Gestational Diabetes

GDM: Scope of Guideline (2016)

Guideline Scope Characteristics

Below you will find a list of characteristics that describe the Scope of this Guideline.

Disease/Condition(s)

The purpose of this guideline is to provide the most current evidence-based summary of recommendations for nutrition practice in the management of gestational diabetes mellitus (GDM) in pregnant women. Nutrition and lifestyle recommendations have been formulated for GDM within the context of the nutrition care process and should be used to provide individualized nutrition care. Other modifications or adjunct therapies such as pharmacologic therapy, while important in the management and treatment of GDM, were outside the scope of this project. In addition, two subtopics that were included in the systematic review were not included in the guideline. The evidence analysis for MNT intervention for the prevention of GDM was outside the scope of this guideline. The evidence analysis for the impact of the type of dietary fat for women with GDM yielded very limited evidence (one study). The conclusion statements for these topics can be found in the systematic review.  

This guideline is primarily intended for use by registered dietitian nutritionists (RDNs) involved in the management and treatment of women with GDM. It may also be a valuable resource for other health care professionals involved in the care and treatment of women with GDM. In addition, other stakeholders (e.g., public health and nutrition program and policy planners, and hospital and community outreach workers) may find the information in this guideline helpful to assess effective practice in the nutrition management of GDM or for consumer education purposes.

Practitioners interested in more specific information beyond nutrition and lifestyle modifications (e.g., screening women for GDM, blood glucose goals, special populations, insulin or oral medications) during pregnancy are encouraged to review GDM resources from other organizations, such as the American Diabetes Association (ADA), the American College of Obstetricians and Gynecologists (ACOG), and The Endocrine Society. 

Guideline Category

Assessment of Therapeutic Effectiveness, Counseling, Evaluation, Management, Screening, Treatment

Clinical Specialty

Endocrinology, Family Practice, Nursing, Nutrition, Obstetrics and Gynecology

Intended Users

Registered Dietitians, Advanced Practice Nurses, Health Care Providers, Nurses, Nurse Midwives, Pharmacists, Physician Assistants, Physicians, Students

Guideline Objective(s)

Overall Objective

  • To provide evidence-based medical nutrition therapy (MNT) recommendations for management of GDM that assist in achieving and maintaining glycemia, promote appropriate maternal weight gain and optimal fetal growth and development, and reduce the risk of adverse maternal and neonatal outcomes.
Specific Objectives
  • To define evidence-based recommendations for RDNs that are carried out in collaboration with other healthcare providers
  • To guide practice decisions that integrate medical and lifestyle interventions (nutrition, physical activity and behavioral elements)
  • To reduce variations in practice among RDNs and other health professionals who may use these guidelines
  • To promote self-management strategies that empower the patient to take responsibility for day-to-day management and to provide the RDN with data to make recommendations to adjust MNT or recommend other therapies to achieve clinical outcomes
  • To enhance the quality of life for the patient, utilizing customized strategies based on the individual’s preferences, lifestyle and goals
  • To develop content for intervention that can be tested for impact on clinical outcomes
  • To define the highest quality of care within cost constraints of the current healthcare environment.

Target Population

Adult (19 to 44 years), Female

Target Population Description

Adult pregnant women with GDM.
 

Interventions and Practices Considered

The GDM Evidence-Based Nutrition Practice Guideline is based on the Academy of Nutrition and Dietetics' Nutrition Care Process and Model, which involves the following steps. Terms relevant to the treatment of women with GDM come from the Nutrition Terminology Reference Manual (eNCPT, 2016).

  • Nutrition Assessment
  • Nutrition Diagnosis
  • Nutrition Intervention
  • Nutrition Monitoring and Evaluation.
This guideline addresses topics that correspond to the following areas of the Nutrition Care Process.
 
I. Referral to a Registered Dietitian Nutritionist
II. Medical Nutrition Therapy.

Reference:
 
Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. 2016 edition. Accessed Nov 16, 2016: http://ncpt.webauthor.com.

Future Research Needs

The GDM Expert Work Group identified several areas for future research based on their review of the literature and subsequent evidence analysis. Suggestions regarding research methodology and reporting of outcomes was also made. 

Additional research is needed in women with GDM to clarify or determine the effect of the following on neonatal/fetal and maternal outcomes:
  • MNT intervention, including the frequency and duration of visits provided by an RDN (or international equivalent) in women with GDM and those at risk for GDM 
  • MNT in the treatment of GDM in a variety of patient ethnicities, cultures, and populations
  • Calorie consumption (reported as kcals/kg pre-pregnancy body weight) 
  • Amount and type of each macronutrient (carbohydrate, protein and fat) consumed (both independently and in combination)
  • Amount and type of each macronutrient consumed at the breakfast meal, including specific foods (i.e., fruit, milk)
  • Various meal and snack distributions
  • Dietary patterns: 1) Dietary Approaches to Stop Hypertension (DASH); 2) Low glycemic index; 3) Mediterranean; 4) Paleo; 5) Very low carbohydrate
Research methodology and outcomes reporting:
  • High-quality randomized controlled trials comparing MNT interventions provided by RDNs (or international equivalent) vs. standard care are needed.
  • Accepted guidelines should be used for determining a diagnosis of GDM; these include: American Diabetes Association, American College of Obstetricians and Gynecologists, The Endocrine Society
  • In addition to describing planned diet interventions, mean actual intake for each study arm should be reported.  
    • Descriptions of planned diet interventions and actual intake should include energy intake, all macronutrients, relevant micronutrients, and dietary fiber. Type of fat (mono-, poly-, etc.) and type of fiber (soluble, insoluble) should be reported.
  • Inclusion of studies in meta-analysis is an important goal for GDM researchers, as meta-analyses are key components in the development of quality evidence-based guidelines.  
    • Outcomes chosen, as well as the form in which outcomes are reported, should be carefully considered.  At a minimum, outcomes reported should include pre and post-intervention: Fasting and post-meal blood glucose, birth weight (large-for-gestational-age, small-for-gestational-age), maternal weight gain, rate of neonatal hypoglycemia, and need for medication
  • At a minimum, outcomes for each study arm should be reported as: mean, standard deviation, 95% confidence interval, in order to facilitate subsequent meta-analysis.
  • Research is needed in US populations, within US health systems, with RDNs leading or providing the MNT component of treatment.
The Academy of Nutrition and Dietetics supports and encourages member participation in nutrition research. Contribution to nutrition research is essential to improve the effectiveness of nutrition interventions and thus, patient care.  

The Academy has two main resources for data collection, which is free to Academy members:  
  • Dietetics Practice Based Research Network (DPBRN) is a network of RDNs who are members of the Academy and are interested in research. DPBRN provides education resources and opportunities for members to participate in research. 
  • Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) provides tools for RDNs to collect outcomes. Dietitians can collect outcomes for their own research project and add anonymous data to the national Dietetics Outcomes Registry, contributing to the evidence supporting nutrition practice and helping ensure high-quality patient care.