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Recommendations Summary

GDM: Macronutrients 2016

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    GDM: Macronutrient Requirements

    In women with gestational diabetes mellitus (GDM), the registered dietitian nutritionist (RDN) should provide adequate amounts of macronutrients to support pregnancy, based on nutrition assessment, with guidance from the Dietary Reference Intakes (DRI). The DRI for all pregnant women, including those with GDM, recommends a minimum of 175g carbohydrate (CHO), a minimum of 71g protein (or 1.1g per kg per day protein) and 28g fiber.

    Rating: Consensus
    Imperative

    GDM: Carbohydrate Prescription

    The RDN should individualize both the amount and type of CHO for women with GDM based on nutrition assessment, treatment goals, blood glucose response and patient needs. Limited evidence does not confirm an ideal amount (grams or percent of total calories) of CHO for all women with GDM, but suggests an interaction between the amount and type of CHO. Several studies showed positive effects on glycemic control and neonatal/fetal and maternal outcomes in women with GDM, when evaluating varying amounts and types of CHO:

    • Low glycemic index (GI) (less than 55) or medium GI (55 to 69) diets, containing a range of 36.7% to more than 60% CHO 
    • Dietary Approaches to Stop Hypertension (DASH) diets (greater than 65% CHO). 
    However, when two studies evaluated the amount of CHO alone (without specifying the type of CHO) mixed results were found:  
    • A CHO prescription of 202g CHO per day was more effective at reducing post-prandial blood glucose (PPBG), compared to >270g CHO per day. 
    • A 23% incidence of large-for-gestational-age (LGA) infants was found with CHO intake of less than 211g per day day, but no LGA when greater than 211g per day.

    Rating: Fair
    Imperative

    GDM: Carbohydrate and Post Prandial Breakfast Glycemia

    The RDN should individualize both the amount and type of CHO at breakfast based on nutrition assessment, treatment goals, blood glucose response and patient needs. If the woman with GDM continues to experience elevated PPBG after breakfast, the RDN may further modify the amount or the type of CHO at breakfast to achieve blood glucose targets. Limited evidence examining the impact of CHO on PPBG after breakfast does not confirm an ideal amount (grams or percentage of total calories) or type of CHO for all women with GDM to achieve PPBG targets after breakfast, but suggests an interaction between the two. 

    • In women with GDM who followed low or medium glycemic index (GI) diets containing 42-60% total CHO (GI for breakfast meal <55; CHO range 15g to 60g or more) met PPBG targets after breakfast. 
    • One study evaluating a 45% CHO diet overall (without specifying the type of CHO), found improved PPBG after breakfast, compared to one that contained 60% CHO  
    • No studies evaluated the effect of only restricting individual foods (e.g., fruit or milk) at breakfast, although one study showed improved PPBG when fruit bread and milk were eaten in a low GI breakfast vs. a high GI breakfast with CHOs from other sources.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      There were no potential risks or harms associated with the application of these recommendations.

    • Conditions of Application

      For the recommendation GDM: Carbohydrate and Post Prandial Breakfast Glycemia, the RDN should use clinical judgment in individualizing the breakfast meal. Although no evidence was found to support a specific or range of carbohydrate (CHO) distribution at meals or snacks, customary practice suggests limiting the amount and type of CHOs at breakfast (Joslin Diabetes Center & Joslin Clinic, 2013). The CHO intake is reassessed at subsequent visits for possible adjustment according to the blood glucose records (Shields & Tsay, 2015). See the recommendation GDM: Distribution of Meals and Snacks

    • Potential Costs Associated with Application

      • Costs may include expenses associated with receiving care from an RDN. 
      • There may be extra time needed or increased food costs associated with improving the quality of the diet as recommended.

    • Recommendation Narrative

      A total of 12 studies were included in the evidence analysis supporting these recommendations:

      • Six positive quality randomized controlled trials (RCTs) (Asemi et al, 2014; Grant et al, 2011; Moreno-Castillo et al, 2013; Louie et al, 2011; Moses et al, 2009; Perichart-Perera et al, 2012)
      • Two positive quality randomized crossover trial (Hernandez et al, 2014; Louie et al, 2013)
      • Three neutral quality RCTs (Afaghi et al, 2013; Asemi et al, 2013 (a, b); Cypryk et al, 2007)
      • One neutral quality prospective cohort (Romon et al, 2001).
      Impact of the amount of CHO consumed on fetal/neonatal and maternal outcomes [independent of dietary patterns based on the Dietary Approaches to Stop Hypertension (DASH) diet and Glycemic Index]

      Conclusion: Limited evidence was found to demonstrate the impact of the amount of CHO consumption on neonatal or fetal and maternal outcomes in women with gestational diabetes mellitus (GDM). In one study, women prescribed a minimum of 1, 800kcal per day found reductions in post-prandial blood glucose (PPBG) levels at all three meals with 202g per day CHO, while those prescribed >270g CHO showed reductions in PPBG at two meals only. Another study of women with an average intake of 1, 852±343kcal per day found zero incidence of LGA when CHO intake was >211g per day, but a 23% incidence in women consuming less CHO. No other differences in fetal and maternal outcomes were found in these studies.
       
      Overview

      Three studies evaluated the impact of the amount of CHO consumed (independent of dietary patterns including DASH and glycemic index) on fetal or neonatal and maternal outcomes (glycemic control, maternal weight gain, fetal growth or birth weight, and adverse outcomes), in women with GDM.
      • A neutral quality RCT (Cypryk et al, 2007) assigned 30 women with GDM to consume an 1, 800kcal diet with either low-CHO (LC) content [45% CHO (202g), 25% PRO, 30% FAT] or high-CHO (HC) content [>60% CHO (>270g), 25% PRO, 15% FAT] for two weeks. Actual intake was not reported. There was a significant reduction in PPBG concentrations for all meals in the LC group, while the HC group realized significant BG reductions after lunch and dinner only. No significant (NS) differences were observed between groups for ketonuria or obstetric outcomes.
      • A positive quality RCT (Moreno-Castillo, 2013) assigned 150 women with GDM to either a LC diet (40% CHO) or a HC diet (55% CHO). There was no difference between groups regarding the need for insulin therapy. Women in the HC group gained more weight than women in the LC group, but the difference disappeared when time to follow-up was included in the statistical analysis. There was one unexplained stillbirth to a woman in the LC group.  There were no other significant differences between groups for either maternal or neonatal outcomes. 
      • A neutral quality prospective cohort study (Romon et al, 2001), evaluated actual intake in 80 women with an elevated pre-pregnancy BMI. Women consumed an average of 1, 852±343kcal per day [43.4% CHO (202±43g), 18.5% PRO, 37.9% FAT]. Mild ketonuria was present in 45% of the women during week 1, but decreased to 16%. No relationship between the reported calorie intake and infant birth weight was found. However, an inverse relationship between CHO intake and infant birthweight was found. The 32 women who consumed >211g CHO per day and proportionately lower fat had no LGA infants, whereas in women consuming less CHO, 11 women (or 23%) had LGA infants.  
      Impact of dietary patterns based on the Dietary Approaches to Stop Hypertension (DASH) diet on fetal or neonatal and maternal outcomes 

      Conclusion: Dietary patterns based on the DASH diet, (which contained higher amounts of CHO and dietary fiber, and less sucrose, total fat, dietary cholesterol and less sodium) when compared to a control diet, were effective in improving both fetal and maternal outcomes in women with GDM who did not require insulin at the time of diagnosis. Improvements were found in glucose tolerance, glycosylated hemoglobin levels, insulin resistance, less need for insulin, lipid profile, systolic blood pressure and biomarkers of oxidative stress. There was also a lower incidence of Cesarean-section deliveries. Infant birthweights, head circumferences, ponderal indices and the incidence of macrosomia were lower in infants whose mothers consumed the DASH diet.  

      Overview
      • Two RCTs by Asemi et al [2013 (a) and 2014] evaluated the impact of dietary patterns based on the DASH eating plan on fetal/neonatal and maternal outcomes (glycemic control, maternal weight gain, fetal growth/birth weight and adverse outcomes), in Iranian women with GDM who did not require insulin* at time of diagnosis. A third paper by Asemi et al [2013 (b)], reported additional outcomes for the same subjects in 2013 (a). The studies compared the DASH diet to a standard diet for a four-week period in women diagnosed with GDM at 24-28 weeks gestation. Both diets included the same prescribed macronutrient profile [range 40-55% CHO, 10-20% protein, 25-30% fat]. The DASH diet emphasized fruits, vegetables, whole grains and low-fat dairy products and lower amounts of saturated fats (SFA), dietary cholesterol, refined grains and sodium (Na). Based on weekly phone calls and food records, there was NS differences in total calorie and protein intakes between the groups. However, women in the DASH groups consumed less fat and more CHO than the prescribed diet [calculated approximate range (±SD) 65-67% CHO; 17-18% fat], whereas the women in the control groups consumed within the prescribed amount. The DASH group also consumed higher amounts of dietary fiber (more fruits, vegetables, whole grains), less sucrose, less dietary cholesterol, and less sodium, compared to the control group. There were NS differences in maternal weight gain at the end of the intervention in the studies. Fetal and maternal outcomes were as follows:
        • Asemi et al 2013 (a) (N=34) found significant improvements in SBP, glucose tolerance, HbAIc levels, total cholesterol, LDL cholesterol, total:HDL cholesterol ratio and triacylglycerol (TAG) levels in the DASH group. Women in the DASH group had significantly fewer c-section** deliveries and fewer women required insulin after delivery. Mean infant birth weights were lower in the DASH group compared to the control group. Additional outcomes for the subjects (N=32) were reported in Asemi et al 2013 (b).  Significant improvements were found in fasting plasma glucose (FPG), serum insulin levels, HOMA-IR, total antioxidant capacity (TAC) and total glutathione levels in the DASH group compared to the control group. There were no differences in high-sensitivity CRP between groups.
        • Asemi et al 2014 (N=52) found significantly fewer women in the DASH group required c-sections and insulin injections after the intervention compared to those in the control group. Significantly fewer infants were macrosomic in the DASH group and had significantly lower birth weights, head circumferences and ponderal indices compared to those born to the control mothers. The DASH diet outcomes remained significant even after controlling for pre-pregnancy body mass index (BMI <30kg/m2 and >30kg/m2), baseline maternal FPG, and maternal age. NS differences were found between groups in Apgar scores, percentage of fetal/neonatal polyhydraminos or gestational age in weeks. 
      * The authors noted that in previous studies conducted in Iran, insulin therapy was often recommended upon diagnosis of GDM, to reduce complications.
      ** The authors noted c-section rates in Iran among women with GDM are very high (almost 90%).

      Impact of dietary patterns based on the glycemic index on fetal/neonatal and maternal outcomes

      Conclusion: A low (LGI) or medium GI (MGI) dietary pattern resulted in glycemic control and had similar neonatal or fetal and maternal outcomes in women with GDM in most studies. In a few studies, an LGI diet (36-47% CHO) was found to significantly reduce the need for insulin therapy and prevent excessive maternal weight gain. One study comparing an LGI-MGI diet (40% CHO, 45% fat) to an LGI-MGI diet (60% CHO, 25% fat) found that both diets achieved glycemia within target levels.

      Overview
      • Six studies evaluated the impact of dietary patterns based on the glycemic index (GI) on fetal or neonatal and maternal outcomes (glycemic control, maternal weight gain, fetal growth or birth weight, and adverse outcomes), in women with GDM.
      • A low (LGI) or medium GI (MGI) dietary pattern resulted in glycemic control and had similar neonatal or fetal and maternal outcomes in women with GDM in most studies. In a few studies, an LGI diet (36-47% CHO) was found to significantly reduce the need for insulin therapy and prevent excessive maternal weight gain. One study comparing an LGI-MGI diet (40% CHO, 45% fat) to an LGI-MGI diet (60% CHO, 25% fat) found that both diets achieved glycemia within target levels. 
      • GI parameters for the purpose of study comparison are as follows: Low GI=0-55; Medium GI=56-69; and High GI=70 or greater (Augustin et al, 2015).
      • No studies reviewed compared LGI or MGI to high GI diets. However, three studies compared an LGI diet to other LGI diets with variations in CHO or fiber. Louie et al, 2011 compared an LGI diet (GI 47±1) to a conventional high fiber (HF) diet (GI 53±1) and Perichart-Perrera et al, 2012 compared an LGI (GI 47.2±6.9) to an all types of CHO diet (GI 48.6±8.4). A third study (Afaghi et al, 2013), compared an LGI diet with added wheat fiber (GI ≤55) to an LGI diet without added wheat fiber (same composition). Two studies compared LGI diets to MGI diets. Grant et al, 2011 compared an LGI diet (GI 49±0.8) to an MGI diet (GI 58±0.5) and Moses et al, 2009 compared an LGI diet (GI 48) to a conventional HF diet (GI 56). The macronutrients as a percentage of total calories in these studies were similar between the comparison groups.  One study (Hernandez et al, 2014) compared two low to medium GI (LGI-MGI) diets with inverse macronutrient percentages (GI for breakfast meals were <35.7). A macronutrient and GI comparison of the studies and outcome results are below.
      • In women with GDM, four of five studies reported that glycemic control was achieved (Afaghi; Grant; Hernandez; Perichart-Perrera) and two of five studies showed the need for insulin therapy was significantly reduced (Afaghi, Moses), when following either an LGI or MGI diet. Afaghi et al, 2013 demonstrated improved glycemic control and reduced need for insulin in women who followed an LGI diet with added wheat fiber at each meal, compared to those following an LGI without the added wheat fiber. Moses et al, 2009 reported that fewer women on an LGI diet required insulin to achieve BG control, compared to a conventional HF (MGI) diet. Three other studies did not find differences in insulin use among women with GDM (Perichart, Grant, Louie). Perichart-Perrera et al, 2012 found that an LGI diet was equally effective in improving glycemic control, as a diet including all types of CHO with a similar GI. Grant et al, 2011 found that women who consumed an LGI diet, compared to an MGI diet had more PPBG values within target range, but other BG values were NS. However, neither study found significant between-group differences for insulin initiation. One study (Louie et al, 2011) found NS between-group differences in either BG control or insulin use in women following an LGI vs. a conventional HF (LGI) diet. Hernandez et al, 2014 did not report insulin use, but did find that women following LGI-MGI diets with either 60% CHO/25% FAT or 40% CHO/45% FAT resulted in overall glycemic control within treatment targets.
      • Two studies reported prevention of excessive maternal weight gain when comparing diets that were lower in GI. Louie et al, 2011, found that excessive weight gain occurred less frequently and women tended to gain less weight when following an LGI compared to those following a conventional HF, also LGI. Another study (Perichart-Perrera et al, 2012) found that a lower proportion of LGI subjects exhibited excessive weight gain, compared to those following an LGI diet that included all types of CHO. However, the LGI women in this study were more likely to have a premature birth.
      • A brief description of the comparison diets and specific outcomes and results for each study are as follows:
        • Low GI vs. Low GI Diets
          • Afaghi et al 2013 (N=31) found that women with GDM had significant reductions in fasting blood glucose (FBG) when consuming either an LGI diet (42% CHO; GI ≤55; GL 67-72) with 15g wheat fiber added to each of 3 meals per day or an LGI control diet (same composition, but no added wheat fiber). Further between group differences were found, with the LGI diet (+ wheat fiber) group experiencing significant improvements in two-hour PPBG and BG control, compared to controls.  Fewer women in the LGI + wheat fiber group (38.9%; N=7) required insulin, compared to controls (76.9%; N=10).
          • Louie et al, 2011 (N=91) found that excessive weight gain occurred less frequently and women tended to gain less weight when following an LGI (40-45% CHO; GI 47±1; GL 84±3), compared to those following a conventional HF (40-45% CHO; GI 53±1; GL105±4). Infant birth weight, birth weight percentile, head circumference and ponderal index were very similar and were within healthy norms in both groups (NS). There were no significant differences between groups for LGA, SGA, or macrosomic babies. Fewer women in the LGI group required insulin, but the difference was NS.
          • Perichart-Perrera et al, 2012 (N=107; N=52 GDM; N=55 T2D) found that an LGI diet (46.6% ±9.1 CHO; GI 47.2 ± 6.9) was equally effective in improving glycemic control, as a diet including all types of CHO (45.8% ±8.3CHO; GI 48.6 ± 8.4), and there were no differences in glycemic control within groups between women with type 2 diabetes (T2D) and women with GDM.  A lower proportion of LGI subjects exhibited excessive weight gain, but LGI women were more likely to have a premature birth.  There was a trend toward lower birthweight in LGI infants, and one infant from the LGI group had a low head circumference. There were NS differences in macrosomia or low birth weight between groups and NS differences in wasting or stunting between groups. The risk of pre-eclampsia, intrauterine and neonatal death was the same for both groups. 
        • Low GI vs. Medium GI Diets
          • Grant et al, 2011 (N=38) found NS differences in fasting serum glucose, mean post-prandial SMBG, HbA1C, fasting insulin, lipids or CRP between a group of women with GDM consuming an LGI diet (GI 49±0.8; GL 98.2±5.1) and a control group consuming a significantly higher GI (GI 58±0.5; GL125±8.8). The LGI diet group had significantly fewer fasting serum glucose measurements below target, and over twice as many on target, than the control group. Fewer PPBG measurements were above target in the LGI group. There was NS difference between groups in the number of women started on insulin, and insulin treatment was associated with significantly greater maternal weight gain. There were NS differences between groups in infant birth weight, LGA infants and SGA infants.
          • Moses et al, 2009 (N=63) found that women with GDM who consumed an LGI diet (36.7±1% CHO; GI 48) needed insulin therapy significantly less often than women who consumed a conventional HF diet (37.8±1% CHO; GI 56). Of women in the HF group who met criteria for insulin therapy, nearly half were able to avoid insulin use after switching to the LGI diet. There were NS differences between groups for maternal weight gain, induction of delivery or type of delivery. No significant (NS) differences were found between groups for fetal outcomes including gestational age at delivery, fetal or birth centile, or ponderal index.
        • Low-Medium GI vs. Low-Medium GI Diets
          • Hernandez et al, 2014 (N=16) found no between-diet differences for fasting or preprandial glucose in a group of women with GDM consuming either a low CHO/high fat diet (LC/CONV) (40% CHO, 45% fat; low to medium GI; breakfast GI 35.7) or a higher complex CHO/lower fat diet (CHOICE) diet (60% CHO, 25% fat; low to medium GI; breakfast 34.8).  When considered as a mean across three meals, 1- and 2-hour PPBG and daytime mean glucose were modestly higher on the CHOICE diet. However, both diets produced results well within current treatment targets for daytime, nocturnal, post-prandial and mean BG levels. Free fatty acid (FFA) levels were significantly lower for the CHOICE diet. 
      Impact of the type or amount of CHO consumed on post-prandial breakfast glycemia

      Conclusion: Limited evidence was found to demonstrate the impact of the type or amount of carbohydrate (CHO) consumption on post-prandial breakfast glycemia in women with gestational diabetes mellitus (GDM). Three studies that evaluated glycemic index (GI) reported that lower GI diets containing 42-60% total CHO (GI for breakfast meal <55; CHO range 15g to 60g or more) improved glycemic control after breakfast. One study that did not consider the glycemic index showed that lower CHO (45% vs. 60% of kcals) improved post-prandial blood glucose after breakfast. No studies evaluated the effect of only  restricting individual foods (e.g., fruit or milk) at breakfast although one study showed improved blood sugars when fruit bread and milk were eaten in a low GI breakfast over a high GI breakfast with carbohydrates from other sources. 

      Overview
      • Five studies evaluated the impact of the type or amount of CHO on breakfast PPBG values in women with GDM. Three studies evaluated dietary patterns based on the GI with varying amounts of CHO (Grant et al, 2011; Hernandez et al, 2014; Perichart-Perrera et al, 2012) and one study (Louie et al, 2013) evaluated an LGI and HGI breakfast meal alone. One study evaluated the amount of CHO as a percentage of calories (Cypryk et al, 2007). GI parameters for the purpose of study comparison of the GI studies are as follows: Low GI=0-55; Medium GI=56-69; and High GI=70 or greater (Augustin et al, 2015). Three of these studies (Hernandez 2014, Perichart-Perrera 2012, and Louie 2013) specifically tested a controlled breakfast meal.
      • A brief description of the comparison diets and specific glycemic outcomes and results for each study are as follows:
        • Cypryk et al, 2007 (N=30) compared a low-CHO diet (45% CHO, 30% fat) to a high-CHO diet (>60% CHO, 15% fat) and found a significant reduction in PPBG concentrations for all meals, including breakfast in women consuming a low-CHO diet (45% CHO, 30% fat) compared to women consuming a high-CHO diet (>60% CHO, 15% fat).  he high-CHO group realized significant BG reductions only after lunch and dinner only.
        • Grant et al, 2011 (N=38) compared an LGI diet (% CHO NR; GI 49±0.8) to an MGI diet (% CHO NR; GI 58±0.5) and found a significant relationship between post-prandial SMBG after breakfast and pre-pregnancy BMI at baseline (P<0.001) in two study groups of women (control and low GI) diagnosed with gestational hyperglycemia. During the study, NS differences were observed between the changes in the low GI (fasting, -0.48±0.11 mmol/L; postprandial, -0.58±0.19 mmol/L) and control (fasting, -0.35±0.19 mmol/L; postprandial, -0.44±0.21 mmol/L) groups, although the fasting and (p=0.001) and mean postprandial (p < 0.001) fell significantly. Also, the control group demonstrated a strong positive relationship between pre-pregnancy BMI and SMBG after breakfast (R=0.75, P<0.001); although the low-GI group did not demonstrate this correlation, and the difference between groups was significant (P=0.021). However, post-intervention, the LGI group consumed significantly more dietary fiber than controls (30±1.6 and 23±1.0g, respectively; P=0.001) and had a significantly lower diet GI than control (49±0.8 vs. 58±0.5g; P=0.001). The result was the LGI group had a significantly lower GL than control post-intervention (98.2±5.1 vs. 125±8.8; P=0.014). 
        • Hernandez et al, 2014 (N=16) compared two low to medium GI (LGI-MGI) diets (40% CHO, 45% fat; GI NR; breakfast GI 35.7) vs. (60% CHO, 25% fat; GI NR; breakfast 34.8) and found modestly higher 1- and 2-hour PPBG in women on a higher complex CHO/lower fat diet (60% CHO, 25% fat; low to medium GI; breakfast GI 34.8), compared to a lower CHO/high-fat diet (40% CHO, 45% fat; low to medium GI; breakfast GI 35.7). However, PPBG after breakfast was within current treatment targets at one and two hours for both diets (1 hour, 115±2 vs. 107±3mg/dL, P≤0.01; 2 hours, 106±3 vs. 97±3mg/dL, P=0.001). The breakfast meal contained 25% of total kcals and reflected the overall macronutrient percentage for each diet.
        • Louie et al, 2013 (N=10, crossover study design provided two groups of 10 subjects each), in a study focused on only a controlled breakfast meal compared a low-GI breakfast (GI 45, GL 21) that included fruit bread and milk, with a high-GI breakfast (GI 82, GL 31). Louie et al found significantly lower peak BG levels (6.7±0.3mmol/L vs. 8.6±0.3mmol/L; P=0.001) in women consuming a low GI breakfast (GI 45; GL 21; 44.7g CHO*) compared with those consuming a high-GI breakfast (GI 82; GL 36; 42.7g CHO*). The area under the glucose curve (iAUCglucose) was significantly lower for the LGI group (212.7±22.9 vs. 340.8±23.4; P=0.001). There was large inter-subject variability in the timing of the peak BG level between the test meals, with peaks occurring at 45-75 minutes for the LGI meal and between 30-60 minutes for the HGI meal.
        • Perichart-Perrera et al, 2012 (N=107; N=52 GDM; N=55 T2D) compared an LGI diet (46.6±9.1% CHO; GI 47.2±6.9) to an all types of CHO diet (45.8±8.3% CHO; GI 48.6±8.4) and found that an LGI diet was equally effective in improving glycemic control, as a diet including all types of CHO. Breakfast was limited to 15-30g CHO in both diets. At the end of the study, there was a statistically significant increase in the number of women in the LGI group who met glycemic targets after lunch, pre-dinner and post-dinner (P<0.05); and in the all types of CHO diet group, the increase was only at the post-lunch time (P<0.03). There was NS difference between groups or within groups for two-hour post-prandial breakfast glucose throughout the study.
      *calculated value.

    • Recommendation Strength Rationale

      • The recommendation GDM: Macronutrient Requirements is based on consensus publications. The topic was not included in the EAL systematic review. 
      • Three conclusion statements supporting the recommendation GDM: Carbohydrate Prescription are grade III
        • Interpretation of results for the topic on impact of dietary patterns based on the glycemic index on fetal or neonatal and maternal outcomes is limited due to inability to compare diets across studies and none of the studies included a comparison to the high GI (HGI) diet.
        • Interpretation of results for the topic on impact of dietary patterns based on the DASH diet on fetal or neonatal and maternal outcomes is limited due to subjects consuming relatively the same diet (despite differences in prescribed diet), limited population. 
        • Interpretation of results for the topic on impact of the amount of CHO consumed (independent of dietary patterns including DASH and GI/GL) on fetal and maternal outcomes and the topic of impact of dietary patterns based on the DASH diet on fetal and maternal outcomes is limited because results of CHO were confounded by use of prescribed vs. reported intakes, variable sample sizes and different outcomes reported, making comparison and synthesis of the research challenging. In addition, studies used varying types and amounts of carbohydrates and outcomes measured varied widely among studies.
      • Conclusion statement supporting the recommendation GDM: Carbohydrate and Post Prandial Breakfast Glycemia is grade III
        • Interpretation of results for the topic on impact of the type or amount of CHO consumed on post-prandial breakfast glycemia was challenging due to inability to compare diets across studies (varying amounts of CHO and GI), prescribed vs. reported intakes, or lack of description of the breakfast meal. 

    • Minority Opinions

      None.