EAL

Recommendations Summary

GDM: Nutrition Assessment 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: Assessment of Food/Nutrition-Related History of Women with GDM

The registered dietitian nutritionist (RDN) should assess the food and nutrition-related history of women with gestational diabetes mellitus (GDM) including, but not limited to:
- Food, beverage and nutrient intake including:
  - Calorie intake
  - Types and amount of carbohydrate (including fiber), fat, protein; with special attention to high calorie, low-nutrient dense foods such as desserts, candy, sugar-sweetened beverages
  - Serving sizes
  - Meal and snack patterns, including frequency and duration
    - Recent changes
    - Preferences, avoidance, intolerances, allergies including:
      
      In relationship to gastrointestinal discomforts (e.g., nausea, vomiting, heartburn, constipation, ptyalism)
      
      Reaction to or changes in food tastes/smells related to pregnancy
      
      Cultural and religious considerations.
- Appetite and changes in appetite
- Eating environment and meals eaten away from home
- Diet history and behavior: previous diets and diet adherence, disordered eating
- Factors affecting access to food: Psychosocial/economic issues (e.g., social support) impacting nutrition therapy
- Method of food preparation, food safety
- Pharmacologic therapy (including insulin or oral glucose-lowering agent)
- Substance use: Alcohol, tobacco, caffeine, recreational drugs
- Use of dietary supplements, prenatal vitamins, over-the-counter medications, complementary and/or herbal
- Knowledge, beliefs or attitudes: Motivation, readiness to change, self-efficacy; willingness and ability to make lifestyle changes
- Physical activity and function: Exercise patterns, functionality for activities of daily living, sleep patterns.
Assessment of these factors is needed to effectively determine nutrition diagnoses and formulate a nutrition care plan. Inability to achieve optimal nutrient intake may contribute to poor outcomes.

Rating: Consensus
Imperative

GDM: Assessment of Anthropometric Measurement of Women with GDM

The RDN should assess the following anthropometric measurements in women with GDM, including but not limited to:
- Height, current weight, pre-pregnancy weight and body mass index (BMI)
- Weight changes during pregnancy.
Assessment of these factors is needed to effectively determine nutrition diagnoses and formulate a nutrition care plan.

Rating: Consensus
Imperative

GDM: Assessment of Biochemical Data, Medical Tests, and Procedures of Women with GDM

The RDN should evaluate available data of women with GDM and recommend as indicated: Biochemical data, medical tests and procedures including, but not limited to:
- Glycemic tests: Glucose challenge test (GCT), oral glucose tolerance test (OGTT), glycosylated hemoglobin (A1C), fasting glucose, random glucose
- Use of self-monitoring blood glucose (SMBG) meters and urinary ketones, if recommended
- Maternal and fetal testing (e.g., ultrasounds, biophysical profile, non-stress testing)
- Nutritional anemia profile (e.g., hemoglobin, hematocrit, folate, B₁₂, iron)
- Vitamin D and other micronutrient levels, as appropriate
- Thyroid function
- Kidney function.
Assessment of these factors is needed to effectively determine nutrition diagnoses and formulate a nutrition care plan.

Rating: Consensus
Imperative

GDM: Assessment of Nutrition-Focused Physical Findings and Client History of Women with GDM

The RDN should evaluate available data regarding the client history and nutrition-focused physical findings of women with GDM including, but not limited to:

Patient/Family/Client Medical/Health history
Assessment of these factors is needed to effectively determine nutrition diagnoses and formulate a nutrition care plan.

Rating: Consensus
Imperative
- Risks/Harms of Implementing This Recommendation
  There are no potential risks or harms associated with the application of these recommendations.
- Conditions of Application
  - RDNs should be appropriately trained to conduct a nutrition-focused physical exam
  - If necessary data are not available, the RDN should use professional judgment to request or obtain addition data
  - Women who have complicating conditions such as renal disease or eating disorders may require more indepth or specialized nutrition assessments [American Diabetes Association (ADA), 2016]
  - RDNs should be alert to psychosocial stressors, such as family and household strain, verbal or physical abuse, exposure to discrimination, food insecurity, unemployment, low resources, major or catastrophic life events and anxiety about the current pregnancy. Such stressors may indicate need for further screening and referral to a mental health professional for early treatment to prevent adverse pregnancy outcomes (Kaiser and Campbell, 2014).
- Potential Costs Associated with Application
  Accessibility and costs of additional testing should be considered.
- Recommendation Narrative
  The purpose of the nutrition assessment is to identify nutrition-related problems, their causes and their significance. Relevant data is verified and interpreted by the RDN through an ongoing, non-linear and dynamic process of collecting data and continual analysis of the patient or client’s status, compared to specified criteria (eNCPT, 2016). Nutritional assessment encompasses changes in anthropometric, biochemical and clinical indicators throughout the course of pregnancy (Kaiser and Campbell, 2014). Data are obtained from the patient or client through interview, observation and measurements or may come from the medical record or other health care providers. Nutrition assessment findings are then documented in nutrition diagnosis statements and nutrition intervention goal setting (eNCPT, 2016).
  
  Nutrition assessment is organized under five domains (categories). These are: Food/Nutrition-Related History; Anthropometric Measurements; Biochemical Data, Medical Tests, and Procedures; Nutrition-Focused Physical Findings; Client History (eNCPT, 2016). The last two are combined in the narrative below.
  
  Food or Nutrition-Related History
  
  Food and nutrition-related history pertinent to diabetes and pregnancy include:
  - Dietary history includes a thorough review of usual food intake, pattern of intake (timing, meals and snacks) and previous history of diet adherence (ADA, 2013)
  - Educational knowledge, such as nutrition and meal-planning skills, barriers to dietary compliance, such as lack of family support, daily schedule or economic issues, etc. (ADA, 2013)
  - Macronutrient (especially carbohydrate and fiber) and micronutrient dietary intake (ADA, 2013)
  - Vitamin and mineral supplement use (prenatal and non-prenatal) or use of natural remedies, such as herbs or alternative therapies (ADA, 2013)
  - Food allergies or intolerances (ADA, 2013)
  - Use of alcohol, tobacco, caffeine or other substances [Joslin Diabetes Center & Joslin Clinic (Joslin), 2011]
  - Medications: Prescription (diabetes-related, non-diabetes-related); over the counter medications (ADA, 2013)
  - Screening for other nutrition risks (e.g., eating disorders, pica, adolescence, low literacy, low income, psychosocial issues) (Shields and Tsay, 2015)
  - Exercise pattern: Type, frequency, duration [American College of Obstetricians and Gynecologists (ACOG), 2015; Joslin, 2011]
  - Finally, language, cultural background, ethnic or religious beliefs should be taken into consideration (Shields and Tsay, 2015).
  Anthropometric Measurements
  
  Anthropometric measurements pertinent to diabetes and pregnancy include:
  - Height, weight, weight history, pre-pregnancy weight and BMI should be assessed at the initial visit and weight should be tracked at each visit to determine if the gestational weight gain (GWG) is appropriate (within range), based on IOM revised guidelines for weight gain during pregnancy (IOM, 2009) (Shields and Tsay, 2015; Joslin, 2011; Kaiser and Campbell, 2014)
  - While the total amount of weight gained in normal-term pregnancies varies in women (IOM, 2009), the IOM recommends that women achieve GWG within the range identified for their pre-pregnant BMI for singleton or multiple pregnancies, as appropriate (Kaiser and Campbell, 2014; IOM, 2009)
  - Inappropriate weight gain (excess or inadequate weight gain) may require further assessment of food and kcal intake and adjustment in the nutrition prescription (ADA, 2016).
  Biochemical Data, Medical Tests and Procedures
  
  Clinical data related to medical tests pertinent to diabetes and pregnancy include:
  - Glycemic tests, including GCT, OGTT, A1c, fasting and random glucose and fasting, pre-prandial, and post-prandial self-monitoring of blood glucose are recommended (ADA, 2016) to determine glycemic control throughout pregnancy (Shields and Tsay, 2015; ACOG, 2013)
  - A nutritional anemia profile (hemoglobin/hematocrit, folate, B₁₂, iron) and Vitamin D and other micronutrient screening, as needed help determine if the woman may benefit from additional counseling targeting specific nutrients (Shields and Tsay, 2015). For example, serum ferritin may be useful to identify pregnant women who would benefit from additional counseling about iron-rich foods and supplements (Kaiser and Campbell, 2014) or vitamin D screening may be considered for those who may be at risk of deficiency, such as lack of sun exposure, vegan or northern latitude (Kaiser and Campbell, 2014).
  - Kidney function tests (creatinine clearance) (Shields and Tsay, 2015)
  - Thyroid function (Shields and Tsay, 2015).
  Nutrition-Focused Physical Findings and Client History
  
  Nutrition-focused physical findings and client history related to diabetes and pregnancy include:
  - Pertinent medical history (diseases, conditions, illnesses), previous obstetrical history
  - Age, number of fetuses, weeks of gestation, EDD
  - History of GDM duration of diabetes hypoglycemia, diabetes complications, family history (Shields and Tsay, 2015)
  - GI discomforts, such as nausea, vomiting, etc. that may interfere with the ability to consume adequate nutrients
  - Vital signs, such as blood pressure (Shields and Tsay, 2015) and general health
  - Social history, living situation, health literacy, attitudes toward health including current diabetes knowledge (Shields and Tsay, 2015) and numeracy that may affect learning ability or needs and ability to implement dietary strategies or to make appropriate food choices
  - Educational background and occupation, including financial and employment status (Shields and Tsay, 2015) may affect meal timing and schedule and healthy food purchasing ability.
- Recommendation Strength Rationale
  Consensus: This topic was not included in the EAL systematic review. The recommendations are based on consensus publications.
- 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
  - 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.
  - American College of Obstetricians and Gynecologists (ACOG). Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015;126: e135-142.
  - ACOG. Committee on Practice Bulletins--Obstetrics. Practice Bulletin No. 137: Gestational diabetes mellitus. Obstet Gynecol. 2013 Aug;122 (2 Pt 1): 406-416. PMID: 23969827.
  - American Diabetes Association (ADA). Standards of Medical Care in Diabetes-2016: Summary of Revisions. Diabetes Care. 2016 Jan;39 Suppl 1:S4-5. doi: 10.2337/dc16-S003. Review. No abstract available. PMID: 26696680.
  - Coustan DR. Editor. Medical Management of Pregnancy Complicated by Diabetes. American Diabetes Association. Alexandria, VA. 2013.
  - Institute of Medicine (IOM) and National Research Council. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: The National Academies Press, 2009.
  - Institute of Medicine (IOM). Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: The National Academies Press, 2002.
  - Joslin Diabetes Center and Joslin Clinic Guideline for Detection and Management of Diabetes in Pregnancy. 9/10/2010: Revised 06-15-11 Accessed Aug 5, 2016: http://www.joslin.org/info/joslin-clinical-guidelines.html.
  - Kaiser LL, Campbell CG; Academy Positions Committee Workgroup. Practice paper of the Academy of Nutrition and Dietetics abstract: nutrition and lifestyle for a healthy pregnancy outcome. J Acad Nutr Diet. 2014 Sep; 114 (9): 1, 447. PMID: 25699300.
  - Procter SB, Campbell CG. Position of the Academy of Nutrition and Dietetics: nutrition and lifestyle for a healthy pregnancy outcome. J Acad Nutr Diet. 2014 Jul; 114 (7): 1, 099-1, 103. PMID: 24956993.
  - Shields, L and Tsay, GS. Editors, California Diabetes and Pregnancy Program Sweet Success Guidelines for Care. Developed with California Department of Public Health; Maternal Child and Adolescent Health Division; revised edition, updated September 2015. Accessed August 9, 2016: http://www.cdappsweetsuccess.org/Portals/0/2015Guidelines/2015__CDAPPSweetSuccessGuidelinesforCare.pdf.