Gestational Diabetes Mellitus Helping Your Client Make Healthy Lifestyle Choices

Gestational Diabetes MellitusHelping Your Client Make Healthy Lifestyle Choices

IntroductionFollowing appropriate screening guidelines, understanding causation and associated conditions, and effectively managing the client with GDM can improve both short term and long term health conditions associated with GDM

DefinitionsGestational Diabetes (GDM)Insulin Resistance (IR)Glycemic Index (GI)Syndrome XBody Mass Index (BMI)

Gestational Diabetes (GDM)A carbohydrate intolerance of varying degrees and severity with onset or first recognition during pregnancy with a probable resolution after the end of pregnancy. Diabetes, glucose intolerance or insulin resistance may have existed before the pregnancy. GDM is not the same as Type 1 or Type 2 Diabetes

Insulin Resistance (IR)Insulin resistance is the resistance of the skeletal muscles and adipose to the affects of insulin. The pancreas produces more insulin, and over time cells become more and more resistant to the actions of insulin. As blood sugars and insulin increase, eventually the pancreas fails to produce enough insulin and diabetes occurs.

Glycemic Index (GI)The glycemic index ranks foods on how they affect our blood sugar levels. This index measures how quickly an individual's blood sugar increases in the two or three hours after eating.http://www.mendosa.com/gi.htm

Factors That Affect the GIThe GI of a food is influenced by the characteristics of the food or meal.Processing, preparation, storage, physical form, and ripeness of foods affect the GI.The GI varies within the same individual and between individuals.

Value of the GIEach client can determine how she reacts to certain foods by monitoring food intake and postprandial blood glucose levelsThe primary goal of GDM management is to achieve and maintain euglycemia throughout pregnancy to improve the outcomes for both mother and fetus

Syndrome XThe loss of responsiveness of the body to insulin is associated with a clustering of cardiovascular risk factors that includes abdominal obesity, hypertension, dyslipidemia, glucose intolerance and hyperinsulinemia. This association is referred to as the insulin resistance syndrome, which is also known as Syndrome X.

Body Mass Index (BMI)A commonly used measure to differentiate underweight, normal weight, overweight and obesity. Obtained by dividing the weight of the subject (in kilos) by the square of his (her) height in meters.A BMI of approximately 25 kg/m2 corresponds to about 10 percent over ideal body weight.http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/body.html

Body Mass Index Definitions

ClassificationBMIUnderweight 40.0

Body Mass Index and Recommended Weigh Gain

Pre-pregnant weight status Recommended range of weight gainA. Twin Pregnancy 35-45 lbs B.Underweight (BMI 30.0) 15 lbs

How These Conditions Are RelatedWomen with a history of GDM are metabolically vulnerable with insufficient -cell reserve, and many are insulin resistant. Approximately 50 % of women who are diagnosed with gestational diabetes during pregnancy will develop it in future pregnancies, and are at a much greater risk of developing type 2 diabetes in later life. The insulin resistance is the factor that exists in the woman with GDM. The aim of the lifestyle changes to be discussed here are to decrease insulin resistance.

Pregnancy PathophysiologyInsulin resistance occurs because the hormonal changes associated with pregnancy partially block the effects of insulin.Insulin resistance causes glucose to be shunted from the mother to the fetus to facilitate fetal growth and development.

Pregnancy PathophysiologyDuring the third trimester of pregnancy, insulin resistance increases by 50%.Maternal pancreatic beta cells increase insulin secretion almost threefold to compensate for increased insulin resistance.

Pregnancy PathophysiologyThe subsequent increase in insulin secretion causes the maternal glucose levels to increase 80% of the blood levels of non-pregnant womenIf the mothers pancreas is unable to produce sufficient insulin to overcome insulin resistance, maternal glucose levels increase and GDM occurs

Pregnancy PathophysiologyGDM complicates pregnancy by further increasing insulin resistanceGDM disappears after pregnancy because the hormonal changes that caused insulin resistance are no longer presentUseful physiologic process out of balance

Action Plan for PreventionApproximately 60% to 80 % of the women with GDM are obese and experience insulin resistance associated with both obesity and GDM.A decrease in caloric intake and caloric redistribution of foods may help decrease abnormally high blood glucose levels by improving target-organ insulin sensitivity.

Laboratory Screening for GDMDemographicsWho to ScreenScreening

Pat Sonnenstuhl,ARNP, CNM

Demographics of GDMMost common medical complication of pregnancyOccurs in 4% of all pregnancies (all ethnicities) Changes in diagnostic criteria will increase incidence of this metabolic complication (involves a recognition of a lower level of blood glucose)

Who Should Be ScreenedWomen over 25Women who are obeseWomen with a family history of diabetesWomen of ethnic/racial high risk groupsWomen who have had a >9 # baby

Value of Screening During the Current Pregnancy

Increased screening, identification and treatment can decrease the morbidity and mortality of GDM:Decreased macrosomia, cesarean birth and birth trauma due to a > 4000g infantDecreased neonatal hypoglycemia, hypocalcaemia, hyperbilirubinemia, polycythemiaIdentify women at future risk for diabetes and those with insulin resistance

Routine Screening (ACOG,1994)

50 G Glucose screening test (GST) between 24 and 28 weeks (non-fasting)If results 130-140, proceed to 3 hr GTT, or repeat the 1 hour test in one week. May or may not be done with a Carbohydrate Challenge Diet

Screening and Diagnosis of GDM(ACOG, 1994)Nearly 25 % of women will have a + 1hr GTT, and will need a 3 hour GTT.A GTT is considered diagnostic for GDM when 2 or more values are met or exceeded.

Determination of GDM (ACOG, 1994)

100 G GTTRanges of Accepted ValuesFasting95-1051 hour180-1902 hour155-1653 hour140-1452 or more values met or exceeded = GDM

Retesting (32-34 Weeks) When?Negative initial test, risk factors presentObesity>33 years of agePositive 1 hour screen followed by a negative OGGT3+/4+ glucosuria

Factors That Influence the Development of Type 2 Diabetes Mellitus

1. A classification of impaired glucose tolerance postpartum 2. Ethnic group with high risk of developing diabetes (Hispanic, African, Native American, South or East Asian, Pacific Islands or Indigenous Australian)

Factors That Influence the Development of Type 2 Diabetes Mellitus

3. A first-degree relative with type 2 diabetes4. Elevated fasting plasma glucose in pregnancy and degree of initial and postpartum glucose intolerance 5. Need for insulin therapy or early diagnosis in pregnancy

Factors That Influence the Development of Type 2 Diabetes Mellitus

6. Obesity, especially abdominal obesity, weight gain postpartum7. Physical inactivity 8. Diet higher in fat content (38-40% of total calories)

Teachable MomentsWomen with GDM and/or IR present an ideal group for diabetes prevention and education because they are teachable and usually more motivated to change behaviors and improve their long range health and the health of their families.

Teachable MomentsSeen as a positive thing, the diagnosis of GDM during pregnancy identifies these women at risk and this awareness can encourage healthy lifestyle changes

Management of GDM During Pregnancy and Post PartumHealthy food ChoicesEncouraging Lifestyle changesEducation and supportLaboratory follow-upPost Partum and BeyondTeachable Moments

Healthy Food ChoicesVarious OptionsMedical Nutritional TherapyNutritional Prescription

Pat Sonnenstuhl,ARNP, CNM

Making Healthy Food ChoicesWhat are healthy choices ?Goals of medical nutrition therapy respect the needs of the pregnant woman and her developing fetusFood combination options encourage maternal euglycemia

What Are Healthy Choices ?Nutritional management is understudied, with no randomized control studies looking specifically at optimal medical nutrition for GDM, lean or obese.

What Are Healthy Choices ?Distribution of Macronutrients: Optimal distribution of calories is unknown (little consensus, wide variability, not adequate research).

What Are Healthy Choices ?The ideal caloric recommendations for GDM are unknown or have not been well studied. Factors such as maternal height, pregravid wt, maternal age, physical activity and smoking all need to be considered.

What Are Healthy Choices ?The majority of women should eat 2200-2400 calories. Moderate calorie restrictions (to 1800) have been shown to reduce macrosomia and its associated morbidity and maternal ketonuria

Goals of Medical Nutrition Therapy

1. Optimal nutrition for developing fetus 2. Optimal nutrition for mother 3. Maternal euglycemia without distorting diet

Goals of Medical Nutrition Therapy

4. Good nutrition patterns taught to the family 'gatekeeper'5. Nutritional patterns that prevent or forestall recurrence of GDM and onset of type 2 diabetes

Goal of Medical Nutrition TherapyDeborah Thomas-Dobersen suggests three reasonable options which seem to accomplish this goal

Option ITraditional Food PyramidHigh Carb/low fat 55% carbohydrate, 25% protein, 20% fatHttp://www.mjbovo.Com/PregWt.Html

Option II Balanced Discuss with your client the effect of high GI carb foods versus low GI-carb foods35-40% carbohydrates,20--25% protein

35-40% fat

Option III Low Glycemic CarbohydratesMore ProteinLow GI CarbsAppropriate Fats

http://www.enteract.com/~jldavid/lowcarb/pyramid.html

Nutritional PrescriptionFor GDM, the nutritional prescription should satisfy the minimum requirements for pregnant womenMinimal caloric intake for those with GDM is debatedThere is little risk of ketonuria when diets provide 25kcal/kg, which is based on the womans actual body weight

Nutritional RecommendationsDistribution of total calories is:35-45 % carbohydrates20-25 % protein35-40 % fatTolstoi & Jusmovich

ADA Clinical GuidelinesRestriction of carbohydrates to 3540% of calories has been shown to decrease maternal glucose levels and improve maternal and fetal outcomes

American Diabetes Association: Clinical Practice Recommendations 2001

Limiting Carbohydrate IntakeWhen starchy carbohydrate intake is limited, postparandial blood glucose levels are lower compared with diets higher in carbohydrate content.

Factors That Affect Blood Glucose LevelsStress: physical and psychologicalTime of dayExerciseAmount of carbohydrate consumedLifestyle choices such as smoking

Goals of Nutritional TherapyEncourage euglycemia Prevent KetosisDecrease maternal hyperglycemia

Making Healthy Lifestyle ChoicesModifying Eating BehaviorDaily ExerciseLifestyle Management

Pat Sonnenstuhl,ARNP, CNM

Healthy Lifestyle Choices "Lifestyle changeis the central determinant of whether people will lose weight and maintain loss' Kelly D. Brownell.Lifestyle management is the systematic change of behavior and thinking patterns that affect weight.

Healthy Lifestyle ChoicesBrownell cites helping with the modification of eating behavior, physical activity, and a change in attitude, goals and emotions as specific ways practitioners can help women make these lifestyle changes.

Healthy Lifestyle Choices Practitioners can help individuals acquire skills to change the ways they think and act that affect their eating habits.

Healthy Lifestyle Choices

Simply giving the advice to 'eat better' and 'exercise more' will work in only a small handful of patients. Health professionals commonly ask their clients to lose weight without providing the ways to ensure success. "We must give patients the best chance of success."

Exercise !Moderate regular exercise such as walking, cycling or swimming are excellent forms of exercise for pregnant women. Keeping well-hydrated and well-nourished is essential

Exercises to EncourageBrisk walking, cycling and swimming are often done safely by pregnant women. Staying balanced and avoiding falls is important

Benefits of ExerciseExercising for 15-20 minutes after a meal may help to keep blood glucose levels within the target range for women with GDM. Individualized programs can start with 20 minutes/day, gradually increasing to 45-60 minutes/day.

Education and SupportFood JournalsOngoing SupportOngoing Education

Pat Sonnenstuhl,ARNP, CNM

Food JournalsProvide a tool for ongoing evaluation and discussion, and increasing your clients awareness of the effects specific foods and activities.

Food JournalsKeeping a record of all foods and beverages consumed can motivate women to alter caloric intake and learn the affect of specific foods and activates on blood sugar.

Viewpoints About Food JournalsJournals reinforce the expectation of improvement.Approach your clients food choices carefully, as she needs affirmation, not criticism for long term support. Encourage the food record to be a learning tool, not a rigid diet to follow.

Supportive CommunitiesHave available resources of support groups in your community that can be helpful for your client.Be familiar with the many on line resources available for women who are gestational diabetics, or who want to make these lifestyle changes.

Ongoing EducationKeep current with available educational resources available that might be helpful for your client.Involve your client in her own learning as much as possible.Take the time to explain her progress to her.

Laboratory Follow-upSelf-monitoring Blood Glucose Checking for KetonuriaFBS and 2 Hour PP

Pat Sonnenstuhl,ARNP, CNM

Self-monitoring of Blood Glucose (SMBG)SMBG can improve outcomes in pregnancies by early recognition of abnormal blood sugar levels. New meters and lancing devices make the process of obtaining blood almost painless.SMBG empowers women with GDM to become active participants in their care. Women can readily see the impact of their choices.

SMBGSelf-monitoring will give women immediate feedback about portion size, particular foods that cause hyperglycemia, and the impact of exercise on blood sugarNewer and more appealing tools will improve clients willingness to monitor their blood glucose

SMBG Promotes EmpowermentStudies have shown that SMBG helps clients follow goals of treatment and learn about the impact of specific food and activity choices.Clients are more likely to believe the advice they receive when they can see high blood glucose levels 2 hours after eating, or see a level decrease after walking.

Checking for KetonuriaClients who are following a hypocaloric or carbohydrate restricted diet might benefit from testing ketones before breakfast.The persistence of small to moderate ketones can signal inadequate calories, a misunderstanding of the meal plan, or a woman secretly restricting food to avoid the addition of insulin.

Checking for KetonesRecommended for women on a hypo caloric or carbohydrate restricted diet.Small to moderate ketones can signal inadequate calories or identify women who are restricting food.

FBS and 2 Hour PPConsidered the follow-up test to determine effectiveness of managementHgA1c also might provide insights to ongoing blood glucose levels

Blood Glucose Values for PregnancyRubin, A. L. Diabetes for Dummies, p 95Normal blood glucose range: 60-120 mg/dl

Fasting and Pre-meal1 Hour After2 Hours After65-85< 140-150< 120-130

Post Partum and BeyondBreastfeedingFollow-up LabsFollow-up EducationHealthy Lifestyle Choices

Pat Sonnenstuhl,ARNP, CNM

BreastfeedingExtensive research documents the superiority of human milk for infant feedingBreastfeeding in the postpartum period is associated with better maternal weight loss, improved fasting blood glucose levels, glucose tolerance and lipid levels

Postpartum and Beyond Follow-up labs: at 6-12 week postpartum a 75g GTT can help determine a woman's risk of developing diabetes.Subsequent annual screening for diabetes and CV risk factors (Lipid profile).Discuss prevention of a diabetic pregnancy in subsequent pregnancies.

Postpartum Fasting and 2 Hour Screening and Diagnosis Criteria

Normoglycemia IFG or IGT DM FPG < 110mg/dl FPG > 110 and < 126 mg/dl (IFG) FPG >126 mg/dl 2 hr PG 140 and < 200 mg/dl (IGT) 2hr PG >200 mg/dlSymptoms of DM and random plasma glucose concentration > 200 mg/dl

Additional DefinitionsFPG: Fasting Plasma Glucose.IFG: Impaired fasting glycemia: a fasting glucose concentration lower than those required to diagnose diabetes but higher than the 'normal' reference range.

Additional DefinitionsIGT: Impaired Glucose Tolerance: a stage in the natural history if disordered carbohydrate metabolism. This marker serves as an indicator or marker along with the other elements of Metabolic Syndrome. Individuals with IGT manifest glucose intolerance only when challenged with an oral glucose load.

Significance of GDM and Insulin Resistance Post PartumUp to 60% of women will develop type 2 diabetes during their lifetimeRecurrence rate in subsequent pregnancies is up to 65 %

Postpartum Monitoring A FBG >125 mg/dl on two occasions denotes DMA FPG of 110-125 mg/dl = impaired fasting glucose2HR PG 140-199 = Impaired FBGA level >200mg/dl = DM

Post Partum and Beyond "All women with GDM history should be counseled on the modifiable risk factors, such as the importance of healthy weight maintenance and daily exercise and the risk of postpartum weight gain to the development of subsequent GDM and type 2 diabetes.

Post Partum and BeyondWomen should receive medical nutrition therapy to decrease dietary fat. If they can achieve a 10-lb weight loss postpartum, they can decrease the risk of subsequent diabetes by one-half"

Deborah Thomas-Doberson

A Woman With a History of GDMIs metabolically vulnerable with insufficient -cell reserve, and many are insulin resistantIf type 2 diabetes is delayed by 6 years the risk of developing sight-threatening retinopathy would be reduced by 65%

Women With a History of GDM Often are not followed intensively for modifiable lifestyle changes that may prevent type 2 diabetesNeed to be identified before pregnancy because, the incidence of fetal structural anomalies increases during the first 2 months of gestation

Recommendations PostpartumAll women with a history of GDM should be screened annually for diabetes and heart disease risk factors.

Significance of GDM and Insulin Resistance Post Partum

Offspring of women with GDM have an increased risk for developing obesity and glucose intolerance as they grow and mature.

Teachable MomentsPreconceptionPostpartumPrevious Pregnancy

Pat Sonnenstuhl,ARNP, CNM

Preconception CounselingStrict glucose control greatly reduces the incidence of structural defects which occur in the first two months of gestationPreconception counseling and monitoring becomes a major objective in the care of these women

PostpartumWomen with a history of GDM present an ideal group for diabetes prevention, not only in preventing diabetes in themselves, bur for their family, for whom they are often the gatekeepers for nutrition and exercise.Pregnancy a teachable moment when women are usually very focused on their own health and the health of their baby.

The Value of ExerciseContinues !

Dietary RecommendationsA high dietary fat intake between pregnancies can be a predictor for the recurrence of GDM. A diet with a high glycemic index and low fiber count appears to increase the relative risk of developing type 2 diabetes.

Modifiable Nutritional and Non-nutritional Factors for Diabetes Prevention

Risk Risk

High-GI, low fiber diet 10 # weight loss ppHigh total and saturated fat intake Breast feeding Hi fat intake, low carb, low fiber Regular physical activity

Modifiable Nutritional and Non-nutritional Factors for Diabetes Prevention. Source: Deborah Thomas-Doersen

Risk Risk

Current food pyramid guidelines(high carb, low fat, low protein) Low-GI carbohydrates, high fiber, adequate protein and fat diet

Concerns and QuestionsIs lowering carbs better than initiating insulin?Will increasing fat increase CV risk?How can a woman be encouraged to make food choices, and how rigid must she be?Does a reduction to 35% total carbs lead to nutrient deficiencies ?

In Conclusion Strive for an accurate diagnosis and identification of the woman with IR and GDM Consult and refer as indicated should lab values persist outside of the range of euglycemia

In Conclusion Help your client establish Healthy Lifestyle Changes in Pregnancy Encourage continuing Healthy Lifestyle Choices Postpartum Offer ongoing support and follow-up

Long Term Goals of ManagementPrimary prevention of type 2 diabetesImprovement of existing IR or obesityPermanent lifestyle changes

Pat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*

Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*

Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Insulin Resistance (IR)Insulin improves the intake of insulin into the fat and skeletal muscles. When these tissues do not react normally to insulin Insulin resistance occurs, and it becomes more difficult for glucose to enter the cells and, to compensate for this defect, the pancreas produces more insulin. Increasing insulin results in excessive insulin and excessive blood sugar. As glycemia increases the pancreas fails to produce the necessary amounts of insulin, and type 2 diabetes may appear in genetically predisposed patients. Research suggests the end result of prolonged insulin resistance is type 2 diabetes [http://www.ir-web.com/english/gp/ir/irmenu1/irmenu1.asp] Insulin improves the intake of insulin into the fat and skeletal muscles. When these tissues do not react normally to insulin Insulin resistance occurs, and it becomes more difficult for glucose to enter the cells and, to compensate for this defect, the pancreas produces more insulin. Increasing insulin results in excessive insulin and excessive blood sugar. As glycemia increases the pancreas fails to produce the necessary amounts of insulin, and type 2 diabetes may appear in genetically predisposed patients. Research suggests the end result of prolonged insulin resistance is type 2 diabetes[http://www.ir-web.com/english/gp/ir/irmenu1/irmenu1.asp]

Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*The glycemic index ranks foods on how they affect our blood sugar levels. This index measures how quickly an individual's blood sugar increases in the two or three hours after eating. The glycemic index is about foods high in carbohydrates. Foods high in fat or protein don't cause your blood sugar level to rise much. Using the glycemic index to make healthy food choices promotes euglycemia. Recent studies of large numbers of people with diabetes show that those who keep their blood sugar under tight control best avoid the complications of diabetes. What works well for people with diabetes -- is regular exercise, little saturated fat, and a high-fiber diet.

Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*

Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*The loss of responsiveness of the body to insulin is associated with a clustering of cardiovascular risk factors that includes abdominal obesity, hypertension, dyslipidemia, glucose intolerance and hyperinsulinemia. This association is referred to as the Insulin Resistance syndrome, which is also known as Syndrome X.

Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Women with a history of GDM are metabolically vulnerable with insufficient beta cell reserve, and many are insulin resistant.. The insulin resistance is the factor that exists in the woman with GDM. The aim of the lifestyle changes to be discussed here are to decrease insulin resistance. Hypertension, hyperlipidemia and Syndrome X are conditions associated with Insulin Resistance.Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Recognition and screening NormoglycemiaIGF or IGTDiabetes MellitusFPG < 110mg/dlFPG > 110 and < 126 mg/dl (IFG)FPG >126 mg/dl2 hr PG 140 and < 200 mg/dl (IGT)2hr PG >200 mg/dlSymptoms of DM and random plasma glucose concentration > 200 mg/dlAvailable:http://journal.diabetes.org/FullText/Supplements/DiabetesCare/Supplement100/s20.htm

Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Making Healthy Food ChoicesThe following goals of Nutrition Therapy respect the needs of the pregnant woman and her developing fetus:

Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*

Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Available:http://journal.diabetes.org/FullText/Supplements/DiabetesCare/Supplement100/s20.htmIFG: Impaired fasting glycemia: a fasting glucose concentration lower than those required to diagnose diabetes but higher than the 'normal' reference rangeIGT: Impaired Glucose Tolerance: a stage in the natural history if disordered carbohydrate metabolism. This marker serves as an indicator or marker along with the other elements of Metabolic Syndrome. Individuals with IGT manifest glucose intolerance only when challenged with an oral glucose load.FPG: Fasting Plasma Glucose Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNMPat Sonnenstuhl,ARNP, CNM*Pat Sonnenstuhl,ARNP, CNM