Nutritional instructions generally include a carbohydratecontrolled diet suicient to maintain normoglycemia and avoid ketosis. On average, this includes a daily caloric intake of 30 to 35 kcallkg. Moreno-Castilla and associates (2013) randomly assigned 152 women with gestational diabetes to either a 40-or a 55-percent daily carbohydrate diet and found no diference in insulin levels and pregnancy outcomes. he American College of Obstetricians and Gynecologists (2017 a) suggests that carbohydrate intake be limited to 40 percent of total calories. The remaining calories are apportioned to give 20 percent as protein and 40 percent as fat.
The most appropriate dietary approach for women with gestational diabetes has not been established. One metaanalysis of trials of low-glycemic index diets found that diets higher in complex carbohydrates and dietary iber reduced the risk of macrosomia and likelihood of insulin use in women with gestational diabetes (Wei, 2016). That said, there clearly are limitations to what can be accomplished with various dietary approaches alone. Most and Langer (2012) found that insulin was efective in reducing the risk of excessive birthweight in ofspring of obese women with gestational diabetes. Casey and colleagues (20 15 b) also found that dietary treatment alone for morbidly obese women with mild gestational diabetes did not reduce neonatal fat mass or LGA birthweights.
Few trials have evaluated exercise speciically for women with gestational diabetes. he American College of Obstetricians and Gynecologists (2017a,b) recommends regular physical activity that incorporates aerobic and strength-conditioning exercise during pregnancy and extends this to women with gestational diabetes. Two recent metaanalyses demonstrate that structured exercise programs during pregnancy diminish weight gain during pregnancy and even reduce the risk of developing gestational diabetes (Russo, 2015; Sanabria-Martinez, 2015). Exercise during pregnancy in woman with gestational diabetes also lowers glucose levels Qovanovic-Peterson, 1989).
Hawkins and colleagues (2008) compared outcomes in 315 women with diet-treated gestational diabetes who used personal glucose monitors with those of 615 gestational diabetics who were also diet-treated but who underwent intermittent fasting glucose evaluation during weekly obstetrical visits. Women using daily blood-glucose self monitoring had significantly fewer macrosomic newborns. They also gained less weight after diagnosis than women evaluated during clinic visits only. hese indings support the common practice of blood-glucose self monitors for women with diet-treated gestational diabetes.
Postprandial surveillance for gestational diabetes has been shown to be superior to preprandial surveillance (De Veciana, 1995). At Parkland Hospital, we reviewed the impact of changing to postprandial monitoring in women with diet-treated gestational diabetes and demonstrated a signiicant reduction in maternal weight gain per week-0.63lb/week to 0.45 lb/weekin women managed with a postprandial monitoring schema. The merican College of Obstetricians and Gynecologists (2017 a) and the ADA (20 17b) recommend glucose assessment four times daily. The first check is performed fasting, and the remainder are done 1 or 2 hours ater each meal.