Robert G. Moses

Can a Low–Glycemic Index Diet Reduce the Need for Insulin in Gestational Diabetes Mellitus?: A randomized trial

OBJECTIVE A low–glycemic index diet is effective as a treatment for individuals with diabetes and has been shown to improve pregnancy outcomes when used from the first trimester. A low–glycemic index diet is commonly advised as treatment for women with gestational diabetes mellitus (GDM). However, the efficacy of this advice and associated pregnancy outcomes have not been systematically examined. The purpose of this study was to determine whether prescribing a low–glycemic index diet for women with GDM could reduce the number of women requiring insulin without compromise of pregnancy outcomes. RESEARCH DESIGN AND METHODS All women with GDM seen over a 12-month period were considered for inclusion in the study. Women (n = 63) were randomly assigned to receive either a low–glycemic index diet or a conventional high-fiber (and higher glycemic index) diet. RESULTS Of the 31 women randomly assigned to a low–glycemic index diet, 9 (29%) required insulin. Of the women randomly assigned to a higher–glycemic index diet, a significantly higher proportion, 19 of 32 (59%), met the criteria to commence insulin treatment (P = 0.023). However, 9 of these 19 women were able to avoid insulin use by changing to a low–glycemic index diet. Key obstetric and fetal outcomes were not significantly different. CONCLUSIONS Using a low–glycemic index diet for women with GDM effectively halved the number needing to use insulin, with no compromise of obstetric or fetal outcomes.

Gestational diabetes; can a low glycemic index diet reduce the need for insulin? A randomised trial

OBJECTIVE A low–glycemic index diet is effective as a treatment for individuals with diabetes and has been shown to improve pregnancy outcomes when used from the first trimester. A low–glycemic index diet is commonly advised as treatment for women with gestational diabetes mellitus (GDM). However, the efficacy of this advice and associated pregnancy outcomes have not been systematically examined. The purpose of this study was to determine whether prescribing a low–glycemic index diet for women with GDM could reduce the number of women requiring insulin without compromise of pregnancy outcomes. RESEARCH DESIGN AND METHODS All women with GDM seen over a 12-month period were considered for inclusion in the study. Women (n = 63) were randomly assigned to receive either a low–glycemic index diet or a conventional high-fiber (and higher glycemic index) diet. RESULTS Of the 31 women randomly assigned to a low–glycemic index diet, 9 (29%) required insulin. Of the women randomly assigned to a higher–glycemic index diet, a significantly higher proportion, 19 of 32 (59%), met the criteria to commence insulin treatment (P = 0.023). However, 9 of these 19 women were able to avoid insulin use by changing to a low–glycemic index diet. Key obstetric and fetal outcomes were not significantly different. CONCLUSIONS Using a low–glycemic index diet for women with GDM effectively halved the number needing to use insulin, with no compromise of obstetric or fetal outcomes.

The Recurrence Rate of Gestational Diabetes in Subsequent Pregnancies

OBJECTIVE To define the recurrence rate of gestational diabetes mellitus (GDM) in a subsequent pregnancy and to determine what factors could be predictive. RESEARCH DESIGN AND METHODS The subjects of the index pregnancy were 480 personally cared for women with GDM. One hundred women had had a subsequent pregnancy and had been tested for GDM. RESULTS The recurrence rate of GDM was 35% (95% CI, 25.5–44.5). An increase in weight between the two pregnancies and a higher maternal age and parity were risk associates for a recurrence. A recurrence of GDM was not associated with a higher glucose level, insulin use, or fetal birth weight in the index pregnancy. CONCLUSIONS GDM occurs in only one-third of subsequent pregnancies. Those women who had a recurrence of their GDM were older, more parous, and also had an increase in weight between the pregnancies.

The recurrence of gestational diabetes: Could dietary differences in fat intake be an explanation?

OBJECTIVE To present the results of a comprehensive dietary review of a group of women with a recurrence of gestational diabetes mellitus (GDM), compared with a group of women with no recurrence of GDM during a subsequent pregnancy. RESEARCH DESIGN AND METHODS The dietary intake of 14 women with a recurrence of GDM was compared with 21 women with no recurrence of GDM. Women with GDM in one pregnancy have a recurrence rate of only 30–50%. While the reasons for this have not been determined, dietary factors have been considered probable. RESULTS The women with a recurrence of GDM consumed 38.4 (by diet history) and 41.4% (by food record) of their total energy intake as fats, compared with 34.1 (P <0.01) and 33.1% (P <0.001), respectively, for women with no recurrence. The percentage intake of polyunsaturated, monounsaturated, and saturated fatty acids was similar in both groups. There was a proportionate reduction in carbohydrate intake as a percentage of total energy and in fiber intake in grams for the women with a recurrence of GDM. CONCLUSIONS When the relationship between saturated fat intake and insulin resistance is considered, the possibility exists that dietary modification of fat intake before and during pregnancy may reduce the recurrence rate of GDM.

Pregnancy Outcomes in Women Without Gestational Diabetes Mellitus Related to the Maternal Glucose Level: Is there a continuum of risk?

OBJECTIVE To examine selected pregnancy outcomes in women without gestational diabetes mellitus to see whether there was a continuum of risk related to the maternal glucose level. RESEARCH DESIGN AND METHODS Consecutive women attending two prenatal clinics and three obstetricians in private practice were tested for GDM at the beginning of the third trimester using a 75-g glucose load in the fasting state. The rate of induction, the number of assisted deliveries, the presence of pregnancy-induced hypertension, fetal birth weights, and morbidity were examined with respect to the maternal 2-h glucose level. RESULTS Data were available for 1,441 women with a 2-h glucose level < 8.0 mmol/l (144 mg/dl). For each 1.0 mmol/l (18 mg/dl) increase in the glucose level, the odds in favor of an assisted delivery increased by 15.2%, and the odds in favor of the baby being admitted to a special care nursery (SCN) increased by 22.6%. There was no significant association between maternal glucose levels and the probability of either pregnancy-induced hypertension or a large-for-gestational-age (LGA) baby after adjustment for other variables. CONCLUSIONS In normal women there is a continuum of risk related to the maternal glucose level 2 h after a glucose tolerance test for the probability of having an assisted delivery and the likelihood of the baby being admitted to an SCN. The chance of having pregnancy-induced hypertension or a LGA baby also increased as the maternal glucose level increased but could be largely explained by an increasing body mass index.

Glycemic index and pregnancy: a systematic literature review.

Background/Aim. Dietary glycemic index (GI) has received considerable research interest over the past 25 years although its application to pregnancy outcomes is more recent. This paper critically evaluates the current evidence regarding the effect of dietary GI on maternal and fetal nutrition. Methods. A systematic literature search using MEDLINE, EMBASE, CINAHL, Cochrane Library, SCOPUS, and ISI Web of Science, from 1980 through September 2010, was conducted. Results. Eight studies were included in the systematic review. Two interventional studies suggest that a low-GI diet can reduce the risk of large-for-gestational-age (LGA) infants in healthy pregnancies, but one epidemiological study reported an increase in small-for-gestational-age (SGA) infants. Evidence in pregnancies complicated by gestational diabetes mellitus (GDM), though limited (n = 3), consistently supports the advantages of a low-GI diet. Conclusion. There is insufficient evidence to recommend a low-GI diet during normal pregnancy. In pregnancy complicated by GDM, a low-GI diet may reduce the need for insulin without adverse effects on pregnancy outcomes. Until larger-scale intervention trials are completed, a low-GI diet should not replace the current recommended pregnancy diets from government and health agencies. Further research regarding the optimal time to start a low-GI diet for maximum protection against adverse pregnancy outcomes is warranted.

New consensus criteria for GDM: problem solved or a pandora's box?

For at least a generation there has been a divergence of opinions about gestational diabetes mellitus (GDM). On one hand were those who, on the basis of largely observational studies in humans and extrapolation of animal data, felt that women should be tested for GDM and have their diagnosed GDM treated. On the other hand, there were the “obskeptics” who felt that no significant action should be taken until evidence of benefits and risks was available. Clinicians of either persuasion undoubtedly have found developments over the last few years most exciting. In 2005, Crowther et al. (1) published the results of the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS). For women diagnosed with GDM, the rate of prespecified perinatal complications was lower for the women randomized to the intervention (treatment) group. In a recent publication, Landon et al. (2) found that women with mild glucose intolerance who were assigned to treatment had a significant reduction in prespecified complications, mainly related to fetal size. Although universal testing for GDM was not applied in either study, the advantages of treatment …

Point: Universal Screening for Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is one of the most common medical disorders found in pregnancy. Rates can range from 2 to >10%, and sometimes much higher, depending on the population being tested and the diagnostic criteria being used (1). The prevalence of GDM ultimately reflects the background rate of type 2 diabetes. There has also been an increase in the rate of GDM over the last generation, possibly related to community lifestyle factors as well as better case ascertainment (2,3). ### Significance of GDM GDM is associated with a trilogy of risks. Significant pregnancy complications including increased perinatal morbidity and possibly mortality can occur (4,5). A diagnosis of GDM also identifies a mother at high risk for the future development of type 2 diabetes (1). The effects of maternal hyperglycemia (of any kind) are associated with the development of metabolic problems including type 2 diabetes in the offspring (6). It is, perhaps, for this effect of intrauterine programming that the disorder is most worthy of detection. It has now been demonstrated that the treatment of GDM improves pregnancy outcomes. In the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS), the incidence of serious perinatal complications (a composite of death, shoulder dystocia, nerve palsy, and fracture) was 4% among women randomized to routine care compared with 1% among the intervention group (5). The number of GDM cases that needed to be treated to prevent one serious perinatal complication was 34. This indicates that excess serious perinatal complications will occur in 3% of cases of untreated or unrecognized GDM. This is a most compelling immediate argument for the screening of GDM given that the failure to identify a woman with GDM denies her the opportunity to have treatment for potentially preventable serious fetal complications. ### Why conduct selective screening for GDM? Therefore, if we accept that GDM is …

An evaluation and comparison of Reflolux II and Glucometer II, two new portable reflectance meters for capillary blood glucose determination

The Reflolux II and the Glucometer II, two new battery-operated portable reflectance meters (PRMs) for blood glucose measurement have been evaluated for accuracy, precision and ease of operation. Both PRMs are pocket-size and simple to use. The calibration of the two instruments is fundamentally different, but in both cases the calibration data are provided with the reagent test strips and require minimal operator participation. The analysis time is 50 s for the Glucometer II and 120 s for the Reflolux II. The Reflolux II has a measuring range of 0.5-27.7 mmol/l, which is superior to the 2-22 mmol/l range of Glucometer II. Both PRMs had excellent correlation (r greater than 0.97) and minimal bias when compared by regression analysis to a laboratory method on capillary and whole blood samples. The precision of the Reflolux II was marginally better than the Glucometer II with coefficients of variation less than 6.57% for the Glucometer II and less than 5.21% for the Reflolux II. Neither the Reflolux II nor the Glucometer II offer significant advantages one over the other, both are adequate for their designed use, and both are distinct improvements over their predecessors.

Pregnancy and Glycemic Index Outcomes study: effects of low glycemic index compared with conventional dietary advice on selected pregnancy outcomes

BACKGROUND Eating carbohydrate foods with a high glycemic index (GI) has been postulated to result in fetoplacental overgrowth and higher infant body fat. A diet with a low glycemic index (LGI) has been shown to reduce birth percentiles and the ponderal index (PI). OBJECTIVES We investigated whether offering LGI dietary advice at the first antenatal visit would result in a lower fetal birth weight, birth percentile, and PI than providing healthy eating (HE) advice. This advice had to be presented within the resources of routine antenatal care. DESIGN The Pregnancy and Glycemic Index Outcomes study was a 2-arm, parallel-design, randomized, controlled trial that compared the effects of LGI dietary advice with HE advice on pregnancy outcomes. Eligible volunteers who attended for routine antenatal care at <20 wk of gestation were randomly assigned to either group. RESULTS A total of 691 women were enrolled, and 576 women had final data considered. In the LGI group, the GI was reduced from a mean (± SEM) of 56 ± 0.3 at enrollment to 52 ± 0.3 (P < 0.001) at the final assessment. There were no significant differences in primary outcomes of fetal birth weight, birth percentile, or PI. In a multivariate regression analysis, the glycemic load was the only significant dietary predictor (P = 0.046) of primary outcomes but explained <1% of all variation. CONCLUSION A low-intensity dietary intervention with an LGI diet compared with an HE diet in pregnancy did not result in any significant differences in birth weight, fetal percentile, or PI.