Nutrition Breaking in Pregnancy: Convention: …Nutrition in Pregnancy: Lessons from Gestational...

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Teri L. Hernandez, PhD, RN Associate Professor of Medicine and Nursing University of Colorado Anschutz Medical Campus Pediatric Nurse Scientist | Children’s Hospital Colorado March 3, 2018 CWHR Women’s Health Symposium Breaking Convention: The Case for Complex Carbohydrates in Nutrition Therapy for Gestational Diabetes Nutrition in Pregnancy: Lessons from Gestational Diabetes Nutrition in Pregnancy: Lessons from Gestational Diabetes

Transcript of Nutrition Breaking in Pregnancy: Convention: …Nutrition in Pregnancy: Lessons from Gestational...

Page 1: Nutrition Breaking in Pregnancy: Convention: …Nutrition in Pregnancy: Lessons from Gestational Diabetes Objectives 1. Describe the powerful influence of nutrition in pregnancy on

Teri L. Hernandez, PhD, RNAssociate Professor of Medicine and Nursing

University of Colorado Anschutz Medical CampusPediatric Nurse Scientist | Children’s Hospital Colorado

March 3, 2018CWHR Women’s Health Symposium

Breaking Convention:

The Case for Complex Carbohydrates in Nutrition 

Therapy for Gestational Diabetes

Nutrition in Pregnancy:Lessons from GestationalDiabetes

Nutrition in Pregnancy:Lessons from Gestational Diabetes

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Objectives1. Describe the powerful influence of nutrition in pregnancy 

on glucose, lipids, and infant adiposity2. Articulate the case for complex carbohydrates in nutrition 

therapy for GDM

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“Implications of maternal 

fuels…go far beyond 

diabetes in pregnancy…”

‐Dr. Norbert FreinkelBanting Lecture, 1980

Nutrition in Pregnancy: A Powerful Influence

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Intrauterine environment:“Incubation medium”

Fetus

Glucose

Glucose

Pedersen, 1952; Freinkel, 1980, Diabetes, 29(12):1023

FFA

TG

FFA

AA

FFA

FFA

OvernutritionInsulin ResistanceInsulin Deficiency

Glucose Fat Protein

FetalOvergrowth

AmnioticFluid insulin

Glucose

Growth

Insulin

19 lbs/8600g

FFA

AAFFA

Mother Placenta

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Nutrition in Pregnancy: Overall Goals

Carbohydrate Fiber Total Fat  Protein

Pregnant 175g 28g ‘Not Determined’

71g

Non‐Pregnant

130g 25g ‘Not Determined’

45g

% of total calories

45‐65% 20‐35% 10‐35%

Dietary Reference Intakes (RDA)

Energy Intake Adjustments for Pregnancy

Otten JJ, Institute of Medicine, 2006, http://www.nap.edu

Healthy Eating Patterns are emphasized

USDA, 2015

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Suggested Postprandial TargetsBased on +1SD from weighted means:1-hour: <122 mg/dL2-hour: <110 mg/dL

Goal for Glucose Management: “Good” Glycemic Control by mimicking 

Normoglycemia

• 2011: In nearly 50 years of research, only n=255 women• NW to OW, BMI range 22‐28 kg/m2

• Pre‐pregnancy BMI vs. BMI at time of study unclear• Only 1 study had characterized glycemia in obese pregnant women (n=15)

Hernandez TL, 2011, Diabetes Care, 34(7): 1660Freinkel N, 1980, Diabetes, 29(12):1023Hernandez TL, 2015, Curr Diab Rep, 15: 565

FBG from HAPO:80.9±6.9 mg/dL

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Infa

nt B

ody

Fat

(%)

More than Maternal Glucose:Maternal Lipids Matter for Fetal Growth 

Olmas PR Obesity 2014; Whyte K Europ J Ob Gyn 2013; Misra VK Obesity 2011; Vrijkotte TG J Peds 2012; Hyun Son GA Acta Obst Gynecol 2010; Gobl CS Diab Care 2010; Schaefer-Graf U Diab Care 2008; Akcakus M 2007; Di Cianna G Diabet Med 2005; Kitajima M Obst Gynecol 2001

Harmon K, Hernandez T, Bessesen D, Barbour L Diab Care 2011;34:2198

R=0.67

Slide credit: Linda Barbour, MD

Late Pregnancy Early Pregnancy

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Meal‐Driven Triglycerides Drive Infant Adiposity

OB Late

NW Early

OB Early ~ NW Late

Fasting & 1‐hr PPTG at 14 wks predict infant %Fat in obesity

Measures after 3 d controlleddiet; Liquid meal, blood sampled at 10 points over 4 hrs at ~14 and ~28 wks

r=0.6r=0.7

1‐hr Total PPTGDriven by CM TG

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Obesity has changed the Landscape of Pregnancy:

High Potential for Nutrition Therapy in GDM• Nutrition therapy:  the original and most potent approach to 

treatment of diabetes (Joslin diet was 2% carbohydrate)1,2

• Recognized as the cornerstone to treatment of GDM3

• Pioneers in obstetrics and diabetes recognized that in‐utero environmental conditions are shaped by maternal nutrition4

• Diet therapy has the potential to effectively treat GDM without medication and fetal surveillance5

• Nutrition therapy is the single treatment component that will reach every woman with the diagnosis independent of diagnostic criteria and GDM phenotype6 1. Mestman JH, 2002, The Endocrinologist; 12:224

2. Hernandez TL, 2014, Curr Diab Rep, 15:565 3. Gunderson EP, 2004, Curr Diab Rep, 4(5):3774. Freinkel, 1980, Diabetes, 29(12):1023 5. Hernandez TL, 2013, Clin Obstet Gynecol, 56(4):8036. Hernandez TL, 2017, book chapter in press

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Nutrition Therapy in GDM: Doomed from the Start?The Denver Experience: Anxiety, Rigid Adherence, and 

Unintended Consequences

Until GDM diagnosis, pregnancy was “normal”…• Suddenly: High risk pregnancy label, “diet”, rigid control of glucose, 

surveillance, medications• Anxiety, fear, depression

Psychology related to nutrition therapy in GDM• Focus:  rigid restriction of carbohydrate• Rapid adaptation in late pregnancy is challenging; food selection is mentally 

taxing• Infringement on cultural/social beliefs• Feel confined by the diet

o Narrow range of “acceptable foods,” limited food choices 

• Rigid diet control: the most difficult componentto treatmento Unintended consequences: fat intake

Lawson EJ, 1994, Social Health Illn, 16(4):536Hui AL, 2014, Diabetes Educ, 40(5); 668Teixeira PJ, 2015, BMC Med, 13:84

University of Colorado Hospital, circa 2002

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A Clinical Paradox• Does the conventional carbohydrate‐restricted diet worsen maternal insulin resistance in women with GDM?… resulting in increased substratedelivery and fetal growth?

Funded in 2010R21 DK 088324:

Role of Macronutrient Diet Compositionon Maternal and Infant MetabolicOutcomes in Gestational Diabetes 

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Nutrition Therapy is the Cornerstone to GDM Treatment

• Choosing Healthy Options In Carbohydrate Energy = CHOICE™o High Complex Carb/Low‐Fat (HCC/LF)o 60% carb, mostly complexo 25% fato 15% protein

• ‘Conventional Diet’o Low‐Carb/Conventional (LC/CONV)o 40% carbo 45% fato 15% protein

• Both dietso SFA‐ 35‐45%; MUFA‐ 35‐45%; PUFA‐ 15‐20%o Simple Sugars:  fixed at 70±5g in both dietso Carbs are ‘complex,’ low‐moderate glycemic indexo Fiber is similar (~24g/day in LC, ~29g/day in CHOICE)

Dinner30%

Snacks20%

Breakfast25%

Lunch25%

Caloric Distribution

Hernandez, TL, 2014, Diabetes Care, 37(5):1254.R01 DK 101659

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Similar 24‐hour Glycemia

-Similar patterns-No difference in nocturnal or FBG-No difference in mean glucose

1-hour target

2-hour targetCHOICELC/CONV

6%Difference

91±2 95±2*

LC/CONVCHOICE

Hernandez, TL, 2014, Diabetes Care, 37(5):125

Randomized, Crossover Study:

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Average Post‐Meal Glucose is within Treatment Targets

*Data from Continuous Glucose Monitoring x3 days

115±2 mg/dL

107±3 mg/dL

106±3 mg/dL

97±3 mg/dL

Hernandez, TL, 2014 Diabetes Care, 37(5):1254.

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Higher Insulin Excursion on CHOICE™

*post-breakfast plasma data

Hernandez, TL, 2014 Diabetes Care, 37(5):1254.

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Similar Postprandial TG on both Diets

*post-breakfast plasma data

Hernandez, TL, 2014 Diabetes Care, 37(5):1254.

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Higher FFA on the Conventional Diet

*post-breakfast plasma data

19% Difference

Hernandez, TL, 2014 Diabetes Care, 37(5):1254.

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What does FFA response to the Atkin’s Diet look like?

n=32

Atkin’s diet (20g carb/day)vs. 55% Carbafter 6 weeks of weight loss

Hernandez TL, 2010,AJCN, 91(3):578

Also: Hernandez, TL, 2016,Diabetes Spectr, 29(2), 82

**Non-pregnant humans

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Lower Fasting Glucose on CHOICE™after 6‐7 weeks

Hernandez, TL, 2016, Diabetes Care, 39(1), 39

-8

-6

-4

-2

0

2

4

6

8

Ch

ang

e F

asti

ng

Glu

cose

, 37

-31

wks

, mg

/dL

LC/CONV CHOICE

p=0.002

n=12 “completers”

Weight Gain over 6-7 wks: 2.6kg 2.3kg

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Lower Fasting Insulin on CHOICE™after 6‐7 weeks

Hernandez, TL (2013), Preliminary data, R21DK 088324

*

*p=0.06

Baseline

CHOICE™=HCC/LF

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Greater insulin‐suppression of Lipolysis on CHOICE™ after 6‐7 weeks 

Hernandez, TL, 2016, Diabetes Care, 39(1), 39

Week 37 Adipose tissue biopsies

32%

0

10

20

30

40

50

60

70

1

% S

uppr

essi

on, I

sopr

oter

enol

+ In

sulin

LC/CONV CHOICE

p=0.005

30%

56%

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Lower Infant Adiposity withCHOICE Exposure

LC/CONV CHOICE

N 6 6

C‐section 2 0

Sex (M/F) 2/4 3/3

Gest Age, weeks 39.2±0.4 40.5±0.5

Birth Weight, g 3421±186 3273±104

Adiposity, PeaPod, 2wks

12.6±2.0 10.1±1.4

Mean±SEMp>0.05

Hernandez, TL, 2016, Diabetes Care, 39(1), 39

0

2

4

6

8

10

12

14

16

% bod

y fat, PE

APO

LC/CONV CHOICE

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Maternal insulin resistance at 37 weeks predicts neonatal adiposity

Maternal Fasting insulin, Week 37Vs. Infant Adiposityr=0.694, p=0.03

Hernandez, TL, 2016, Diabetes Care, 39(1), 39

0

5

10

15

20

0 2 4 6 8 10 12

%B

F,

Pea

Po

d

HOMA-IR, 37 weeks

LC/CONV CHOICE

r=0.731p=0.007

Can maternal insulin actionbe targeted with nutritiontherapy in pregnancyand GDM?

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State of the Science:  Insufficient Evidence

2017 Update

Approaches reviewed across trials:Glycemic Index (Low, Moderate, Higher) ~ Energy‐restricted ~ Dietary Approachesto Stop Hypertension (DASH) ~ Low vs. Higher Carbohydrate ~ High vs Low Unsaturated Fat~ Higher vs. Standard Fiber ~ Diet recommendations + behavior advice ~ Soy‐protein enrichment ~ Ethnic‐specific

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Suggestions of Benefit:  The Case for Higher Quality Complex Carbs instead of pure Carb Restriction

Improved• Maternal glucose control, equal 

to or superior to carbohydrate restriction

• Fasting glucose• Response to OGTT• A1C• Insulin action, insulin resistance 

index• Systolic BP

Decreased• Total, LDL cholesterol• Fasting, postprandial lipemiaVascular Benefits• total glutathione/anti‐oxidant 

capacityAppropriate GWG when calories notin excessLess C‐section deliveryLess macrosomia, lower birth weights

References on last slide

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Prevention of GDM starts long before pregnancyPre‐pregnancy interventions can include:• Good nutrition focused on diet quality, healthy eating 

patterns• Return to normal body weight before conception• Attention on psychological factors such as anxiety, 

depression, and dysfunctional eating patterns

Nutrition Implications for all pregnant women, children and families:• Focus on increasing diet quality and reinforcing healthy 

eating patterns:  fruits, vegetables, legumes, whole grains

• Avoidance of simple sugars: contribute to hyperglycemia• Fats in moderation: high total and increased saturated 

fats contribute to insulin resistance

Nutrition in GDM and Pregnancy: Evidence‐Based Advice for Moving Forward

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015‐ 2020 Dietary guidelinesfor Americans.  2015. Report No.: 8th Edition.

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60

70

80

90

100

110

120

2330 630

1230

1830

InterstitialGlucose, m

g/dL

Time (Military)

Patterns of 24‐hr Glycemia

NW Early OB Early NW Late OB Late

Higher Patterns of 24‐hr Glycemia in OB vs. NW Women Across Gestation

Arrows showmeal start times

Barbour LA, R01DK78645Hernandez TL…Barbour LA, 2018, data in preparation

NW, n=24Ob, n=22

24‐hr glucose AUC ~ total potential fetal glucose exposure

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N= 4 GDM at diagnosisbefore treatment

Who are we treating???

Barbour LA, R01DK78645

Nutrition Principles for GDM may extendto Overweight/Obesity without GDM

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0

50

100

150

200

250

0 20 40 60 90 120 150 180 210 240

Plasma TG

, mg/dL

Time, Minutes

NW (n=27) OB (n=24) GDM (n=18)

60

70

80

90

100

110

120

2330 25 120

215

310

405

500

555

650

745

840

935

1030

1125

1220

1315

1410

1505

1600

1655

1750

1845

1940

2035

2130

2225

2320Interstitial G

lucose, m

g/dL

Time, Military

24hr Glycemia by CGM, Wk 28‐31

GDM (n=18) OB (n=23) NW (n=25)

Nutrition in GDMis Nutrition for all Pregnancy

Similar Glucose and Lipid Exposure: Nutrition-Treated GDM and Obesity

Hernandez TL & Barbour LA, 2018, in-press

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• Linda A. Barbour, MD, MSPH• Jacob E. Friedman, PhD• Rachael E. Van Pelt, PhD• Nicole Hirsch, MS, CLC• Sarah Farabi, PhD, RN• Libby Haugen, BA, Nursing Student • Emily Zans, MS, RD, CDE• Laurie Moss, MS• Nancy Krebs, MD• Dan Frank, PhD• Theresa Powell, PhD• Becky DelaHoussaye, MS• Kristy Heiss, BS• Robert H. Eckel, MD• CCTSI grant support• R01 DK 078645• Judith Regensteiner, PhD• CU Center for Women’s 

Health Research• CCTSI  Adult/Pediatric Nursing Core• R01 DK 101659

It takes a Village…