Diet and Weight Gain During Diabetic Pregnancy

A nutritionally balanced diet is always essential to maintaining a healthy mother and successful pregnancy.

The foods you choose become the nutrient building blocks for the growth of the fetus. F

or a woman with , gestational diabetes, proper diet alone often keeps blood sugar levels in the normal range and is generally the first step to follow before resorting to insulin injections.

Careful attention should be paid to the total calories eaten daily, to avoid foods which increase blood sugar levels, and to emphasize the use of foods which help the body maintain a normal blood sugar. A registered dietitian is the best person to help you with meal planning to meet your individual needs.

Your physician can help you find a dietitian if this service is not a part of his or her office or clinic. Your local chapter of the American Dietetic Association or the American Diabetes Association can also help you locate a registered dietitian.

How much weight should I gain?

Of all questions asked by pregnant women, this is the most common. The answer is particularly important for women with gestational diabetes. The weight that you gain is a rough indication of how much nutrition is available to the fetus for growth. An inadequate weight gain may result in a small baby who lacks protective calorie reserves at birth. This baby may have more illness during the first year of life. An excessive weight gain during pregnancy, however, has an insulin­resistant effect, just like the hormones produced by the placenta, and will make your blood sugar level higher.

The ?optimal? weight to gain depends on the weight that you are before becoming pregnant. Your pre-pregnancy weight is also a rough indication of how well-nourished you are before becoming pregnant. If you are at a desirable weight for your body size before you become pregnant, a weight gain of 24 to 27 pounds is recommended. If you are approximately 20 pounds or more above your desirable weight before pregnancy, a weight gain of 24 pounds is recommended.

Many overweight women, however, have healthy babies and gain only 20 pounds. If you become pregnant when you are underweight, you need to gain more weight during the pregnancy to give your baby the extra nutrition he or she needs for the first year. You should gain 28 to 36 pounds, depending on how underweight you are before becoming pregnant. Table 3 shows whether your pre-pregnancy weight is considered underweight, normal weight, or overweight. Your nutrition advisor or health care provider can recommend an appropriate weight gain. How your weight gain is distributed is illustrated in figure 3.

TABLE 3. Pre­-Pregnancy Weight

Use this chart to determine if your pre­pregnancy weight is normal, underweight, or overweight.

*Normal weight for ?thin-boned? women will be closer to the lower end of this range. For “big-boned” women, it will be closer to the higher end.

Reprinted with permission from: Judith E. Brown. Nutrition for Your Pregnancy. University of Minnesota Press, 1983.

Total recommended weight gain is often not as helpful as a weekly rate of gain. Most women gain 3 to 5 pounds during the first trimester (first 3 months) of pregnancy. During the second and third trimesters, a good rate of weight gain is about three­quarters of a pound to one pound per week. Gaining too much weight (2 or more pounds per week) results in putting on too much body fat. This extra body fat produces an insulin-resistant effect which requires the body to produce more insulin to keep blood sugar levels normal. An inability to produce more insulin, as in gestational diabetes, causes your blood sugar levels to rise above acceptable levels. If weight gain has been excessive, often limiting weight gain to approximately three-quarters of a pound per week (3 pounds per month) can return blood sugar levels to normal. Fetal growth and development depend on proper nourishment and will be placed at risk by drastically reducing calories. However, you can limit weight gain by cutting back on excessive calories and by eating a nutritionally-sound diet that meets your needs and the needs of your baby. Remember that dieting and severely cutting back on weight gain may increase the risk of delivering prematurely. If blood sugar levels continue to go up and you are not gaining excessive weight or eating improperly, the safest therapy for the well-being of the fetus is insulin.

Occasionally, your weight may go up rapidly in the last trimester (after 28 weeks) and you may notice an increase in water retention, such as swelling in the feet, fingers, and face. If there is any question as to whether the rapid weight gain is due to eating too many calories or too much water retention, keeping records of how much food you eat and your exercise patterns at this time will be very helpful. A Food and Exercise Record Sheet is included at the end of this book. By examining your Food and Exercise Record Sheet, your nutrition advisor can help you determine which is causing the rapid weight gain. In addition, by examining your legs and body for signs of fluid retention, your physician can help you to determine the cause of your weight gain. If your weight gain is due to water retention, cutting back drastically on calories may actually cause more fluid retention. Bed rest and resting on your side will help you to lose the build-up of fluid. Limit your intake of salt (sodium chloride) and very salty foods, as they tend to contribute to water retention.

Marked fluid retention when combined with an increase in blood pressure and possibly protein in the urine are the symptoms of preeclampsia. This is a disorder of pregnancy that can be harmful to both the mother and baby. Inform your obstetrician of any rapid weight gain, especially if you are eating moderately and gaining more than 2 pounds per week. Should you develop preeclampsia, be especially careful to eat a well-balanced diet with adequate calories.

After being diagnosed as having gestational diabetes, many women notice a slower weight gain as they start cutting the various sources of sugar out of their diet. This seems to be harmless and lasts only I or 2 weeks. It may be that sweets were contributing a substantial amount of calories to the diet.

FIGURE 3: Distribution of Weight Gain During Pregnancy

WEIGHT IN POUNDS AREA 7.5 – 8.5 FETUS 7.5 STORES OF FAT & PROTEIN 4 BLOOD 2.7 TISSUE FLUIDS 2 UTERUS 1.8 AMNIOTIC FLUID 1.5 PLACENTA & CORD 10 BREASTS 28 – 29 POUNDS

How should I eat during my pregnancy?

As with any pregnancy, it is important to eat the proper foods to meet the nutritional needs of the mother and fetus. An additional goal for women with gestational diabetes is to maintain a proper diet to keep blood sugars as normal as possible.

TABLE 4. Protein Equivalents

The daily need for calories increases by 300 calories during the second and third trimesters of pregnancy. If non­pregnant calorie intake was 1800 calories per day and weight gain was maintained, a calorie intake of 2100 calories per day is usual from 14 weeks until delivery. This is the equivalent of an additional 8 ounce glass of 2milk and one­half of a sandwich (1 slice of bread, approximately 1 ounce of meat, and I teaspoon of margarine, mayonnaise, etc.) per day. The need for protein also increases during pregnancy. Make sure your diet includes foods high in protein, but not high in fat (table 4). Most vitamins and minerals are also needed in larger amounts during pregnancy. This can be attained by increasing dairy products, especially those low in fat, and making sure you include whole grain cereals and breads, as well as fruits and vegetables in your diet each day. To make sure you get enough folate (a B vitamin critical during pregnancy) and iron, your obstetrician will probably recommend a prenatal vitamin. Prenatal vitamins do not replace a good diet; they merely help you to get the nutrients you need. To absorb the most iron from your prenatal vitamin, take it at night before going to bed, or in the morning on an empty stomach.

The Daily Food Guide (table 5) serves as a guideline for food sources that provide important vitamins and minerals, as well as carbohydrates, protein, and fiber during pregnancy. The recommended minimal servings per day appear in parenthesis after each food group listed. This guide emphasizes foods that are low in fat and in sugar (discussed later).

TABLE 5. Daily Food Guide (Each item equals one serving)

*1 oz. low­fat cheese can also be used as 1 serving from the Meat, Poultry, Fish, and Meat Substitutes group if sufficient calcium is already being provided from 4 servings.

**This refers to plain yogurt. Commercially fruited yogurt contains a lot of added sugar

***Starchy vegetables such as corn, peas, and potatoes are included in Breads, Cereals, and Other Starches list.

The food guide is divided into six groups: milk and milk products; meat, poultry, fish, and meat substitutes; breads, cereals, and other starches; fruits; vegetables; and fats. Each group provides its own combination of vitamins, minerals, and other nutrients which play an important part in nutrition during pregnancy (figure 4). Omitting the foods from one group will leave your diet inadequate in other nutrients. Plan your meals using a variety of foods within each food group, in the amounts recommended, and you’ll be most likely to get all the vitamins, minerals, and other nutrients the fetus needs for growth and development.

Other Nutritional and Non­Nutritional Considerations:

Alcohol.
There is no known safe level of alcohol to allow during pregnancy. Daily heavy alcohol intake causes severe defects in development of the body and brain of the fetus, called Fetal Alcohol Syndrome. Even moderate drinking is associated with delayed fetal growth, spontaneous abortions, and lowered birth weight in babies. The Surgeon General’s office warns: ?Women who are pregnant or even considering pregnancy should avoid alcohol completely and should be aware of the alcohol content of food and drugs.?

Salt.
Salt restriction is no longer routinely advised during pregnancy. Recent research shows that during pregnancy the body needs salt to help provide the proper fluid balance. Your health care provider may recommend that you use salt in moderation.

Caffeine
Studies conflict on the potential danger of caffeine to the fetus. Caffeine is found primarily in coffee, tea, and some sodas (table 6). Moderation is recommended. Talk to your doctor or other health professional about the maximum amount of caffeine recommended.

TABLE 6. Caffeine Comparisons

Megavitamins.
Megavitamins are defined as 10 times the Recommended Dietary Allowance* of vitamins and minerals and are not recommended for pregnant women. Although it is possible to get all of the necessary nutrients from food alone, your doctor may prescribe some prenatal vitamins and minerals. If taken regularly, along with a balanced diet, you will be getting all the vitamins and minerals needed during your pregnancy.

Smoking.
Research has shown without question that smoking during pregnancy increases the risk of fetal death and pre-term delivery, impairs fetal growth, and can lead to low birth weight. It is best to stop smoking entirely and permanently, or at the very least, to cut back drastically on the number of cigarettes you smoke.

What food patterns help keep blood sugar levels normal?

The following outlines food patterns which help to keep blood sugar levels within an acceptable range.

Avoid sugar and foods high in sugar. Most women with gestational diabetes, just like those without diabetes, have a desire for something sweet in their diet. In pregnant women, sugar is rapidly absorbed into the blood and requires a larger release of insulin to maintain normal blood sugar levels. Without the larger release of insulin, blood sugar levels will increase excessively when you eat sugar-containing foods.

There are many forms of sugar such as table sugar, honey, brown sugar, corn syrup, maple syrup, turbinado sugar, high fructose corn syrup, and molasses. Generally, food that ends in ?ose? is a sugar (e.g., sucrose, dextrose, and glucose).

Foods that usually contain high amounts of sugar include pies, cakes, cookies, ice cream, candy, soft drinks, fruit drinks, fruit packed in syrup, commercially fruited yogurt, jams, jelly, doughnuts, and sweet rolls. Many of these foods are high in fat as well.

Be sure to check the list of ingredients on food products. Ingredients are listed in order of amount. If an ingredient is first on the list, it is present in the highest amount. If some type of sugar is listed first, second, or third on the list of ingredients, the product should be avoided. If sugar is further down, fourth, fifth, or sixth, it probably will not cause your blood sugar levels to go up excessively.

Fruit juices should only be taken with a meal and limited to 6 ounces. Tomato juice is a good choice because it is low in sugar. Six ounces of most other juice (apple, grapefruit, orange) with no sugar added still contain approximately 4 to 5 teaspoons of sugar. However, these do not contain much of the fiber of a piece of fruit which normally would act to slow the absorption of sugar into the blood. If you drink juice frequently to quench your thirst during the day, a high blood sugar level may result. Use only whole fruit for snacks.

To help with the occasional sweet tooth that we all have, artificial sweeteners may be used in foods. Aspartame has been extensively tested for safety. Use during pregnancy has been approved by the Food and Drug Administration and by the American Medical Association’s Review Board. However, aspartame has not been tested for long­term safety and has not been on the market very long. It may be best to avoid its use until more tests have been done.

Saccharin is not advised during pregnancy. Likewise, use of mannitol, xylitol, sorbitol, or other artificial sweeteners is not recommended until further research is done.

Fructose is a special type of sugar that is slowly absorbed into the system. A small amount of fructose can be used if your blood sugar levels are within normal range. However, fructose still has 4 calories per gram, as much as table sugar. High fructose corn syrup is part fructose and part corn syrup, making it very similar to table sugar in composition. It will raise blood sugar levels and should definitely be avoided.

*Dietary allowances established by the National Academy of Sciences-National Research Council.

Emphasize the use of complex carbohydrates. These include vegetables, cereal, grains, beans, peas, and other starchy foods. A well­balanced diet with plenty of fiber provided by vegetables, dried beans, cereals, and other starchy foods decreases the amount of insulin your body needs to keep blood sugars within a normal range. Anything that decreases the need for insulin is beneficial The American Diabetes Association recommends that at least one-half of your calories come from complex carbohydrates. Starchy foods include pasta, rice, grains, cereals, crackers, bread, potatoes, dried beans, peas, and legumes. Also, contrary to popular belief, carbohydrates are not highly fattening when eaten in moderate amounts and without the rich sauces and toppings often added.

Emphasize foods high in dietary fiber. Fiber is the edible portion of foods of plant origin that is not digested (e.g., skins, membranes, seeds, bran). Foods with a high fiber content include whole grain cereals and breads, fruits, vegetables, and legumes (dried peas and beans). Fiber aids digestion and helps prevent constipation. The fiber found in fruits, vegetables, and legumes also helps keep your blood sugar level from becoming too high without requiring extra insulin.

Keep your diet low in fat. Some fat is needed to help with the absorption of certain vitamins and to provide the essential fatty acids necessary for fetal growth. A diet which is high in fat causes the insulin to react in a less efficient manner, necessitating more insulin to keep blood sugar levels within normal range. Foods high in saturated fats such as fatty meats, butter, bacon, cream (light, coffee, sour cream, etc.), and whole milk cheeses are likely to be high in total fat. Most foods with saturated fat are also high in cholesterol because they are fats from animal origin. However, foods such as crackers made with coconut, palm, or palm kernel oil can be high in saturated fats as well. Read labels carefully. Unsaturated fats are found in foods such as fish, margarine and vegetable oils. Keep your use of salad dressings to a minimum and whenever possible use those prepared with olive oil. To help keep the diet lower in fat, avoid adding extra fats such as rich sauces and creamy desserts, and bake or broil foods instead of frying them. Replacing fatty foods with those high in complex carbohydrates is also helpful.

Include a bedtime snack that is a good source of protein and complex carbohydrates. Women with gestational diabetes have a tendency toward lower than normal blood sugar levels during the night. This causes the body to increase its utilization of fats as a fuel source. As fat is used, ketones (discussed later) are produced as a by­product of the breakdown of fats, and in large amounts, may be harmful to the fetus. This can be prevented by having a bedtime snack that provides protein and complex carbohydrates such as starchy foods. Starch will stabilize your blood sugar level in the early night, while protein acts as a long­acting stabilizer.
Examples of a bedtime snack are:

1 oz. American­processed cheese + 5 crackers

1/2 chicken sandwich on whole wheat bread

3 cups unbuttered popcorn + 1/4 cup nuts

If you need to take insulin, a bedtime snack is critical and you should not omit it. When taken by injection, insulin acts to lower blood sugar level, even during the night when meals are not eaten. A bedtime snack is protective against low blood sugars while sleeping or upon arising. If a bedtime snack causes heartburn, sleep with your head raised on pillows, and be careful that you are not eating too large a bedtime snack.

How do I plan meals?

A registered dietitian or qualified nutritionist can help you plan a meal pattern that is right for you. Most women with gestational diabetes need three meals and a bedtime snack each day. It is unwise for anyone who is pregnant to go long periods of time (greater than 5 hours) without eating, as this will produce ketones. Extra snacks are necessary if your schedule results in a long time between meals. Blood sugars will be easier to keep in the normal range if meal times and amounts (total calories) are evenly spaced. It’s more likely that a higher blood sugar will result if the majority of calories are eaten at dinner) than if they are distributed more evenly throughout the day. If insulin injections prove necessary, the time at which meals are eaten and the amounts eaten should be approximately the same from day to day. Do not skip meals and snacks, as this often results in hypoglycemia (low blood sugar), which may be harmful to the fetus and makes you feel irritable, shaky, or may result in a headache.

Sample Menu ? 2000 Calories

This diet is planned for women whose normal non-pregnant weight should be 130­135 lbs. For women who weigh less than 130 before pregnancy, the diet should contain fewer calories. Women who are overweight are at higher risk for gestational diabetes. Your health care provider can discuss this and help you make necessary changes.

What can be done to slow weight gain during pregnancy?

Gaining too much weight during pregnancy will make blood sugar levels higher than normal for women with gestational diabetes. Yet, for many pregnant women it is very difficult to gain weight slowly and still get all of the recommended nutrients. Luckily, fat, which is high in calories (9 calories per gram), is needed in only small amounts during pregnancy. Carbohydrates and protein, in contrast to fat, provide only 4 calories per gram. To cut calories without depriving the fetus of any necessary nutritional factors, it is best to avoid fats and fatty foods.

Avoid high­fat meats. Choose lean cuts of beef, pork, and lamb. Emphasize more fish and poultry (without the skin).

Avoid frying meat, fish, or poultry in added oil, shortening, or lard. Bake, broil, or roast instead.

Avoid foods fried in oil such as chips, french fries, and doughnuts. Substitute pretzels, unbuttered popcorn, or breadsticks instead.

Avoid using cream sauces and butter sauces, as well as salt pork for seasoning on vegetables. Season with herbs instead.

Avoid using the fat drippings from meat or poultry for gravy. Use broth or bouillon instead and thicken with cornstarch.

Avoid using mayonnaise or oil for salads. Use vinegar, lemon juice, or low-calorie salad dressings instead.

To help reduce calories choose low-fat dairy products. During pregnancy you need 1200 mg calcium daily to build the fetal skeleton without drawing from maternal calcium stores. Table 7 points out foods in which the calcium content is almost the same, yet the calories are not due to the difference in fat content.

The difference between 600 calories and 340 calories is only 260 calories and may seem insignificant. Yet, if your diet is cut by 260 calories daily for I week, your weight gain slows down by approximately 1/2 pound per week. In other words, instead of gaining 1-1/2 pounds per week you will only gain 1 pound per week.

If cheese is a part of your daily diet, use low­fat cheeses such as low­fat cottage cheese, Neufchatel, mozzarella, farmers, and pot cheese. Avoid using cream cheese, as it has little protein and most of its calories come from fat.

Even though pregnancy can be a very hectic time, with little time for meal preparation, eat less and less often at ?fast food? restaurants. Studies have shown that some foods from fast food restaurants average 40 to 60 percent of their calories from fat, and are quite high in calories.* For example, chicken and fish that are coated with batter and deep-fried in fat may contain more fat and calories than a hamburger or roast beef sandwich.

*Fast Food Facts: Nutritive and Exchange Values for Fast Food Restaurants Marion J. Franz, International Diabetes Center. Minneapolis, Minnesota, 1987. 54 pp.

TABLE 7. Calorie Comparisons

Is breast-feeding recommended?

Breast-feeding is strongly encouraged. For most women this represents the easiest way back to pre-pregnancy weight after delivery. The body draws on the calories stored during the first part of pregnancy to use in milk production. Approximately 800 calories per day are used during the first 3 months of milk production, and even more during the next 3 months. By 6 weeks after delivery, women who breast-feed usually have lost 4 pounds more than women who bottle-feed. This can be a very important factor, as it is strongly recommended that women with gestational diabetes return to their desirable body weight 4 to 5 months postpartum. As previously mentioned, maintaining a weight appropriate for your height and frame may reduce the risk of developing diabetes later in life.

In addition, breast-feeding has many advantages for your baby. Protection from infection and allergies are transferred to the baby through breast milk. This milk is also easier to digest than formula, and its minerals are better absorbed than those in formula.

NIDDK