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Applied nutritional investigation

Nutrient intake of women with and without gestational diabetes with aspecific focus on fatty acids

Beverley Thomas, M.Phil.a,*, Kebreab Ghebremeskel, Ph.D.a, Clara Lowy, M.D., Ph.D.b,Michael Crawford, Ph.D., F.R.C.Path.a, and Bridget Offley-Shore, R.N.b

a Institute of Brain Chemistry and Human Nutrition, London Metropolitan University, London, United Kingdomb Endocrine and Diabetic Day Centre, Guy’s and St. Thomas’ Hospital Trust, London, United Kingdom

Manuscript received March 17, 2005; accepted July 15, 2005.

bstract Objective: Diet therapy is the cornerstone for the management of gestational diabetes mellitus(GDM). Women with GDM are commonly given dietary advice that broadly focuses on a reductionof total energy and fat consumption. We compared nutrient intake and specifically fatty acids ofwomen with GDM who had received individualized nutritional counseling with those of non-diabetic women who did not.Method: Women with GDM (n � 44) and healthy pregnant women (n � 44) with uncomplicatedsingleton pregnancies were recruited during the third trimester. Women with GDM were givenconsultation on diet, health, and macronutrient content of foods commonly consumed by theindividual. The non-diabetic group did not receive any dietary advice. Both groups were asked tokeep a detailed record of all of foods and fluid consumed over a 4-d period.Results: After dietary counseling, the GDM group had lower intakes of energy (P � 0.05), refinedsugar (P � 0.0001), total and saturated fats (P � 0.0001), and monounsaturated (P � 0.01) and trans(P � 0.0001) fatty acids and higher levels of docosahexaenoic acid and fiber (P � 0.05) comparedwith the non-diabetic group.Conclusions: Individualized dietary advice was associated with a lower consumption of the targetnutrients in women with GDM. Another benefit of the advice was a slight increase in intake ofeicosapentaenoic and docosahexaenoic acids, although consumption of �-3 fatty acids by bothgroups was well below the recommendations for pregnancy. There is evidence that docosahexaenoicacid modulates insulin resistance and that it is vital for neurovisual development. We suggest thatdietary management for women with GDM should foster the current recommendations for essentialfatty acids in pregnancy. © 2006 Elsevier Inc. All rights reserved.

Nutrition 22 (2006) 230–236www.elsevier.com/locate/nut

eywords: Gestational diabetes mellitus; Nutrients; Dietary fatty acids

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ntroduction

Gestational diabetes mellitus (GDM) is one of the com-onest metabolic disorders of pregnancy [1]. In the Unitedingdom, 3% to 5% of pregnant women develop GDM [2].owever, the prevalence is two and four times higher inomen of African and Asian origin, respectively, compared

This study was supported by Diabetes UK, the March of Dimes Birthefect Foundation, the Mother and Child Foundation, and Shida Kanzumeo. Ltd.

* Corresponding author. Fax: �44-0207-133-2453. (B. Thomas).

GE-mail address: b.thomas@londonmet.ac.uk

899-9007/06/$ – see front matter © 2006 Elsevier Inc. All rights reserved.oi:10.1016/j.nut.2005.07.017

ith Caucasians [3–5]. The disorder is characterized byncreased insulin resistance [6,7], impaired insulin secretion8], or a combination [9]. The etiology of GDM is not wellnderstood, but it is thought to be due to a non-immune,unctional defect of pancreatic �-cells and failure to com-ensate for the normal insulin resistance of pregnancy [10].

Gestational diabetes mellitus is associated with increasedisk of maternal morbidity and adverse perinatal outcomes11–16]. Women with a history of GDM [17,18] and theirffspring [13,19] have a higher risk of developing type 2iabetes later in life.

Nutritional management is the main treatment option for

DM [20,21]. Those who do not respond are given insulin

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231B. Thomas et al. / Nutrition 22 (2006) 230–236

r oral hypoglycemic agents in conjunction with dietaryherapy [22–24]. The goal of nutritional therapy is to attainormoglycemia, maintain normal weight gain for preg-ancy, and decrease accelerated fetal fat deposition. Al-hough dietary guidelines for the management of womenith GDM exist in the United States [21], there is a lack of

imilar guidelines in the United Kingdom. Nevertheless,hese women are commonly advised to decrease intakes ofnergy, total and saturated fats, and refined carbohydratesnd to increase complex carbohydrates and fiber. There is aaucity of comprehensive published data of the effect ofuch broad dietary advice on intakes of vital nutrients,pecifically �-6 and �-3 essential fatty acids. This is sur-rising because diabetes impairs the synthesis of long-chain-6 and �-3 fatty acids [25], and women with GDM and

heir newborn babies have decreased levels of red cellrachidonic acid and docosahexaenoic acid (DHA) [26].his study compared nutrient intake, specifically fatty acids,f women with GDM who had received individualizedutritional counseling with that of non-diabetic women whoid not.

aterials and methods

ubjects and recruitment

Forty-four women with GDM and uncomplicated single-on pregnancies were recruited during the third trimesterweeks 28 to 32) from St. Thomas’ Hospital (London,nited Kingdom). Healthy pregnant women (n � 44) with-ut a family history of diabetes, high blood pressure, andther chronic disorders were enrolled as controls.

Detailed demographic, clinical, and obstetric data wereollected from both groups of women. Ethical approvalrom the ethics committee of Lambeth & Southwark Healthuthority and written consent from subjects were obtained.

iagnosis of GDM

All subjects underwent a screening test for GDM. Theiagnosis was based on the standard criteria of the Europeanssociation for the Study of Diabetes [27], involving a 75-gral glucose load after an overnight fast. Blood glucoseoncentration was monitored at 60 and 120 min. If bloodlucose concentration at 60 min was less than or equal to 8.0mol/L, results were considered normal. If at 60 min blood

lucose concentration was greater than 8 mmol/L, a secondample was taken at 120 min. GDM was diagnosed if theasting plasma glucose concentration at 120 min exceeded 9mol/L.

utritional advice and dietary assessment

At diagnosis, all women with GDM were referred to a

ietician. During this initial consultation, information was g

btained on dietary and lifestyle habits and on generalnowledge and attitudes to nutrition and health. A basicxplanation was provided on the nutrient composition ofood and food products commonly consumed. Women weredvised of the need to decrease total fat, saturated fat, andefined sugar and to increase complex carbohydrates andber consumption, but all received dietary advice that was

ailored to their individual requirements. Dietary advice wasased on the recommendations of the British Diabetic As-ociation, which prescribes that 45% to 60% of energy peray be derived from carbohydrates and less than 35% fromat and distributed as evenly as practical throughout the day.

omen who had GDM and a body mass index (BMI)reater than 25 kg/m2 were also advised to restrict dietarynergy. Women with GDM were seen every 2 wk through-ut the remainder of their pregnancy in a combined diabeticntenatal clinic. The non-diabetic group received no suchietary advice.

Both groups were asked to record details of all foods anduid consumed during 4 consecutive days, with 1 weekenday included. Participants were given written and oral in-tructions on how to complete the diary using householdeasurements but were also provided with quick-reading

igital scales. They were asked to keep food wrappers andontainers, so that weights and descriptions of prepackagedoods eaten could be evaluated. Recipes were analyzed anddded to the database of frequently consumed dishes thatere not present in the original database. All dietary recordsere taken between weeks 2 and 3 after the dietary advice.The energy and nutrient content of their diets were cal-

ulated using FOODBASE (Institute of Brain Chemistrynd Human Nutrition, London Metropolitan University,ondon, UK). This is a nutritional analysis program basedn the fifth edition of McCance & Widdowson’s the Com-osition of Foods [28], and its 10 accompanying supple-ents (including Immigrant Foods), plus enhanced fatty

cid data produced by the Institute of Brain Chemistry anduman Nutrition. The food diary and nutrition software haseen validated in previous pregnancy studies [29,30]. Toliminate interpersonal variability in coding and assessmentf portion sizes, the same experienced individual carried outhe analysis and interpretation of the food diaries. Diariesere rejected during this process if information was incom-lete.

tatistical analysis

Demographic, clinical, macronutrient, and fatty acid re-ults are expressed as mean � standard deviation. Two-ailed unpaired t test was used to compare differences inietary intake between women with GDM and healthyomen without diabetes. The effects of ethnicity and GDM

nd their interaction on intake were investigated by the usef two-way analysis of variance. The Games-Howell postoc test was employed for pairwise comparison to identify

roups that were significantly different. P � 0.05 was con-

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idered statistically significant. SPSS 10 for WindowsSPSS UK Ltd., Woking Surrey, UK) was used to analyzeata.

esults

omen with and without GDM

emographic and clinical characteristicsDemographic and clinical data are presented in Table 1.

omen with GDM were older (P � 0.05), heavier (P �.0001), and had a higher BMI before pregnancy and atiagnosis (P � 0.0001) compared with controls. Bloodlucose concentrations before and 60 min after oral glucoseolerance testing, glycosylated hemoglobin (P � 0.001) andystolic (P � 0.014) and diastolic (P � 0.001) blood pres-ures of women with GDM were also higher.

nergy and macronutrientsMean daily intakes of energy, protein, carbohydrate, and

able 1emographic and clinical characteristics of the mothers

Control (n � 44) GDM (n � 44)

ge (y) 28.02 � 5.8 31.25 � 5.3*eight (m) 1.64 � 0.06 1.64 � 0.07repregnancy weight (kg) 61.4 � 10.8 74.59 � 20.4‡

repregnancy BMI (kg/m2) 22.82 � 4.1 27.97 � 6.9‡

Range 17.1–35.5 17.2–55.1eight at recruitment (kg) 71.49 � 12.7 89.69 � 19.4‡

MI at diagnosis (kg/m2) 27.57 � 4.52 32.87 � 6.15‡

Range 19.9–38.7 22.3–56.8thnicity (n)Caucasian 31 13Afro-Caribbean/African 8 23Asian 2 4Others§ 3 —Information not given — 4

arity (n)0 29 171 8 11�2 7 12Information not given — 4

ystolic blood pressure(mmHg)

113.20 � 12.16 121.08 � 15.61*

ystolic blood pressure(mmHg)

68.68 � 8.84 76.54 � 11.76†

lucose at 0 min (mmol/L) 4.18 � 0.32 5.76 � 1.76‡

lucose at 60 min (mmol/L) 6.16 � 1.21 12.21 � 2.95‡

lucose at 120 min (mmol/L) — 10.78 � 2.42bA1C (%) 4.52 � 0.21 5.72 � 0.69‡

ength of gestation (wk) 39.3 � 1.4 38.5 � 1.1†

BMI, body mass index; GDM, gestational diabetes mellitus; HbA1C,lycosylated hemoglobin* Significantly different from corresponding controls at P � 0.05.† Significantly different from corresponding controls at P � 0.01.‡ Significantly different from corresponding controls at P � 0.0001.§ These subjects described themselves as Middle Eastern, Mediterra-

ean, or Greek Orthodox.

at and percentage of energy derived from macronutrients (

re listed in Table 2. For comparative purposes, referenceutrient intakes [31] for UK pregnant women are alsohown. Women with GDM had lower intakes of energy (P

0.05), total fat, and total sugar (P � 0.0001) and higherietary fiber (P � 0.05) than did women without GDM.hey also obtained a larger proportion of their daily energy

rom protein and complex carbohydrates (P � 0.0001) andess from total fat (P � 0.0001) and refined sugar (P �.01) than did healthy controls.

ood sources of energy and macronutrientsWomen in both groups derived carbohydrates and fat

rom similar food sources. Cereals and cereal products (40%o 50%), vegetables including potatoes (16% to 18%), andruit juice and concentrated drinks (10% to 12%) were theajor contributors of carbohydrates. Cooking oils, spread-

ble vegetable and animal fats (32% to 35%), cheese, eggs,hole and semi-skimmed milk (12% to 15%), and meatroducts and poultry (10%) were the principal sources ofietary fat. The GDM group obtained dietary proteinsainly from meat and poultry (28%), cereal (20%), dairy

roducts (13%), fish (13%), and vegetables (8%). Meat andoultry (30%), cereal (19%), dairy products (16%), fish9%), and vegetables (8%) accounted for most of the pro-eins consumed by the non-GDM group.

atty acidsMean daily intakes of total, saturated, monounsaturated,

nd polyunsaturate fatty acids and their contribution tonergy are listed in Table 2. Consumption of polyunsatu-ated (P � 0.0001), monounsaturated (P � 0.01), and transP � 0.0001) fatty acids and �-6/�-3 metabolites (P �.01) was lower and DHA (P � 0.05) and percentage ofnergy from total �-3 polyunsaturated fatty acids wereigher in the GDM group. The two groups had comparablentakes of linoleic acid (LA), �-linolenic acid (ALA), andrachidonic acid (P � 0.05).

thnicity, GDM, and nutrients

nergy, macronutrients, and fatty acidsMean daily energy, macronutrient, and fatty acid con-

umptions of Afro-Caribbean and Caucasian women withnd without GDM are listed in Table 3. Afro-Caribbeanomen with GDM had lower intakes of sugar (P � 0.01)

nd saturated and trans fatty acids (P � 0.05) than did theirorresponding counterparts without diabetes. In addition,heir intakes of energy (�14%) and total (�20%) andonounsaturated (�21%) fatty acids were lower and those

f total polyunsaturated (�13%), �-3 (�7%) and �-6�14%,) fatty acids and DHA (�50%) were higher. Simi-arly, Caucasian women with GDM had lower intakes ofnergy (�4.2%), total fat (�14%), sugar (�7.3%), andaturated (�28%), trans (�33.5%, P � 0.05), and mono-nsaturated (�11%) fatty acids and higher intakes of �-6

�23.8%) and �-3 (�15%) fatty acids, DHA (�30%), and

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233B. Thomas et al. / Nutrition 22 (2006) 230–236

rotein (�27.5%, P � 0.05) compared with their counter-arts without GDM.

The effects of GDM and ethnicity and their interactionn intake of some nutrients is presented in Table 4. Ethnic-ty had a significant influence on consumption of fiber (P �.049), total fat (P � 0.003), and saturated (P � 0.006),onounsaturated (P � 0.028), and trans (P � 0.006) fatty

cids, and DHA (P � 0.030).

iscussion

acronutrient intake

Although diet counseling is the cornerstone for the man-gement of GDM in the United Kingdom, there is a scarcityf comprehensive published data of the effect of such ad-ice on intakes of vital nutrients. Mean energy and macro-utrient intakes of women with GDM in the present studyere broadly comparable with those of British [32], Chinese

able 2ean dietary intakes and percentage of energy contribution of the macron

utrients UK RNI§

nergy (kcal/d) 1,940 (�200)rotein (g/d) 45.0 (�6)% Energy 15

at (g/d) 73.5 (�)% Energy 35

aturated fatty acid 24.4% Energy 11UFA 28.9% Energy 13

UFA 16.7% Energy 7.5�

18:2�-6 —20:4�-6 —Total �-6 PUFA 14.4

% Energy 6.5�

18:3�-3 —20:5�-3 —22:6�-3 —Total �-3 PUFA 2.2

% Energy 1�

rans fatty acid 4.4% Energy 2

HO (g/d) 193 (�)% Energy from total CHO 50Complex CHO (starch) 106Refined CHO (added sugar) —

iber (NSP) 12.5 (�)

�, No increment required; CHO, carbohydrate; GDM, gestation diabeteUFA, polyunsaturated fatty acid; RNI, reference nutrient intake* Significantly different from corresponding controls at P � 0.05.† Significantly different from corresponding controls at P � 0.01.‡ Significantly different from corresponding controls at P � 0.0001.§ Values are for non-pregnant women 19 to 50 y of age [31]. Additiona� Subsequent to the RNI, recommendations were made for adequate int

33], Italian [14], and American [34,35] data. These similar b

ndings from countries with different dietary traditionseem to suggest that the broadly comparable conventionalietary advice given to women with GDM led to harmoni-ation of intake of macronutrients.

Consistent with the advice given, women with GDM hadower intakes of dietary energy, total and saturated fats, anddded sugar and higher intake of complex carbohydratesnd fiber compared with women without GDM. Womenith GDM were given individualized and tailored dietary

dvice, which may provide an explanation for the highompliance. A report by the American Diabetic Association36] has stated that, to be effective, nutritional therapy foriabetics should be personalized, with consideration giveno habitual food intake and eating habits. Other studies haveeported that women with GDM are compliant to dietarydvice [37], and that dietary management is effective inchieving good glycemic control [38–40].

The energy intake of the GDM group was about 9%ower than the U.K. recommendation of 2140 kcal/d duringregnancy. This modest deficit in energy intake would not

s

Control GDM

2213 � 521.9 1955 � 551.0*81.08 � 23.2 84.9 � 28.814.54 � 3.5 17.64 � 4.05‡

91.02 � 27.2 69.7 � 25.1‡

37.25 � 5.3 31.90 � 5.9‡

32.57 � 12.23 19.89 � 8.59‡

13.25 � 3.6 9.16 � 2.96‡

26.79 � 8.97 21.18 � 8.20†

10.89 � 3.63 9.75 � 3.7713.55 � 5.57 14.29 � 7.155.51 � 2.27 6.58 � 3.29

11.71 � 5.18 12.21 � 6.590.12 � 0.07 0.13 � 0.08

11.92 � 5.21 12.41 � 6.624.85 � 2.12 5.71 � 3.051.33 � 0.56 1.42 � 0.770.11 � 0.22 0.16 � 0.250.13 � 0.14 0.20 � 0.17*1.63 � 0.66 1.88 � 0.940.66 � 0.27 0.87 � 0.43*2.67 � 1.60 1.40 � 0.85‡

1.09 � 0.65 0.65 � 0.39‡

282.30 � 75.1 260.99 � 87.547.48 � 6.09 50.30 � 6.12*

150.40 � 38.41 175.0 � 75.461.19 � 36.93 26.62 � 31.37‡

12.25 � 4.9 14.9 � 6.1*

us; MUFA, monounsaturated fatty acid; NSP, non-starch polysaccharides;

rements for pregnancy are presented in parentheses.the British Nutrition Foundation [45] and Simopoulos et al. [46].

utrient

s mellit

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e expected to have an adverse effect on the mother or fetus

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234 B. Thomas et al. / Nutrition 22 (2006) 230–236

n women who are obese (BMI � 29 kg/m2) or of normalody weight. There is evidence that obese women withDM are protected from ketosis induced by energy restric-

ion because of their higher hepatic glucose output10,41,42]. Nevertheless, about 9% energy restriction innderweight women with GDM may have a negative effectn fetal development and maternal health. The prepreg-ancy BMI range for women with GDM was 17.2 to 55.1g/m2. Others [43,44] have reported a detrimental effectrom fasting ketosis on neurophysiologic and fetal develop-ent in diabetic pregnancy with severe energy restriction.he American Diabetic Association [21] guidelines on nu-

ritional management of GDM state that energy intakehould be based on prepregnancy and current body weights.

e feel that there is a need for similar guidelines in thenited Kingdom to avoid adverse effects that may result

rom energy restrictions.

atty acid intake

In the United Kingdom, there are no specific recommen-ations for saturated, monounsaturated, �-6, and �-3 fattycids for pregnant women who are healthy or who haveDM. For non-pregnant healthy adults, it is generally rec-mmended that saturated and monounsaturated fatty acidshould constitute less than 11% and 13% of daily energyntake. In addition, LA, ALA, and eicosapentaenoic acidEPA) plus DHA should account for 6%, 1%, and 0.5% ofietary energy, respectively [31,45]. More recently, a work-hop on the essentiality of dietary �-6 and �-3 fatty acids,

able 3ean daily energy, macronutrient, and fatty acid intakes of Afro-Caribbe

utrients Caucasian Controla

(n � 31)Caucasi(n � 13

nergy (kcal/d) 2271b,c 2176a,c,d

rotein (g/d) 80.09 � 22.39c,d 102.08 �otal fat (g/d) 97.85 � 25.74b,c 84.20 �Saturated fatty acid 35.61 � 12.24c 25.65 �MUFA 28.13 � 8.98b,c 25.01 �PUFA 13.27 � 5.74b,c,d 16.28 �

LA 11.47 � 5.40b,c,d 14.20 �AA 0.12 � 0.01b,c,d 0.15 �Total �-6 11.67 � 5.43b,c,d 14.45 �ALA 1.38 � 0.53b,c,d 1.55 �EPA 0.07 � 0.10b,c,d 0.08 �DHA 0.10 � 0.10b,c 0.13 �Total �-3 1.60 � 0.57b,c,d 1.84 �

Trans 3.01 � 1.65b,c 2.03 �otal carbohydrate (g/d) 279.8 � 78.3b,c,d 266.2 �Starch 151.61 � 40.9b,c,d 148.56 �Sugar 124.33 � 45.1b,c 115.98 �

iber (NSP) (g/d) 13.03 � 5.05b,c,d 17.28 �

AA, arachidonic acid; ALA, �-linolenic acid; DHA, docosahexaenoic accid; MUFA, monounsaturated fatty acid; NSP, non-starch polysaccharide

* Women were grouped based on their ethnic background and assignedifferent at the 0.05 or 0.01 level.

hich was held by the National Institutes of Health, rec- D

mmended 4.4 to 6.7 g of LA, 2.2 g of ALA, 0.65 g of EPAlus DHA, and a ratio of 1 to 1.9 for �-6/�-3 per day fordults, and an additional 300 mg/d of DHA for pregnantomen [46]. Women without GDM in the present study hadigher intakes of LA and �-6/�-3 ratio and lower intakes ofLA, EPA, and DHA compared with the recommendations

ited above. The present findings were consistent with thosef previous reports [47–49] and a reflection of the “Westerniet,” which is high in saturated and �-6 fatty acids and lown �-3 fatty acids.

There is very limited comprehensive information on fattycid intake of UK GDM women on habitual diet or dietaryherapy. Nevertheless, the women with GDM in this studyonsumed less saturated and monounsaturated fatty acidsompared with their Italian [14] and American [34,50]ounterparts. In addition, they had higher intakes of EPAnd DHA compared with American women with GDM34,50]. Women with GDM in the present and Americantudies had broadly comparable dietary counseling. Never-heless, American women with GDM who were given di-tary advice had higher intake of monounsaturated fat andimilar intake of saturated fat compared with their non-iabetic counterparts who did not receive dietary counsel-ng. Moreover, mean intakes of arachidonic acid, EPA, andHA of women with GDM were 1.5, 2.5, and 2.3 timesigher [34] and 1.2, 1.3, and 2.0 times lower [50] than inomen without GDM.The GDM group in the present study had lower intakes

f saturated (39%) and monounsaturated (21%) fatty acidsnd higher intakes of �-6 (4%), �-3 (53%), EPA (45%), and

Caucasian women*

b Afro-Caribbean Controlc

(n � 8)Afro-Caribbean GDMd

(n � 23)

2151a,b,d 1855b,c

c 80.80 � 30.63a,b,d 79.02 � 22.46a,c

a,c,d 78.38 � 29.22a,b,d 62.44 � 20.97b,c

26.58 � 13.94a,b 17.49 � 8.10,c,d 23.96 � 10.47a,b,d 19.00 � 7.04b,c

,c,d 11.82 � 4.86a,b,d 13.36 � 6.0a,b,c

,c,d 9.88 � 4.01a,b,d 11.36 � 5.61a,b,c

,c,d 0.15 � 0.07a,b,d 0.12 � 0.07a,b,c

,c,d 10.15 � 4.10a,b,d 11.56 � 5.66a,b,c

,c,d 1.24 � 0.68a,b,d 1.25 � 0.70a,b,c

,c,d 0.21 � 0.41a,b,d 0.20 � 0.31a,b,c

,c,d 0.16 � 0.15a,b,d 0.24 � 0.19b,c

,c,d 1.68 � 0.90a,b,d 1.80 � 0.91a,b,c

,c,d 2.02 � 1.40a,b,d 1.11 � 0.72b,c

,c,d 295.9 � 88.1a,b,d 260.6 � 110.9a,b,c

,c,d 148.83 � 38.7a,b,d 184.19 � 92.19a,b,c

,c 143.63 � 68.4a,b 72.09 � 39.95,d 10.45 � 4.44a,d 14.03 � 6.80a,b,c

, eicosapentaenoic acid; GDM, gestational diabetes mellitus; LA, linoleicA, polyunsaturated fatty acid(a, b, c, or d). Means that do not share a superscript letter are significantly

an and

an GDM)

32.1329.067.56c

9.41a

9.51a

8.64a

0.18a

8.65a

0.82a

0.08a

0.12a

1.01a

0.84a

39.9a

27.9a

31.3a

4.52a

id; EPAs; PUF

a letter

HA (53%) compared with the non-GDM group. A similar

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235B. Thomas et al. / Nutrition 22 (2006) 230–236

attern was evident between Afro-Caribbean and Caucasianomen with GDM and their respective non-diabetic coun-

erparts. Hence, the observed contrast in intake of fatty acidsetween diabetics and non-diabetics was most likely due tohe effect of the dietary advice given to the women withDM rather than a reflection of the different habitual dietsf the two groups.

The advice given to women with GDM was to decreaseotal and saturated fats. Specific advice was not given withespect to intakes of monounsaturated, �-6, or �-3 fattycids. However, the net effect of the advice was a decreasen saturated and monounsaturated fatty acids that waschieved by decreased consumption of dairy productscheese and milk), margarines, and beef and a concomitantncrease in �-3 fatty acids by increased fish consumption.he proportions of women who consumed more than twoortions of fish per week was about 46% in the GDM groupnd 19% in the non-GDM group. The GDM group con-umed more ALA, EPA, and DHA compared with theon-GDM group, but intakes were lower than the recom-ended amounts [46] by approximately 35% and 62%,

espectively. The corresponding shortfalls for the non-GDMroup were about 39% and 75%. A higher intake of �-3atty acids during pregnancy is related to gestational lengthnd cerebral maturation in the newborn [51] and lowerrenatal and postnatal depression [52]. Diabetes impairsynthesis of DHA, and there is evidence that pregnantomen with GDM and their newborn offspring have lower

evels of membrane DHA [25,26]. As a consequence, aower intake of �-3 fatty acids would be expected to be

ore critical for the GDM group than for the healthy controlroup.

This study demonstrates that dietary counseling was ef-ective because it decreased intakes of the target nutrients,amely total energy and saturated and total fats, but itsffect on blood glucose level remains to be established.nother benefit was an increased intake of the �-3 fatty

cids EPA and DHA, although the amounts were well belowhe recent recommendations for pregnancy. Diet therapyemains the cornerstone for the management of GDM. How-ver, the advice given is generally broad, with minimalocus on vital nutrients. We contend that there is a need fortandardized nutritional guidelines for the management ofDM. The guidelines should foster the current knowledgef the long-chain unsaturated fatty acids, arachidonic acidnd DHA, which are vital for maternal health and fetalevelopment.

cknowledgments

The authors thank all the women who participated in the

tudy.

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