Recommendations Summary

GDM: Referral to an RDN 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: Referral to an RDN

  Pregnant women who are diagnosed with gestational diabetes mellitus (GDM), should be referred to a registered dietitian nutritionist (RDN) for medical nutrition therapy (MNT). Individualized MNT is important in helping pregnant women with GDM achieve and maintain normal glycemic levels and appropriate weight gain, while meeting essential nutrients for pregnancy to promote positive maternal and fetal outcomes.

  Rating: Strong
  Imperative

  • Risks/Harms of Implementing This Recommendation

    There are no potential risks or harms associated with the application of this recommendation.

  • Conditions of Application

    It is preferable to refer to an RDN who has experience in working with patients who have diabetes or who specialize in diabetes management [e.g., Certified Diabetes Educator (CDE)].

  • Potential Costs Associated with Application

    Costs of MNT sessions and reimbursement vary. However, MNT is essential for improved outcomes.

  • Recommendation Narrative

    The recommendation GDM: Referral of Women with GDM to an RDN is based on the American Diabetes Association's (ADA) Standards of Medical Care in Diabetes 2016 and the Endocrine Society's Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline (Blumer et al, 2013) provide support for the recommendation as follows:

    • In Management of Diabetes in Pregnancy, the ADA makes the following clinical practice recommendation for women with gestational diabetes mellitus (GDM) (ADA 2016):
      • "Lifestyle change is an essential component of management of GDM and may suffice for treatment for many women. Medications should be added if needed to achieve glycemic targets. Rating: Level of Evidence: A"
        • Summary of support for the recommendation:
          • "After diagnosis, treatment starts with MNT, physical activity and weight management depending on pregestational weight and glucose monitoring aiming for the targets recommended by the Fifth International Workshop-Conference on GDM."
          • "GDM is characterized by increased risk of macrosomia and birth complications and an increased risk of maternal diabetes after pregnancy. Although there is some heterogeneity, many randomized controlled trials suggest that the risk of GDM may be reduced by diet, exercise, and lifestyle counseling."

    The Endocrine Society's Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline (Blumer et al, 2013) make the following recommendations:

    • Management of Elevated Blood Glucose
      • "2.3b. We recommend that the initial treatment of gestational diabetes should consist of MNT and daily moderate exercise for 30 minutes or more. Rating: 1/+++ (Strong recommendation / Moderate quality evidence)"
      • Summary of support for the recommendation:
        • "Lifestyle therapy for GDM results in a lower incidence of reduced birth weight, large-for-gestational-age births, and preeclampsia. Both aerobic exercise and non–weight-bearing exercise have been shown to lower blood glucose levels in women with gestational diabetes."
    • Nutrition therapy and weight gain targets for women with overt or gestational diabetes
      • "4.1. "We recommend medical nutrition therapy for all pregnant women with overt or gestational diabetes to help achieve and maintain desired glycemic control while providing essential nutrient requirements. Rating: 1/++ (Strong recommendation / Low quality evidence)"
      • Summary of support for the recommendation:
        • "Although nutrition intervention for overt diabetes and GDM is a fundamental treatment modality, there is a paucity of evidence-based data on this topic. Nevertheless, nutrition therapy has been shown to improve glycemic control for people living with overt diabetes and for women with GDM."

  • Recommendation Strength Rationale

    This topic was not included in the EAL systematic review. The Academy of Nutrition and Dietetics and the GDM Expert workgroup concur with the American Diabetes Association's Standards of Medical Care in Diabetes 2016 recommendaton rating for "Management of Diabetes in Pregnancy (GDM)" and The Endocrine Society's Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline recommendation ratings for "Nutrition Therapy and Weight Gain Targets for Women with Overt or GDM" and "Management of Elevated Blood Glucose."
     

  • Minority Opinions

    None.

• Supporting Evidence

  The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

  • References
  • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

    • American Diabetes Association (ADA). Classification and diagnosis of diabetes. Sec. 2. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016; 39 (Suppl. 1): S13–S22.
    • ADA. Management of diabetes in pregnancy. Sec.12. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016; 39 (Suppl. 1): S94–S98.
    • Blumer I, Hadar E, Hadden DR, Jovanovic L, Mestman JH, Murad MH, Yogev Y. Diabetes and pregnancy: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2013 Nov; 98(11): 4, 227-4, 249. doi: 10.1210/jc.2013-2465. PMID:  24194617.