 minutes or more).

·

If you exercise right after a meal, eat the snack after the exercise. If the exercise is 2 hours or more after a meal, eat the snack before the exercise.

Home Exercise Program: Exercise During Pregnancy and the Postnatal Period. American College of Obstetricians and Gynecologists May 1985 6 pp.

13

Guidelines 39

What Happens If Diet and Exercise Fail to Control My Blood Sugars? If your blood sugars tend to go over the acceptable levels (105 mg/dl or below for fasting, 120 mg/dl or below 2 hours after a meal) you may need to take insulin injections. Insulin is a protein and would be digested like any other protein in food if it were given orally. The needles used to inject insulin are extremely fine, so there is little discomfort. If insulin injections are necessary, you will be taught how to fill the syringe and how to do the injections yourself. Your physician will calculate the amount of insulin needed to keep blood sugar levels within the normal range. It is very likely that the amount or dosage of insulin needed to keep your levels of blood sugar normal will increase as your pregnancy advances. This does not mean your gestational diabetes is getting worse. As any healthy pregnancy progresses, the placenta will grow and produce progressively higher levels of contra-insulin hormones. As a result you will likely need to inject more insulin to overcome their effect. Some women may even require two injections each day. This does not imply anything about the severity of the problem or the outcome of the pregnancy. The goal is to maintain normal blood sugar levels with whatever dosage of insulin is needed.

Can My Blood Sugar Level Go Too Low? Occasionally, your blood sugar level may get too low if you are taking insulin. This can happen if you delay a meal or exercise more than usual, especially at the time your insulin is working at its peak. This low blood sugar is called “hypoglycemia” or an “insulin reaction.” This is a medical emergency and should be promptly treated, never ignored. The symptoms of insulin reaction vary from sweating, shakiness, or dizziness to feeling faint, disoriented, or a tingling sensation. Remember, if you take insulin injections, you need to keep some form of sugar-sweetened candy in your purse, at home, at work, and in your car. In case of an episode of hypoglycemia, you will be prepared to treat it immediately. Be sure to eat something more substantial afterward. Also, report any insulin reactions or high blood sugar levels to your doctor right away in case an adjustment in your treatment needs to be made.

40 Gestational Diabetes

As you can see from reading this booklet, extra care, work, and commitment on the part of you and your spouse or partner are required to provide the special medical care necessary. Don't worry if you occasionally go off your diet or miss a planned exercise program. Your doctor and other health care professionals will work along with you to make sure you receive the specialized care that has resulted in dramatically improved pregnancy outcome. An ounce of prevention is worth a pound of cure! Eat as directed. Exercise as directed. Monitor as directed. Do these things and you are doing your part toward a happy, healthy pregnancy. A Practical Guide to a Healthy Pregnancy U.S. Department of Healath and Human Services Public Health Service National Institutes of Health National Institute of Child Health and Human Development NIH Publication No. 93-2788 Reprinted February 1993

More Guideline Sources The guideline above on gestational diabetes is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to gestational diabetes. Many of the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with gestational diabetes. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly.

Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. From there you

Guidelines 41

can either search using the alphabetical index or browse by broad topic areas.

If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it only includes material linked within the MEDLINEplus system (mostly patient-oriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search.

The Combined Health Information Database (CHID) CHID Online is a reference tool that maintains a database directory of thousands of journal articles and patient education guidelines on gestational diabetes and related conditions. One of the advantages of CHID over other sources is that it offers summaries that describe the guidelines available, including contact information and pricing. CHID’s general Web site is http://chid.nih.gov/. To search this database, go to http://chid.nih.gov/detail/detail.html. In particular, you can use the advanced search options to look up pamphlets, reports, brochures, and information kits. The following was recently posted in this archive: ·

Gestational Diabetes: Diabetes When You're Pregnant Source: Santa Cruz, CA: ETR Associates. 2000. 6 p. Contact: Available from ETR Associates. P.O. Box 1830, Santa Cruz, CA 95061-1830. (800) 321-4407. Fax (800) 435-8433. Website: www.etr.org. PRICE: $16.00 for 50 copies; larger bulk orders available. Summary: This brochure focuses on gestational diabetes. This form of diabetes occurs during pregnancy if a woman has too much sugar in her blood. A one hour glucose test and a glucose tolerance test are used to diagnose gestational diabetes. The brochure provides a checklist of health risks for gestational diabetes and suggests ways women can manage gestational diabetes. Tips include eating healthy foods every day, eating small meals and snacks, drinking eight glasses of water per day, drinking caffeine free drinks, taking vitamin supplements, avoiding foods that increase blood sugar, avoiding alcoholic beverages, checking blood sugar levels, quitting smoking, being physically active, and keeping track of weight gain. Other topics include labor, delivery, and follow up.

42 Gestational Diabetes

·

Gestational Diabetes: All You Need to Know About You and Your Baby. [Diabetes Gestacional: Todo Lo Que Debe Saber Acerca de Usted y Su Bebe] Source: San Diego, CA: Sweet Success: California Diabetes and Pregnancy Program. 1998. 22 p. Contact: Available from Sweet Success: California Diabetes and Pregnancy Program. Resource Center, 4543 Ruffner Street, Suite 130, San Diego, CA 92111. (619) 467-4990. Fax (619) 467-4993. Website: www.llu.edu/llumc/sweetsuccess. PRICE: $3.50 each plus shipping and handling. Order number: SD9022 for English version; SD9023 for Spanish version; SD9024 for Vietnamese version. Summary: This booklet uses a question and answer format to provide information about gestational diabetes. Topics include reasons for high blood sugar, risk factors for gestational diabetes, the effects of gestational diabetes, the symptoms of high blood sugar, the role of each member of the health care team, the need for frequent visits to the health care team, ways to reduce stress, self care tips, the effect of diabetes on delivery, postpartum care, and breastfeeding. The booklet discusses the need to follow a meal plan, exercise, and test blood sugar and ketone levels. In addition, it advises women to take insulin if a physician has prescribed it to keep their blood sugar normal, identifies special tests to check the health of the fetus, and lists warning signs for all pregnant women. The booklet includes a sample meal plan, a personal food plan sheet, and a record sheet for monitoring blood sugar and urine ketone.

·

About Gestational Diabetes Source: South Deerfield, MA: Channing L. Bete Company, Inc. 1997. 15 p. Contact: Available from Channing L. Bete Company, Inc. 200 State Road, South Deerfield, MA 01373-0200. (800) 628-7733. Fax (800) 499-6464. PRICE: $0.89 each for 1-99 copies; discounts available for larger orders. Item number: 39495A396. Summary: This booklet provides basic information about gestational diabetes. Written in non-technical language, the booklet defines and describes gestational diabetes. Topics include risk factors for developing gestational diabetes; problems that gestational diabetes can cause in a fetus; and screening tests. The booklet also discusses the role of good nutrition as the basis of gestational diabetes management; recommendations for exercise; self-monitoring; insulin therapy; coping with the psychological stresses associated with gestational diabetes; tests used to monitor the fetus' health before delivery; and post-natal health care and the risk of the mother later developing type 2 diabetes. The

Guidelines 43

booklet concludes with a brief summary and section of questions and answers. The booklet is illustrated with cartoon drawings of patients and health care providers from a variety of ethnic groups. ·

Gestational Diabetes: Dealing with Diabetes During Pregnancy Source: San Diego, CA: Sweet Success: California Diabetes and Pregnancy Program. 1997. [2 p.]. Contact: Available from Sweet Success: California Diabetes and Pregnancy Program. Resource Center, 4543 Ruffner Street, Suite 130, San Diego, CA 92111. (619) 467-4990. Fax (619) 467-4993. Website: www.llu.edu/llumc/sweetsuccess. PRICE: $0.50. Order number: SS2400. Summary: This pamphlet offers advice on coping with gestational diabetes. The pamphlet identifies the members of a health care team for women with gestational diabetes, highlights feelings and body changes that women may experience during pregnancy, notes the effects of these changes, and outlines steps that women diagnosed with gestational diabetes need to take to have a healthy pregnancy.

·

Gestational Diabetes: When You and Your Baby Need Special Care Source: San Bruno, CA: Krames Communications. 1996. 16 p. Contact: Available from Krames Communications. Order Department, 1100 Grundy Lane, San Bruno, CA 94066. (800) 333-3032. Fax (650) 2444512. PRICE: $1.35; discounts available for larger quantities. Order number 1784 (English) or 1792 (Spanish). Summary: This brochure familiarizes readers with gestational diabetes, a type of diabetes that happens only during pregnancy. Topics include understanding how the body uses energy, and problems resulting from high blood glucose levels; nutrition and diet therapy; the role of exercise; testing one's blood glucose levels; insulin therapy; monitoring the baby; labor and delivery considerations; and postnatal care for the mother, particularly that designed to reduce the risk of subsequent diabetes. The brochure is written in nontechnical language and features full-color line drawings, charts and graphs illustrating the concepts presented. The brochure depicts men and women of different ethnicities, and is available in English or Spanish. 3 references.

·

Diabetes Health Care Facts: Gestational Diabetes Source: Tarrytown, NY: Bayer Corporation. 1996. 4 p.

44 Gestational Diabetes

Contact: Available from Bayer Corporation. Diagnostics Division, 511 Benedict Avenue, Tarrytown, NY 10591-5097. (800) 445-5901. PRICE: Single copy free. Summary: This brochure, which is presented in question and answer format, provides information about gestational diabetes. According to the brochure, a family history of diabetes, obesity, a previous pregnancy with delivery of a large baby (10 pounds or more), and previous miscarriages or stillbirths tend to increase the risk of developing gestational diabetes. Topics include the causes of gestational diabetes, common problems of gestational diabetes, treatment, and insulin. The authors point out that a pregnant woman with diabetes can increase her chances of having a healthy pregnancy and baby by testing her blood glucose and urine ketones daily and following her meal plan closely. A list of products concludes the brochure. (AA-M). ·

Gestational Diabetes and You Source: Olathe, KS: Nutrition Counseling/Education Services (NCES). 1995. 28 p. Contact: Available from Nutrition Counseling/Education Services (NCES). 1904 East 123rd Street, Olathe, KS 66061. (800) 445-5653 for orders, or (913) 782-4385. Fax (913) 782-8230. PRICE: $2.95 each; $16.95 for 10 copies (as of 1995). Summary: This patient education booklet on gestational diabetes (GDM) provides detailed information in an easy-to-read, accessible format. Topics include a definition of GDM; the causes of GDM; how GDM affects the fetus; normal blood glucose levels; recording blood glucose levels, insulin, and exercise; the use of a food diary; meal planning; the use of exchange lists; weight loss; meal planning considerations for patients using insulin; emotional adjustment; breastfeeding; and optimizing choices for a healthy baby. The booklet is illustrated with line drawings depicting both Caucasian and African-American pregnant women. The booklet is available in English or Spanish.

·

Gestational Diabetes: Caring for Yourself and Your Baby Source: Minneapolis, MN: International Diabetes Center, Park Nicollet Medical Foundation. 1995. 29 p. Contact: Available from HealthSource. 3800 Park Nicollet Boulevard, Minneapolis, MN 55416-9963. (800) 372-7776. PRICE: $2.95. ISBN: 1885115210.

Guidelines 45

Summary: This brochure provides basic information about gestational diabetes. It covers caring for mother and baby with blood glucose control and monitoring; emotional balance; nutrition needs during pregnancy, including carbohydrate, protein, fat, making food choices, caloric intake, and weight gain; food and blood glucose control; physical activity and blood glucose control; taking insulin; testing guidelines and goals, including those for blood glucose and ketones; record-keeping; and postpregnancy considerations. The booklet features lists of practical suggestions for implementing each recommendation. The booklet also includes blank forms for readers to use for keeping blood glucose records. Simple charts and line drawings illustrate the booklet. ·

How to Manage Gestational Diabetes Source: Indianapolis, IN: Eli Lilly and Company. 1994. 11 p. Contact: Available from Eli Lilly and Company. Lilly Corporate Center, Indianapolis, IN 46285. (800) 545-5979 or (317) 276-2000. PRICE: Single copy free. Summary: This brochure describes gestational diabetes mellitus (GDM) and its effect on pregnant women and fetuses. Because GDM usually has no symptoms, all pregnant women should have their blood tested between the 24th and 28th weeks of pregnancy, or earlier if they had GDM in an previous pregnancy. The brochure advises that women who develop gestational diabetes work with a health care team follow special meal plans devised by a registered dietitian, test their blood sugar and urine ketones, keep accurate records, maintain a healthy weight, and exercise in accordance with their doctor's advice. The brochure also describes the use of insulin in GDM, tests doctors may perform to measure the growth of the fetus, and the post-partum effects of GDM.

·

Gestational Diabetes: You're in Control Source: Cypress, CA: Medcom, Inc. 1994. (videocassette and booklet). Contact: Available from Medcom, Inc. P.O. Box 6003, Cypress, CA 90630. (800) 320-1444. Fax (714) 898-4852. PRICE: $19.95 plus shipping (as of 1995). Summary: This patient education kit, consisting of a videotape program and pocket sized guide, is designed to ease the fears associated with gestational diabetes by providing the tools necessary to control the disease. The program answers common questions and reassures pregnant women with gestational diabetes that a safe pregnancy and the delivery of a healthy baby are possible. The program explains how diabetes develops; provides answers to myths about diabetes and insulin;

46 Gestational Diabetes

emphasizes the need for women to work with their health care providers; lists five things pregnant women must do to take control of their disease state; discusses the risk factors for developing permanent diabetes after pregnancy; and provides information to empower women to take control of their disease state. The content is based on the latest medical information available on diabetes and was reviewed by a consulting staff of nurses, nurse practitioners, registered dietitians, and diabetic educators. The accompanying booklet provides written reinforcement of the concepts presented in the video, and includes a daily food and blood glucose diary for patient recordkeeping. (AA-M). ·

Taking Care of Gestational Diabetes. [El Cuidado de la Diabetes Gestacional] Source: Minneapolis, MN: International Diabetes Center. 1992. 44 p. Contact: Available from International Diabetes Center. Attention: IDC Publishing. 3800 Park Nicollet Boulevard, Minneapolis, MN 55416. (612) 993-3874. PRICE: $2.95. Summary: This patient education booklet is designed to explain the basics of gestational diabetes in clear, easy-to-understand language. Topics covered include a review of gestational diabetes; how it can affect the pregnant woman and fetus; normal blood glucose levels; how to control blood glucose levels; the emotions that may arise when a woman learns she has gestational diabetes; desirable weight gain during pregnancy; nutrition during pregnancy, including guidelines for meal planning and food groups and exchanges; types of insulin and how it is administered; problems with low blood sugar; what happens after pregnancy; and breastfeeding. Numerous line drawings illustrate the concepts presented. The booklet is available in English or Spanish.

·

Gestational Diabetes Mellitus Source: Dallas, TX: Methodist Medical Center. 1991. 22 p. Contact: Available from Methodist Medical Center. Women's Center, 301 West Colorado, Dallas, TX 75208. (214) 944-7160. PRICE: $2 for 1-120, $1.75 for 11-49, $1.50 for 50 or more. Summary: A booklet for pregnant women provides information on the characteristics, potential causes, diagnosis, treatment, and potential consequences of gestational diabetes. Answers are given to a variety of typical questions covering pregnancy, delivery, and after birth. Dietary information, diet tips, and a sample menu are included for managing gestational diabetes.

Guidelines 47

·

How to Have a Healthy Baby: Gestational Diabetes Source: Albuquerque, NM: Indian Health Service. 1991. 24 p. Contact: Available from IHS HQW Diabetes Program. 5300 Homestead Road, NE, Albuquerque, NM 78110. (505) 837-4182. Fax (505) 837-4188. PRICE: Materials are available only to health care professionals serving American Indian populations; contact the IHS Diabetes Program for list of currently available materials. Summary: This brochure, written for Native American women with gestational diabetes, explains steps to take to increase the chances of a healthy pregnancy and a healthy baby. Topics include pregnancy and high blood glucose, problems that high blood glucose can cause during pregnancy, healthy food choices, exercise during pregnancy, selfmonitoring of blood glucose (SMBG), and special diagnostic tests that may be used. This brochure is written in clear, easy-to-understand language, with culturally relevant line drawings illustrating the concepts presented. Space is included for specific clinic information and phone numbers and for patient notes.

·

Gestational Diabetes: How You Can Deal With It Source: Lexington, KY: Lexington-Fayette County Health Department. 199x. 9 p. Contact: Available from Lexington-Fayette County Health Department. Division of Nutrition and Health Education, 650 Newtown Pike, Lexington, KY 40508. (606) 288-2333. Fax (606) 288-2359. PRICE: $38.00 per 25 copies plus shipping. Summary: This guide to gestational diabetes is one in a series of 22 diabetes education materials that combine practical tips and humorous drawings with current diabetes information. The series is written at a sixth grade reading level and is designed to teach and motivate patients to take good care of themselves. The booklet provides specific suggestions for readers to implement in their everyday diabetes management. Gestational diabetes is defined as high blood glucose levels during pregnancy. The booklet provides information about the causes of gestational diabetes, how gestational diabetes can affect the fetus and baby, how to keep blood glucose levels normal, what to eat, snack ideas, sweets and desserts, and what happens after the baby is born. The booklet also provides a sample 1-day, 2,000-calorie menu designed for a person with gestational diabetes. Readers are cautioned against smoking and alcohol use.

48 Gestational Diabetes

·

Gestational Diabetes Source: Montgomery, AL: Alabama Department of Public Health Diabetes Program. 199x. [7 p.]. Contact: Available from Alabama Department of Public Health Diabetes Program. 201 Monroe Street, Suite 1460, P.O. Box 30317, Montgomery, AL 36130-3017. (334) 206-2060. Fax (334) 206-2064. E-mail: [email protected]. Website: www.alapubhealth.org. PRICE: Single copy free. Summary: This booklet uses a question and answer format to provide women with information on gestational diabetes, which occurs during pregnancy and usually goes away after the baby is born. Topics include risk factors for gestational diabetes; the diagnosis; the complications of gestational diabetes for the baby and mother such as macrosomia, polyhydramnios, toxemia, and edema; and the maintenance of excellent blood sugar control during pregnancy through diet, increased physical activity, and medication. In addition, the booklet provides general guidelines on dietary management of gestational diabetes, explains the process of self monitoring of blood glucose levels, and discusses the need for insulin in controlling blood sugar in some cases. The booklet concludes with information on tests to monitor the baby's development, delivery, and postpartum care.

·

Diabetes Day-by-Day Source: Alexandria, VA: American Diabetes Association. 199x. [168 p.]. Contact: Available from American Diabetes Association, Inc. Order Fulfillment Department, P.O. Box 930850, Atlanta, GA 31193-0850. (800) 232-6733. Fax (770) 442-9742. PRICE: $9.95 (members), $11.95 (nonmembers) for 50 copies of each fact sheet in the series; single copies free. Summary: This information package consists of 42 fact sheets about daily living and coping with diabetes. The series emphasizes self care and the value of a positive attitude. Topics include sugars and artificial sweeteners; nutrition; eating out; alcohol and smoking; weight loss and exercise; health care and the patient care team; diagnosis; insulin; tight diabetes control; oral diabetes medications; drug interactions; blood glucose and urine self testing; hypoglycemia; the glycated hemoglobin test; sexual health; pregnancy; gestational diabetes; genetics; information for parents and teens; discrimination; emotions and stress; traveling; skin, foot, and mouth care; complications; transplantation; and cardiovascular health. The fact sheets are written in nontechnical language and provide starting points for exploring important diabetes topics. Each fact sheet

Guidelines 49

refers readers to others in the series that may be useful, as well as to other American Diabetes Association materials.

The National Guideline Clearinghouse™ The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “gestational diabetes” or synonyms. The following was recently posted: ·

Gestational diabetes mellitus. Source: American Diabetes Association.; 1986 (revised 2000; republished 2002 Jan); 3 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 2364&sSearch_string=gestational+diabetes

·

Gestational diabetes practice guidelines. Source: International Diabetes Center.; 2000; 33 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1789&sSearch_string=gestational+diabetes Healthfinder™

Healthfinder™ is an additional source sponsored by the U.S. Department of Health and Human Services which offers links to hundreds of other sites that contain healthcare information. This Web site is located at http://www.healthfinder.gov. Again, keyword searches can be used to find guidelines. The following was recently found in this database: ·

Understanding Gestational Diabetes Summary: This document answers many questions that women and their families have about gestational diabetes including diet, measurement of blood sugar levels, and general medical and obstetric care of women Source: National Institute of Child Health and Human Development, National Institutes of Health http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=839

50 Gestational Diabetes

The NIH Search Utility After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to gestational diabetes. The drawbacks of this approach are that the information is not organized by theme and that the references are often a mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for relatively rare or specific disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html.

Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats

·

drkoop.comÒ: http://www.drkoop.com/conditions/ency/index.html

·

Family Village: http://www.familyvillage.wisc.edu/specific.htm

·

Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/

·

Med Help International: http://www.medhelp.org/HealthTopics/A.html

·

Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/

·

Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/

·

WebMDÒHealth: http://my.webmd.com/health_topics

Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter:

Guidelines 51

Acidosis: A pathologic condition resulting from accumulation of acid or depletion of the alkaline reserve (bicarbonate content) in the blood and body tissues, and characterized by an increase in hydrogen ion concentration. [EU] Amniocentesis: Percutaneous transabdominal puncture of the uterus during pregnancy to obtain amniotic fluid. It is commonly used for fetal karyotype determination in order to diagnose abnormal fetal conditions. [NIH] Aspartame: Flavoring agent sweeter than sugar, metabolized as phenylalanine and aspartic acid. [NIH] Bilirubin: A bile pigment that is a degradation product of heme. [NIH] Calcium: A mineral that the body needs for strong bones and teeth. Calcium may form stones in the kidney. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Dehydration: The condition that results from excessive loss of body water. Called also anhydration, deaquation and hypohydration. [EU] Digestion: The process of breakdown of food for metabolism and use by the body. [NIH] Dizziness: An imprecise term which may refer to a sense of spatial disorientation, motion of the environment, or lightheadedness. [NIH] Edema: Excessive amount of watery fluid accumulated in the intercellular spaces, most commonly present in subcutaneous tissue. [NIH] Elastic: Susceptible of resisting and recovering from stretching, compression or distortion applied by a force. [EU] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond

52 Gestational Diabetes

that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Heartburn: Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. [NIH] Hormone: A natural chemical produced in one part of the body and released into the blood to trigger or regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down urine production. [NIH] Hunger: The desire for food generated by a sensation arising from the lack of food in the stomach. [NIH] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Jaundice: A clinical manifestation of hyperbilirubinemia, consisting of deposition of bile pigments in the skin, resulting in a yellowish staining of the skin and mucous membranes. [NIH] Mannitol: A diuretic and renal diagnostic aid related to sorbitol. It has little significant energy value as it is largely eliminated from the body before any metabolism can take place. It can be used to treat oliguria associated with kidney failure or other manifestations of inadequate renal function and has been used for determination of glomerular filtration rate. Mannitol is also commonly used as a research tool in cell biological studies, usually to control osmolarity. [NIH] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Molasses: The syrup remaining after sugar is crystallized out of sugar cane or sugar beet juice. It is also used in animal feed, and in a fermented form, is used to make industrial ethyl alcohol and alcoholic beverages. [NIH] Obstetrics: A medical-surgical specialty concerned with management and care of women during pregnancy, parturition, and the puerperium. [NIH] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Oxytocin: A nonapeptide posterior pituitary hormone that causes uterine contractions and stimulates lactation. [NIH] Palpitation: A subjective sensation of an unduly rapid or irregular heart beat. [EU] Pancreas: A mixed exocrine and endocrine gland situated transversely across the posterior abdominal wall in the epigastric and hypochondriac

Guidelines 53

regions. The endocrine portion is comprised of the islets of langerhans, while the exocrine portion is a compound acinar gland that secretes digestive enzymes. [NIH] Placenta: A highly vascular fetal organ through which the fetus absorbs oxygen and other nutrients and excretes carbon dioxide and other wastes. It begins to form about the eighth day of gestation when the blastocyst adheres to the decidua. [NIH] Polyhydramnios: Excess of amniotic fluid greater than 2,000 ml. It is a common obstetrical complication whose major causes include maternal diabetes, chromosomal disorders, isoimmunological disease, congenital abnormalities, and multiple gestations. [NIH] Postnatal: Occurring after birth, with reference to the newborn. [EU] Preeclampsia: A toxaemia of late pregnancy characterized by hypertension, edema, and proteinuria, when convulsions and coma are associated, it is called eclampsia. [EU] Prenatal: Existing or occurring before birth, with reference to the fetus. [EU] Pulse: The rhythmical expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle of the heart as it contracts. [NIH] Saccharin: Flavoring agent and non-nutritive sweetener. [NIH] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Sorbitol: A polyhydric alcohol with about half the sweetness of sucrose. Sorbitol occurs naturally and is also produced synthetically from glucose. It was formerly used as a diuretic and may still be used as a laxative and in irrigating solutions for some surgical procedures. It is also used in many manufacturing processes, as a pharmaceutical aid, and in several research applications. [NIH] Spices: The dried seeds, bark, root, stems, buds, leaves, or fruit of aromatic plants used to season food. [NIH] Toxemia: A generalized intoxication produced by toxins and other substances elaborated by an infectious agent. [NIH] Transfusion: The introduction of whole blood or blood component directly into the blood stream. [EU] Urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder, and expelled from the body through the urethra by the act of voiding or urinating. [NIH]

54 Gestational Diabetes

Uterus: The hollow muscular organ in female mammals in which the fertilized ovum normally becomes embedded and in which the developing embryo and fetus is nourished. In the nongravid human, it is a pear-shaped structure; about 3 inches in length, consisting of a body, fundus, isthmus, and cervix. Its cavity opens into the vagina below, and into the uterine tube on either side at the cornu. It is supported by direct attachment to the vagina and by indirect attachment to various other nearby pelvic structures. Called also metra. [EU] Vagina: The tube in a woman's body that runs beside the urethra and connects the womb (uterus) to the outside of the body. Sometimes called the birth canal. [NIH]

Seeking Guidance 55

CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with gestational diabetes. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.14 In addition to support groups, your physician can be a valuable source of guidance and support. Therefore, finding a physician that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with gestational diabetes. The chapter ends with a discussion on how to find a doctor that is right for you.

Associations and Gestational Diabetes As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of an illness can be as taxing as the physical side.15 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, your expectations, and how well you cope with your condition can all Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 15 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 14

56 Gestational Diabetes

influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. In addition to associations or groups that your doctor might recommend, we suggest that you consider the following list (if there is a fee for an association, you may want to check with your insurance provider to find out if the cost will be covered): ·

Diabetes Insipidus Foundation, Inc Address: Diabetes Insipidus Foundation, Inc. 4533 Ridge Drive, Baltimore, MD 21229 Telephone: (410) 247-3953 E-mail: [email protected] Website: http://diabetesinsipidus.maxinter.net Email: [email protected] Web Site: http://diabetesinsipidus.maxinter.net Background: The Diabetes Insipidus Foundation is concerned with all forms of diabetes insipidus (DI), namely neurogenic, nephrogenic, gestagenic (gestational DI), and dipsogenic. The three major goals of the Foundation include promoting research, providing information, and offering support to affected individuals and their families. In the area of research, the Foundation strives to increase research dollars by educating the biomedical community about the prevalence of diabetes insipidus and its numerous extra- urinary manifestations. The Foundation also strives for more accurate diagnosis, more specific therapy, and, ultimately, the prevention and cure of diabetes insipidus. In addition, the Foundation strives for greater public awareness and understanding of the disease by promoting public education and offering informational material such as a quarterly newsletter.

·

JDF The Diabetes Research Foundation Address: JDF The Diabetes Research Foundation 89 Granton Avenue, Richmond Hill, Ontario, L4B 2N5, Canada Telephone: (905) 889- 4171 Toll-free: (800) 287-2533 Fax: (905) 889-4209 Email: [email protected] Web Site: http://www.jdfc.ca

Seeking Guidance 57

Background: JDF The Diabetes Research Foundation is an international not-for- profit organization in Canada dedicated to raising funds to support and promote diabetes research. Diabetes is a chronic metabolic disorder that affects the body's ability to properly manufacture or utilize insulin, a hormone necessary for the body to transport food glucose into cells for energy. There are several types of diabetes including InsulinDependent Diabetes Mellitus, IDDM (also known as Juvenile Diabetes); Non-Insulin Dependent (Type II, also known as Adult-Onset Diabetes); and Gestational Diabetes. Established in 1974 and consisting of 14 chapters, JDF supports research advances in therapies to reduce the risk of diabetes- caused blindness, decrease the number of amputations due to diabetes, and control high blood pressure associated with diabetes; disease management practices that help maintain tight control of glucose levels to prevent or delay complications of diabetes; and practices that afford women with diabetes the opportunity for safe pregnancies and healthy children. JDF also supports advancements in methods to detect the earliest signs of diabetes; therapeutic treatments to prevent or delay the disease's onset; experimental techniques for programming cells from outside the pancreas to produce insulin; and research that has contributed to the increased understanding of transplantation immunology, which has helped to make transplantation of pancreatic tissue a reality. JDF publishes a quarterly magazine entitled 'Countdown Canada,' regularly produces 'Research News Updates,' and has a web site on the Internet at http://www.jdfc.ca.

Finding More Associations There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information than what is listed above, by consulting all of them, you will have nearly exhausted all sources for patient associations.

The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about gestational diabetes. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797.

58 Gestational Diabetes

DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “gestational diabetes” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations.

The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “gestational diabetes”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then, select your preferred language and the format option “Organization Resource Sheet.” By making these selections and typing in “gestational diabetes” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with gestational diabetes. You should check back periodically with this database since it is updated every 3 months. The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option called “Organizational Database (ODB)” and type “gestational diabetes” (or a synonym) in the search box. Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMDÒ, for example, offers such a service at their Web site:

Seeking Guidance 59

http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your doctor or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective.

Finding Doctors One of the most important aspects of your treatment will be the relationship between you and your doctor or specialist. All patients with gestational diabetes must go through the process of selecting a physician. While this process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:16 ·

If you are in a managed care plan, check the plan's list of doctors first.

·

Ask doctors or other health professionals who work with doctors, such as hospital nurses, for referrals.

·

Call a hospital’s doctor referral service, but keep in mind that these services usually refer you to doctors on staff at that particular hospital. The services do not have information on the quality of care that these doctors provide.

·

Some local medical societies offer lists of member doctors. Again, these lists do not have information on the quality of care that these doctors provide.

Additional steps you can take to locate doctors include the following: ·

Check with the associations listed earlier in this chapter.

·

Information on doctors in some states is available on the Internet at http://www.docboard.org. This Web site is run by “Administrators in Medicine,” a group of state medical board directors.

·

The American Board of Medical Specialties can tell you if your doctor is board certified. “Certified” means that the doctor has completed a training program in a specialty and has passed an exam, or “board,” to assess his or her knowledge, skills, and experience to provide quality patient care in that specialty. Primary care doctors may also be certified as specialists. The AMBS Web site is located at

16

This section is adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

60 Gestational Diabetes

http://www.abms.org/newsearch.asp.17 You can also contact the ABMS by phone at 1-866-ASK-ABMS. ·

You can call the American Medical Association (AMA) at 800-665-2882 for information on training, specialties, and board certification for many licensed doctors in the United States. This information also can be found in “Physician Select” at the AMA's Web site: http://www.amaassn.org/aps/amahg.htm.

If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of doctors with expertise in various rare diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.

Finding an Obstetrician-Gynecologist The American College of Obstetricians and Gynecologists (ACOG) provides a searchable Physician Directory at http://www.acog.org/memberlookup/disclaimer.cfm. The directory is provided as a public service to help women find obstetrician-gynecologists in their area. The ACOG’s database includes over 43,000 of its members who practice obstetrics and/or gynecology in the U.S., Canada, and internationally. The Physician Directory is searchable by physician name, state, country, or zip code. Some of the topics covered can include information about each physician’s practice, such as office hours, affiliated hospitals, and languages spoken. A green icon next to a physician’s name denotes that information about this practice is available. By clicking on a linked name, you will be redirected to the associated physician’s home page.

While board certification is a good measure of a doctor's knowledge, it is possible to receive quality care from doctors who are not board certified. 17

Seeking Guidance 61

Selecting Your Doctor18 When you have compiled a list of prospective doctors, call each of their offices. First, ask if the doctor accepts your health insurance plan and if he or she is taking new patients. If the doctor is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen physician. During the first visit you will have the opportunity to evaluate your doctor and to find out if you feel comfortable with him or her. Ask yourself, did the doctor: ·

Give me a chance to ask questions about gestational diabetes?

·

Really listen to my questions?

·

Answer in terms I understood?

·

Show respect for me?

·

Ask me questions?

·

Make me feel comfortable?

·

Address the health problem(s) I came with?

·

Ask me my preferences about different kinds of treatments for gestational diabetes?

·

Spend enough time with me?

Trust your instincts when deciding if the doctor is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your doctor to get to know each other.

Working with Your Doctor19 Research has shown that patients who have good relationships with their doctors tend to be more satisfied with their care and have better results. Here are some tips to help you and your doctor become partners: ·

You know important things about your symptoms and your health history. Tell your doctor what you think he or she needs to know.

·

It is important to tell your doctor personal information, even if it makes you feel embarrassed or uncomfortable.

18 This

section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm. 19 This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

62 Gestational Diabetes

·

Bring a “health history” list with you (and keep it up to date).

·

Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications.

·

Tell your doctor about any natural or alternative medicines you are taking.

·

Bring other medical information, such as x-ray films, test results, and medical records.

·

Ask questions. If you don't, your doctor will assume that you understood everything that was said.

·

Write down your questions before your visit. List the most important ones first to make sure that they are addressed.

·

Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers.

·

Ask your doctor to draw pictures if you think that this would help you understand.

·

Take notes. Some doctors do not mind if you bring a tape recorder to help you remember things, but always ask first.

·

Let your doctor know if you need more time. If there is not time that day, perhaps you can speak to a nurse or physician assistant on staff or schedule a telephone appointment.

·

Take information home. Ask for written instructions. Your doctor may also have brochures and audio and videotapes that can help you.

·

After leaving the doctor's office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your doctor, call for your test results. If your doctor recommended that you have certain tests, schedule an appointment to get them done. If your doctor said you should see an additional specialist, make an appointment.

By following these steps, you will enhance the relationship you will have with your physician.

Seeking Guidance 63

Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:20 ·

Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html

·

Choosing a Doctor or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html

·

Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html

Vocabulary Builder The following vocabulary builder provides definitions of words used in this chapter that have not been defined in previous chapters: Blindness: The inability to see or the loss or absence of perception of visual stimuli. This condition may be the result of eye diseases; optic nerve diseases; optic chiasm diseases; or brain diseases affecting the visual pathways or occipital lobe. [NIH] Chronic: Lasting a long time. Chronic diseases develop slowly. Chronic renal failure may develop over many years and lead to end-stage renal disease. [NIH] Gynecology: A medical-surgical specialty concerned with the physiology and disorders primarily of the female genital tract, as well as female endocrinology and reproductive physiology. [NIH] Nephrogenic: Constant thirst and frequent urination because the kidney tubules cannot respond to antidiuretic hormone and therefore pass too much water. [NIH] Neurogenic: Loss of bladder control caused by damage to the nerves controlling the bladder. [NIH] You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.

20

64 Gestational Diabetes

65

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL

ABOUT PART II In Part II, we introduce you to additional resources and advanced research on gestational diabetes. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on gestational diabetes. In Part II, as in Part I, our objective is not to interpret the latest advances on gestational diabetes or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with gestational diabetes is suggested.

Studies 67

CHAPTER 3. STUDIES ON GESTATIONAL DIABETES Overview Every year, academic studies are published on gestational diabetes or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or physicians. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on gestational diabetes. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on gestational diabetes and teach you how to keep current on new studies as they are published or undertaken by the scientific community.

The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and gestational diabetes, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the

68 Gestational Diabetes

format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type in “gestational diabetes” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is a sample of what you can expect from this type of search: ·

Screening for MODY Mutations, GAD Antibodies, and Type 1 Diabetes-Associated HLA Genotypes in Women with Gestational Diabetes Mellitus Source: Diabetes Care. 25(1): 68-71. January 2002. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This article reports on a study undertaken to investigate whether genetic susceptibility to type 1 diabetes or maturity onset diabetes of the young (MODY) increases susceptibility to gestational diabetes mellitus (GDM). The authors studied mutations in MODY1-4 genes, the presence of GAD antibodies, and HLA DQB1 risk genotypes in 66 Swedish women with GDM and a family history of diabetes. An oral glucose tolerance test (OGTT) was repeated in 46 women at 1 year postpartum. There was no increase in type 1 diabetes associated HLADQB1 alleles or GAD antibodies when compared with a group of patients with type 2 diabetes (n = 82) or healthy control subjects (n = 86). Mutations in known MODY genes were identified in 3 of the 66 subjects. Of the 46 GDM subjects, 2 had diabetes (4 percent) and 17 had impaired glucose tolerance (IGT, 37 percent) at 1 year postpartum. The authors conclude that MODY mutations but not autoimmunity contribute to GDM in Swedish women with a family history of diabetes and increase the risk of subsequent diabetes. 2 tables. 25 references.

·

Gestational Diabetes Mellitus: Diagnosis, Treatment, and Beyond Source: Diabetes Educator. 27(1): 69-72, 74. January-February 2001. Contact: Available from American Association of Diabetes Educators. 100 West Monroe Street, 4th Floor, Chicago, IL 60603-1901. (312) 424-2426. Summary: This article discusses the diagnosis and treatment of gestational diabetes mellitus (GDM). Early recognition and treatment are critical to a successful outcome for both mother and infant. GDM is

Studies 69

defined by the American Diabetes Association (ADA) as any degree of glucose intolerance with onset or first recognition during pregnancy. A risk assessment for GDM during the first prenatal visit is important. The ADA recommends screening and the 100-gram oral glucose tolerance test for diagnosing GDM. Daily self monitoring of blood glucose can be used to determine the effectiveness of diet, exercise, and insulin in maintaining target blood glucose goals. Medical nutrition therapy is used to ensure that the woman is consuming adequate calories and nutrients for maternal and fetal health. An individualized meal plan can be developed by the patient and a registered dietitian. Exercise is vital for maintaining euglycemia because regular exercise enhances insulin sensitivity and glucose utilization. Human insulin is the only pharmacologic treatment recommended to lower blood glucose during pregnancy. Postpartum care is important because approximately 40 percent to 60 percent of women with GDM will develop type 2 diabetes. 4 tables. 4 references. ·

Gestational Diabetes Mellitus Diagnosed with a 2-h 75-g Oral Glucose Tolerance Test and Adverse Pregnancy Outcomes Source: Diabetes Care. 24(7): 1151-1155. July 2001. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This review article describes a cohort study that evaluated American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes. Although the ADA recommends a 3 hour 100 gram oral glucose tolerance test (OGTT) for the diagnosis of GDM, it has also recently included in its recommendations the use of a 2 hour 75 gram OGTT. GDM is defined by the new ADA test recommendations for the two hour 75 gram OGTT as at least two values greater than a fasting glucose of 5.3 mmol per liter, a 1 hour glucose of 10 mmol per liter, and a 2 hour glucose of 8.6 mmol per liter. WHO criteria require a fasting plasma glucose of equal to or greater than 7.0 mmol per liter or a 2 hour glucose of equal to or greater than 7.8 mmol per liter. The study population consisted of 4,977 Brazilian adult women attending general prenatal clinics who underwent a standardized 2 hour 75 gram OGTT between their estimated 24th to 28th gestational weeks. Among the women, 2.4 percent presented with GDM by ADA criteria and 7.2 percent by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia, preeclampsia, and perinatal death. Similarly, GDM by WHO criteria predicted increased risk for macrosomia, preeclampsia, and

70 Gestational Diabetes

perinatal death. Of women positive by WHO criteria, 260 were negative by ADA criteria. Conversely, 22 women positive by ADA criteria were negative by WHO criteria. The article concludes that GDM based on a 2 hour 75 gram OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes. Thus, until consensual criteria are reached, these two criteria are valid options for the detection of a glucose tolerance state predictive of adverse pregnancy outcomes. 1 appendix. 1 figure. 2 tables. 18 references. (AA-M). ·

Gestational Diabetes: Clinical Management Guidelines for Obstetrician-Gynecologists Source: Obstetrics and Gynecology. 98(3): 525-538. September 2001. Contact: Available from Elsevier Science, Inc. 655 Avenue of the Americas, New York, NY 10010. (212) 989-5800. Summary: Gestational diabetes mellitus (GDM) is one of the most common clinical issues facing obstetricians and their patients. A lack of data from well-designed studies has contributed to the controversy surrounding the diagnosis and management of this condition. This document provides a brief overview of the understanding of GDM and then provides management guidelines that have been validated by appropriately conducted clinical research. When outcomes based research is not available, expert opinion is provided to aid the practitioner. The background section covers definition and prevalence, maternal and fetal complications of GDM, and controversies regarding current screening practices and treatment benefits. Clinical considerations and recommendations are provided for: screening for GDM, gestational age at which laboratory screening should be performed, the use of venous versus capillary blood, appropriate threshold values for laboratory screening tests, the diagnosis of GDM, monitoring blood glucose values in women with GDM, the role of diet therapy in the treatment of GDM, the role of insulin in the treatment of GDM, the role of exercise and oral antidiabetic agents in the treatment of GDM, fetal assessment in pregnancies complicated by GDM, childbirth considerations in pregnancies complicated by GDM, and postpartum follow up of women who had GDM during their pregnancy. The article concludes with a summary of recommendations, categorized by those based on research studies and those based on consensus and expert opinion. 2 tables. 105 references.

Studies 71

·

Comparison of Glyburide and Insulin in Women with Gestational Diabetes Mellitus Source: New England Journal of Medicine. 343(16): 1134-1138. October 19, 2000. Summary: This article describes a study that compared glyburide and insulin in the treatment of women with gestational diabetes. The study population consisted of 404 women with singleton pregnancies and gestational diabetes that required treatment. The women were randomly assigned between 11 and 33 weeks of gestation to receive glyburide or insulin according to an intensified treatment protocol. The primary end point was achievement of the desired level of glycemic control Secondary end points included maternal and neonatal complications. The study found that the mean pretreatment blood glucose concentration as measured at home for one week was 114 plus or minus 19 milligrams (mg) per deciliter (dl) in the glyburide group and 116 plus or minus 22 mg per dl in the insulin group. The mean concentrations during treatment were 105 plus or minus 16 mg/dl in the glyburide group and 105 plus or minus 18 mg per dl in the insulin group. Eight women in the glyburide group required insulin therapy. There were no significant differences between the glyburide and insulin groups in the percentage of infants who were large for gestational age, who had macrosomia, who had lung complications, who had hypoglycemia, who were admitted to a neonatal intensive care unit, or who had fetal anomalies. The cord serum insulin concentrations were similar in the two groups, and glyburide was not detected in the cord serum of any infant in the glyburide group. The article concludes that, in women with gestational diabetes, glyburide is a clinically effective alternative to insulin therapy. 4 tables. 49 references. (AA-M).

·

Oral Hypoglycemic Drugs for Gestational Diabetes (editorial) Source: New England Journal of Medicine. 343(16): 1178-1179. October 19, 2000. Summary: This editorial comments on the use of oral hypoglycemic drugs for the treatment of gestational diabetes. Early use of first generation sulfonylurea drugs was not effective, as many women delivered infants with profound and prolonged hyperinsulinemic hypoglycemia. The observation that sulfonylurea drugs could cross the placenta and stimulate fetal insulin secretion was another cause for concern about their use in pregnancy. The risk of late fetal death for women with gestational diabetes is another concern that has been debated. Lastly, there has been concern about the possibility of congenital malformations in women taking sulfonylurea drugs during pregnancy.

72 Gestational Diabetes

However, a recent randomized, controlled trial comparing the sulfonylurea drug glyburide with traditional insulin therapy found that only 4 percent of women in the glyburide group failed to achieve adequate blood glucose control. In addition, there was no evidence of any of complications resulting from fetal or neonatal hyperinsulinemia due to transplacental passage of the drug. The editorial considers the implications of these findings for clinical practice. 10 references. ·

Carbohydrate and Lipid Metabolism in Pregnancy: Normal Compared with Gestational Diabetes Mellitus Source: American Journal of Clinical Nutrition. 71(5 Supplement): 1256S1261S. May 2000. Contact: Available from American Journal of Clinical Nutrition. Production Office, 9650 Rockville Pike, Bethesda, MD 20814. (301) 5307038. Fax (301) 571-8303. Website: www.ajcn.org. Summary: This article reviews maternal metabolic strategies for accommodating fetal nutrient requirements in normal pregnancy and in gestational diabetes mellitus (GDM). Pregnancy is characterized by a progressive increase in nutrient stimulated insulin responses despite an only minor deterioration in glucose (sugar) tolerance, consistent with progressive insulin resistance. The hyperinsulinemic (too much insulin in the blood) euglycemic (ideal levels of blood glucose) glucose clamp technique and intravenous glucose tolerance test have indicated that insulin action in late normal pregnancy is 50 to 70 percent lower than in nonpregnant women. Metabolic adaptations do not fully compensate in GDM and glucose intolerance ensures. GDM may reflect a predisposition to type 2 diabetes or may be an extreme manifestation of metabolic alterations that normally occur in pregnancy. Recent advances in understanding carbohydrate metabolism during pregnancy suggest that preventive measures should be aimed at improving insulin sensitivity in women predisposed to GDM. Further research is needed to elucidate the mechanisms and consequences of alterations in lipid (fats) metabolism during pregnancy. 49 references.

·

Nutritional Management of Gestational Diabetes and Nutritional Management of Women with a History of Gestational Diabetes: Two Different Therapies or the Same? Source: Clinical Diabetes. 17(4): 170-176. 1999. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org.

Studies 73

Summary: This article offers practical suggestions for the nutritional management of gestational diabetes mellitus (GDM) and nutritional management of women with a history of GDM. GDM, which is the most common medical complication of pregnancy, is defined as carbohydrate intolerance of varying degrees of severity with onset or first recognition during pregnancy. Women who have GDM have a significant risk of developing GDM with a subsequent pregnancy and of developing type 2 diabetes later in life. Nutritional management is the cornerstone of treatment for GDM. Medical nutrition therapy for GDM is discussed in terms of optimal maternal weight gain; ideal caloric intake; and amount, timing, and distribution of carbohydrate intake. Other topics include self monitoring of blood glucose, testing for ketones, keeping records of all food and caloric beverages consumed, exercising, breastfeeding, and following up 6 to 12 weeks postpartum. In addition, the article addresses the issues of caring for women with a history of GDM and identifying nutritional factors influencing recurrence of GDM and progression to type 2 diabetes. The article recommends that nutrition therapy start with a modest carbohydrate level distributed among three meals and three snacks, exercise be used as an adjunct to treatment if possible to help maintain maternal euglycemia, and insulin be added to the treatment regimen if necessary. In addition, the article advises that practitioners who have chosen to use a carbohydrate level of less than 45 percent of kcal be sure to educate and evaluate postpartum whether the woman has switched to a low fat diet and has maintained the low fat diet. 1 figure. 4 tables. 37 references. ·

Nutritional Guidelines for Women with Gestational Diabetes Source: Clinical Diabetes. 17(4): 177. 1999. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This article provides nutritional guidelines for women who have gestational diabetes. Guidelines include eating three meals and three snacks per day, omitting foods high in sugar and concentrated sweets, eating whole pieces of fruit instead of drinking fruit juices, spreading carbohydrates out throughout the day, eating foods high in fiber and low in fat, limiting foods from fast food restaurants, and gaining at least 1/2 pound per week.

·

Gestational Diabetes: What It Means for You and Your Baby Source: American Family Physician. 60(3): 1009-1010. September 1, 1999.

74 Gestational Diabetes

Contact: Available from American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (800) 274-2237. Website: www.aafp.org. Summary: This article uses a question and answer format to provide women with information on gestational diabetes. This type of diabetes occurs during pregnancy, and affects about 3 percent of all pregnant women. Gestational diabetes can cause a baby to grow somewhat larger than a normal baby and can cause hypoglycemia or jaundice in the baby at birth. Between the 24th and 28th week of pregnancy, women may undergo blood glucose testing to monitor blood glucose levels. Women diagnosed with gestational diabetes need to eat well-balanced meals with plenty of fruits, vegetables, and grains, and participate in a safe form of moderate exercise. Gestational diabetes usually goes away following the baby's birth; however, it may return during a subsequent pregnancy. Most babies born to mothers with gestational diabetes do not have diabetes after birth, but they may be at higher risk of getting type 2 diabetes as adults. ·

Sweet Taste and Intake of Sweet Foods in Normal Pregnancy and Pregnancy Complicated by Gestational Diabetes Mellitus Source: American Journal of Clinical Nutrition. 70(2): 277-284. August 1999. Contact: Available from American Journal of Clinical Nutrition. Production Office, 9650 Rockville Pike, Bethesda, MD 20814. (301) 5307038. Fax (301) 571-8303. Website: www.ajcn.org. Summary: Dietary compliance in gestational diabetes mellitus (GDM) is poor. Changes in sweet taste perception might alter food preferences in GDM, making dietary compliance difficult to achieve. This study documented changes in sweet taste perception and dietary intakes in pregnancy women with and without GDM and determined whether these differences persisted postpartum (after the pregnancy). Subjects were 30 pregnant women without GDM, 25 pregnancy women with recently diagnosed GDM, and 12 nonpregnancy control subjects. Pregnancy women were tested at 28 to 32 weeks gestations and retested 12 weeks postpartum. Subjects evaluated the taste of strawberry flavored milks with different sucrose (0 to 10 percent) and fat (0 to 10 percent) contents and glucose solutions. Women with GDM showed no differences in liking for the milk samples across test sessions and their liking ratings were not significantly different from those of nonpregnant control subjects. Women without GDM liked the 10 percent sucrose sweetened milk samples less during pregnancy that at 12 weeks postpartum, at which time their ratings were not significantly different

Studies 75

from those of nonpregnant control subjects. In women with GDM, plasma glucose after a 50 gram glucose load was correlated with both increased liking for the taste of glucose and higher consumption of fruit and fruit juices. The authors summarize that normal pregnancy was associated with a lower preference for 10 percent sucrose sweetened milk samples late in gestation than postpartum, whereas GDM was associated with no such differences. Plasma glucose in women with GDM was related to a higher preference for the sweet taste of glucose and higher dietary sweet food intakes from fruit and fruit juices. These findings have important implications for the dietary management of GDM. 3 figures. 2 tables. 37 references. ·

Maternal Plasma Phospholipid Polyunsaturated Fatty Acids in Pregnancy with and without Gestational Diabetes Mellitus: Relations with Maternal Factors Source: American Journal of Clinical Nutrition. 70(1): 53-61. July 1999. Contact: Available from American Journal of Clinical Nutrition. Production Office, 9650 Rockville Pike, Bethesda, MD 20814. (301) 5307038. Fax (301) 571-8303. Website: www.ajcn.org. Summary: The fatty acids arachidonic acid (AA) and docosahexaenoic acid (DHA) are essential for fetal grown and development, but their metabolism may be altered in insulin resistance. This article reports on a study of maternal plasma (blood) phospholipid polyunsaturated fatty acid concentrations in pregnancy women receiving diet therapy for gestational diabetes mellitus (GDM, n = 15); the study identified maternal factors associated with plasma phospholipid AA and DHA concentrations in the third trimester. The study included a control group of 15 healthy, pregnancy women without GDM. Maternal plasma phospholipid linoleic acid, AA, and 22:5n-6 (another fatty acid) did not differ significantly between women with GDM and control subjects. The other n-6 long chain polyunsaturated fatty acids were lower in GDM subjects than in control subjects. Plasma phospholipid and summed precursors of DHA were lower and DHA adjusted for dietary DHA intake, was 13 percent higher in GDM subjects than in control subjects. Maternal blood hemoglobin A1c (glycosylated hemoglobin, a measure of blood glucose levels over time) was inversely related to plasma phospholipid AA in control subjects and positively associated with plasma phospholipid AA in women with GDM. Pregravid (before pregnancy) body mass index was negatively associated with plasma phospholipid DHA in control subjects and in women with GDM with a body mass index less than 30. The authors conclude that, in pregnancy women, both with and without GDM, maternal glycemic control and

76 Gestational Diabetes

pregravid BMI appear to be significant predictors of plasma phospholipid AA and DHA, respectively, during the third trimester. Additionally, dietary DHA significantly affects phospholipid DHA concentrations. 5 tables. 34 references. ·

Gestational Diabetes: Detection, Management and Implications Source: Clinical Diabetes. 16(1): 4-11. January-February 1998. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This review article addresses the detection, management, and implications of gestational diabetes. The authors note that gestational diabetes is the most common medical complication and metabolic disorder of pregnancy. It is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. Topics include pathophysiology; maternal morbidity; perinatal morbidity and mortality; diagnosis; management; delivery timing; and postpartum follow up. Treatment for gestational diabetes includes diet therapy, glucose monitoring, and exercise. The article notes that oral hypoglycemic agents are not currently used in treating gestational diabetes. Because women with gestational diabetes have a significant risk for developing diabetes later in life, it is imperative that these women be identified. If diagnostic criteria and management based on maternal and fetal outcomes are to be established, continued research is necessary. 1 figure. 5 tables. 65 references. (AA-M).

·

Gestational Diabetes: Antepartum Characteristics That Predict Postpartum Glucose Intolerance and Type 2 Diabetes in Latino Women Source: Diabetes. 47(8): 1302-1310. August 1998. Summary: This article describes a study that examined antepartum clinical characteristics along with measures of glucose tolerance, insulin sensitivity, pancreatic beta cell function, and body composition in Latino women with gestational diabetes mellitus (GDM) for their ability to predict type 2 diabetes or impaired glucose tolerance (IGT) within 6 months after delivery. A total of 122 islet cell antibody-negative women underwent an oral glucose tolerance test (OGTT) and an intravenous glucose tolerance test (IVGTT), hyperinsulinemic-euglycemic clamps, and measurement of body fat between 29 and 36 weeks of gestation and returned between 1 and 6 months postpartum for a 75-gram OGTT. Logistic regression analysis was used to examine the relationship between antepartum variables and glucose tolerance status postpartum.

Studies 77

Results revealed that, at postpartum testing, 40 percent of the cohort had normal glucose tolerance, 50 percent had IGT, and 10 percent had diabetes by American Diabetes Association criteria. Independent antepartum predictors of postpartum diabetes were the 30-minute incremental insulin:glucose ratio during a 75-gram OGTT and the total area under the diagnostic 100-gram glucose tolerance curve. Independent predictors of postpartum IGT were a low first-phase IVGTT insulin response, a diagnosis of GDM before 22 weeks of gestation, and weight gain between prepregnancy and the postpartum examination. All subjects had low insulin sensitivity during late pregnancy, but neither glucose clamp nor minimal model measures of insulin sensitivity in the third trimester were associated with the risk of IGT or diabetes within 6 months after delivery. Results highlight the importance of pancreatic beta cell dysfunction, detectable under conditions of marked insulin resistance in late pregnancy, to predict abnormalities of glucose tolerance soon after delivery in pregnancies complicated by GDM. Moreover, the association of postpartum IGT with weight gain and an early gestational age at diagnosis of GDM suggests a role for chronic insulin resistance in mediating hyperglycemia outside the third trimester in women with such a beta cell defect. 1 appendix. 5 figures. 3 tables. 36 references. (AA-M). ·

Is Self-Monitoring of Blood Glucose Necessary in the Management of Gestational Diabetes Mellitus? Source: Diabetes Care. 21(Supplement 2): B118-B122. August 1998. Contact: Available from American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. (800) 232-3472. Website: www.diabetes.org. Summary: This article addresses the issue of whether self-monitoring of blood glucose (SMBG) is necessary for managing gestational diabetes mellitus (GDM). Controversy continues over the role of blood glucose monitoring in the management of pregnant women with GDM, specifically with regard to the use of capillary versus venous samples, as well as the frequency and timing of blood glucose determinants. At the Third International Workshop Conference, it was noted that selfmonitoring has allowed women to participate in their own care but that its utility in mild GDM not requiring the use of insulin has not been formally proved. The article reviews the existing evidence in the literature on the impact of SMBG on outcomes in pregnancies complicated by GDM. This evidence suggests a role for the selfmonitoring of capillary blood glucose in pregnancies complicated by even mild GDM. The article also presents data on the optimal timing, accuracy, costs, and psychosocial effects of self-monitored glucose

78 Gestational Diabetes

determinations and concludes that SMBG provides important information on guiding and assessing dietary and insulin therapy in pregnancies complicated by GDM. Furthermore, it enhances patient education, facilitates lifestyle modifications, and allows women to actively participate in their own care. SMBG has been shown to improve neonatal outcomes in pregnancies complicated by GDM without apparently causing undue stress for the mother and at a potentially lower cost. However, the optimal management scheme of blood glucose monitoring and the appropriate threshold of glucose values for initiating insulin therapy have yet to be firmly established. 38 references. (AA-M).

Federally-Funded Research on Gestational Diabetes The U.S. Government supports a variety of research studies relating to gestational diabetes and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.21 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site at http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to gestational diabetes and related conditions. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore gestational diabetes and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for gestational diabetes: ·

Project Title: Fetal Metabolic Consenquences Of Spontaneous Gestational Diabetes Mellitus Principal Investigator & Institution: Friedman, Jacob E.; ; Case Western Reserve University 10900 Euclid Ave Cleveland, Oh 44106 Timing: Fiscal Year 2000

21 Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).

Studies 79

Summary: The long-term goal of these studies is to understand how defects in maternal insulin transduction contribute to gestational diabetes mellitus (GDM) and the mechanisms leading to fetal macrosomia and obesity. Metabolic imprinting suggests the transmission of diabetic susceptibility genes from moth to offspring is less important than the maternal environment in producing second-generation insulin resistance, obesity, and diabetes. This proposal will use a series of established heterozygous transgenic mouse models will combined gene knockouts in the insulin receptor (IR/+), insulin receptor substrate-1 (IRS-1/+), and leptin receptor (db/+) genes to establish how genetic defects in insulin signaling and the hormones of pregnancy interact to provoke abnormalities in insulin signal transduction, beta-cell hypertrophy, and spontaneous hyperglycemia during pregnancy. Our studies will also determine how modifying maternal insulin resistance during pregnancy decreases hyperglycemia and the development of fetal macrosomia by studying db/+ mice that over-express the human GLUT4 gene. The association between maternal hyperglycemia and fetal genotype on fetal over/under growth and expression of insulin signaling proteins in liver and skeletal muscle will be determined during the perinatal period. The last goal will be to determine whether insulin resistance and obesity in early and later life is modified by inheritance of an abnormal genotype or the consequences of epigenetics (i.e. information that is heritable and alters the phenotype of offspring but is not encoded specifically in the genetic code of DNA. One of the immediate benefits of these models is that they provide information on the role of biochemical defects expressed against a constant genetic background, thus enabling us to observe epigenetic transmission of an altered metabolic phenotype originally induced by a genetic event (inheritance of the IR/IRS-1 or leptin receptor mutation). Because many metabolic disorders, such as diabetes, have both genetic and epigenetic components, this approach offers an opportunity to identify metabolic alterations that may be unique to genetic or epigenetic effects. The outcome of these studies will have important implications for the prevention and treatment of GDM. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Gestational Diabetes: Diagnostic Criteria and Outcomes Principal Investigator & Institution: Ferrara, Assiamira; Kaiser Foundation Research Institute 1800 Harrison St, 16Th Fl Oakland, Ca 94612 Timing: Fiscal Year 2000; Project Start 1-SEP-2000; Project End 1-AUG2004

80 Gestational Diabetes

Summary: (Adapted from Investigator's Abstract) Gestational diabetes mellitus (GDM) is associated with increased risk of several adverse infant and maternal outcomes and its clinical recognition can reduce these risks. There is concern that the current criteria for GDM may be to restrictive and that residual excess risk of perinatal complications exists below present cutoff values. The proposed study will evaluate whether among women without GDM (as defined by current criteria), increasing levels of maternal glycemia are associated with increased risk of selected perinatal complications: infant severe macrosomia, severe hyperbilirubinemia, hypoglycemia, respiratory distress syndrome, and maternal preeclampsia/eclampsia. To accomplish this, the investigators propose to conduct five nested case-control studies, one for each of the complications of interest, within a large multiethnic cohort of approximately 74,000 women who were screened at 24 to 28 weeks of gestation at Kaiser Permanente, Northern California between 1995 and 1998. In this setting nearly 94 percent of the pregnant women are screened for GDM by a 50 gm., 1 hr. oral glucose tolerance test (50 g, 1-h OGTT) and approximately 15 percent have are abnormal screening and go on to receive the diagnostic (100-g, 3-h OGTT) test. Potential cases of each type of complication will be identified by searching computerized hospitalization and laboratory databases. For each of the infant complications, 500 cases will be randomly selected without knowledge of the maternal glucose values. A single control group for the infant complication case groups will be 1,000 infants randomly selected from all births and frequency matched on gestational age to the distribution of the combined case group. Five hundred women with either preeclampsia or eclampsia and 500 age-matched controls will be randomly selected. The medical records of the 3,000 mother-infant pairs in the four case-control studies on infant complications, and 1,000 women for the case-control study of preeclampsia/eclampsia, will be abstracted to confirm eligibility, and, if so, to ascertain data on possible maternal and infant covariates. Logistic regression will be used to estimate the odds ratios associated with several levels of pregnancy glycemia and perinatal complications. The investigators state that the proposed study will provide important knowledge about the magnitude of the risk of severe perinatal complications associated with degrees of maternal hyperglycemia below the glucose cutpoints currently used to diagnose GDM. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

Studies 81

·

Project Title: Molecular Genetics of Gestational Diabetes Mellitus--A Genetic Predisposition Principal Investigator & Institution: Lowe, William; ; Northwestern University 303 E Chicago Ave Chicago, Il 60611 Timing: Fiscal Year 2000 Summary: Women who develop gestational diabetes mellitus (GDM) progress to diabetes outside of pregnancy at a rate >5%/yr and account, therefore, for a sizable proportion of people with non-insulin dependent diabetes mellitus (NIDDM) whose mean age at diagnosis is relatively young. Moreover, impaired b-cell function is an important early predictor of the risk of developing DM among women with GDM. For these reasons, we have hypothesized that women with gestational diabetes mellitus (GDM) share a unique set of genetic characteristics apart from other presentations of NIDDM. The proposed studies are designed to create a bank of genomic DNA from and phenotypic information on several groups of participants, including (i)women with NIDDM subsequent to a history of GDM, (ii)women with a history of GDM who have normal glucose tolerance, (iii)women who do not have a history of GDM, (iv)individuals with typical, late-onset NIDDM (defined as onset after age 50), and (v)a reference group of individuals with normal glucose tolerance but who are at risk factor for late-onset NIDDM based upon a family history of a first degree relative with NIDDM, age over 50, or ethnicity (African-American, Hispanic, or Native American). This DNA and phenotypic information will be used to address our hypothesis in the present and future studies by examining the frequency of polymorphisms/mutations in previously identified genes that predispose to the development of maturity onset diabetes of the young (MODY), NIDDM, and obesity (a risk factor for NIDDM) in the different groups of participants and the association of those polymorphisms/mutations with alterations in the different phenotypic characteristics. These studies will be conducted using the about 1000 people who are currently undergoing oral glucose tolerance tests to determine their eligibility for participation in the Diabetes Prevention Program at Northwestern University Medical School and about 450 people who will be enrolled in another CRC-approved study ("Are Polymorphic Variants of the Leptin Receptor Gene Associated with Obesity and Gestational Diabetes Mellitus" - Protocol 597). The specific analysis that will be conducted in the proposed study will be to determine the prevalence rate of mutations in the transcription factor hepatocyte nuclear factor-1a in women with NIDDM subsequent to a history of GDM compared to the other four groups. Mutations in this

82 Gestational Diabetes

gene result in maturity-onset diabetes of the young (MODY) and are, thus, associated with onset of diabetes at a young age. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Nutrition Practice Guidelines for Gestational Diabetes Principal Investigator & Institution: Pleuss, Joan; ; Medical College of Wisconsin 8701 Watertown Plank Rd Milwaukee, Wi 53226 Timing: Fiscal Year 2000; Project Start 1-DEC-1991; Project End 0-NOV2001 Summary: The purpose of this study is to compare two types of nutrition care provided to women with gestational diabetes (GDM) by registered dietitians. The study will answer the question: Does nutrition care delivered according to new nutrition practice guidelines result in better pregnancy outcomes than usual nutrition care delivered according to new practice guidelines provided by registered dietitians? Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

·

Project Title: Troglitazone in Women with Prior Gestational Diabetes Mellitus Principal Investigator & Institution: Buchanan, Thomas A.; Professor; University of Southern California University Park Los Angeles, Ca 90007 Timing: Fiscal Year 2000 Summary: This is a 5-year trial to test whether improvements in whole body insulin sensitivity can prevent or delay the development of noninsulin-dependent diabetes mellitus to Hispanic women identified to be at high risk for diabetes by history of gestational diabetes and by their oral glucose tolerance test profile when not pregnant. This investigatorinitiated project is a direct result of information obtained on the prediction and mechanisms of NIDDM in women with GDM from a current NIH-funded cohort study (GCRC Protocol #626). Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

·

Project Title: Birthweight and Gestational Age and Chronic Disease Risk Principal Investigator & Institution: Byers, Tim E.; Professor of Preventive Medicine; Preventive Med and Biometrics; University of Colorado Hlth Sciences Ctr 4200 E 9Th Ave Denver, Co 80262 Timing: Fiscal Year 2000; Project Start 1-AUG-1999; Project End 1-MAR2002

Studies 83

Summary: Several studies have shown that people born small or thin have increased risk for developing Insulin Resistance Syndrome (IRS), non-insulin dependent diabetes mellitus (NIDDM), and cardiovascular disease (CVD) as adults. These observations have led to the "fetal origins" hypothesis - that susceptibility to these chronic adult conditions may be programmed in utero. The profound metabolic and hemodynamic changes that occur in gestation make pregnancy a physiologic stress test for glucose intolerance, hypertension, and other IRS-related abnormalities. Gestational diabetes (GDM) and pregnancy-induced hypertension (PIH) are two common complications of pregnancy that share many characteristics of IRS, and also predict a woman's risk for the later development of NIDDM and CVD. We propose to investigate the effects of a woman's growth before her own birth (indicated by her own birthweight and gestational age) on her risk in young adulthood for PIH or GDM. Apart from promising preliminary work we have recently completed in Colorado, this is an area of investigation that has not previously been explored. The proposal is to conduct a case-control study based on birth registry and hospital discharge data from New York State and New York City, computer-linked across a generation. Subjects will be women who were born in NY after 1959 and delivered a live singleton infant in New York between 1990 and 1996. Cases will be subjects who had PIH and/or GDM diagnosed during a recent pregnancy (1990-1996), while controls will be subjects frequency matched to cases on hospital and year of delivery, but without a diagnosis of PIH or GDM. The records of each subject's recent pregnancy (1990-1996) will be matched to those of her own birth (12-36 years earlier). We will use multiple logistic regression to estimate the independent effects of a mother's own early growth, as indicated by birth weight and gestational age, on her later risk of developing GDM or PIH. The analysis will account for potential confounding and effect-modifying factors, including race/ethnicity, maternal age, and smoking. We will also conduct a sub-study of the validity of the diagnoses of GDM and PIH on the birth records. This study will thus offer a powerful and cost-efficient way to investigate the hypothesis of the fetal origins of GDM and PIH, two common but still poorly understood complications of pregnancy which are associated with increased risk for chronic disease later in life. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Diabetes Prevention Program (DDP-2) Principal Investigator & Institution: Kitabchi, Abbas E.; Medicine; University of Tennessee Health Sci Ctr Health Science Center Memphis, Tn 38163

84 Gestational Diabetes

Timing: Fiscal Year 2000; Project Start 0-AUG-1994; Project End 0-JUN2003 Summary: Non-insulin dependent diabetes mellitus (NIDDM) has reached an epidemic proportion in the United States. Although NIDDM, cardiovascular diseases, and cancer account for two-thirds of all deaths in the United States, there is strong evidence to indicate that these diseases may be related to the lifestyle of the patients. There is no compelling evidence in the literature that the following are combined, or independent risk factors for development of NIDDM: (a) obesity, (b) family history of NIDDM, (c) upper body adiposity, (d) ethnicity, (e) hyperinsulinemia, (f) impaired glucose tolerance, (g) gestational diabetes, (h) sex hormone binding globulin (SHBG), (i) sedentary life. We hypothesize that in such individuals with high risk, alteration of lifestyle, such as dietary modification and physical exercise, will ameliorate or delay development of NIDDM. We, therefore, propose the following specific aims for this multicenter primary prevention trial: 1. To recruit a cohort of subjects at high risk for NIDDM consisting of 100 persons with previous history of gestational diabetes, most of whom will be African American, and 100 other persons who are hyperinsulinemic with upper body adiposity, insulin resistant, impaired glucose tolerant and strong family history of diabetes. Some of the patients will be undiagnosed NIDDM with fasting blood glucose of < 140 mg/dl. 2. To randomize these subjects into intensive therapy group versus usual care group (attention control). 3. The intensive therapy group will be designed to accomplish the following aims: (a) to modify the diets in these high risk subjects to reduce total fat to less than 30% of total calories and saturated fat to less than 10%, (b) to increase energy expenditure from physical activity to 2000 Kcal per week, (c) to combine dietary therapy with effective moderate exercise therapy to achieve a reduction of body weight of greater than 10% per individual which will be maintained over time, (d) to design these dietary and exercise interventions so they are flexible enough that they can be modified for the different target ethnic, gender, educational level, and other subgroups, and (e) to design a long term adherence program that will maximize adherence to prescribed therapies while minimizing drop outs and therapeutic cross overs. 4. To provide baseline and semi-annual evaluations of glycemic control and insulin resistance in all groups of patients, and repetition of all initial laboratory and physical examination data on an annual basis. We estimate 75% of our study population will be African American, and 25% will be Caucasian. Both male and female populations will be represented, with the majority being female, as 50% of our patients will consist of those persons with gestational diabetes. We understand the final protocol will

Studies 85

be based on the decision arrived at by the Steering Committee, and may involve the use of insulin-resistance-modifying drugs. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Diabetes Prevention Program (DPP) Principal Investigator & Institution: Shamoon, Harry; Professor and Dcrc Program Director; Medicine; Yeshiva University 500 W 185Th St New York, Ny 10033 Timing: Fiscal Year 2000; Project Start 5-AUG-1994; Project End 0-JUN2003 Summary: There is increasing evidence that the development of noninsulin dependent diabetes mellitus (NIDDM) is presaged many years earlier by the presence of biochemical and other phenotypic features in susceptible individuals. Earlier intervention in such individuals may prevent or slow the occurrence of overt hyperglycemia which, in turn, may limit the morbidity and mortality associated with diabetes. By selecting populations at higher than average risk for the ultimate development of NIDDM, we propose to be able to practically test the following hypothesis: The reduction in risk of developing NIDDM in persons at high risk for the development of diabetes will be dependent on treatment which affects insulin resistance, islet B-cell dysfunction, and/or hepatic glucose production. Interventions which include diet, exercise sulfonylurea drugs, and metformin in a factorial design can address this hypothesis. The Diabetes Center at the Albert Einstein College of Medicine is a multidisciplinary aggregation of scientists and clinicians actively involved in various aspects of diabetes. With the resources and expertise available among individuals in the Center, we will participate in a multicenter NIDDM Prevention Trial. The Albert Einstein Center would be able to contribute to the success of such a Trial for the following reasons: l) a Diabetes Research and Training Center underpinning and the Institutional commitment to addressing issues in underserved populations of New York City; 2) our participation in the Diabetes Control and Complications Trial as a clinical center; 3) the availability of a large, identified population of individuals from racial and ethnic minority groups in the Bronx and Westchester Counties who receive their medical care in Einstein-affiliated programs; 4) an identified and well characterized population of women who had gestational diabetes diagnosed between 1988 and the present, and an annual accrual of an additional cohort of women with gestational diabetes; 5) expertise in the design and implementation of clinical trials; 6) strong research foci of the principal and co-investigators in areas such as pathophysiology and diagnosis as well as nutritional and pharmacologic treatment of

86 Gestational Diabetes

NIDDM; 7) members of the treatment team with specific competence in diabetes in Hispanic and in African-American individuals; 8) a new outpatient facility in which to conduct a clinical trial; 9) expertise in related areas such as hypertension control, cardiovascular risk reduction, and behavioral techniques intended to achieve therapeutic goals; and lO) a track record of participating in constructive collaborative efforts to achieve the goals of NIH-initiated multicenter projects. We will participate in the Trial by providing personnel, resources, and study volunteers to achieve the aims of the planning, implementation, and data analysis phases of the proposed 7-year study. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Glucose and Amino Acid Metabolism in Pregnancy Principal Investigator & Institution: Kalhan, Satish C.; Professor; Case Western Reserve University 10900 Euclid Ave Cleveland, Oh 44106 Timing: Fiscal Year 2000 Summary: The objectives of the proposed studies are to quantify longitudinally maternal metabolic responses to progressions of pregnancy and growth of the fetus. Specifically, the impact of pregnancy and alterations in fetal growth, e.g. in diabetes, upon whole body amino acid and glucose metabolism will be quantified using stable isotope tracer method. Data from our previous studies in human pregnancy have shown that while changes in energy delivering substrates, e.g. glucose and fatty acids, during pregnancy occur parallel with the energy requirements of the mother and growing conceptus, adaptive responses in protein/nitrogen metabolism appear in anticipation of the fetal needs. In addition, preliminary data suggest that (a) liver/splanchnic tissue may be an important organ system involved in the pregnancy related adaptation, and (b) amino acid transamination may be an important component of nitrogen conservation and accretion. The proposed studies are aimed at testing these two hypotheses. Multiple isotope tracers will be used simultaneously to quantify splanchnic extraction and metabolism of essential amino acids. Whole body kinetics of glutamine, a major nitrogen source for urea and for the fetus and its nitrogen source will be quantified. Since fetal macrosomia has continued to be a persistent problem in gestational diabetes despite rigorous intervention strategies, this clinical model of abnormal fetal growth will be evaluated for the changes in gluconeogenesis and amino acid metabolism. A recently developed novel method employing labeling of body water which has already been applied to normal pregnancy will be used to quantify gluconeogenesis in gestational diabetes. These studies will quantify kinetics of key nutrients and substrates in the whole body (mother and

Studies 87

fetus) which can impact fetal growth. It is anticipated that these data will permit the development of intervention strategies for amelioration of aberrant fetal growth. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: HAPO: Data Coordinating Center Principal Investigator & Institution: Dyer, Alan R.; Professor; Preventive Medicine; Northwestern University 303 E Chicago Ave Chicago, Il 60611 Timing: Fiscal Year 2000; Project Start 4-MAY-1999; Project End 1-MAR2004 Summary: There is a consensus that overt diabetes mellitus (DM), whether or not accompanied by symptoms or signs of metabolic decompensation, is associated with a significant risk of adverse pregnancy outcome. On the other hand, the risk of adverse outcome associated with degrees of glucose intolerance less severe than overt DM is controversial. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study is a basic epidemiologic investigation aiming to clarify unanswered questions on the association of various levels of glucose intolerance during the third trimester of pregnancy and risk of adverse outcomes. Its General Aim -- by means of an international cooperative study involving 16 centers and approximately 25,000 pregnant women -is to achieve a major advance in knowledge on levels of glucose during pregnancy that place the mother, fetus, and neonate at increased risk. The primary hypothesis is that hyperglycemia during pregnancy, less severe than overt DM, is associated with increased risk of adverse maternal, fetal, and neonatal outcome that is independently related to the degree of metabolic disturbance. Specific Aims of HAPO are: 1. to examine glucose tolerance in a large, heterogeneous, multinational, multicultural, ethnically diverse cohort of women in the third trimester of gestation with medical caregivers "blinded" to status of glucose tolerance (except in those instances where fasting and/or two hour OGTT plasma glucose concentration exceeds a predefined cutoff value); and 2. to derive internationally acceptable criteria for the diagnosis and classification of gestational diabetes mellitus (GDM) based on the specific relationships between maternal glycemia and the risk of specific adverse outcomes that are established through this study. The study is to be accomplished with high quality standardized data collection on the women during the third trimester of gestation (including the OGTT) and at time of delivery for assessment of adverse outcomes, including operative delivery (caesarean section), increased fetal size (macrosomia/obesity), neonatal morbidity (hypoglycemia), and fetal hyperinsulinism. HAPO is to include a Clinical Coordinating Center and Data Coordinating Center, both located at the

88 Gestational Diabetes

Northwestern University Medical School in Chicago, as well as a Central Laboratory located in Belfast, United Kingdom. This application requests support for the Data Coordinating Center for HAPO. Cost effectiveness for HAPO is enhanced through cost sharing by colleagues in non-U.S. centers. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Insulin Resistance and Glucose Metabolism in Pregnancy Principal Investigator & Institution: Catalano, Patrick M.; ; Case Western Reserve University 10900 Euclid Ave Cleveland, Oh 44106 Timing: Fiscal Year 2000 Summary: The long term objectives are to understand the relationship of pregavid maternal lipid metabolism and maternal metabolic adaptations during pregnancy at the system and cellular level. The specific aims of this proposal are to : evaluate the longitudinal changes in maternal insulin sensitivity as it relates to maternal lipid metabolism and fat accretion in lean and obese women with normal glucose tolerance and gestational diabetes; evaluate the alterations in maternal lipid metabolism in late pregnancy in relationship to neonatal body composition; and, identify the cellular mechanisms underlying decreased insulin sensitivity in adipose tissue during late gestation in normal glucose tolerance and gestational diabetes. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

·

Project Title: Niddm Primary Prevention Trial (DPT 2) Principal Investigator & Institution: Goldstein, Barry J.; Director; Medicine; Thomas Jefferson University 1020 Walnut St Philadelphia, Pa 19107 Timing: Fiscal Year 2001; Project Start 5-AUG-1994; Project End 0-JUN2003 Summary: The objective of this multicenter clinical trial is to develop interventions to prevent the development of NIDDM in people with a history of gestational diabetes (GDM) and impaired glucose tolerance (IGT) (Cohort I primary prevention) and the worsening of glucose tolerance in people with newly diagnosed NIDDM with an FPG less than 140 mg/dl (Cohort II, secondary prevention). The central hypothesis of this application is that improvement of insulin resistance will delay the onset of NIDDM in individuals at risk. Therefore, we propose a five year randomized non-pharmacological and pharmacological factorial treatment design aimed to improve insulin resistance: Stratification will assure an overall trial representation of Black (0.4), Hispanic (0.2), Native

Studies 89

American (0.2), GDM (0.2) and other races including Caucasian (1.0) Power calculations indicate that 20 centers contributing with 200 patients each will be necessary to fulfill the goal of the study. We will recruit the study subjects from among the Thomas Jefferson University employees. From a preliminary survey of the 7,294 full-time employees with a response rate of 58% revealed that 52% of the employees are at risk for NIDDM and that 76% have indicated interest in a NIDDM prevention trial, if available. It is hoped that the screening treatment follow-up and outcome measures methods will be translated to the society at large. To this end, it is important that both community and work-site models be developed. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Niddm Primary Prevention Trial (DPT 2) Principal Investigator & Institution: Bray, George A.; Director; None; Lsu Pennington Biomedical Research Ctr 6400 Perkins Rd Baton Rouge, La 70808 Timing: Fiscal Year 2000; Project Start 5-AUG-1994; Project End 0-JUN2003 Summary: Non-insulin Dependent Diabetes Mellitus develops in individuals who have peripheral tissue resistance to the action of insulin. These individuals often make normal or increased amounts of insulin but are unable to maintain physiologic blood glucose concentrations because of this defect. Women who develop gestational diabetes mellitus manifest this peripheral insulin resistance and 30% go on to develop non-insulin dependent diabetes within five years of the diagnosis of gestational diabetes mellitus. Women with increased risk for developing NIDDM will be identified as high risk at the Genesis Obstetrical Center in Tampa. These women will be evaluated after pregnancy and divided into two categories based upon fasting plasma glucose values. The first will be those women with fasting plasma glucose values less than 110 mg/ dl. The second will be women with fasting plasma glucose equal to or greater than 110 mg/ dl but less than 140 mg/dl. These individuals will have serum islet cell antibodies, insulin autoantibodies, tested to determine that they do not have autoimmune diabetes mellitus. They will then have an oral glucose tolerance test to determine whether they have normal or impaired glucose tolerance or diabetes mellitus as defined by the National Diabetes Data Group. These individuals will then be randomized into four intervention groups. Each individual will have peripheral insulin sensitivity determined with a glucose clamp experiment. The first group will be placed on a calorically restricted diet (1600-1800 Kcal/day) and started on an aerobic exercise program

90 Gestational Diabetes

designed to reduce body mass index. The next group will receive one of a number of oral agents (sulfonylureas, thiozolidinolione, or magnesium chloride) with potential for reducing peripheral insulin resistance will be evaluated. The third group will have intensified insulin therapy provided 5 days annually since this has been shown in insulin dependent diabetes to reduce peripheral insulin resistance. The fourth group will receive an oral placebo and serve as controls. Each of these individuals will be seen on a quarterly basis to measure their height, weight, blood pressure, fasting plasma glucose levels, glycosylated hemoglobin, sex hormone binding protein, serum insulin and urinary C-peptide levels. Each of these individuals will have a glucose clamp experiment performed to determine the degree of insulin resistance and oral glucose tolerance test as an indicator of glucose homeostasis on an annual basis. This protocol will require two years to enroll the study subjects and 5-6 years of followup to determine the role of peripheral insulin resistance and the above interventions for the delay or prevention of NIDDM. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Niddm Primary Prevention Trial (DPT-2) Principal Investigator & Institution: Goldberg, Ronald B.; Medicine; University of Miami Box 016159 Miami, Fl 33101 Timing: Fiscal Year 2000; Project Start 0-AUG-1994; Project End 0-JUN2003 Summary: The objectives of this research proposal is to participate as a clinical center in a multicenter trial to determine whether the development of non- insulin dependent diabetes (NIDDM) can be prevented. We propose to identify 200 subjects at high risk for developing NIDDM over a 12-month period. Group I subjects with impaired glucose tolerance (IGT) will be identified from the AfricanAmerican minority group by oral glucose tolerance testing (OGTT) and Group Il subjects with IGT will be identified from a large data base of women who have had post-gestational diabetes. In the course of screening these populations, it is anticipated that a proportion of subjects with undiagnosed diabetes will be identified by OGTT. Those without fasting hyperglycemia (