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Recommendations Summary

GDM: Nutrition Monitoring and Evaluation 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: Nutrition Monitoring and Evaluation

    Following the nutrition intervention of women with gestational diabetes mellitus (GDM), to check progress, the registered dietitian nutritionist (RDN) should monitor and evaluate the following components at each visit and compare to desired individual outcomes relevant to the nutrition diagnosis and nutrition intervention. This may include, but is not limited to:

    Food/Nutrition-Related History Outcomes

    • Daily food intake in relation to post-meal glucose readings  
    • 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 to food choices and/or eating pattern
      • 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 
      • Frequency and intake of meals and snacks; meals eaten away from home
      • Methods of food preparation; food safety
      • Recommendation to add pharmacologic therapy (oral and/or insulin therapy) to maintain nutrient intake and achieve glycemic targets
        • Pharmacologic therapy – dose of diabetes medications: Oral glucose-lowering agent and insulin.
      • Changes in substance use: alcohol, tobacco, caffeine, recreational drugs 
      • Knowledge, beliefs or attitudes: Motivation, readiness to change, self-efficacy; willingness and ability to make lifestyle changes; understanding of the treatment plan for GDM
      • Physical activity and function: Exercise patterns, functionality for activities of daily living, sleep patterns.
    Anthropometric Measurement Outcomes
    • Weight changes compared to previous obstetric visit or medical nutrition therapy (MNT) visit.
    Biochemical Data, Medical Tests, and Procedure Outcomes: 
    • Self-monitoring blood glucose (SMBG) records, including meter downloads 
    • Ketone testing records (if previously recommended because of weight loss or inadequate calorie intake)
    • Updated fetal and maternal testing or lab values.
    Nutrition monitoring and evaluation of these factors is needed to correctly/effectively diagnose nutrition problems that should be the focus of further nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes or initiation of or changes in pharmacologic therapy. 

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

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

       

    • Conditions of Application

      • 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 nutrition M&E is to assess the effectiveness of nutrition intervention through monitoring, measuring, and evaluating changes in nutrition care indicators. The RDN determines the progress made for the nutrition intervention and whether the patient/client's nutrition related goals or desired outcomes are being achieved (eNCPT, 2016).

      Outcomes are measured by data collection of appropriate nutrition outcome indicator(s).

      Nutrition M&E in GDM is organized under three domains (categories): Food/Nutrition-Related History Outcomes; Anthropometric Measurement Outcomes; and Biochemical Data, Medical Tests, and Procedure Outcomes (eNCPT, 2016).

      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 CHO and fiber) and micronutrient food 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/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) 
      • Exercise pattern – type, frequency, duration [American College of Obstetricians and Gynecologists (ACOG, 2015; Joslin, 2011].
      Anthropometric Measurements

      Anthropometric measurements pertinent to diabetes and pregnancy include:
      • Weight should be tracked at each visit to determine if the gestational weight gain (GWG) is appropriate (within range), based on Institute of Medicine (IOM) revised guidelines for weight gain during pregnancy (IOM, 2009) (Shields and Tsay, 2015; Joslin, 2011; Kaiser and Campbell, 2014)
      • Inappropriate weight gain (excess or inadequate weight gain) may require further assessment of food and calorie 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:
      • Post-prandial SMBG is recommended (ADA, 2016) to determine glycemic control throughout pregnancy (Shields and Tsay, 2015; ACOG, 2013).

    • Recommendation Strength Rationale

      Consensus: This topic was not included in the EAL systematic review. The recommendation is 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). Committee on Practice Bulletins--Obstetrics. Practice Bulletin No. 137: Gestational diabetes mellitus. Obstet Gynecol. 2013 Aug;122 (2 Pt 1): 406-416. PMID: 23969827.
      • 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. 
      • 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 (Joslin). 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.