Case Study #1 Stacy Cliff Gestational Diabetes Mellitus (GDM)

1. What are the criteria for diagnosis of GDM? Two step approach per the American Diabetes Association is as follows: 1) Perform an initial screening by administering a 50 gram glucose load. Measure plasma serum levels. (Fasting is not necessary for this initial step in this 2 step process) A glucose threshold of >139 mg/dL on the 1 hour screen identifies ~80% of women with GDM, and a threshold of >129 identifies ~90%. 2) A diagnostic oral glucose tolerance test should be performed on women that exceed the glucose threshold level on the one hour screening test. This test should be done in the morning after an overnight fast, 3 days of unrestricted diet (150 CHO/day) and unrestricted physical activity. Two or more of the following plasma concentration values must be met or exceeded for a positive diagnosis.1 Diagnosis with 100g glucose load Fasting One Hour Two Hour Three Hour

95 mg/dL 180 mg/dL 155 mg/dL 140 mg/dL

2.

Identify the risk factors that are associated with GDM. What risks factors does Mrs. Doolittle have? Of the major risk factors only maternal obesity is potentially treatable or reversible. Mrs. Doolittle has several risk factors for GDM including the fact that she was overweight before conceiving. If she plans to have subsequent children, she should try to conceive at an ideal weight for her height next time. Her ideal body weight range, in pounds, calculated using the Hamwi equation is: 103<115<126 Mrs. Doolittles physician suspects GDM due to results of 50g OGTT at 172 mg/dL at 2 hours. 100g OGTT was administered and confirmed the doctors suspicions. Results of 100g OGTT: (H)= High value Fasting 126mg/dL (H) 1 hour 175mg/dL 2 hour - 170mg/dL (H) 3 hour 155mg/dL (H)

Following is a chart of other risk factors and Mrs. Doolittles values for those risk factors. Risk Factor Age greater than 25 Family or personal history Overweight before pregnancy Non-white High Blood Pressure Too much amniotic fluid Birth to baby >9lbs, or had birth defect Unexplained miscarriage/stillbirth Present? Yes Yes Yes Yes Unknown Unknown No No Mrs. Doolittles Values 41 years of age Mother DMII, Mother & Aunts possible GDM Pre BMI= (165/(632))703 = 29.22 Overweight African American Value not available Gravida 1, Para 0

3. What are the risks for untreated or poorly manage hyperglycemia in pregnancy? The HAPO (Hyperglycemia and Adverse Pregnancy Outcome) study looks at whether there are increased risks of adverse pregnancy outcomes in those with maternal glucose levels below those that would incur a diagnosis of GDM. Seven glucose categories were used with increasing maternal glucose levels. Birth weight above the 90th percentile is positively correlated with increasing glucose levels. Also positively associated with increasing glucose levels are Cesarean delivery, clinical neonatal hypoglycemia, cord blood serum C-peptide >90th percentile. Secondary findings included positive associations with increasing glucose levels and preeclampsia, shoulder dystocia or birth injury, premature delivery, intensive neonatal care and hyperbilirubinemia. These outcomes are known complications of mothers with pre-existing diabetes and GDM2. 4. Compare Mrs. Doolittles weight gain to the recommended rate of weight gain during pregnancy.

Prepregnancy BMI

BMI+ (kg/m2) (WHO) <18.5 18.5-24 25.0-29.9 30.0

Total Weight Gain Range (lbs) 2840 2535 1525 1120

Underweight Normal weight Overweight Obese (includes all classes)

Rates of Weight Gain 2nd & 3rd Trimester (Mean Range in lbs/wk) 1 (1-1.3) 1 (0.8-1) 0.6 (0.5-0.7) 0.5 (0.4-0.6)

The best available measure of pre-pregnancy weight is the body mass index (BMI). Total weight gain is given as a range because a single number is not effective when you consider variables such as age, race and other factors that may affect pregnancy outcomes. AND guidelines use a

BMI based on actual pre-pregnancy weight as a baseline to determine recommended weight gain in pregnant women including those with GDM. BMI is a better indicator of maternal nutritional status than is weight alone.3 Mrs. Doolittles pre-pregnancy BMI puts her in the overweight category and allows her a gain of 15-25 pounds. Since she is borderline obese her doctor may recommend that she stay within 11-20 pounds of weight gain. Mrs. D is in her 22nd week of pregnancy. She is in the second half of her 2nd trimester. No weight gain is recommended in the first trimester and at a rate of .5 pounds per week she should weigh 170 pounds. Her current weight is 175, she has gained 5 more pounds than recommended. A weight gain of .5 pounds a week for the remainder of her pregnancy will put her at a total weight gain of 19 pounds. This is within the limits for both the overweight and obese categories and a good goal for Mrs. Doolittle.

5.

Mrs. Doolittles calorie and protein requirements: Energy requirements are increased in the second and third trimesters to accommodate fetal growth and the metabolic demands of pregnancy. Metabolism increases by 15% in the singleton pregnancy. Energy is increased by 340-360 kcal/day in the second trimester and by an additional 112 kcal/day in the third trimester. The estimated energy requirement is the average dietary intake needed to maintain energy balance in a healthy adult of a defined age, gender, weight, height and level of physical activity consistent with good health. The IOMs equation for overweight pregnant women takes into account the total energy expenditure (TEE) plus the caloric requirements for energy deposition.4 TEE = 448 7.95 x age + PA x (11.4 x wt. kg + 619 x height [m]) PA = 1.14 because PAL is estimated to be 1.4 <1.6 (Low active) TEE = 2226 First trimester = TEE + 0 pregnancy energy disposition Second trimester = TEE + 340 = 2566 Third trimester = TEE + 452 = 2678 Protein requirements increase during pregnancy to support the synthesis of maternal and fetal tissues. During the first half of pregnancy protein requirement stay the same at .8g/kg/day. For the second half of pregnancy protein needs increase to 71g/day, which is based on 1.1g/kg/day of pre-pregnant weight according to the IOM. Protein deficiency should be avoided due to adverse consequences. Protein requirements for Mrs. Doolittle: 1.1(75) = 82.5g/day

6.

Evaluate 24 hour recall. Calculate total E and E distribution C, P, F and other relevant nutrients. Food Kcal* Exchange (g) Exchange breakdown5 C=15 P=3 1 cup Special K 120 1 starch/bread C=6 P=4 F=2.5 cup 2% milk 61 low fat milk C=30 F=10 4 inch doughnut 190 2 carbohydrate 2 med fat C=45 12 oz. OJ 165 3 fruit 4 C=20 P=2 F=13 Chick-fil-A Cobb salad 430 (from website)5 C=22 P=5 F=1 8 crackers (saltines) 140 1 starch trace fat C=120 16 oz. orange shake 400 8 CHO (orange sorbet) C=10 P=4 1 cup Grilled Veg. 50 2 veg C=60 P=12 2 cups fettuccine pasta 320 4 starch C=30 P=6 F=10 2 slices garlic bread 320 2 starch 2 fat C=30 1 c straw/blueberries 60 2 fruit C=24 P=16 F=10 16 oz. 2% milk 244 2 low fat milk C=30 F=10 4 Oreos 212 2 CHO 2 fat C=12 P=8 F=5 1 C 2% milk 122 1 low fat milk Total= 2969 *Calories C=454 P=60 454(4)= 1816 from My F= 61.5 60(4)= 240 fitness 61.5(9)=553 pal Total= 2609

Protein = Low CHO= Very high Fat= 61.5 grams is high, yet DRIs for pregnancy are not determined My fitness pal values: 31 g sat fat (should be around 28 grams) Sodium= was 2837 should be 1500 Fiber= 16g need to increase to 28 or more grams Potassium= 2.4g need to increase to 4.7 Carbohydrate= was 284g over the DRI of 175g From this 24 hour recall A, C, Calcium and Iron were adequate. However, blood work shows low Iron. Mrs. D may need to change the dietary sources she is receiving her iron from. The absorption rate of non-heme from grains, vegetables and fruit is lower than that of heme iron from meat sources. The fact she did drink orange juice, an orange drink, and eat strawberries at each meal, helped increase the absorption rate of iron consumed. Ascorbic acid binds to iron to form a readily absorbed complex.3

7. Lab evaluation Osmolality= 296 (H) Increases with dehydration and higher than normal levels could be due to hyperglycemia. She complained of increased thirst. Mrs. D needs to increase water intake.6 Glucose= 186 (H) High is considered over 160. Due to hypoglycemia. Causes higher levels of thirst.7 Triglycerides= 155 (H) borderline high. Precursor of Heart disease.8 HgA1c= 8.5 (H) As the A1c increases, so does the risk of complications from diabetes. The A1c test may be used to screen for and diagnose diabetes. However, A1c should not be used for diagnosis in pregnant women.9 RBC= 4.1 (L) If you eat a well-balanced diet, you can prevent anemia due to a lack of iron, vitamin B12, or folate in the foods you eat. Sometimes use of a supplement is recommended if you are at risk of a vitamin deficiency. Mrs. D is on a prenatal vitamin and should be getting adequate iron.10 Increase the iron received from the diet. Bleeding due to hemorrhoids not mentioned? HCT= 36.6 (L) could be indicative of an iron, folate or B12 deficiency. Folate and B12 values not reported. Order test. Dehydration. Hematocrit mirrors the results of the RBC count and hemoglobin.11 Ferritin= 12 (L) Determines your body's total iron storage capacity. If available iron is insufficient to meet the needs, iron stores are depleted and ferritin levels decrease. This may occur due to insufficient iron intake, poor absorption, or increased need for iron such as during pregnancy or due to a condition that causes chronic blood loss.12 8. Urinalysis: Glu= +2 (H) Glucose is normally not present in urine. When glucose is present, the condition is called glucosuria. Pregnancy can cause glucosuria.13 Urobil= 0 When urine urobilinogen is low or absent in a person with urine bilirubin and/or signs of liver dysfunction, it can indicate the presence of hepatic or biliary obstruction.14 Leu bst= 0 White blood cells (leukocytes) may be a sign of an infection.13 Prot chk= 0

9. Pharmacokinetics: Lantus: Starts: 12 h Peaks: 6 hr.

Ends: 1826 h Low most likely at: 510 h

*While essential for patients with DM or GDM to maintain good metabolic control before conception and during pregnancy, there are no well-controlled clinical studies of the use of LANTUS in pregnant women. Lantus should be used during pregnancy only if the benefit justifies the risk to the fetus. Insulin requirements may decrease during the first trimester, generally increase during the second and third trimesters, and rapidly decline after delivery. Careful monitoring of glucose control is essential in these patients.15 Aspart: Start: 1020 m Peaks: 1.52.5 h Ends: 4.56 h Low most likely at: 25 h 10. Can Mrs. D continue her pregnancy exercise class at the community center? How will this affect her blood glucose control? The review article by Gavard et al, suggests exercise is effective in improving glycemic control. While the exact amount of exercise needed to control glucose levels is unknown, 3 or more times a week at 15-30 minutes per duration is the typical recommendation. Exercising both before and during pregnancy has the greatest correlation with protection against developing GDM.16 11. Nutrition Diagnosis PES statements: 1. Mrs. D has an excessive CHO intake, related to her diagnosis of gestational diabetes which requires a modified CHO intake, also Mrs. D is pregnant and the DRI for CHO for pregnant women is 175g. This is evidenced by her 24 hour diet recall of 454g CHO was 284g CHO over the recommended 175g and 134g over the recommended amount in her diabetic exchange meal plan. 2. Mrs. D has an inadequate protein intake, related to her increased metabolic needs during her pregnancy, as evidenced by her 24 hour recall protein total of 60g of the minimum 71g recommended by the IOM in the DRIs. It was 100g under the protein allowed in her diabetic exchange meal plan.

12. Nutrition Intervention: 1. Mrs. D will reduce her CHO intake by 50g a day because she is aware of the importance of modifying her intake due to her recent diagnosis of GDM. Mrs. D will record her diet every day for the next 7 days, upon which she will return to her RD to review her progress. She then realizes further modification will be necessary. 2. Mrs. D will increase her protein intake due to the increasing protein demands of her pregnancy. She will include two exchanges of lean protein at both lunch and dinner for an estimated 28 of additional protein. This will be reviewed along with her CHO reduction goal in her 7 day diet record upon her next visit one week from today.

13. Meal plan incorporating MNT Second Trimester Calorie allowance= 2566/day CHO= 2566(.50)/4 = 320g PRO= 2566(.25)/4 = 160g FAT= 2566(.25)/9 = 71g total fat/28g of this can be saturated

# Starch C=15 P=3 Meat P=7 F=3,5,8 Veg C=5 P=2 Fruit C=15 Bean C=15 P=10 Milk C=12 P=8 F=0,5,8 Fat F=5 +/8

CHO 320g 120

PRO 160g 24

FAT 71 0

# 8

Bfast 2

Snack 1

Dinner 2

Snack 1

Supper 1

Snack 1

42

18

10

50

20

10

2 5

30 75

0 50

0 0

2 5

1 1 1 1 2

45

24

10

0 0

0 0

40 +3

8 Ttl CHO

1 50cho

1 52

2 50

1 57

3 50 52

1. http://andevidencelibrary.com/topic.cfm?cat=3731 Need login information. 2. Metzger BE, Lowe LP, Dyer AR, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991-2002.

3. L. Kathleen Mahan MS RD CDE, Sylvia Escott-Stump MA RD LDN, Janice L Raymond MS RD CD. Krause's Food &amp; the Nutrition Care Process. Saunders; 4. Chick-Fil-A. Allergen, Gluten, Diabetic Exchange.http://www.chick-fil-a.com/Food/AllergenGluten-Diabetic.Accessed October 27, 2013.

5. The University of Arkansas. The Exchange List System for Diabetic Meal Planning.http://www.uaex.edu/Other_Areas/publications/PDF/FSHED-86.pdf.Accessed October 27, 2013. 6. MedlinePlus.Osmolalityblood.http://www.nlm.nih.gov/medlineplus/ency/article/003463.htm.Accessed October 27, 2013. 7. Joslin Diabetes Center. High Blood Glucose: What does it mean and how to treat it? http://www.amc.edu/pathology_labservices/addenda/addenda_documents/Americandiabetesa ssociationrecommendations2.pdf Accessed October 27, 2013.

8. Lab tests online. Triglycerides. http://labtestsonline.org/understanding/analytes/triglycerides/tab/test.Updated September 27, 2013.Accessed October 27, 2013. 9. Lab tests online. A1c.http://labtestsonline.org/understanding/analytes/a1c/tab/test.Updated July 18, 2013.Accessed October 27, 2013.

10. Lab tests online.RBC.http://labtestsonline.org/understanding/analytes/rbc/tab/faq#4.Updated May 22, 2013.Accessed October 27, 2013. 11. Lab tests online.Hematocrit. http://labtestsonline.org/understanding/analytes/hematocrit/tab/test.Updated May 22, 2013. Accessed October 27, 2013.

12. Lab tests online.Ferritin.http://labtestsonline.org/understanding/analytes/ferritin/tab/sample Updated July 21, 2013.Accessed October 26, 2013.

13. Lab tests online.Urinalysis.http://labtestsonline.org/understanding/analytes/urinalysis/uiexams/start/1.Accessed October 26, 2013. 14. Lab tests online.Urinalysis.http://labtestsonline.org/understanding/analytes/urinalysis/uiexams/start/1#uro.Accessed October 27, 2013.

15. DiabetesNet.com. Insulin Actions Times and Peak Times.http://www.diabetesnet.com/aboutdiabetes/insulin/insulin-action-time.Accessed October 26, 2013. 16. Gilmartin AB, Ural SH, Repke JT. Gestational diabetes mellitus. Rev Obstet Gynecol. 2008;1(3):129-34.