Gestational Diabetes · Jensen DM, Damm P, Sorensen B, Molsted-Pedersen L, Westergaard JG, Klebe J,...

Gestational DiabetesGestational Diabetes (GDM) Guideline (2008)

Gestational Diabetes

GDM: Major Recommendations (2008)Gestational Diabetes Evidence-Based Nutrition Practice Guideline

Below you will find a list of Gestational Diabetes (GDM) Recommendations. You may also view the Executive Summary ofRecommendations or print the guideline information at Print Reports.

Gestational Diabetes (GDM) Major Recommendations

GDM: Risk Assessment and Screening for Gestational DiabetesGDM: Pregnant Women at Risk for GDMGDM: MNT for Pregnant Women with IGT or GDM

Nutrition Assessment

GDM: Assessment of Food Intake, Physical Activity and MedicationsGDM: Assessment of BMI and Weight Gain

Nutrition Intervention

GDM: Caloric IntakeGDM: Macronutrient and Micronutrient IntakeGDM: Physical ActivityGDM: Blood Glucose Monitoring GDM: Use of Non-Nutritive SweetenersGDM: Promotion of BreastfeedingGDM: Alcohol ConsumptionGDM: Pharmacologic TherapyGDM: Ketone Testing

Nutrition Monitoring and Evaluation

GDM: Monitor and Evaluate MNT EffectivenessGDM: Prevention of Recurrence/Type 2 Diabetes

The recommendations listed below were originally developed for other ADA evidence-based nutrition practice guidelines, but havebeen integrated into the Gestational Diabetes Evidence-based Nutrition Practice Guideline and may provide additional guidancefor the practitioner.

Diabetes Type 1 and 2 Evidence-Based Nutrition Practice Guideline for Adults Recommendations

DM: Fiber and DiabetesDM: Carbohydrate Intake and Insulin Dose AdjustmentDM: Glycemic Index and Diabetes


Quick Links

Recommendations SummaryGDM: Risk Assessment and Screening for Gestational Diabetes Mellitus 2006

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels(Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use thehyperlinks in the Supporting Evidence Section below.

Recommendation(s) GDM: Risk Assessment and Screening for Gestational Diabetes Mellitus

All pregnant women should be assessed for risk of gestational diabetes mellitus (GDM) at the first prenatal visit. Depending on level of risk, timing of screening for gestational diabetes mellitus (GDM) and/or impaired glucose tolerance(IGT) will differ. Most women are screened between 24 - 28 weeks of gestation. Research indicates the similaritiesbetween gestational diabetes mellitus (GDM) and impaired glucose tolerance (IGT), and both are associated withincreased risks of poor maternal/neonatal outcomes if left untreated.

Rating: StrongImperative

Risks/Harms of Implementing This Recommendation

International consensus of the screening and diagnostic criteria have not been established Screening may result in false-positives

© 2015 Academy of Nutrition and Dietetics (A.N.D.), Evidence Analysis Library. Printed on: 12/28/15 - from:http://www.andeal.org

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Screening may result in false-positives Screening may result in psychological stress for some individualsScreening may cause gastrointestinal upset and other symptoms in some individuals

Conditions of Application

Low risk: blood glucose testing not routinely required if all of the following characteristics are present:

Member of an ethnic group with a low prevalence of GDMNo known diabetes in first-degree relativesAge

implemented by registered dietitians on pregnancy outcomes. J Am Diet Assoc 2006 Sep;106(9):1426-33.

Sunsaneevithayakul P, Kanokpongsakdi S, Sutanthavibul A, Ruangvutilert P, Boriboohirunsarn D, Keawprasit T,Tantawattana R. Result of ambulatory diet therapy in gestational diabetes mellitus. J Med Assoc Thai. 2006 Jan;89(1): 8-12.

Svare JA, Hansen BB, Molsted-Pedersen L. Perinatal complications in women with gestational diabetes mellitus.Acta Obstet Gynecol Scand 2001;80(10):899-904.

Taricco E, Radaelli T, Nobile de Santis MS, Cetin I. Foetal and placental weights in relation to maternalcharacteristics in gestational diabetes. Placenta 2003 Apr;24(4):343-7.

Aberg A, Rydhstroem H, Frid A. Impaired glucose tolerance associated with adverse pregnancy outcome: Apopulation-based study in southern Sweden. Am J Obstet Gynecol 2001;184:77-83.

Bo S, Menato G, Gallo M, Bardelli C, Lezo A, Signorile A, Gambino R, Cassader M, Massobrio M and Pagano G. Mildgestational hyperglycemia, the metabolic syndrome and adverse neonatal outcomes. Acta Obstet Gynecol Scand2004; 83(4):335-40.

Bonomo M, Corica D, Mion E, Goncalves D, Motta G, Merati R, Ragusa A, Morabito A. Evaluating the therapeuticapproach in pregnancies complicated by borderline glucose intolerance: a randomized clinical trial. Diabet Med2005;22:1536-1541.

Ergin T, Lembet A, Duran H, Kuscu E, Bagis T, Saygili E, Batioglu S. Does insulin secretion in patients with oneabnormal glucose tolerance test value mimic gestational diabetes mellitus? Am J Obstet Gynecol 2002;186(2):204-209.

Gruendhammer M, Brezinka C, Lechleitner M. The number of abnormal plasma glucose values in the oral glucosetolerance test and the feto-maternal outcome of pregnancy. Eur J of Obstet and Gynecol Reproductive Biology2003; 108(2):131-136.

Hedderson MM, Ferrara A, Sacks DA. Gestational Diabetes Mellitus and Lesser Degrees of PregnancyHyperglycemia: Association With Increased Risk of Spontaneous Birth. Obstetrics & Gynecology2003;102:850-856.

Jensen DM, Damm P, Sorensen B, Molsted-Pedersen L, Westergaard JG, Klebe J, Beck-Nielsen H. Clinical impact ofmild carbohydrate intolerance in pregnancy: A study of 2904 nondiabetic Danish women with risk factors forgestational diabetes mellitus. Am J Obstet Gynecol 2001;108(2):131-6.

Jiménez-Moleón JJ, Bueno-Cavanillas A, Luna-del-Castillo J, García Màrtín M, Lardelli-Claret P, Gálvez-Vargas R.Impact of different levels of carbohydrate intolerance on neonatal outcomes classically associated with gestationaldiabetes. Eur J Obstet Gynecol Reprod Biol 2002;102(1):36-41.

Lao TT, Ho LF. Perinatal Morbidity and Placental Size in Gestational Impaired Glucose Tolerance. J Soc GynecolInvestig 2001;8(6):347-350.

Lao TT, Ho LF. Does Maternal Glucose Intolerance Affect the Length of Gestation in Singleton Pregnancies? J SocGynecol Investig 2003;10(6):366-371.

Lao TT, Wong KY. Perinatal Outcome in Large-for-Gestational Infants: Is it influenced by gestational impairedglucose tolerance? The Journal of Reproductive Medicine 2002; 47(6):497-502.

Nordin NM, Wei JWH, Naing NN, Symonds EM. Comparison of maternal-fetal outcomes in gestational diabetes andlesser degrees of glucose intolerance. J Obstet Gynecol Res 2006; 32(1):107-114.

Ostlund I, Hanson U, Bjorklund A, Hjertberg R, Eva N, Nordlander E, Marja-Liisa S, Wager J. Maternal and FetalOutcomes if Gestational Impaired Glucose Tolerance Is Not Treated. Diabetes Care 2003;26(7):2107-2111.

Parretti E, Carignani L, Cioni R, Bartoli E, Borri P, Torre PL, Mecacci F, Martini E, Scarselli G, Mello G. SonographicEvaluation of Fetal Growth and Body Composition in Women With Different Degrees of Normal GlucoseMetabolism. Diabetes Care 2003;26(10):2741-2748.

Retnakaran R, Zinman B, Connelly PW, Sermer M, Hanley AJG. Impaired Glucose Tolerance of Pregnancy Is aHeterogeneous Metabolic Disorder as Defined by the Glycemic Response to the Oral Glucose Tolerance Test.Diabetes Care 2006;29(1):57-62.

Saldana TM, Siega-Riz AM, Adair LS, Savitz DA and Thorp JM. The Association Between Impaired GlucoseTolerance and Birth Weight Among Black and White Women in Central North Carolina. Diabetes Care2003;26(3):656-661.

Schaefer-Graf UM, Kjos SL, Kilavuz O, Plagemann A, Brauer M, Dudenhausen JW, Vetter K. Determinants of FetalGrowth at Different Periods of Pregnancies Complicated by Gestational Diabetes Mellitus or ImpairedGlucose Tolerance. Diabetes Care 2003;26(1):193- 198.

Tuffnell DJ, West J, Walkinshaw SA. Treatments for gestational diabetes and impaired glucose tolerance inpregnancy. Cochrane Database Syst Rev 2003; (3):CD003395.

Vambergue A, Nuttens MC, Verier-Mine O, Dognin C, Cappoen JP and Fontaine P. Is mild gestationalhyperglycemia associated with maternal and neonatal complications? The Diagest Study. British DiabeticAssociation. Diabetes Medicine 2000;17: 203-208.

Yang X, Hsu-Hage B, Zhang H, Zhang C, Zhang Y, Zhang C. Women With Impaired Glucose Tolerance DuringPregnancy Have Significantly Poor Pregnancy Outcomes. Diabetes Care 2002; 25:1619-1624.

References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

Clinical Management Guidelines for Obstetrician-Gynecologists. ACOG Practice Guidelines Number 30,2001;98(3):525-538.


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2001;98(3):525-538.

Metzger BE, Buchanan TA, Coustan DR, de Leiva A, Dunger DB, Hadden DR, Hod M, Kitzmiller JL, Kjos SL, Oats JN,Pettitt DJ, Sacks DA, Zoupas C. Summary and recommendations of the Fifth International Workshop Conferenceon Gestational Diabetes Mellitus. Diabetes Care 2007;30 Suppl 2:S251-60.

The HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med2008;358(19):1991-2002.

U. S. Preventive Services Task Force. Screening for Gestational Diabetes Mellitus: U. S. Preventive Services TaskForce Recommendation Statement. Annals of Internal Medicine 2008;148:759-765.

World Health Organization (1999). Definition, diagnosis and classification of Diabetes Mellitus and itscomplications: Report of a WHO Consultation. Part 1. Diagnosis and Classification of Diabetes Mellitus.


Quick Links

Recommendations SummaryGDM: Pregnant Women at Risk for GDM 2006


Recommendation(s) GDM: Pregnant Women At Risk for GDM

For pregnant women at average or high risk for gestational diabetes mellitus (GDM), the RD should monitor weight gain, nutritional intake and physical activity. Research indicates that obesity, excessive weight gain prior to pregnancy andincreased saturated fat intake are associated with the development of glucose abnormalities in pregnancy and increasedrisk of gestational diabetes. In addition, regular physical activity during pregnancy reduces the risk of gestationaldiabetes mellitus (GDM).

Rating: WeakConditional


Contraindications to exercise during pregnancy may include but are not limited to: pregnancy-inducedhypertension, premature rupture of membranes, intrauterine growth retardation, preterm labor or history ofpreterm labor, incompetent cervix/cervical cerclage, and persistent second or third trimester bleeding.


For pregnant women at average or high risk for gestational diabetes mellitus (GDM).

GDM risk assessment should be ascertained at the first prenatal visit.

Low risk:

Member of an ethnic group with a low prevalence of GDMNo known diabetes in first-degree relativesAge

Twelve studies were evaluated to investigate nutrition and physical activity interventions and the prevention ofgestational diabetes.

Obesity, excessive weight gain prior to pregnancy and increased saturated fat intake are associated withthe development of glucose abnormalities in pregnancy and increased risk of gestational diabetes (Wang,Storlien et al, 2000; Bo, Menato et al 2001; Glazer et al, 2004; Saldana et al, 2004; Rudra et al, 2006).Evidence regarding the consumption of micronutrients are conflicting, as the relationship between theprevalence of gestational diabetes and vitamin and mineral intake may be related to nutritional adequacyof the diet and gestational weight gain; further research is needed in this area (Gunton et al, 2001; Lao etal, 2001; Tan et al, 2001; Lao et al, 2004; Zhang, Williams, Frederick et al, 2004; Zhang, Williams,Sorenson et al, 2004; Bo et al, 2005).

Fourteen studies were evaluated to investigate the relationship between physical activity during pregnancy andmaternal/neonatal outcomes and glycemic control in women with gestational diabetes mellitus.

Regular physical activity during pregnancy reduces the risk of gestational diabetes mellitus, as well as thecommon discomforts of pregnancy, without a negative effect on maternal or neonatal outcomes (ACOG,1994; Clapp et al, 1996; Horns et al, 1996; Gray-Donald et al, 2000; Dempsey, Butler et al, 2004;Dempsey, Sorensen et al, 2004; Symons-Downs and Ulbrecht, 2006).Physical activity for 30 minutes per day for a minimum of three times per week is needed to aid withimproved glycemic control. In addition, social support may encourage women with gestational diabetesmellitus to engage in physical activity (Langer and Hod, 1996; Soultanakis et al, 1996; Avery et al, 1997;4th International Workshop-Conference on Gestational Diabetes Mellitus, 1998; Avery and Walker, 2001;Brankston et al, 2004).In addition, social support may encourage women with gestational diabetes mellitus to engage in physicalactivity (Thornton et al, 2006).

Recommendation Strength Rationale

Conclusion Statement were both given Grade II.

Minority Opinions

Consensus reached.

Supporting Evidence The recommendations were created from the evidence analysis on the following questions. To see detail of the evidenceanalysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

What are the nutrition interventions that may prevent the diagnosis of gestational diabetes mellitus in preganant women?

In women with GDM, what is the relationship between physical activity during pregnancy and maternal/neonataloutcomes and glycemic control?

References Bo S, Lezo A, Menato G, Gallo ML, Bardelli C, Signorile A, Berutti C, Massobrio M, Pagano GF. Gestationalhyperglycemia, zinc, selenium, and antioxidant vitamins. Nutrition 2005;21:186-191.

Bo S, Menato G, Lezo A, Signorile A, Bardelli C, De Michieli F, Massobrio M, Pagano G. Dietary fat and gestationalhyperglycaemia. Diabetologia 2001;44:972-978.

Glazer NL, Hendrickson AF, Schellenbaum GD, Mueller BA. Weight Change and the Risk of Gestational Diabetes inObese Women. Epidemiology 2004;15(6):733-737.

Gunton JE, Hams G, Hitchman R, McElduff A. Serum chromium does not predict glucose tolerance in latepregnancy. Am J Clin Nutr 2001;73:99-104.

Lao TT, Ho LF. Impact of Iron Deficiency Anemia on Prevalence of Gestational Diabetes. Diabetes Care2004;27(3);650-656.

Lao TT, Chan PL, Tam KF. Gestational diabetes mellitus in the last trimester - a feature of maternal ironexcess? Diabetes Medicine 2001;18:218-223.

Rudra CB, Williams MA, Lee IM, Miller RS, Sorensen TK. Perceived Exertion in Physical Activity and Risk ofGestational Diabetes Mellitus. Epidemiology 2006; 17(1): 31-37.

Saldana TM, Siega-Riz AM, Adair LS. Effect of macronutrient intake on the development of glucose intoleranceduring pregnancy. Am J Clin Nutr 2004; 79:479-86.

Tan M, Sheng L, Qian Y, Ge Y, Wang Y, Zhang H, Jiang M, Zhang G. Changes in Serum Selenium in PregnantWomen with Gestational Diabetes Mellitus. Biological Trace Element Research 2001;83:231-237.

Wang Y, Storlein LH, Jenkins AB, Tapsell LC, Jin Y, Pan JF, Shao YF, Calvert GD, Moses RG, Shi HL, Zhu XX.Dietary Variables and Glucose Tolerance in Pregnancy. Diabetes Care 2000; 23(4):460-464.

Zhang C, Williams MA, Frederick IO, King IB, Sorensen TK, Kestin MM, Dashow EE, Luthy DA. Vitamin C and theRisk of Gestational Diabetes Mellitus: A Case Control Study. Journal of Reproductive Medicine 2004;49(4):257-266.

Zhang C, Williams MA, Sorensen TK, King IB, Kestin MM, Thompson ML, Leisenring WM, Dashow EE, Luthy DA.Maternal Plasma Ascorbic Acid (Vitamin C) and Risk of Gestational Diabetes Mellitus. Epidemiology 2004;15(15):597-604.

Summary and Recommendations of the 4th International Workshop-Conference on Gestational Diabetes Mellitus. Metzger BE, Coustan DR. Diabetes Care 1998;21; Suppl 2:B161-167.


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Exercise during pregnancy and the postpartum period. American College of Obstetricians andGynecologists Technical Bulletin Number 189 - February 1994. Int J Gynecol Obstet 1994;45:65-70.

Avery MD, Walker AJ. Acute effect of exercise on blood glucose and insulin levels in women with gestationaldiabetes. J Matern Fetal Med 2001;10:52-58.

Avery MD, Leon AS, Kopher RA. Effects of a partially home-based exercise program for women with gestationaldiabetes. Obstet Gynecol 1997;89:10-15.

Brankston GN, Mitchell BF, Ryan EA, Okun NB. Resistance exercise decreases the need for insulin in overweightwomen with gestational diabetes mellitus. Am Journal of Obs and Gyn 2004;190:188-93.

Clapp JF. Morphometric and neurodevelopmental outcome at age five years of the offspring of women whocontinued to exercise regularly throughout pregnancy. J Pediatr 1996;129:856-863.

Dempsey JC, Butler CL, Sorensen TK, Lee IM, Thompson ML, Miller RS, Frederick IO, Williams MA. A case-controlstudy of maternal recreational physical activity and risk of gestational diabetes mellitus. Diabetes Research andClinical Practice 2004;66:203-215.

Dempsey JC, Sorensen TK, Williams MA, Lee IM, Miller RS, Dashow EE and Luthy DA. Prospective study ofgestational diabetes mellitus risk in relation to maternal recreational physical activity before and duringpregnancy. Am J Epidemiol 2004;159:663-670.

Gray-Donald K, Robinson E, Collier A, David K, Renaud L, Rodrigues S. Intervening to reduce weight gain inpregnancy and gestational diabetes mellitus in Cree communities: An evaluation. CMAJ 2000;163(10):1247-1251.

Horns PN, Ratcliffe LP, Leggett JC, Swanson MS. Pregnancy outcomes among active and sedentary primiparouswomen. JOGNN 1996; 25:49-54.

Langer O, Hod M. Management of gestational diabetes mellitus. Obstet Gynecol Clin North Am1996;23(1):137-159.

Soultanakis HN, Artal R, Wiswell RA. Prolonged exercise in pregnancy: glucose homeostasis, ventilatory andcardiovascular responses. Seminars in Perinatology, 1996;20(4):315-327.

Symons Downs D, Ulbrecht J. Understanding exercise beliefs and behaviors in women with gestational diabetesmellitus. Diabetes Care 29:236-240, 2006.

Thornton PL, Kieffer EC, Salabarria-Pena Y, Odoms-Young A, Willis SK, Kim H, Salinas MA. Weight, diet, andphysical activity-related beliefs and practices among pregnant and postpartum Latino women: The role of socialsupport. Maternal and Child Health Journal, 2006;10:95-104.


Committee on Nutritional Status During Pregnancy and Lactation, Institute of Medicine. Nutrition DuringPregnancy: Part I: Weight Gain, Part II: Nutrient Supplements. National Academy Press, Washington, DC, 1990.

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Quick Links

Recommendations SummaryGDM: MNT for Pregnant Women with IGT or GDM 2006


Recommendation(s) GDM: MNT for Women with GDM

The Registered Dietitian (RD) should initiate Medical Nutrition Therapy (MNT) within one week after diagnosis ofgestational diabetes mellitus ( GDM), and include a minimum of three nutrition visits. Research indicates that MNTresults in improved maternal and neonatal outcomes, especially when diagnosed and treated early.


GDM: MNT for Pregnant Women with IGT

For women with impaired glucose tolerance (IGT) during pregnancy, the Registered Dietitian (RD) should initiate thesame recommendations of Medical Nutrition Therapy (MNT) as those for gestational diabetes mellitus (GDM). Researchindicates that impaired glucose tolerance (IGT) and gestational diabetes mellitus (GDM) carry similar risks of adverseoutcomes.


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outcomes.



None.


None.

Potential Costs Associated with Application

Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essentialfor improved outcomes.

Recommendation Narrative

Six studies were evaluated to investigate the relationship between Medical Nutrition Therapy on pregnancyoutcomes in women with gestational diabetes mellitus.

Medical Nutrition Therapy, initiated within one week of diagnosis and with a minimum of three nutritionvisits, results in decreased hospital admissions and insulin use, improves likelihood of normal fetal andplacental growth, and reduces risk of perinatal complications, especially when diagnosed and treatedearly(Svare et al, 2001; Taricco et al, 2003; Gabbe et al, 2004; Crowther et al, 2005; Reader et al,2006; Sunsaneevithayakul et al, 2006).

Twenty studies were evaluated to investigate the relationship between impaired glucose tolerance (definitionsvary) during pregnancy and poor outcomes.

Two studies demonstrate the metabolic similarities between impaired glucose tolerance and gestationaldiabetes mellitus (Ergin et al, 2002; Retnakaran et al, 2006). Twelve studies report increased risks of large for gestational age newborns and macrosomia in womenwith impaired glucose tolerance (Vambergue et al, 2000; Aberg et al, 2001; Jensen et al, 2001;Jimenez-Moleon et al, 2002; Gruendhammer et al, 2003; Ostlund et al, 2003; Parretti et al, 2003;Saldana et al, 2003; Schaefer-Graf et al, 2003; Bo et al, 2004; Bonomo et al, 2005; Nordin et al, 2006) . Additional research notes increased risks of preterm birth (Yang et al, 2002; Hedderson et al, 2003; Laoand Ho, 2003), perinatal morbidity (Lao and Ho, 2001; Lao and Wong, 2002) and neonatal hypoglycemia(Tuffnell et al, 2003).


Conclusion Statements were given a Grade I and II.

Minority Opinions

Consensus reached.


What is the evidence regarding Medical Nutrition Therapy on pregnancy outcomes (morbidity, birth weight, glucosecontrol, pharmacological therapy, pre-term delivery, satisfaction with care) in women with gestational diabetes?

What is the relationship between impaired glucose tolerance and poor outcomes in pregnant women?

References Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS, for the Australian Carbohydrate IntoleranceStudy in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus onpregnancy outcomes. N Engl J Med 2005;352:2477-86.

Gabbe SG, Gregory RP, Power ML, Williams SB, Schulkin J. Management of diabetes mellitus byobstetrician-gynecologists. Obstet Gynecol 2004 Jun;103(6):1229-34.

Reader D, Splett P, Gunderson EP, for the Diabetes Care and Education DieteticPractice Group. Impact of gestational diabetes mellitus nutrition practice guidelinesimplemented by registered dietitians on pregnancy outcomes. J Am Diet Assoc 2006 Sep;106(9):1426-33.

Sunsaneevithayakul P, Kanokpongsakdi S, Sutanthavibul A, Ruangvutilert P, Boriboohirunsarn D, Keawprasit T,Tantawattana R. Result of ambulatory diet therapy in gestational diabetes mellitus. J Med Assoc Thai. 2006 Jan;89(1): 8-12.

Svare JA, Hansen BB, Molsted-Pedersen L. Perinatal complications in women with gestational diabetes mellitus.Acta Obstet Gynecol Scand 2001;80(10):899-904.

Taricco E, Radaelli T, Nobile de Santis MS, Cetin I. Foetal and placental weights in relation to maternalcharacteristics in gestational diabetes. Placenta 2003 Apr;24(4):343-7.


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Aberg A, Rydhstroem H, Frid A. Impaired glucose tolerance associated with adverse pregnancy outcome: Apopulation-based study in southern Sweden. Am J Obstet Gynecol 2001;184:77-83.

Bo S, Menato G, Gallo M, Bardelli C, Lezo A, Signorile A, Gambino R, Cassader M, Massobrio M and Pagano G. Mildgestational hyperglycemia, the metabolic syndrome and adverse neonatal outcomes. Acta Obstet Gynecol Scand2004; 83(4):335-40.

Bonomo M, Corica D, Mion E, Goncalves D, Motta G, Merati R, Ragusa A, Morabito A. Evaluating the therapeuticapproach in pregnancies complicated by borderline glucose intolerance: a randomized clinical trial. Diabet Med2005;22:1536-1541.

Ergin T, Lembet A, Duran H, Kuscu E, Bagis T, Saygili E, Batioglu S. Does insulin secretion in patients with oneabnormal glucose tolerance test value mimic gestational diabetes mellitus? Am J Obstet Gynecol 2002;186(2):204-209.

Gruendhammer M, Brezinka C, Lechleitner M. The number of abnormal plasma glucose values in the oral glucosetolerance test and the feto-maternal outcome of pregnancy. Eur J of Obstet and Gynecol Reproductive Biology2003; 108(2):131-136.

Hedderson MM, Ferrara A, Sacks DA. Gestational Diabetes Mellitus and Lesser Degrees of PregnancyHyperglycemia: Association With Increased Risk of Spontaneous Birth. Obstetrics & Gynecology2003;102:850-856.

Jensen DM, Damm P, Sorensen B, Molsted-Pedersen L, Westergaard JG, Klebe J, Beck-Nielsen H. Clinical impact ofmild carbohydrate intolerance in pregnancy: A study of 2904 nondiabetic Danish women with risk factors forgestational diabetes mellitus. Am J Obstet Gynecol 2001;108(2):131-6.

Jiménez-Moleón JJ, Bueno-Cavanillas A, Luna-del-Castillo J, García Màrtín M, Lardelli-Claret P, Gálvez-Vargas R.Impact of different levels of carbohydrate intolerance on neonatal outcomes classically associated with gestationaldiabetes. Eur J Obstet Gynecol Reprod Biol 2002;102(1):36-41.

Lao TT, Ho LF. Perinatal Morbidity and Placental Size in Gestational Impaired Glucose Tolerance. J Soc GynecolInvestig 2001;8(6):347-350.

Lao TT, Ho LF. Does Maternal Glucose Intolerance Affect the Length of Gestation in Singleton Pregnancies? J SocGynecol Investig 2003;10(6):366-371.

Lao TT, Wong KY. Perinatal Outcome in Large-for-Gestational Infants: Is it influenced by gestational impairedglucose tolerance? The Journal of Reproductive Medicine 2002; 47(6):497-502.

Nordin NM, Wei JWH, Naing NN, Symonds EM. Comparison of maternal-fetal outcomes in gestational diabetes andlesser degrees of glucose intolerance. J Obstet Gynecol Res 2006; 32(1):107-114.

Ostlund I, Hanson U, Bjorklund A, Hjertberg R, Eva N, Nordlander E, Marja-Liisa S, Wager J. Maternal and FetalOutcomes if Gestational Impaired Glucose Tolerance Is Not Treated. Diabetes Care 2003;26(7):2107-2111.

Parretti E, Carignani L, Cioni R, Bartoli E, Borri P, Torre PL, Mecacci F, Martini E, Scarselli G, Mello G. SonographicEvaluation of Fetal Growth and Body Composition in Women With Different Degrees of Normal GlucoseMetabolism. Diabetes Care 2003;26(10):2741-2748.

Retnakaran R, Zinman B, Connelly PW, Sermer M, Hanley AJG. Impaired Glucose Tolerance of Pregnancy Is aHeterogeneous Metabolic Disorder as Defined by the Glycemic Response to the Oral Glucose Tolerance Test.Diabetes Care 2006;29(1):57-62.

Saldana TM, Siega-Riz AM, Adair LS, Savitz DA and Thorp JM. The Association Between Impaired GlucoseTolerance and Birth Weight Among Black and White Women in Central North Carolina. Diabetes Care2003;26(3):656-661.

Schaefer-Graf UM, Kjos SL, Kilavuz O, Plagemann A, Brauer M, Dudenhausen JW, Vetter K. Determinants of FetalGrowth at Different Periods of Pregnancies Complicated by Gestational Diabetes Mellitus or ImpairedGlucose Tolerance. Diabetes Care 2003;26(1):193- 198.

Tuffnell DJ, West J, Walkinshaw SA. Treatments for gestational diabetes and impaired glucose tolerance inpregnancy. Cochrane Database Syst Rev 2003; (3):CD003395.

Vambergue A, Nuttens MC, Verier-Mine O, Dognin C, Cappoen JP and Fontaine P. Is mild gestationalhyperglycemia associated with maternal and neonatal complications? The Diagest Study. British DiabeticAssociation. Diabetes Medicine 2000;17: 203-208.

Yang X, Hsu-Hage B, Zhang H, Zhang C, Zhang Y, Zhang C. Women With Impaired Glucose Tolerance DuringPregnancy Have Significantly Poor Pregnancy Outcomes. Diabetes Care 2002; 25:1619-1624.


Recommendations SummaryGDM: Assessment of Food Intake, Physical Activity and Medications 2006


Recommendation(s)


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GDM: Assess Food Intake, Physical Activity and Medications

The Registered Dietitian (RD) should assess food intake, physical activity and medications of pregnant women, includingthose with gestational diabetes mellitus (GDM). Evaluation of a pregnant woman's dietary pattern, augmented byquestions about medications, special concerns, conditions, and/or food preferences that might affect her nutritionaladequacy or needs, provides the basis for Medical Nutrition Therapy (MNT).

Rating: ConsensusImperative


None.


None.




Committee on Nutritional Status During Pregnancy and Lactation, Institute of Medicine Clinical Recommendations:

Routine assessment of dietary practices is recommended for all pregnant women in the United States toallow evaluation of the need for improved diet or vitamin or mineral supplementsPeriodic prenatal care provides opportunities for identifying potential problems and intervening as early aspossible


The ADA Gestational Diabetes Mellitus Expert Work Group concurs with the clinical recommendations from theCommittee on Nutritional Status During Pregnancy and Lactation, Institute of Medicine.

Minority Opinions

Consensus reached.


References References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process



Recommendations SummaryGDM: Assessment of BMI and Weight Gain 2006


Recommendation(s) GDM: Assessment of BMI and Weight Gain

The Registered Dietitian (RD) should assess body mass index (based on actual or estimated prepregnancy weight) as abaseline to determine recommended weight gain in pregnant women, including those with gestational diabetes mellitus(GDM). Body mass index (BMI) is a better indicator of maternal nutritional status than is weight alone.

Rating: ConsensusImperative



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None.


None.




Committee on Nutritional Status During Pregnancy and Lactation, Institute of Medicine Clinical Recommendations:

Prior to conception use consistent and reliable procedures to accurately measure and record in themedical record the woman's height and weight without shoesDetermine the woman's prepregnancy BMIMeasure height and weight at the first prenatal visit carefully by procedures that have been rigorouslystandardized at the site of prenatal careEstimate the woman's gestational age from the onset of her last menstruationRecord weight in a table and plot it on a chart included in the obstetric record

For BMI < 19.8: recommended total weight gain of 28 - 40 lbs (12.5 - 18 kg), at rate of approximately 0.5 kg(slightly more than 1 lb) per week in the second and third trimesters of pregnancy

For BMI 19.8 - 26: recommended total weight gain of 25 - 35 lbs (11.5 - 16 kg), at rate of approximately 0.4 kg(~1 lb) per week in the second and third trimesters of pregnancy

For BMI > 26 - 29: recommended total weight gain of 15 - 25 lbs (7 - 11.5 kg), at rate of 0.3 kg (0.66 lb) perweek in the second and third trimesters of pregnancy

For BMI > 29: recommended total weight gain of at least 15 lbs (6.8 kg), at individually determined rate


The ADA Gestational Diabetes Mellitus Expert Work Group concurs with the clinical recommendations from theCommittee on Nutritional Status During Pregnancy and Lactation, Institute of Medicine.

Minority Opinions

Consensus reached.


References References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process



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Recommendations SummaryGDM: Caloric Intake 2006


Recommendation(s) GDM: Caloric Intake for Normal and Underweight Women

The Registered Dietitian (RD) should encourage normal and underweight pregnant women, including those withgestational diabetes mellitus (GDM), to consume adequate calories to promote appropriate weight gain, with guidancefrom the Dietary Reference Intakes (DRI) for pregnant women. Research indicates that low or inadequate weight gainduring pregnancy is associated with an increased risk of preterm delivery, regardless of prepregnancy BMI levels.


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Rating: FairConditional

GDM: Caloric Intake for Overweight/Obese Women with GDM

Since weight loss in pregnancy is not recommended, the Registered Dietitian (RD) should encourage a modest energyrestriction to slow weight gain in women with gestational diabetes mellitus (GDM) who are also overweight/obese. Caloricrestriction [~70% of the Dietary Reference Intakes (DRI) for pregnant women] results in considerable slowing of maternalweight gain in obese women with gestational diabetes mellitus (GDM), without causing maternal or fetal compromiseand/or ketonuria.



Caloric restriction may result in non-adherence to the nutrition prescription


These recommendations only apply to singleton gestation.

BMI Categories based on the Institute of Medicine:

Underweight: BMI < 19.8

Normal weight: BMI 19.8 - 26

Overweight: BMI > 26 - 29

Obese: BMI > 29




Two clinical trials report that obese women who develop GDM have a higher risk of adverse perinataloutcomes than normal weight women with GDM. In addition, caloric restriction (~70% DRI for pregnantwomen) can result in a considerable slowing of maternal weight gain in obese women with GDM, withoutcausing maternal or fetal compromise and/or ketonuria (Rae et al, 2000; Langer et al, 2005). Four studies report that both prepregnancy underweight (BMI30) are associatedwith an increased risk of preterm delivery. However, low or inadequate weight gain during pregnancy, not excessive weight gain, is associated with an increased risk of preterm delivery, regardlessof prepregnancy BMI levels (Churchill et al, 1969; Scholl et al, 1995; Siega-Riz et al, 1996; Ray et al,2001). Two studies were evaluated to investigate caloric intake and appropriate weight gain. Research oncaloric requirements is limited (Durnin et al, 1985; Ho et al, 2005); further research is needed on thedetermination of caloric requirements in women with gestational diabetes mellitus. American Diabetes Association Recommendation: Adequate energy intake that provides appropriateweight gain is recommended during pregnancy. Weight loss is not recommended; however, foroverweight and obese women with GDM, modest energy and carbohydrate restriction may be appropriate(Grade E).


Conclusion Statements were given Grade II and Grade III.

Minority Opinions

Consensus reached.


What is the relationship between caloric restriction, weight management and ketonuria for the obese woman withgestational diabetes mellitus?

In women with GDM, is there a particular caloric intake recommendation for appropriate weight gain?

References Durnin JVGA, McKillop FM, Grant S, Fitzgerald G. Is nutritional status endangered by virtually no extra intakeduring pregnancy? Lancet 1985; 2:823-827.

Ho LF, Benzie IF, Lao TT. Relationship between caloric intake and pregnancy outcome in diet-treated gestationaldiabetes mellitus. Nurs Health Sci 2005 Mar;7(1):15-20.

Churchill JA, Berendes HW, Nemore J. Neuropsychological deficits in children of diabetic mothers. Am J ObstetGynecol 1969; 105:257-268.


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Langer O, Yogev Y, Xenakis EMJ, Brustman L. Overweight and obese in gestational diabetes: The impact onpregnancy outcome. Am J Obs Gyn 2005; 192:1768-76.

Rae A, Bond D, Evans S, North F, Roberman B, Walters B. A randomised controlled trial of dietary energyrestriction in the management of obese women with gestational diabetes. Aust N Z J Obstet Gynaecol2000;40(4):416-422.

Ray JG, Vermeulen MJ, Shapiro JL, Kenshole AB. Maternal and neonatal outcomes in pregestational andgestational diabetes mellitus, and the influence of maternal obesity and weight gain: the DEPOSIT study. Q J Med2001;94:347-356.

Scholl TO, Hediger ML, Schall JI, Ances IG, Smith WK. Gestational weight gain, pregnancy outcome, andpostpartum weight retention. Obstet Gynecol 1995;86(3):423-427.

Siega-Riz AM, Adair LS, Hobel CJ. Maternal underweight status and inadequate rate of weight gain during thethird trimester of pregnancy increases the risk of preterm delivery. J Nutr 1996; 126:146-153.


American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statementof the American Diabetes Association. Diabetes Care 2007;30 Suppl 1:S48-65.

Clinical Management Guidelines for Obstetrician-Gynecologists. ACOG Practice Guidelines Number 30,2001;98(3):525-538.


Institute of Medicine: Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,Protein, and Amino Acids. Washington, DC, National Academies Press, 2002.

Wylie-Rosett J, Albright AA, Apovian C, Clark NG, Delahanty L, Franz MJ, Hoogwerf B, Kulkarni K, Lichtenstein AH,Mayer-Davis E, Mooradian AD, Wheeler M. 2006-2007 American Diabetes Association NutritionRecommendations: issues for practice translation. J Am Diet Assoc 2007;107(8):1296-304.


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Recommendations SummaryGDM: Macronutrient and Micronutrient Intake 2006


Recommendation(s) GDM: Carbohydrate Intake

The Registered Dietitian (RD) should encourage pregnant women, including those with gestational diabetes mellitus(GDM), to consume a minimum of 175 grams of carbohydrate per day based on the Dietary Reference Intake (DRI) forpregnant women for provision of glucose to the fetal brain and to prevent ketosis. Total carbohydrate intake should beless than 45% of energy to prevent hyperglycemia in women with GDM. Carbohydrate intake affects postprandial bloodglucose levels; increased postprandial blood glucose levels are associated with increased incidence of large-for-gestationalage infants and increased rate of Cesarean sections. Research is limited regarding fiber intake and glycemic index inwomen with gestational diabetes mellitus (GDM).

Rating: FairImperative

GDM: Protein and Fat Intake

The Registered Dietitian (RD) should encourage pregnant women, including those with gestational diabetes mellitus(GDM), to consume adequate protein and fat based on the Dietary Reference Intakes (DRI) for pregnant women. Research is limited regarding protein and fat intake in women with gestational diabetes mellitus (GDM).


GDM: Vitamin and Mineral Supplementation

If usual dietary intake does not meet the Dietary Reference Intakes (DRI) for pregnant women, including those withgestational diabetes mellitus (GDM), the Registered Dietitian (RD) should encourage vitamin and mineral supplementationto prevent nutritional deficiencies.

Rating: ConsensusConditional


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Some individuals may not tolerate vitamin and/or mineral supplementation


The recommendation on Vitamin and Mineral Supplementation may be especially important for women who do notordinarily consume an adequate diet and those in high-risk categories, such as women carrying more than onefetus, heavy cigarette smokers, and alcohol and drug abusers.


Vitamin and mineral supplementation may be costlyAlthough costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essentialfor improved outcomes.


Ten studies were evaluated to investigate the consumption of macronutrients in pregnant women and women withgestational diabetes mellitus.

Carbohydrate intake affects postprandial blood glucose levels; increased postprandial blood glucose levelsare associated with increased incidence of large-for-gestational age infants and increased rate of Cesareansections (Peterson and Jovanovic-Peterson, 1991; Clapp, 1998; Parretti et al, 2001; Romon et al, 2001).Three studies showed improved outcomes at carbohydrate intakes of less than 45% of energy (Snyder etal, 1994; Major et al, 1998; Kalkwarf et al, 2001).Research is limited regarding protein, fat, fiber and glycemic index in women with gestational diabetesmellitus (Lauszus et al, 2001; Sloan et al, 2001; Loosemore et al, 2004); further research is needed inthese areas.


Conclusion Statement was given Grade II.

Minority Opinions

Consensus reached.


Is there a specific amount, type, form of carbohydrate, fat and protein for women with gestational diabetes?

References Clapp JE. Effect of dietary carbohydrate on the glucose and insulin response to mixed caloric intake and exercisein both nonpregnant and pregnant women. Diabetes Care 1998; (Suppl 2) 21:B107-B112.

Kalkwarf HJ, Bell RC, Khoury JC, Gouge AL, Miodovnik M. Dietary fiber intakes and insulin requirements inpregnant women with type 1 diabetes. J Am Diet Assoc 2001;101:305-310.

Lauszus FF, Rasmussen OW, Henriksen JE, Klebe JG, Jensen L, Lauszus KS,Hermansen K. Effect of a high monounsaturated fatty acid (MUFA) diet on blood pressure and glucosemetabolism in women with gestational diabetes mellitus. Eur J Clin Nutr 2001;55(6):436-43.

Loosemore ED, Judge MP, Lammi-Keefe CJ. Dietary intake of essential and long-chain polyunsaturated fatty acidsin pregnancy. Lipids 2004;39(5):421-4.

Major CA, Henry MJ, De Veciana M, Morgan MA. The effects of carbohydrate restriction in patients withdiet-controlled gestational diabetes. Obstet & Gynecol 1998;91:600-604.

Parretti E, Mecacci F, Papini M, Cioni R, Carignani L, Mignosa M, La Torre P, Mello G. Third-trimester maternalglucose levels from diurnal profiles in nondiabetic pregnancies: correlation with sonographic parameters of fetalgrowth. Diabetes Care 2001; 24:1319-1323.

Peterson CM, Jovanovic-Peterson L. Percentage of carbohydrate and glycemic response to breakfast, lunch anddinner in women with gestational diabetes. Diabetes 1991; 40 (Suppl 2):172-174.

Romon M, Nuttens MC, Vambergue A, Verier-Mine O, Biausque S, Lemaire C, Fontaine P, Salomez JL, Beuscart R.Higher carbohydrate intake is associated with decreased incidence of newborn macrosomia in women withgestational diabetes. J Am Diet Assoc 2001;101(8):897-902.

Sloan NL, Lederman SA, Leighton J, Himes JH, Rush D. The effect of prenatal dietary protein intake on birthweight. Nutrition Research 2001; 21:129-139.

Snyder J, Gray-Donald K, Koski KG. Predictors of infant birth weight in gestational diabetes. Am J Clin Nutr1994;59:1409-14.


Institute of Medicine: Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,


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Institute of Medicine: Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,Protein, and Amino Acids. Washington, DC, National Academies Press, 2002.


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Recommendations SummaryGDM: Physical Activity 2006


Recommendation(s) GDM: Physical Activity

Unless contraindicated, the Registered Dietitian (RD) should encourage pregnant women, including those with gestationaldiabetes mellitus (GDM), to participate in physical activity for 30 minutes per day for a minimum of three times per week. Research indicates that regular physical activity during pregnancy reduces the common discomforts of pregnancy withouta negative effect on maternal or neonatal outcomes, and improves glycemic control in those with gestational diabetesmellitus (GDM).



Physical activity may cause hypoglycemia in women with gestational diabetes mellitus (GDM) usingpharmacological therapyContraindications to exercise during pregnancy may include but are not limited to: pregnancy-inducedhypertension, premature rupture of membranes, intrauterine growth retardation, preterm labor or historyof preterm labor, incompetent cervix/cervical cerclage, and persistent second or third trimester bleeding.


This recommendation applies to women with GDM for whom physical activity during pregnancy is notcontraindicated. Medical clearance is recommended prior to initiating an exercise program.


None.


Fourteen studies were evaluated to investigate the relationship between physical activity during pregnancy andmaternal/neonatal outcomes and glycemic control in women with gestational diabetes mellitus.

Regular physical activity during pregnancy reduces the risk of gestational diabetes mellitus, as well as thecommon discomforts of pregnancy, without a negative effect on maternal or neonatal outcomes (ACOG,1994; Clapp et al, 1996; Horns et al, 1996; Gray-Donald et al, 2000; Dempsey, Butler et al, 2004;Dempsey, Sorensen et al, 2004; Symons-Downs and Ulbrecht, 2006).Physical activity for 30 minutes per day for a minimum of three times per week is needed to aid withimproved glycemic control. In addition, social support may encourage women with gestational diabetesmellitus to engage in physical activity (Langer and Hod, 1996; Soultanakis et al, 1996; Avery et al, 1997;4th International Workshop-Conference on Gestational Diabetes Mellitus, 1998; Avery and Walker, 2001;Brankston et al, 2004).In addition, social support may encourage women with gestational diabetes mellitus to engage in physicalactivity (Thornton et al, 2006).


Conclusion Statement was given Grade II

Minority Opinions

Consensus reached.



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In women with GDM, what is the relationship between physical activity during pregnancy and maternal/neonataloutcomes and glycemic control?

References Summary and Recommendations of the 4th International Workshop-Conference on Gestational Diabetes Mellitus. Metzger BE, Coustan DR. Diabetes Care 1998;21; Suppl 2:B161-167.

Exercise during pregnancy and the postpartum period. American College of Obstetricians andGynecologists Technical Bulletin Number 189 - February 1994. Int J Gynecol Obstet 1994;45:65-70.

Avery MD, Walker AJ. Acute effect of exercise on blood glucose and insulin levels in women with gestationaldiabetes. J Matern Fetal Med 2001;10:52-58.

Avery MD, Leon AS, Kopher RA. Effects of a partially home-based exercise program for women with gestationaldiabetes. Obstet Gynecol 1997;89:10-15.

Brankston GN, Mitchell BF, Ryan EA, Okun NB. Resistance exercise decreases the need for insulin in overweightwomen with gestational diabetes mellitus. Am Journal of Obs and Gyn 2004;190:188-93.

Clapp JF. Morphometric and neurodevelopmental outcome at age five years of the offspring of women whocontinued to exercise regularly throughout pregnancy. J Pediatr 1996;129:856-863.

Dempsey JC, Butler CL, Sorensen TK, Lee IM, Thompson ML, Miller RS, Frederick IO, Williams MA. A case-controlstudy of maternal recreational physical activity and risk of gestational diabetes mellitus. Diabetes Research andClinical Practice 2004;66:203-215.

Dempsey JC, Sorensen TK, Williams MA, Lee IM, Miller RS, Dashow EE and Luthy DA. Prospective study ofgestational diabetes mellitus risk in relation to maternal recreational physical activity before and duringpregnancy. Am J Epidemiol 2004;159:663-670.

Gray-Donald K, Robinson E, Collier A, David K, Renaud L, Rodrigues S. Intervening to reduce weight gain inpregnancy and gestational diabetes mellitus in Cree communities: An evaluation. CMAJ 2000;163(10):1247-1251.

Horns PN, Ratcliffe LP, Leggett JC, Swanson MS. Pregnancy outcomes among active and sedentary primiparouswomen. JOGNN 1996; 25:49-54.

Langer O, Hod M. Management of gestational diabetes mellitus. Obstet Gynecol Clin North Am1996;23(1):137-159.

Soultanakis HN, Artal R, Wiswell RA. Prolonged exercise in pregnancy: glucose homeostasis, ventilatory andcardiovascular responses. Seminars in Perinatology, 1996;20(4):315-327.

Symons Downs D, Ulbrecht J. Understanding exercise beliefs and behaviors in women with gestational diabetesmellitus. Diabetes Care 29:236-240, 2006.

Thornton PL, Kieffer EC, Salabarria-Pena Y, Odoms-Young A, Willis SK, Kim H, Salinas MA. Weight, diet, andphysical activity-related beliefs and practices among pregnant and postpartum Latino women: The role of socialsupport. Maternal and Child Health Journal, 2006;10:95-104.


Quick Links

Recommendations SummaryGDM: Blood Glucose Monitoring and Ketone Testing 2006


Recommendation(s) GDM: Blood Glucose Monitoring

The Registered Dietitian (RD) should advise women with gestational diabetes mellitus (GDM) to monitor their bloodglucose, including fasting and postprandial levels. Several studies report a correlation between elevated fasting andpostprandial blood glucose values with poor maternal and neonatal outcomes.


GDM: Ketone Testing

The Registered Dietitian (RD) should recommend ketone testing for women with gestational diabetes melltius(GDM) who have insufficient calorie and/or carbohydrate intake and/or weight loss. Two of threestudies regarding ketonemia and ketonuria with poor metabolic control during a diabetic pregnancy report a positiveassociation with lower IQ in offspring.

Rating: Fair


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Frequent glucose self-monitoring may cause pain and discomfortIndividuals should know of proper disposal of hazardous waste


Persons must receive education and training in order to use the SMBG devices and data correctly.Persons with low hematocrit values and their healthcare providers should be aware of inaccurate bloodglucose monitoring results.Ketone testing is recommended for women with gestational diabetes melltius (GDM) who may haveinsufficient calorie and/or carbohydrate intake and/or weight loss. Not all healthcare professionals recognize the value of ketone testing.A1C is not routinely used to assess blood glucose control in gestational diabetes mellitus (GDM).


Costs and time associated with blood glucose monitoring and ketone testing need to be addressed.Insurance coverage for blood glucose monitoring and ketone testing may vary.Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essentialfor improved outcomes.


Sixteen studies were evaluated regarding blood glucose monitoring and ketone testing in pregnant women and inwomen with gestational diabetes mellitus.

Six studies report that fasting blood glucose

Gestational Diabetes · Jensen DM, Damm P, Sorensen B, Molsted-Pedersen L, Westergaard JG, Klebe J,...

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