Buy this Article for $7.95

Have a coupon or promotional code? Enter it here:

When you buy this you'll get access to the ePub version, a downloadable PDF, and the ability to print the full article.

Authors

  1. Craven, Kay MPH, RDN, CDE
  2. Haven, Kelley MD
  3. Kolasa, Kathryn M. PhD, RDN, LDN

Abstract

Medical nutrition therapy is considered the cornerstone of treatment for gestational diabetes mellitus, even though there is no consensus on the best dietary approach to achieve optimal glycemic control and positive maternal and fetal outcomes. In this article, we present a case from our clinic of a woman with gestational mellitus, the evidence for the level of macronutrients to include in the diet, and the use of glycemic index for dietary planning. We also review the evidence for emerging dietary therapies and provide general recommendations that should be individualized to the patient.

 

Article Content

Gestational diabetes mellitus (GDM) is diabetes diagnosed in the second or third trimester of pregnancy that is clearly not type 1 or type 2.1 It has been associated with complications during and after pregnancy. In addition, it is a risk factor for developing GDM in subsequent pregnancies or type 2 diabetes mellitus (T2DM) in the future. The key strategies for prevention and reduced risk of complications from GDM include (1) achieving and maintaining optimal glycemic control during pregnancy, (2) consuming a carbohydrate (CHO) controlled meal plan with adequate nutrient content to support maternal needs and fetal growth that has been individualized by a registered dietitian nutritionist (RDN), (3) gaining weight according to the Institute of Medicine guidelines, (4) increasing physical activity, and (5) using medications if unable to achieve glycemic control with lifestyle management alone.1-8 The conventional dietary approach of restricting CHOs to 30% to 40% of calories has been challenged, but because of limited evidence, there is no consensus on which dietary approach, especially related to the type and amount of CHO, leads to the optimal outcomes.9-11 There is agreement that it is critical for the woman to keep her blood glucose level under control to minimize the complications to mother and infant. The primary outcomes studied related to different types of dietary advice for mother and infant are listed in Table 1.11

  
Table 1 - Click to enlarge in new windowTABLE 1 Different Types of Dietary Advice for Women With Gestational Diabetes Mellitus: Primary Outcomes

The conventional dietary approach of restricting CHOs to 30% to 40% of calories has been challenged.

 

A 2017 Cochrane11 review identified 10 different types of advice including but not limited to the levels of CHO and use of the glycemic index (GI) to manage blood glucose levels. In 2017 the American College of Obstetrics and Gynecology2 updated its Practice Bulletin to present management guidelines that have been validated by appropriately conducted clinical research. In this article, we focus on the evidence for the level of CHO to include in the diet as well as the use of GI for planning a diet for a woman with GDM. We present a case from our clinic of a woman with GDM, and the type of advice she received from her clinician, as well as her diet and exercise plan, could have been individualized in collaboration with an RDN, and we make suggestions for individualizing nutritional care.

 

CASE PRESENTATION

Ms J.C. is a 31-year-old woman with morbid obesity who has had 6 previous pregnancies and 2 live births. Her first birth was complicated by a vacuum-assisted vaginal delivery, shoulder dystocia, and fourth-degree perineal laceration. Her second birth was an uncomplicated spontaneous vaginal delivery. She did not have GDM in either of these full-term pregnancies. Prepregnancy, J.C. was measured at 60 inches tall and 241 lb (body mass index, 48 kg/m2). The clinic uses a 2-step screening process that starts with a 50-g oral glucose tolerance test (OGTT) and, if positive, follow-up with a 3-hour OGTT. During this, her ninth pregnancy, she was diagnosed with GDM at 26 weeks after failing both screening tests. Table 2 has her laboratory values from the 1-hour glucose tolerance test or Glucola, the most common method of screening for GDM. Table 3 has the values from her follow-up 3-hour OGTT, which was abnormal. Her physician counseled her on the meaning of the results and the risks to herself and her baby if she did not manage her blood sugar. She was given brief counseling on a diet and physical activity for diabetes management as outlined in the prenatal education book given to all our pregnant patients (Figure 1). She was instructed in-home glucose monitoring with pregnancy goals of fasting less than 90 mg/dL and 2-hour postprandial less than 120 mg/dL and weight maintenance. At the time of her diagnosis, she had gained 23 lb, which exceeded the goal of 11 to 20 lb explained to her at an earlier visit.7

  
Table 2 - Click to enlarge in new windowTABLE 2 Results of Ms J.C.'s 1-Hour Screening Laboratory Test
 
Table 3 - Click to enlarge in new windowTABLE 3 Results of Ms J.C.'s 3-Hour Oral Glucose Tolerance Test
 
Figure 1 - Click to enlarge in new windowFIGURE 1. Typical advice to patients about gestational diabetes mellitus.

In follow-up, 2 weeks later, Ms J.C. presented with a blood glucose but not a diet log. She reported checking her blood glucose levels 6 times a day. All fasting blood glucose levels were above the recommendation at 106 to 198 mg/dL, and postprandial levels were mostly higher than recommended at 101 to 190 mg/dL. She said she liked fruits and vegetables but had a hard time getting them. She stated she was taking a prescription prenatal vitamin mineral supplement. Because her blood glucose was elevated, she was advised to take metformin XR at a dosage of 500 mg twice a day and reminded to eat 3 balanced meals a day plus snacks between meals and avoid foods with lots of sugar in them and be physically active.

 

In follow-up 1 week later, she presented with no logs but verbally reported that her fasting blood sugars were in the range of 100 to 120 mg/dL and her postprandial blood sugars were in the 120s (mg/dL). She stated she took the metformin only once because she did not like the way it made her feel. She was referred for medical nutrition therapy (MNT) but did not keep her appointment.

 

Ms J.C.'s medical history includes morbid obesity, depression with anxiety, and tobacco use. Her pertinent social history includes full-time employment at a social service agency and being a single mother. She missed many of her prenatal appointments because of her work and parenting schedules, and she was seen multiple times in labor and delivery triage for musculoskeletal concerns. She was transferred to a regional high-risk obstetrical clinic for antepartum fetal surveillance at 32 weeks and admitted at 36 weeks for inpatient monitoring because of nonreassuring fetal testing. Her labor was induced at 37 weeks because of poorly controlled GDM despite medical management and associated maternal and fetal risks. She has not yet followed up for postpartum care or a 2-hour glucose tolerance test recommended to diagnose persistent type 2 diabetes at 6 weeks postpartum.

 

Her labor was induced at 37 weeks because of poorly controlled GDM despite medical management.

 

EVIDENCE TO GUIDE DIETARY PLANNING

The conventional diet approach for managing GDM has been CHO restriction (30%-40% energy from total calories), which usually resulted in a higher fat content. There is emerging evidence that a diet higher in nutrient dense CHOs may result in better outcomes. There is the suggestion, as well, that using the GI of foods to plan diets may result in better glucose management. Physicians, nurse midwives, and RDNs are all challenged to advise women on the optimal approach for managing their blood glucose levels.9,10

 

What the Experts, Textbooks, and Manuals Now Recommend

Expert Recommendations

Lifestyle management including diet, appropriate weight gain, and physical activity are considered essential components of controlling GDM.1-8 The 2018 American Diabetes Association Standards of Care1 states MNT for GDM is an individualized nutrition plan developed between the patient and the RDN familiar with the management of GDM and does not specify the optimal amount and type of CHOs. They recommend relying on guidance from the Dietary Reference Intakes, which is a minimum of 175 g of CHO, a minimum of 71 g protein, and 28 g of dietary fiber. The American College of Obstetricians and Gynecologists Practice Bulletin2 continues to specify the percentage of CHO be limited to 33% to 40% of calories, with the remaining calories divided between protein (20%) and fat (40%). In its 2014 practice paper, the Academy of Nutrition and Dietetics3 stated that for women with GDM improved outcomes are observed with dietary intake limiting CHOs to 45% of energy, but further research is needed regarding goals for protein, fat, fiber, and energy.

 

Lifestyle management including diet, appropriate weight gain, and physical activity are considered essential components of controlling GDM.

 

Textbook Descriptions of Lifestyle Management for GDM

Hacker & Moore's Essentials of Obstetrics and Gynecology6 describes a diet that has 45% to 50% of its calories from CHO (with lots of fiber), 20% to 25% from protein, and 20% to 25% from fat. The caloric requirement is calculated on the basis of ideal body weight and distributed throughout the day (20% at breakfast and bedtime snack each and 30% at lunch and dinner each). In an online clinical reference tool used by physicians,5 CHO is described as the primary nutrient affecting postprandial glucose levels and should be limited to 40% calories while ensuring that ketonuria does not ensue. In a highly regarded nutrition textbook8 MNT, a CHO-controlled meal plan with optimal nutrition, adequate energy for appropriate weight gain, and achievement and maintenance of normoglycemia without ketosis are regarded as the cornerstone of treatment for GDM. This text notes the traditional approach has limited CHO to 30% to 40% of energy, but viable alternatives including use of foods with low GI exist. The online Nutrition Care Manual used by RDNs4 recommends a diet with a minimum of 175 g of CHO per day to provide glucose for the fetal brain and prevent ketosis.

 

Observations by Clinicians in Practice

Some physicians observe that women who consume ready-to-eat processed cereal, fruit juices, instant products, and other highly refined products have higher postprandial blood glucose levels compared with those who eat less refined products and whole fruit. They recommend their patients consume unrefined, whole-grain breads, old-fashioned oatmeal, nuts, legumes, and lentils because these foods appear to have a lower glycemic response.9,11

 

What the Research Studies Demonstrate

Ten Dietary Treatments Presented in a 2017 Cochrane Review

Table 4 lists 19 trials of different types of dietary advice given to women with GDM; the number, size, and location of the studies; and outcomes from the intervention.12 Recognizing that the current evidence is very limited, the authors concluded that there were no clear differences in outcomes, except for a possible reduction in cesarean delivery for women receiving a DASH (Dietary Approaches to Stop Hypertension) diet as compared with a control diet.

  
Table 4 - Click to enlarge in new windowTABLE 4 Cochrane Review 2017: Different Types of Dietary Advice for Women With Gestational Diabetes Mellitus and Outcomes

Table 4 lists 19 trials of different types of dietary advice given to women with GDM; the number, size, and location of the studies; and outcomes from the intervention. Researchers have studied the impact of a variety of nutrients and dietary strategies on prevention and management of GDM not included in the Cochrane review12 including vitamin D alone and in combination with calcium supplementation; fish oil, primrose oil or linoleic acid, and [gamma]-linolenic acid; magnesium and zinc supplementation; and dietary bioactive compounds such as flavonoids and polyunsaturated fatty acids.

 

Additional Dietary Studies

There are several studies published since the Cochrane review that merit a brief discussion. There is continued interest in the use of GI to plan meals. Four of the studies included in the Cochrane review,12 especially those from Australia, noted possible benefit from using a diet with low or moderate GI. It should be noted that consumers in Australia have less access to information about the nutrient content, including CHOs, of their food because they do not have Nutrition Facts labeling like the United States. Women participating in a small Australian study were provided all their meals and experienced reduced diurnal glycemic oscillations. The glycemic load was calculated by a dietitian, and the women experienced 50% lower glucose levels, increased time within target range, and less glycemic variability than the conventional diet.13 This suggests that improvement in glycemic control may be obtained by changing the type of CHO rather than by decreasing CHO.

 

In a retrospective cohort study of 436 women, there appeared to be a dose-response relationship and less macrosomia for the infants of women receiving MNT.14 Unfortunately, no details of the type of diet were included in the report. In 2 additional small studies where the food was provided to the women, the diet was liberalized to as high as 50% to 60% of the calories from more complex CHOs and less fat. The question studied was: "Would a high-complex-CHO, lower-fat diet improve maternal insulin resistance and infant adiposity?" This trial, referred to as CHOICE, did result in women achieving glycemic control.11,15

 

Other Strategies Studied

Researchers have studied the impact of a variety of nutrients and dietary strategies on prevention and management of GDM not included in the Cochrane review12 including vitamin D alone and in combination with calcium supplementation; fish oil, primrose oil or linoleic acid, and [gamma]-linolenic acid; magnesium and zinc supplementation; and dietary bioactive compounds such as flavonoids and polyunsaturated fatty acids. Perhaps the most interesting alternative therapy is the use of probiotics. Researchers are investigating the role of gut microbiome as a modulator of metabolic and inflammatory processes. A wide variety of bacteria have been studied in a limited way with findings ranging from no effect to potential positive effects on macrosomia, appropriate weight gain, reduced fasting blood glucose, decreased insulin resistance, and decreased serum insulin. A 2014 Cochrane Review identified a single high-quality trial showing a reduction in rate of GDM among women randomized to probiotics early in pregnancy.16 Currently, the optimal dose, ideal bacterial composition, and safety are unknown.16

 

One study focused not on the composition of the diet itself but on the stress and anxiety women with GDM experience. More than half of the 30 women participating struggled with dietary management between 33 and 37 weeks' gestation, with significantly higher stress scores noted among participants requiring insulin therapy. The authors suggested that tailored care plans and strong communication between the patient and the entire health team may help decrease dietary management stress.17

 

Finding the Balance

Medical nutrition therapy is considered the cornerstone of treatment for GDM. Women who receive only general dietary advice such as that listed in Figure 1 are less likely to achieve glycemic control compared with women who receive tailored MNT from an RDN. Table 5 summarizes the approach we recommend to the teams in our clinic who provide care for women with GDM. Because the stress associated with the diagnosis of GDM can be reduced if all providers help the women improve their diabetes self-management behaviors including a diet, physical activity, and self-monitoring plan tailored to the patient's life circumstances.18 In addition, strong communication between the healthcare team and the woman is critical. Based on our review of the evidence, we compiled the messages we would like our team to give consistently (Table 4). We encourage the RDNs who provide care to women with GDM to proactively reach out to the physicians and other team members to provide this advice until further research warrants a change in approach.

  
Table 5 - Click to enlarge in new windowTABLE 5 Recommendations to Physicians for the Dietary and Physical Activity Management of Gestational Diabetes Mellitus (GDM)

We encourage the RDNs who provide care to women with GDM to proactively reach out to the physicians and other team members to provide this advice until further research warrants a change in approach.

 

Changing the Form of CHO

While research suggests that improvement in glycemic control might be obtained by changing the form of CHO rather than decreasing the amount consumed,13 many of the foods and beverages consumed by patients in the studies testing a low GI diet are neither physically nor culturally available to the women in our clinic. Therefore, we do not routinely use the GI or glycemic load for meal planning. For the rare woman who asks, we can provide the international table of GI and glycemic load values19 (http://www.glycemicindex.com) but caution the woman that a single food can have a range in GI values, making it difficult to determine the impact on glycemic control without closely monitoring their blood glucose levels. To individualize the diet using this approach would require the RDN and the woman with GDM to evaluate the glycemic response to foods, at different times of the day and in different combinations of food.14

 

There may be women who are able to eat a sufficiently high complex CHO and low-fat diet to achieve glycemic control.9 Some clinicians report that their patients respond positively to the message to eat more "brown than white" cereals, breads, and grains rather than a message to eat complex CHO or whole grains.

 

Case Revisited

The guidelines for physicians managing women with GDM all recommend that they refer the patient to an RDN for individualized MNT. But with the conventional approach being challenged, how should the RDN proceed? Ms J.C.'s management of her GDM was not optimal. The following describes how we may have approached her case for diet and physical activity counseling.

 

Initial Visit With RDN

This visit ideally would have occurred before Ms J.C. was diagnosed with GDM. She is at high risk of GDM because of her pregnancy outcome history and obesity, making it important for the RDN to begin counseling her early in her pregnancy. Where possible to reduce the risk of a woman not keeping a referral appointment for MNT, providing these services during the scheduled prenatal visit would be optimal. If the Ms J.C. had kept her appointment(s) with the RDN, the following assessment and counseling would have occurred.

 

In the initial visit, the RDN would conduct a full nutritional assessment utilizing the Nutrition Care Process (http://www.andeal.org/ncp). The RDN would assess the patient's learning needs, willingness, and ability to make changes as well as cultural and food preferences that may affect adherence to a meal plan. The initial assessment would include J.C.'s usual intake of food and beverages, including amounts and variety consumed. During this assessment J.C. would be screened for food insecurity and linked to local resources as needed.20 It should be noted that Ms J.C. was not food insecure at the time of this pregnancy; however, she indicated there have been times when the food she bought just did not last and she did not have the money to get more, suggesting that referral for assistance from local resources is important.20

 

At this visit, the RDN would calculate Ms J.C.'s caloric needs using an acceptable formula for an ambulatory patient. Using the Academy of Nutrition and Dietetics' Nutrition Care Manual,4 interactive calculator, and the Mifflin St Jeor formula for patients with obesity, an estimate of 1733 calories was made. Ms J.C. is sedentary and in her first trimester of pregnancy, so no additional calories were added. An additional 340 calories for the second and an additional 452 calories for the third trimester would be added per day to meet pregnancy needs. The calorie level of the meal plan should be individualized based on the (1) assessment, (2) prepregnancy body mass index, (3) physical activity level, and (4) pregnancy weight gain to date. The RDN would be sensitive to how much information Ms J.C. could use at this visit. The RDN would calculate and document the calorie goal in her chart but might focus the discussion on portion sizes of CHO foods. The RDN would reinforce the physician's counseling on appropriate weight gain.

 

Ms J.C. would be counseled that more than one visit is needed to learn about the best diet and physical activity plan for her. On this visit she would be counseled on the importance of avoidance of sugar-sweetened beverages, as well as sugary foods, fruit juices, and desserts, and the impact of these foods on weight gain. She would be encouraged to consume appropriate amounts of fruits, vegetables, whole grains, and low-fat dairy and to choose lean meals and lower-fat cooking methods. She would also be instructed in food safety practices.

 

The RDN would assess her health literacy and at this visit select a diet plan that would not overwhelm the patient. In this case, the RDN might use the Idaho Plate method found at http://www.platemethod.com. For other women, the RDN might tailor the plan generated for the pregnant patient at http://www.supertracker.usda.gov to the woman's preferences and budget. Figure 2 is an example of MyPlan for a pregnant woman from the Supertracker site. If time allowed, a review of how to use the Nutrition Facts label for portion size and calorie content would be done. The RDN would reinforce the physical activity plan the physician recommended, which was to spend 30 minutes a day walking to the park or playing with her children. At later visits, the RDN would work with Ms J.C. toward meeting the current recommendation for physical activity of 30-minute moderate-intensity aerobic exercise at least 5 days a week or a minimum of 150 minutes per week.1,2 At the end of the visit, Ms J.C. would be assisted in setting a SMART Goal, a goal that is Specific, Measurable, Attainable, Realistic, and Timely/Trackable.21

  
Figure 2 - Click to enlarge in new windowFIGURE 2. Example of MyPlan from

Follow-up Visits With RDN After Diagnosis of GDM

When Ms J.C. was diagnosed with GDM, she would have additional visits with the RDN. The Gestational Diabetes Evidence-Based Nutrition Practice Guideline22 suggests a minimum of 3 encounters with an RDN for self-management education. It notes a phone encounter supplemented with food and blood glucose records obtained via fax or e-mail may be an option. In addition, it recommends a follow-up visit after delivery focusing on lifestyle modifications aimed at reducing weight and increasing physical activity, as GDM is a risk factor for subsequent T2DM.

 

The RDN would again review the importance of avoidance of sugar-sweetened beverages and sugary foods and desserts and their impact on blood glucose levels. Ms J.C. would be taught to monitor blood glucose levels at home, record results, and recognize if she was not achieving her goals and when to call her physician. She would be counseled on eating smaller portions of CHO at meals and spreading intake through the day (in 3 meals and 2-3 snacks) rather than limiting or eliminating CHO from the diet.

 

On follow-up in 2 weeks, the RDN would assess J.C.'s CHO intake and blood glucose levels and based on those assessments may instruct her on goals for CHOs at each meal. An initial goal would be at least 175 g CHO per day, spread through smaller meals and portions. For the patient who desires more detailed guidance, the RDN might suggest a goal of 15 to 30 g of CHO at breakfast if the 2-hour prandial blood glucose level is elevated. Reasonable meal and snack goals would be 45 to 60 g of CHO at meals and 15 to 30 g of CHO at snacks. Again, these would be individualized based on the patient's blood glucose log, personal preferences, CHO intake, and nutritional adequacy of the diet. If goals cannot be met with diet changes, the RDN would contact the physician and inform him/her of the current findings and potentially try using a different approach to CHO control.

 

The RDN might suggest a goal of 15 to 30 g of CHO at breakfast if the 2-hour prandial blood glucose level is elevated. Reasonable meal and snack goals would be 45 to 60 g of CHO at meals and 15 to 30 g of CHO at snacks. Again, these would be individualized based on the patient's blood glucose log.

 

Ms J.C. would have additional visits supplemented with phone encounters with the RDN to support her in self-management and make adjustments as needed. She would be counseled about her risk of T2DM postpartum and scheduled to return for MNT several weeks after delivery.

 

SUMMARY

While lifestyle is considered the cornerstone of prevention and management of GDM, the optimal diet for glycemic control has received little study. Registered dietitian nutritionists are aware of the controversies surrounding the composition, quality, and quantity of CHO in the diet recommended to women with GDM. Registered dietitian nutritionists should take leadership for outlining evidence-based strategies to achieve glycemic control with diet and physical activity for the team managing women with GDM. The team should provide consistent messages to the woman. The RDN should individualize the diet approach to the patient's interest, ability to follow, and response to the diet to reduce the risks of poor outcomes for herself and her infant.

 

Acknowledgment

The authors thank Gina Firnhaber, PhD, MSN, MLS, MPH, for her contributions to the literature search and review of the manuscript.

 

REFERENCES

 

1. American Diabetes Association. 13. Management of diabetes in pregnancy: standards of medical care in diabetes-2018. Diabetes Care. 2018;41(suppl 1):S137-S143. [Context Link]

 

2. American College of Obstetricians and Gynecologists. Gestational Diabetes Mellitus. Practice Bulletin no 190. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2018;121(2):e49-e63. [Context Link]

 

3. Acad. Nutr. Dietet. Nutrition and Lifestyle for a Healthy Pregnancy Outcome. 2014. http://www.eatrightpro.org/~/media/eatrightpro%20files/practice/position%20and%2. Accessed January 19, 2018. [Context Link]

 

4. Academy of Nutrition and Dietetics. Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed November 27, 2017. [Context Link]

 

5. EBSCO Industries Inc. DynaMed. http://www.dynamed.com. Accessed December 1, 2017. [Context Link]

 

6. Hacker N, Gambone J, Hobel C. Hacker & Moore's Essentials of Obstetrics and Gynecology. 6th ed. Philadelphia, PA: Elsevier; 2016. [Context Link]

 

7. Institute of Medicine and National Research Council. Implementing Guidelines on Weight Gain and Pregnancy. Washington, DC: National Academies Press; 2013. http://www.nap.edu. Accessed January 20, 2018. [Context Link]

 

8. Coulston A, Boushey C, Ferruzzi M, et al. Nutrition in Prevention and Treatment of Chronic Disease. 4th ed. Philadelphia, PA: Elsevier Inc; 2017. [Context Link]

 

9. Hernandez TL. Carbohydrate content in the GDM diet: two views: view 1: nutrition therapy in gestational diabetes: the case for complex carbohydrates. Diabetes Spectr. 2016;29(2):82-87. [Context Link]

 

10. Mulla WR. Carbohydrate content in the GDM diet: two views: view 2: low-carbohydrate diets should remain the initial therapy for gestational diabetes. Diabetes Spectr. 2016;29(2):89-91. [Context Link]

 

11. Han S, Middleton P, Shepherd E, van Ryswyk E, Crowther CA. Different types of dietary advice for women with gestational diabetes mellitus. Cochrane Database Syst Rev. 2017;2:CD009275. [Context Link]

 

12. Hernandez TL, van Pelt RE, Anderson MA, et al. A higher-complex carbohydrate diet in gestational diabetes mellitus achieves glucose targets and lowers postprandial lipids: a randomized crossover study. Diab. Care. 2014;37(5):1254-1262. [Context Link]

 

13. Vestgaard M, Christensen AS, Viggers L, Lauszus FF. Birth weight and its relation with medical nutrition therapy in gestational diabetes. Arch Gynecol Obstet. 2017;296(1):35-41. [Context Link]

 

14. Kizirian NV, Goletzke J, Brodie S, et al. Lower glycemic load meals reduce diurnal glycemic oscillations in women with risk factors for gestational diabetes. BMJ Open Diab. Res. Care. 2017;5(1):e000351. [Context Link]

 

15. Hernandez TL, van Pelt RE, Anderson MA, et al. Women with gestational diabetes mellitus randomized to a higher-complex carbohydrate/low-fat diet manifest lower adipose tissue insulin resistance, inflammation, glucose, and free fatty acids: a pilot study. Diabetes Care. 2016;39(1):39-42. [Context Link]

 

16. Barrett HL, Dekker Nitert M, Conwell LS, Callaway LK. Probiotics for preventing gestational diabetes. Cochrane Database Syst Rev. 2014;(2):CD009951. [Context Link]

 

17. Hui AL, Sevenhuysen G, Harvey D, Salamon E. Stress and anxiety in women with gestational diabetes during dietary management. Diabetes Educ. 2014;40(5):668-677. [Context Link]

 

18. Marchetti D, Carrozzino D, Fraticelli F, Fulcheri M, Vitacolonna E. Quality of life in women with gestational diabetes mellitus: a systematic review. J Diab Res. 2017;2017:7058082. [Context Link]

 

19. Foster-Powell K, Holt SH, Brand-Miller JC. International table of glycemic index and glycemic load values: 2002. Am J Clin Nutr. 2002;76(1):5-56. [Context Link]

 

20. Patil SP, Craven K, Kolasa KM. Food insecurity: it is more common than you think, recognizing it can improve the care you give. Nutr Today. 2017;52(5):248-250. [Context Link]

 

21. MacLeod L. Making SMART goals smarter. Physician Exec. 2012;38(2):68-70,72. [Context Link]

 

22. Academy of Nutrition and Dietetics. The Gestational Diabetes Evidence-Based Nutrition Practice Guideline. Chicago, IL: the Academy of Nutrition and Dietetics; 2008. [Context Link]