Aubrey Mahall
FN 440: MNT
Case Study: GDM
1. Gestational Diabetes Mellitus is diagnosed using A1c and glucose as prime markers. The
diagnostic criteria is an A1c >6.5%, fasting glucose >126mg/dL or 1-hour glucose
>200mg/dL1. In pregnant women GDM is screened during the 24th and 28th week with a
75 oral glucose tolerance test (OGTT), fasting glucose >92mg/dL, or 1-hour glucose
>180mg/dL, or 2-hour glucose >153mg/dL1. Mrs. Doolittle is at 22 weeks gestation and
lab tests show she is at risk for gestational diabetes due to a 100g OGTT revealing a
fasting level of 126mg/dL, and 126mg/dL is considered the threshold for high. After one
hour her glucose dropped below the high 180mg/dL to 175mg/dL. However, her values
were abnormally high during the 2 and 3 hour marks, with levels above the 155mg/dL 2hour test and 140mg/dL 3-hour test2. New guidelines have been proposed that women
at higher risk of developing GDM should be tested during the first trimester 1. While she
may not be diagnosed with GDM yet, she should be tested again in her 24th week
gestation to confirm or deny.
2. The risk factors for development of GDM include: gaining too much weight in the first
and second trimesters, Latina or African American ethnicity, and family or personal
history of diabetes or pre-diabetes. Mrs. Doolittle is at risk due to African American
ethnicity and a family history of diabetes mellitus. Her mother developed Type II
Diabetes and both her mother and aunt had problems with blood sugar levels during
their pregnancies. Mrs. Doolittle is also at risk because she is overweight and 41 years
of age.
3. Untreated or poorly managed hyperglycemia during pregnancy has risks for both
mother and baby. If Mrs. Doolittle develops GDM she has a5-10% chance of being
diagnosed with T2DM post-delivery, a 40-60% chance of developing diabetes in 5-10
years, and an increased risk of subsequent pregnancies with GDM. Concerning the fetus,
extra glucose from the mother will cross the placenta causing the fetus’ pancreas to
produce more insulin to cope with higher glucose levels. Excess glucose is then
converted to fat, which causes macrosomia, or infant with excessive birth weight1. A
fetus that is too large for vaginal birth will require a C-section birth. Following birth, the
baby may develop neonatal hypoglycemia if too much insulin is being produced. Since
glucose is no longer available to the fetus after birth until the pancreas adjusts, extra
glucose through intravenous feedings may be required to stabilize blood glucose levels 1.
4. Mrs. Doolittle is 5’3”, 175 pounds currently, and 165 pounds pre-pregnancy. She is 41
years old. Using the Hamwii equation, her ideal body weight is 115 pounds, so entering
her pregnancy at 165 pounds puts her at 50 pounds over IBW. Her calculated BMI prepregnancy was 29.22, placing her in the overweight category (25.0-29.9). For a woman
who enters her pregnancy overweight, her totaled weight gain recommendation is 1525 pounds3. In most pregnancies the woman should only gain about 3-5 pounds in the
first trimester. For an overweight woman she should be gaining 0.6lb/week for the
second and third trimesters3. Based on these recommendations, Mrs Doolittle is gaining
weight at an appropriate rate for her pregnancy. (See attached sheet for BMI
calculations).
5. To calculate Mrs. Doolittle’s energy requirements I used her pre-pregnancy weight.
Using her pre-pregnancy weight will maintain her gains throughout the rest of her
pregnancy. Due to the fact that Mrs. Doolittle was overweight prior to becoming
pregnant, I used the Mifflin St. Joer equation. (See attached sheet for calculations).
After converting her weight and height to appropriate units, I calculated her energy
needs to be about 1,384 kcal. I used a factor 1.3 for her physical activity component
because her exam stated that she was taking an exercise class at a community center. I
kept the activity relatively low because she was overweight prior to pregnancy, worked
at a desk as a paralegal, and was most likely doing light to slightly moderate exercise in
her workout class. This generated a total of about 1,800 kcal before introducing the
thermic effect of food. The thermic effect of food factor is 1.1, adding a total of about
1,979 kcal. Due to the fact that Mrs. Doolittle is in her second trimester, she needs
about 340 kcal extra per day3. Her final energy needs are computed at approximately
2,320 kcal per day. I calculated her fluid needs at about 9.6 cups per day. Her protein
needs were calculated using her pre-pregnancy weight of 75kg, multiplied by 1.1g/kg,
since pregnant women have higher protein needs than 0.8g/kg3. Her protein needs
would be met at 83g per day, but when totaling her carbohydrate, protein, and fat
distributions I increased her protein needs to 87g/day so she would get 15% of her
calories from protein. The remainder of her calories would be 55% from carbohydrate
and 30% from fat. This ends up totaling 319g of carbohydrate per day, 87g of protein
per day, and 77g of fat per day. This information is vital in determining her future MNT
needs.
6. Evaluating her 24-hour recall, I was able to understand where Mrs. Doolittle was overconsuming in calories.
Breakfast:
Exchange:
CHO:
PRO:
FAT:
1 C cereal
2
30
6
0
2% Milk
1
12
8
5
1 4” Donut
2CHO/2FAT
30
0
10
12oz OJ
3
45
0
0
117CHO x
4kcal/g
= 468 kcal
14PRO x 4kcal/g
= 56 kcal
15FAT x 9kcal/g
= 135 kcal
TOTAL:
Lunch:
Salad
Salad
8 crackers
16oz Milkshake
TOTAL:
Exchange:
1 CHO/1 VEG
3medFAT/1highFAT
1 CHO
6CHO/2FAT
CHO:
20
0
15
90
125CHOx4kcal/g
= 500 kcal
PRO:
5
28
3
18
54PRO x 4kcal/g
= 216 kcal
FAT:
0
23
0
10
33FAT x 9kcal/g
= 297 kcal
Dinner:
Vegetables
2C pasta
2 slice bread
1C fruit
Exchange:
2
4
2CHO/2FAT
(butter)
2
CHO:
10
60
30
PRO:
4
12
6
FAT:
0
0
10
30
0
0
16oz 2% Milk
TOTAL:
2
24
154CHOx
4kcal/g
= 616 kcal
16
38PRO x 4kcal/g
= 152 kcal
10
20FAT x 9kcal/g
= 180 kcal
Exchange:
1
2CHO/2FAT
CHO:
12
30
42CHO x 4kcal/g
= 168 kcal
PRO:
8
0
8PRO x 4kcal/g
= 32 kcal
FAT:
5
10
15FAT x 9kcal/g
= 135 kcal
Snack:
1 C 2% Milk
4 Oreo’s
TOTAL:
Using the Exchange Lists provided in class notes and the USDA for combination foods 4, her 24hour recall totaled 2,955 kcal in one day. According to her energy requirements calculated in
the previous question, Mrs. Doolittle is over consuming by 635 calories. If she continues to do
this she may gain too much weight in the rest of her pregnancy, elevating her risk of GDM. In
the previous question I specified the distribution of CHO, PRO, and FAT throughout the day for
Mrs. D, and the other nutrients that are important for her during pregnancy are Vitamin A,
Vitamin D, calcium, and iron3. Vitamin A is important for her pregnancy because it helps with
fetal lung and heart development. The recommendation is 770 micrograms/day. Vitamin D is
for bone and immune function in the fetus, and recommended intake at 200 IU/day. Calcium
peak transfer to fetus is during the third trimester, with a recommendation at 1,000 mg/day.
This is important for bone mineral health. Finally, iron at 27 mg/day is most critical in the last
two months of her pregnancy. During the time the fetus stores 6-8 months worth of iron.
These recommendations for Vitamin D and calcium actually do not increase during pregnancy,
however, they are still important markers to intake since they are crucial for fetal development.
Mrs. Doolittle should focus on these nutrients because whatever she is deficient in, her body
will take first before giving it to the fetus3. I also wanted to monitor her lipid intake for omega3’s and omega-6’s. These are important for brain, retina, and neural development. Omega-6
are recommended at 13 g/day and omega-3 recommended at 1.4 g/day. Fish is a good source
of omega’s, however pregnant women are limited to no more than 12oz, and no more than 6oz
of albacore tuna due to mercury concerns3.
7.
a. Mrs. Doolittle’s CMP reveal levels of glucose, triglycerides, and A1c all well above
normal ranges. Normal levels of glucose are 70-110 mg/dL, and her lab revealed
186 mg/dL. High levels of glucose frequently indicate diabetes. In GDM, with a
50g glucose drink, less than 140 mg/dL is normal, anything higher may indicate
pre-diabetes or diabetes5. The diagnostic test is a 100-OGTT, discussed
previously, over 3-hour marker observations. The normal range for triglycerides
is 35-135 mg/dL, and Mrs. D’s was 155 mg/dL. High triglyceride levels are
associated with an increased risk of heart disease, and can be brought on by
GDM5. Finally, her A1c was abnormal at 8.5%, with a normal range set at 3.95.2%. Since A1c is used to monitor the glucose control in diabetes over time, her
abnormally high levels indicate a lack of controlled glucose levels. However, A1c
should not be used to diagnose pregnant women5. All three abnormal levels
may be due to her over consumption of daily calories, putting her at an
increased risk of developing GDM. Steps should be taken to control her glucose
and triglyceride levels to reduce her risk of GDM.
b. The CBC report indicated lower than normal levels of RBC’s, hematocrit, and
ferritin. A rise or drop in RBC count is monitored in accordance with other
parameters such as hematocrit. Acute or chronic drop in RBC usually result from
conditions or diseases that decrease red cell production in the bone marrow5. In
Mrs. D’s case, her low RBC, hematocrit, and ferritin are all most likely due to a
nutrient deficiency of iron, Vit B12, or folate. Low ferritin may also be an
indicator/risk factor for iron deficiency anemia. This is most likely the case for
Mrs. Doolittle because acceptable iron ranges are 20-120 mg/mL, and Mrs. D’s
report reveals she is extremely low at only 12mg/mL. Adding iron-rich foods to
her diet will help to increase iron stores, thereby elevating her RBC, hematocrit,
and ferritin within acceptable healthy ranges. In pregnancy, if a mother is
deficient the vitamins or nutrients will sustain the mother first, and then transfer
to the baby. It is imperative for Mrs. Doolittle to increase her iron because if she
is anemic then the fetus is deficient as well. Protein intake could help to resolve
iron status for Mrs. Doolittle and her baby.
8. The results of Mrs. Doolittle’s urinalysis reveal urine that is straw colored and hazy.
Straw color is actually a good indicator of hydration, revealing that excess water is being
removed by the urinary system. A hazy appearance is also normal, however, a sample
that is too hazy could result from excess RBC, WBC, or bacteria in the urinary tract5. If
her sample becomes too hazy then more attention is needed. The most abnormal
finding of her urinalysis was the presence of glucose. Glucose is not normally present in
urine, but when it is, the condition is called glucosuria5. An excessively high
concentration of glucose in urine may be present in someone with uncontrolled DM.
Pregnancy is also a common cause of glucosuria. Additional glucose tests can be
performed to determine the exact cause.
9. Mrs. Doolittle was initially prescribed Aspart before meals and Lantus before bed. The
two drugs are rapid-acting, and long-acting insulins, respectively. Aspart has an initial
reaction time of less than 15 minutes, peak reaction at 1-2 hours, and a duration of 3-5
hours1,2. This is an insulin analog that differs in amino acid sequences, but bind to
insulin receptors. Due to its quick reaction time, it is taken prior to meals. The longacting insulin, Lantus, has an initial reaction time of 2-4 hours, peakless reaction, and
duration of 20-24 hours1,2. Its slow dissolution at injection results in constant, or
peakless, delivery of insulin over night. This type has an acidic pH, so therefore it should
not be combined with other insulins2.
10. Exercising during pregnancy, as well as for those at risk of gestational diabetes and
preeclampsia, is beneficial. Exercising has been proven to assist in overcoming
peripheral resistance to insulin and controlling fasting and postprandial hyperglycemia1.
Exercise should be used in combination with medical nutrition therapy in order to
improve maternal glycemia. While brisk walks after meals are recommended, low
intensity exercise classes at her community center would still be beneficial for her,
considering her overweight status pre-pregnancy. Controlling her glucose levels is
crucial for lowering the risk of GDM. Too much, or too intense, exercise may cause
hypoglycemia so balance is important. I would also recommend exercising for Mrs.
Doolittle to lower the risk of developing preeclampsia. Since the only cure of
preeclampsia is birth, at 22 weeks Mrs. Doolittle needs to keep her risks of preeclampsia
much lower.
11. PES statements:
a. Excessive CHO intake related to physiological cause of gestational diabetes
mellitus requiring monitored CHO intake, as evidence by hyperglycemia with a
fasting blood sugar of 126 mg/dL and hemoglobin A1c at 8.5%.
b. Inadequate iron intake related to increased need due to pregnancy and
decreased consumption in diet as evidence by low HCT 36.5% and ferritin 12
mg/mL.
12. Ideal Goals for PES:
a. Excessive CHO intake- Decrease her % of kcals from CHO from 60% to 50% kcals
per day and modify her diet to include complex carbs such as whole grains at
every meal. Limit CHO intake per meal to 50g.
b. Inadequate iron- Increase consumption of iron-rich foods such as spinach, lean
meats, broccoli, beans, and iron-fortified cereals with at least 5 servings of those
foods per day.
13. Using her diet history to determine food preferences, and her 24-hour recall to adjust
distributions of carbohydrate, protein, and fat, the meal plan listed below will meet
acceptable dietary needs. The exchanges listed will provide guidance for Mrs. Doolittle
as to how many servings of each food group she can have per day. Then, she will be
able to decide for herself, which foods she wants to consume. However, I have outlined
her vegetables to include spinach, broccoli, and other iron-rich groups. I have
recommended her starches and carbohydrates are complex carbs with examples as
whole grain bread and oatmeal as an ideal breakfast. To minimize her carb
consumption to 50g per eating event, Mrs. Doolittle will have to eat about 8 times per
day. That allows three big meals and five small snacks. (319 g CHO / 50g/meal) = 7.82.
Snacks could include a piece of fruit, a ½ cup of beans, or vegetables with hummus. Her
exchange list to base her menu from is:
Milk 1%
Starch
Beans
Nuts
Vegetables
Fruit
Meat
Fat
TOTAL:
Breakfast
Snack
Snack
Lunch
Snack
Dinner
Snack
TOTAL:
Exchange:
1
10
2
2
6
6
2 (1 Med/1 High)
7
CHO:
12
150
30
6
30
90
0
0
318g
PRO:
8
30
20
6
12
0
14
0
90g
FAT:
3
0
6
18
0
0
13
35
75g
Exchange:
1 starch, 1 fruit,
1 nuts, 1 milk
3 fruit, 1 veg
3 starch, 2 fat
3 veg, 1 med
meat, 2 starch, 1
nuts, 1 fat
2 beans, 1 veg, 1
starch, 1 fat
2 starch, 1 high
meat, 1 veg, 1
fruit, 2 fats
1 starch, 1 fruit,
2 fat
CHO:
45g
PRO:
14g
FAT:
12g
50g
45g
48g
2g
9g
22g
0g
10g
19g
50g
25g
8g
50g
15g
18g
30g
3g
10g
318g
90g
77g
An ideal healthy breakfast, for example, could be ½ cup oats (1 starch = 15g CHO, 3g
PRO, 0g FAT), ¾ cup blueberries (1 fruit = 15g CHO, 0 PRO, 0 FAT), 6 almonds (1 nuts = 3
CHO, 3 PRO, 9 FAT), and 8 ounces 1% milk (1 milk = 12 CHO, 8 PRO, 5 FAT). This
breakfast combination would keep her carbohydrate intake to 45g, which is our goal to
lower excessive carbohydrate intake, which lead to hyperglycemia and elevated
hemoglobin A1c. This meal also meets the goal of adding in complex carbs like oatmeal
to stabilize blood sugar throughout the day.
In order to lower Mrs. Doolittle’s risk of GDM and preeclampsia, it is highly
recommended she follow this medical nutrition therapy plan to reduce glucose,
triglycerides, A1c, while increasing iron, RBC, and hematocrit count. If we can stabilize
Mrs. Doolittle’s fasting glucose and results of a 100g-OGTT, we can dramatically reduce
her risk of developing GDM, which will benefit her and her baby.
References:
1. Mahan L, Escott-Stump S, Raymond J. Medical Nutrition Therapy for Diabetes Mellitus
and Hypoglycemia of Nondiabetic Origin. In: Alexopoulos Y. Krause’s Food and the
Nutrition Care Process Ed. 13. St. Louis, Missouri: Elsevier; 2012:675-707.
2. Medline Plus. Insulin Aspart Injection, Insulin Lantus. Medline Plus.
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a605013.html. Published
September 25, 2013. Accessed October 20, 2013.
3. Edlestein S, Sharlin J. Nutritional Requirements During Pregnancy and Lactation and
Normal Infant Nutrition. In: Edelstein S. Life Cycle Nutrition: An Evidence-Based
Approach. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2009:39-70.
4. USDA. Carbohydrate Counting and Exchange Lists. USDA. http://fnic.nal.usda.gov/dietand-disease/diabetes/carbohydrate-counting-and-exchange-lists. Published October 25,
2013. Accessed October 26 2013.
5. Lab Tests Online. Urinalysis, CMP, CBC. Lab Tests Online. http://labtestsonline.org/.
Published September 26, 2013. Accessed October 20, 2013.