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- Gestational diabetes mellitus
Gestational diabetes mellitus
Recommendations for pregnant women
Developed by
an endocrinologist at the 1st City Clinical Hospital "City Center for Extragenital Pathology in Pregnancy" O.P. Shchetko,
Deputy Chief Physician for Obstetrics at the 1st City Clinical Hospital "E.V. Fedotova,
obstetrician-gynecologist ( manager) 4 residential complex Denisevich T.V.
Gestational diabetes mellitus
Gestational diabetes mellitus (GDM) or pregnancy diabetes is a disorder of carbohydrate metabolism that appears during pregnancy and is limited to the duration of pregnancy. During pregnancy, the production of maternal and placental hormones (estrogens, progesterone, leptin, cortisol, placental lactogen, placental growth hormone) sharply increases, which suppress the action of insulin and lead to physiological insulin resistance. As a result, the level of glucose in the blood of pregnant women increases. High blood sugar during pregnancy negatively affects both the health of the woman herself and the condition of the fetus, and therefore requires timely diagnosis and subsequent correction.
Who develops GDM? Risk factors and groups.
1. Pregnancy itself is a risk factor for developing GDM.
2. The risk group includes pregnant women:
- overweight or obese (BMI (body mass index) above 25 kg/m2 - the risk doubles, above 30 - triples);
- with multiple pregnancy;
- after IVF (in vitro fertilization);
- over 30 years old;
- with polycystic ovaries- with a large weight gain during real pregnancy;
- with glucosuria (glucose in the urine);
- having close relatives with diabetes;
- with a burdened medical history in previous pregnancies - GDM, the birth of a child weighing over 4000 g, intrauterine fetal death.
Complications of pregnancy.
If GDM is not detected in a timely manner or the expectant mother does not take any action to treat it, then complications of pregnancy develop much more often, such as:
- fetal growth retardation;
- premature birth;
- polyhydramnios;
- formation of a large fruit;
- the occurrence of diabetic fetopathy;
- preeclampsia - increased blood pressure, protein in the urine;
- death of the fetus.
During childbirth, the frequency of cesarean sections, birth trauma for mother and child, hypoglycemia (low blood sugar) and breathing difficulties in the newborn increases.
Long-term consequences of GDM for mother and child.
Table 1
THE CHILD HAS | AT THE MOTHER'S |
---|---|
- aged 4-6 years - overweight or obese - at 10-11 years old - increased blood pressure - in adolescence - the risk of developing diabetes is 20-40% | - 50-60% of women who have had GDM develop type 2 diabetes mellitus, obesity and cardiovascular diseases within 4-5 years - in subsequent pregnancies, GDM occurs earlier |
Diagnosis of GDM
As a rule, GDM occurs without symptoms that could suggest a violation of carbohydrate metabolism.
The gold standard for diagnosing GDM is an OGTT (oral glucose tolerance test) with 75 g of glucose. This study is a safe stress diagnostic test to detect carbohydrate metabolism disorders during pregnancy. Its implementation is recommended at 24-28 weeks of pregnancy.
Rules for conducting an oral glucose tolerance test
- For 3 days before the test, you should follow your normal diet and exercise routine.
- The evening before the test there should be a standard dinner. Last meal at 20.00-21.00
- In the morning you need to be in the laboratory by 8.00, on an empty stomach, after an 8-12 hour fast. The first blood draw is performed on an empty stomach.
- Then within 5-10 minutes you need to drink dissolved glucose (75 g of dry glucose powder per 250-300 ml of warm water). You can add the juice of half a lemon to the solution. Only glucose solution is used! You should not replace glucose with another sweet drink or food.
- Repeated blood sampling is carried out 1 hour and 2 hours after taking glucose.
- You cannot walk during the test. You need to sit comfortably.
- Medicines that affect blood glucose levels (multivitamins, iron supplements (containing carbohydrates), glucocorticosteroids, beta-blockers, beta-adrenergic agonists), if possible, should be taken after the test.
Target glycemic levels for self-monitoring in GDM (blood plasma):
- on an empty stomach up to 5.1 mmol/l
- 1 hour after eating up to 6.7 mmol/l
- 2 hours after eating up to 6 mmol/l
In case of GDM, pregnant women are strictly recommended to:
- Self-monitoring of blood glucose should be carried out at least 4-5 times a day (on an empty stomach, 1 hour after breakfast, lunch and dinner) using a glucometer throughout pregnancy.
- Keeping a self-monitoring diary in which blood glucose levels are recorded indicating the date, time and a detailed description of the food taken. When visiting an obstetrician-gynecologist or an endocrinologist, you must bring a self-monitoring diary.
Principles of treatment of GDM:
- diet
- physical activity
- if they are ineffective - insulin therapy.
Attention!
- insulin does not harm either the child or the mother; it is prescribed to maintain the full health of both mother and baby
- insulin does not penetrate the placenta, but glucose, unlike insulin, passes unhindered and easily from mother to child
- insulin tolerance does not develop
- insulin is discontinued after childbirth
- Any sugar-lowering pills are contraindicated during pregnancy!
Diet. Principles of diet therapy:
- Emphasis on the consumption of complex (slow) carbohydrates (up to 55% of the recommended daily caloric intake) with low fat content (25-30% of the recommended daily caloric intake). Complex (slow) carbohydrates - contain starch, fiber, pectin, glycogen (bread, legumes, cereals, pasta, potatoes, vegetables, cereals, nuts, herbs). They are slowly absorbed, give a feeling of fullness (starch + fiber), regulate intestinal function and support microflora (fiber).
- A low-carbohydrate diet during pregnancy is NOT SUITABLE (a diet with a sharp restriction in the diet of carbohydrates to 40 g, increased consumption of protein and plant foods).
- Calorie restriction (for overweight and obesity) of at least 1800 kcal/day
- The amount of fat should not exceed 30% of the daily calorie intake, while the consumption of saturated fats should be limited to 10%, and trans fats should be eliminated completely (trans fats are modified molecules that appear in unsaturated (vegetable) oils during repeated high-temperature processing). (see table 2).
- The daily amount of fiber should be at least 28 g. Fiber (dietary fiber) is a type of complex carbohydrates in plant products. Fiber forms the structure of vegetables and is also a material for the coating of grains. There is a lot of dietary fiber in bran, cereals, grains, nuts, and any vegetables and fruits. The advantage of fiber products is their low glycemic index (GI).
- To prevent the appearance of ketone bodies, the break between dinner and breakfast should be no more than 10 hours.
- Each meal should contain slowly digestible carbohydrates, protein, mono- and polyunsaturated fats, and dietary fiber. This increases insulin sensitivity, promotes less weight gain, and reduces the frequency of prescribed insulin therapy for GDM.
General recommendations
- Eat 4-5 times a day (eating a large amount of food at one time provokes a rise in blood sugar), limit food portions.
- You cannot completely exclude carbohydrates from your diet (cereals, bread, pasta, fruits, berries, some types of vegetables, liquid dairy products). Preference should be given to grains, vegetables and permitted fruits, refusing sweet, fatty, and salty foods.
- Slow carbohydrates should be consumed with every main meal (breakfast, lunch, dinner).
- completely eliminate ready-made breakfasts (muesli, cereal, fitness bars, instant cereals (3-10 minutes), protein shakes, semolina porridge, white refined rice)
- Products in the “For Diabetics” section are not suitable during pregnancy
- exclude any sugar (white, brown, cane, refined sugar, coconut)
- exclude white flour and products made from it, replace with whole grain
- exclude bananas, grapes, persimmons, cherries, watermelon, melon from the diet, replace them with unsweetened apples, hard pears, kiwis, and citrus fruits.
- exclude fruit juices, freshly squeezed juices, milkshakes, canned fruits, preserves, honey, jams from the diet.
- starch-containing products should be no more than 100 g per serving (rice, wheat, corn, potatoes, sweet potatoes, legumes, bread, pancakes, noodles, pasta, porridge, jelly).
- allowed fruits 100 g (maximum 150 g) per serving
- All low-fat and low-fat dairy and fermented milk products, as a rule, contain starch (simple fast carbohydrate), so it is necessary to replace them with products with a normal percentage of fat content (5%-7%).
- Replace baked goods and sweets (confectionery with trans fats) with dark chocolate (more than 75% cocoa) 25-30 g per day
- limit your consumption of red meat. completely exclude sausages, sausages, carbonates, ham from the diet
- the best culinary processing of products - steaming, boiling, stewing, baking “in the sleeve”
- get the required amount of fat from the right animal and plant products (meat and dairy products from free-range cows, wild fish, eggs, cheese, cottage cheese, butter, nuts, legumes, olive oil, cold-pressed vegetable oils).
- It is recommended to drink 1-1.5 liters of liquid per day
- choose foods high in fiber. Fiber (or dietary fiber) stimulates the intestines and slows down the absorption of excess sugar and fat into the blood. In addition, foods rich in fiber contain large amounts of vitamins and minerals.
High fiber foods
- Bread and wholemeal products
- Whole grain cereals (all gray and brown cereals - rolled oats, oatmeal, buckwheat, barley, pearl barley, bulgur, spelt, flaxseed porridge, rice - wild, brown, red, brown)
- Durum wheat pasta
- Frozen and fresh vegetables, herbs, mushrooms, herbs.
Vegetables that can be eaten without restrictions are zucchini, zucchini, cucumbers, spinach, green beans, radishes, asparagus, broccoli, cauliflower, greens, celery, lettuce.
These foods are low in calories and low in carbohydrates. They can be eaten at main meals and when you feel hungry. It is better to consume these products raw (salads), steamed or boiled.
Vegetables that need to be limited are potatoes, boiled/stewed beets, carrots, pumpkin, peas, corn.
Fats
Table 2
FATTY ACID | ACCEPTABLE INTAKE PER DAY OF THE RECOMMENDED DAILY INTAKE FOR FAT | FOOD |
---|---|---|
MONOUNSATURATED Include in diet | 90% | Avocado, sesame, olivesNuts: almonds, cashews, walnuts, macadamia, Brazil nutsCold pressed oils: olive, sunflower, corn, peanut |
POLYUNSATURATED Include in diet | Sunflower and pumpkin seeds Fish and seafood Fish fat Oils: flaxseed, sesame, walnut | |
SATURATE Limit | 10% | Meat, ham, sausages Salo Cream, sour cream, milk, cheese, ice cream |
TRANSFATS Exclude | 0% | Margarine, spread, chips, fast food White flour baked goods and confectionery Semi-finished products (sausages, sausages, etc.)Low-fat cheeses, cottage cheese and fermented milk products Industrial sauces |
What does the presence of acetone (ketone bodies) in urine indicate:
- Low carbohydrate diet.
- carbohydrates in the daily amount should be at least 45%; they are the main source of energy.
- If you reduce your carbohydrate intake, then in order to provide the cell with energy, fats will begin to break down and ketone bodies will appear in the urine.
- if ketone bodies appear in the urine, it is necessary to revise the diet in the direction of increasing the amount of slow carbohydrates.
2. Insufficient amount of fluid drunk (less than 1 liter per day)
3. Prolonged fasting for more than 10 hours
4. Prolonged physical activity
Glycemic index (GI)
Glycemic index (GI ) is an indicator of the speed at which carbohydrates are absorbed and the ability of different foods to increase blood glucose levels. High GI foods contribute to a rapid increase in blood glucose levels. Low GI foods are digested more slowly, gradually releasing energy.
- The fewer carbohydrates in a product, the lower the glycemic index (GI).
- high GI - above 70 units
- average GI - 40-70 units
- low GI - 10-40 units
How to lower the glycemic index (GI)
- The more fiber a food, including various foods, contains, the lower the total GI will be.
- raw vegetables and fruits have a lower GI than heat-treated ones (raw carrots - GI = 35, boiled - GI = 85)
- Mashed potatoes have a higher GI than boiled potatoes. This is due to different degrees of “denaturation” of starch during the cooking process of potatoes. In general, excessive cooking of any products containing starch (pasta, cereals) increases their GI.
- the combination of proteins with carbohydrates reduces the overall GI. On the one hand, proteins slow down the absorption of carbohydrates into the blood, and on the other hand, the very presence of carbohydrates contributes to better digestibility of proteins.
- The more the product is crushed, the higher its GI. This mainly applies to grains. Whole buckwheat and crushed buckwheat have different GIs.
- adding very little fat to carbohydrates lengthens their digestion time and thereby lowers the GI.
- The longer food is chewed, the slower carbohydrates are absorbed.
Table 3
PRODUCT GROUPS | FEATURED | LIMIT | EXCLUDE |
---|---|---|---|
Low GI/ Slowly digested carbohydrates, slowly raise blood sugar | Average GI/ Slowly digested carbohydrates do not quickly raise blood sugar | High GI/ quickly digestible carbohydrates, quickly increase blood sugar | |
Fruits and berries | Grapefruit, lemon, lime, orange, kiwi, chokeberry, lingonberry, blueberry, blueberry, currant, strawberry, strawberry, raspberry, gooseberry, cranberry, cherry | Apricot, peach, plum. mandarin | Grapes, banana, persimmon, figs, cherries, watermelon, melon. All juices and freshly squeezed |
Vegetables and legumes | Any cabbage (white cabbage, broccoli, cauliflower, Brussels sprouts, collards, kohlrabi), salads, greens, eggplants, zucchini, peppers, radishes, radishes, cucumbers, tomatoes, artichoke, asparagus, leeks, garlic, onions, green beans, spinach. | Corn on the cob, raw beets and carrots, beans, peas, chickpeas, mung beans | Potatoes, pumpkin, boiled beets and carrots, canned corn and peas |
Cereals | Barley, buckwheat | Red rice, wild rice, white brown rice, pearl barley, oatmeal, quinoa, bulgur | Millet, wheat grits, semolina, couscous, white polished rice, sushi rice, cereal, muesli, instant porridge |
Flour and pasta products | Sprout bread without flour | Pasta made from durum wheat or spelt, whole grain bread or crispbread made from whole grain flour | All products made from premium wheat flour, rice flour, rice and buckwheat noodles, cakes, pastries, cookies, waffles, chips |
Dairy | Sour cream, cottage cheese, unsweetened yogurt (without additives) with normal fat content | Kefir, fermented baked milk, yogurt, acidophilus, whole milk | Skim milk, sweet fermented milk products, sweet yoghurts and curds, glazed cheese curds |
Nuts, seeds | All nuts and seeds | ||
Sweets | Dark chocolate more than 75%, cocoa, carob, urbech without sugar | Milk chocolate, halva, ice cream | Sugar (any), honey, preserves, jams, marshmallows, marshmallows, confectionery and baked goods |
What should a woman do after childbirth?
- consultation with an endocrinologist
- 2 months after birth, an OGTT with 75 g of glucose is recommended
- planning a subsequent pregnancy after consulting an endocrinologist