Diabetes/Nutrition/Obesity

Question 1

Describe the incidence, etiology and risk factors for pregestational diabetes in pregnancy

Answer 1

Incidence: 14% of diabetes in pregnancy is pregestational (86% GDM)

High risk for pregestational diabetes:

• Overweight or Obesity (BMI >25; BMI >23 in Asian women) +
  
  • Age > 40 years
  • Previous history of GDM
  • Hypertension (>140/90 or on antiHTNs)
  • Prior macrosomia (> 4000 g)
  • Prior IUFD or fetal congenital anomalies
  • Physical inactivity
  • First-degree relative with diabetes
  • High-risk race or ethnicity (African, Native, or Asian Americans, Latino, or Pacific Islander)
  • HDL < 35 mg/dl, triglycerides >250 mg/dl
  • Polycystic ovarian syndrome or symptom of insulin resistance (ie acanthosis nigricans)
  • Hx of cardiovascular disease
  • HA1C = 5.7 or higher

Question 2

Describe the incidence, etiology and risk factors for gestational diabetes

Answer 2

Risk factors:

• Hispanic, African American, Native American, and Asian or Pacific Islander races
• Age > 40
• BMI > 25
• Prior history of GDM, glycosuria or impaired carbohydrate metabolism
• Strong family history of type 2 diabetes (two first-degree relatives)
• Prior history of stillbirth, infant with congenital anomalies, or macrosomia

Question 3

Acceptable tests for assessing pregestational diabetes:

Answer 3

• Fasting plasma glucose (diagnostic ≥126 mg/dl)
  
  • Fasting = no caloric intake for at least 8 h
• Hemoglobin A1c (diagnostic ≥ 6.5%)
• 2 h OGT after 75 gm glucose load OR random plasma glucose (diagnostic ≥ 200 mg/dl) in patient with classic symptoms
• A 3-hour test has never been validated in early pregnancy
• If first trimester test negative in high risk patient, screen for GDM at 24-28 weeks

Question 4

Pathyphysiology of GDM

Answer 4

“Early type 2 diabetes”

Hormones synthesized by the enlarging placenta (later half of pregnancy) and pro-inflammatory cytokines → increased insulin resistance → parental ß-cells can’t keep up with enough insulin secretion

Hormones involved:

• Human placental lactogen (aka chorionic growth hormone)
• Human placental growth hormone
• Progesterone
• Leptin
• TNFα
• Cortisol

Question 5

Screening methods to identify GDM, including advantages and disadvantages

Answer 5

• Screen at 24 - 28 weeks
• ONE-STEP method (recommended by WHO):
  
  • 75-g, 2 hour OGTT
  • Diagnosis of GDM : If one abnormal value
    
    • Fasting ≥ 92 mg/dl
    • One hour ≥180 mg/dl
    • Two hour ≥153 mg/dl
  • May potentially overdiagnose, but less likely to underdiagnose
  • TWO-STEP method (recommended by ACOG)
    
    • Screening
      
      • 1 hour, 50gm glucose challenge
      • Value > 135 or 140 mg/dl → require diagnostic test
      • Depending on which end of the range you use, you might miss cases or do unnecessary 3-hour OGTTs
    • Diagnosis (Carpenter and Coustan criteria)
      
      • 2 or more abnormal values on 3 hour, 100gm glucose tolerance test
        
        • Fasting > 95 mg/dl
        • 1h> 180 mg/dl
        • 2h> 155 mg/dl
        • 3h> 140 mg/dl

Question 6

Describe risks to the fetus in all types of diabetes

Answer 6

• Increased risk of congenital anomalies: esp cardiac and CNS malformations
  
  • HA1C < 6.5% reduces risk if pregestational
• Macrosomia (birth weight > 4000 gms)
• Birth trauma (shoulder dystocia, nerve palsies)
• Respiratory distress syndrome
• Hypoglycemia
• Hyperbilirubinemia
• Perinatal mortality
• Long term: Increased risk of obesity, type 2 diabetes

Question 7

Describe the role of fetal surveillance in the management of pregnancies complicated by all types of diabetes

Answer 7

• Serial U/S assessments of fetal growth q4-6 wks:
  
  • EFW
  • AC (most predictive of macrosomia)
  • HC/AC ratio
• Fetal movement counting - daily starting at 28 weeks
• If comorbidities (CHTN, nephropathy ) → consider doppler u/s at 28 weeks
• A1 GDM
  
  • NSTs starting at term (some say not necessary)
• A2 GDM and beyond
  
  • NST/BPP 2x/week starting at 32 weeks

Question 8

Describe strategies for the antepartum management of diabetes (all types) in pregnancy

Answer 8

• Office visits q 1-2 weeks
  
  • Weekly after 36 weeks
• Maternal assessments
  
  • Glucose control
  • Urinary ketones and albumin
  • Blood pressure
• Timing of delivery
  
  • Less than 39 weeks with poor or undocumented control → establish lung maturity with amniocentesis (presence of PG)
  • A1 not be before 39 weeks of gestation, unless otherwise indicated. Expectant management up to 40 6/7 weeks.
  • A2 (well controlled) - 39 0/7 to 39 6/7 weeks
  • Offer cesarian if EFW is > 4500 g

Question 9

Blood glucose goals during pregnancy

Answer 9

• Before breakfast: 60-90 mg/dl
• Before lunch, dinner, bedtime snack: 60-105 mg/dl
• 1 hour post prandial: ≤ 130 mg/dl
• 2 hours post prandial: ≤ 120 mg/dl
• 2:00 to 6:00 AM: > 60 mg/dl

Question 10

Medications for GDM

Answer 10

• Insulin: Does not cross placenta → drug of choice
  
  • Typically initiated if fasting or postprandial BG not controlled by diet, activity
  • Start with low dose and adjust as needed
    
    • 0.7-1 unit/kg/day in divided doses
  • Markedly increased requirements 3rd trimester
• Oral drugs: Crosses placenta → long term effects unknown
  
  • Glyburide increasingly used for GDM not controlled with diet: Start with 2.5 mg BID
  • Metformin not as well-studied in pregnancy but is also being used

Question 11

How often should blood glucose be monitored?

Answer 11

• No great evidence
• General consensus: 4x/day
  
  • Fasting
  • After each meal (1 to 2 hours after)

Question 12

Exercise recommendations for GDM

(ACOG)

Answer 12

• Aim for 30 minutes of moderate-intensity aerobic exercise at least 5 days a week
• Or a minimum of 150 minutes per week.

Question 13

Discuss postpartum screening for diabetes

Answer 13

• Scree at 4–12 weeks postpartum
• Use non-pregnancy cutoffs
• 75 g, 2 hour GTT
  • Normal: < 140 mg/dl
  • Impaired: 140-199 mg/dl
  • Diabetes: ≥ 200 mg/dl
• If impaired fasting glucose, IGT, or diabetes → refer for preventive or medical therapy.
• Repeat testing every 1–3 years for women who had normal postpartum screening test results

Question 14

Classification of types of diabetes

(according to White)

Answer 14

• A1 - GDM, managed by diet and lifestyle
• A2 - GDM, managed by insulin or glyburide

These are just FYI (Kim’s slide):

• B - < 10 years duration
• C - 10 - 19 years duration
• D - > 20 years duration, presence of vascular disease
• R - Retinopathy
• F - Nephropathy
• H - Heart disease
• T - s/p transplantation

Question 15

Discuss obstetrical complications of diabetes in pregnancy, including:

• Macrosomia
• Shoulder dystocia
• Operative delivery
• Postpartum hemorrhage

Answer 15

• Macrosomia
  
  • EFW not very accurate. Needs to be > 4800 g to have 50% chance of predicting BW > 4500 g
• Shoulder dystocia
  
  • Higher risk due to macrosomia and also the adiposity of baby with insulin-dependent parent
• Operative delivery
  
  • Offer cesarean if EFW > 4500 g
• Postpartum hemorrhage

Question 16

Describe the implications of GDM on future health for both the parent and infant

Answer 16

• Parent
  
  • GDM is biggest risk factor for Type 2 DM
    
    • 60% within 5 years develop it.
    • Decreases risk:
      
      • Breastfeeding (longer = less likely)
      • Return to prepregnant weight
      • Group/telemedicine support
  • GDM + family hx of type 2 → risk for developing metabolic syndrome
• Infant
  
  • Risk for being overweight/obese, type 2 DM, metabolic syndrome

Question 17

Scope of practice for CNM/WHNP when caring for women with a pregnancy complicated by diabetes or obesity

Answer 17

• GDM commonly managed by CNMs/NPs/PAs
• MD consult for pharm therapy:
  
  • Abnormal fasting glucose levels
  • If < 80– 90% of postprandial values meet glucose target levels

Question 18

Describe risks to the fetus and the role of fetal surveillance in the management of pregnancies complicated by obesity

Answer 18

Risk to fetus:

• Increased breastfeeding difficulties
• Increased risk of macrosomia
• Increased risk of metabolic syndrome, diabetes, obesity later in life (epigenetic effects)

Question 19

Describe obstetrical complications commonly associated with obesity in pregnancy:

Answer 19

• Increase in preterm birth
• Increase in perinatal mortality
• Increased rate of Cesarean birth
• Increased rate of surgical site infections in overweight women
• Increase in postpartum venous thromboembolism
• Slower cervical dilation with increasing obesity
• Preeclampsia
• Post-term pregnancy

Question 20

Dietary recommendations in GDM

Answer 20

• Approximately 35– 40% complex car­bs
  
  • Eliminate simple sugars,
• 20– 30% protein
• The rest fats
• For stable blood glucose:
  
  • 3 meals with 2 to 3 snacks with car­bs evenly distributed throughout day, with the exception of breakfast.
    
    • Eat fewer carbs at breakfast - less well tolerated due to early morning hormones secretion (epinephrine, cortisol)
  • Following these dietary guidelines, glucose levels will normalize in around 75– 80% of women with gestational diabetes .
  • Bedtime snack of about 15– 30 g carbs to prevent overnight ketosis.

Question 21

Discuss evidence-based strategies for achieving postpartum weight loss

Answer 21

• Diet alone
• Diet and exercise

Question 22

Identify the caloric content of 1 gram each of:

Fat, protein, and carbohydrate

Answer 22

• Fat - 9 calories
• Protein - 4 calories
• Carbs - 4 calories

Question 23

Body mass index (BMI) formula

Answer 23

Weight (kg) / Height (m²)

Question 24

Identify the appropriate weight gain for the different levels of pre-pregnant BMIs

Answer 24

• 1st trimester: 1 – 4.4 lbs of weight gain (all BMIs)
  
  • Don’t need extra calories
  • Some women lose weight, which is ok, some are too nauseated to eat
• 2nd + 3rd trimester:
  
  • 2nd trimester: + 350 calories
  • 3rd trimester: + 450 calories
  • Normal weight: 1 lb/week
  • Overweight/obese: 0.5 lb/week

I also attached this chart from Jordan that is similar. Above is from Kim’s lecture

Question 25

Identify components of weight gain during pregnancy

Answer 25

Average pregnancy weight gain distribution

• 6 - 8 lbs: Baby
• 1.5 lbs: Placenta
• 2 lbs each: Amniotic fluid, uterus growth, breast growth
• 8 lbs: added body fluid
• 7 lbs: added muscle and fat stores

Question 26

Identify nutritional concerns for pregnant women who are lactose and/or gluten intolerant

Answer 26

• Lactose intolerant – may be deficient in calcium
  
  • Recommended:
    
    • 1300 mg/day < 19 age
    • 1000 mg/day if > 19 years old
  • Use special products like lactaid
  • Intolerance may improve during the latter part of the pregnancy
  • Tums are good source of Ca++
• Gluten intolerant – may not get enough B vitamins if not eating fortified foods
  
  • Gluten-free products aren’t always fortified, though this might be getting better

Question 27

Define pica and identify the effect of pica on maternal nutrition and fetal well being.

Answer 27

• Compulsive, purposeful intake of nonnutritive substances that the consumer does not define as food for > 1 month
  
  • Examples: ice (pagophagia— 70% of pica), dirt/clay (geophagia— 18% of pica), corn starch (amylophagia), soap (4% of pica), charcoal, ash, paper, chalk, cloth, baby powder, coffee grounds, eggshells, and nail polish
• Etiology poorly understood.
  
  • Possible nutrient deficiencies: zinc, iron, and Ca
  • Associated with iron deficiency anemia (unclear if resulting or predisposing factor)
  • Cultural beliefs
  • Psych/behavioral response to stress, a habit or disorder, or a manifestation of an oral fixation
• Appears to be more common in: African Americans, people living in rural areas, and family hx of pica
• Complications vary based on the type of pica:.
  
  • Heavy metal poisonings (especially lead)
  • Alimentary canal damage
  • Excessive pregnancy weight gain (especially starch ingestion)
  • Nutrient deficiencies, constipation, electrolyte imbalances, gastrointestinal disturbances, parasitic in­­ fections, dental complications, gestational hyperglycemia, and metabolic disturbances.
• Often unreported due to embarassment

Question 28

Define prenatal and postnatal flavor learning. Identify their effects on infant nutrition and child health.

Answer 28

• Flavor preferences start in utero based on what the parent consumes
• Exposure to a variety of healthy food flavors starting in utero and early infancy → children’s flavor preferences → potential to improve lifelong health
• Adding the concept of preand postnatal flavor learning to nutrition education → empower pregnant/breastfeeding parents to influence their child’s future nutritional health by eating a large variety of healthy food.

Question 29

Identify the physiologic functions, recommended daily allowances, principal food/supplemental sources for:

Fats

Answer 29

• Source of vitamins and concentrated calories
• No exact RDI, but 20 – 35% of daily intake.
  
  • Limit saturated and trans fats
• Fatty acids: Omega-3’s
  
  • ALA – in plants, must eat because our body doesn’t make it
  • EPA, DHA found in seafood, we can make it but better to ingest
  • DHA = 30% fetal brain weight and is important for neuro, recommeng 300 mg/day
• Eat seafood 2x/week (limit to 12 oz total)

Question 30

Identify the physiologic functions, recommended daily allowances, principal food/supplemental sources for:

Carbohydrates

Answer 30

• Source of glucose
• Simple carbs - fruit, milk/milk products, processed + refined foods are broken down quickly
• Complex/starches - some cereals, whole grains, some vegetables like corn, broccoli, legumes - take longer to break down.
• RDI 175 g/day (most women already get this)

Question 31

Identify the physiologic functions, recommended daily allowances, principal food/supplemental sources for:

Protein

Answer 31

• Forms structural basis of new cells and tissues.
• Sources: meat/poultry, dairy/eggs, legumes/soy, nuts/seeds.
• RDI 71g for pregnancy + lactation.
• Most women already get 74 g unless no meat diet or food insecure.
• High protein bad (may elevate fetal ammonia)

Question 32

Identify the physiologic functions, recommended daily allowances, principal food/supplemental sources for:

Iron

Answer 32

• Need for increase starts 2nd tri – peaks end of 3rd tri for increased parent/fetus RBCs.
• RDI 25 mg day (amount in most PNVs).
• Heme iron more easily absorbed (meat/poultry/fish) than non heme iron (eggs/plants/legumes).
  
  • Heme absorption efficient and not influenced by what its eaten with.
• Need supplimentation if:
  
  • Hct < 33% in 1st + 3rd trimesters
  • < 32% in 2nd trimester

Question 33

Identify the physiologic functions, recommended daily allowances, principal food/supplemental sources for:

Folate

Answer 33

• Water soluable form of Vitamin B9.
• Found in green leafy vegetables, bananas, fortified cereals (since 1998), lentils.
• Reduces NTD, oral cleft, and cardiovascular problems when taken in early pregnancy.
• Need 400 mcg before and during pregnancy.

Question 34

Identify the physiologic functions, recommended daily allowances, principal food/supplemental sources for:

Calcium

Answer 34

• Needed for fetal skeleton development.
• Active transport across placenta so fetal levels higher than parent.
• RDI: < 19 years old need 1300 mg/day, 19 – 50 years old and breastfeeding need 1000 mg/day.
• Groups at risk for lower Ca intake: adolescent, lactose intolerant, vegetarian, low income.
• Food sources:
  
  • Milk/cheese/yogurt (higher fat = lower Ca),
  • Broccoli, chinese cabbage, kale
  • Ca-fortified orange juice and cereals.

Question 35

Identify the physiologic functions, recommended daily allowances, principal food/supplemental sources for:

Vitamin D

Answer 35

• Fat soluable, acquired through diet or expsosure to sunlight.
• Steroid hormone precursor.
• Helps body use Ca and fetal bone growth
• RDI 600 IU/day
• Food sources: milk, fish liver oils, fortified dairy and cereals, egg yolks

Question 36

Discuss risks of obesity specific to the woman, the fetus, pregnancy, labor and birth

Answer 36

Question 37

Describe medical management guidelines for the care of the obese woman

(this card sucks)

Answer 37

• Assess psychological risk factors, depression, and potential eating disorders. Refer for counseling if necessary.
• Advise a pregnancy wt gain consistent
• Assess comorbidities of obesity and patterns of previous weight gain and loss.
• Perform a nutritional assessment
• Have patient identify one to two nonnutritious foods that could be dropped or changed immediately for more nutritious foods.
• Refer for nutrition counseling if available
• Screen for diabetes at first visit
• Offer early screening for neural tube defects (NTDs) - including early serum screening and ultrasound at 11– 13 weeks to assess nuchal translucency.
• Obesity often limits ultrasound visualization and women may need to be rescheduled 1– 2 weeks later, past the ideal nuchal translucency evaluation time.
• Schedule frequent visits every 2 weeks for regular weight gain assessment and nutrition counseling.

Question 38

Describe disordered eating, eating disorders and therapeutic approaches in the management of pregnant patients with a history of, or current problem with disordered eating

Answer 38

• Classified as: anorexia nervosa, bulimia, or eating disorders not otherwise specified (EDNOS), such as binge eating
  
  • Anorexia nervosa - group of symptoms including unwillingness to maintain weight at a minimal normal weight for age/ht, intense fear of gaining wt, body image disturbances, and amenorrhea x at least 3 consecutive months
  • Bulimia nervosa - symptoms such as inaccurate perception of body image, a sense of lack of control during recurrent binge eating occurring at least 2x/week for at least 3 months, use of compensatory behaviors to prevent weight gain (vomiting/laxatives/excessive exercise) at least 2x/week for at least 3 months
  • EDNOS is a diagnosis of exclusion; it involves those who exhibit some symptoms but do not fit the criteria of anorexia or bulimia.
• Greater likelihood of: miscarriage, cesarean, stillbirth, LBW, low Apgar, microcephaly, breech, and cleft lip and palate
• Successful strategies to assist women with eating disorders include:
  
  • Care from the same provider throughout pregnancy.
  • Increased prenatal visit schedule with small goal setting and nutrition counseling
  • Referral to a nutritionist and a mental health-care provider.

Question 39

Foods to avoid:

Answer 39

• Unpasteurized dairy products and juices
• Smoked and lunch meats (if eaten, reheat until hot)
• > 200 mg caffeine
• Always avoid high mercury: tilefish, mackerel, shark, sword fish, marlin, orange roughie, albacore white tuna (should eat the darker variety)
• Raw fish
• Unwashed fruits/veggies (wash for at least 30 seconds)
• > 12 oz/week of fish
• Saccarine (artificial sweetner)

Question 40

Dietary recommendations:

Answer 40

• Grains: 6 oz daily (ie 1 slice bread, 1 cup cooked rice)
• Veggies: 2 – 3 cups and vary the colors
• Fruits: 2 cups, whole fruit better than juice
• Dairy: 3 – 4 cups, choose low fat if overweight
• Protein: 5 – 6 oz, eat seafood 2x/week
• Oils: 6 tsp

Question 41

Counseling for vegetarians/vegans

Answer 41

Nutrients of concern in vegetarian diets:

• Iron
• Protein
• B vitamins
• Vitamin D and calcium
• Omega-3 fatty acids

Question 42

Obesity vs morbid obesity

Answer 42

• Obese = BMI 30 - 34.9
• Morbidly obese = > 35
• BMI > 40 at especially high risk during pregnancy

Question 43

Identify the components of a diet history

Answer 43

Question 44

Identify the symptoms of nutritional deficiencies

Answer 44

Question 45

Define: hyperemesis gravidarum

Describe diagnostic criteria, risks to the woman and fetus, and management

Answer 45

• Persistent and severe N/V, dehydration, fluid and electrolyte imbalance, and weight loss (can lose 5% or more of body weight).
• Most common cause of hospitalization in 1st half of pregnancy, second only to preterm labor for pregnancy hospitalizations overall
• Maternal complications:
  
  • Vomiting-induced esophageal rupture → GI bleeding Wernicke’s encephalopathy (after several weeks of vomiting) - thiamine deficiency and is a potentially fatal medical emergency. Reversible but can cause persistent neurological deficits. Most common sign is apathy.
  • Persistent vomiting → hyponatremia. Early signs: anorexia, HA, N/V, and lethargy can be missed since the clinical presentation is similar to HG itself.
• Fetal complications:
  
  • FGR
  • Preterm birth, SGA
• Recurrence in subsequent pregnancies is approximately 15%
• Management: antiemetics and intravenous (IV) rehydration
  
  • Restore volume, electrolyes, thiamine (if vomiting > 3 weeks)
  • Often managed outpatient, even on IV therapy.
    
    • Inpatient admission: severe dehydration, ketonuria, weight loss > 5%, and the inability to keep down any food or fluids
  • May be appropriately managed by CNM/NP with MD consult/comanagement as required by the pt condition. Inpatient may require referral for management if the provider does not have inpatient privileges.