Interventions for Obesity and Gestational Diabetes Associated with Pregnancy - Essay Example

INTERVENTIONS FOR OBESITY AND GESTATIONAL DIABETES ASSOCIATED WITH PREGNANCY Introduction Increased weight gain during pregnancy has become a problemof public health concern as it has been shown to be associated with maternal complications like gestational diabetes mellitus (GDM), hypertension, miscarriage, caesarean delivery, endometritis etc. obesity also poses many risks to the fetus which include macrosomia, preterm births, increased susceptibility to childhood obesity and several long term risks. GDM refers to a condition characterized by hyperglycemia in pregnancy which in turn could lead to negative outcomes like enhanced rates of perinatal injury and cesarean delivery due to increased weight gain of the fetus (Hone and Jovanovic 95 : 3578-3585). An imbalance in the placental hormones that are necessary to maintain a healthy pregnancy creates insulin resistance which in turn leads to the development of GDM. According to the American Diabetes Association (ADA), GDM is one of the most common complications of pregnancy and affects around 7% of the pregnant women (S103-105). Changes in diet, appropriate meal planning, increased physical activity and other pharmacological therapies are recommended as intervention strategies for GDM. Interventions Medical nutrition therapy Medical nutrition therapy (MNT) is recommended as the most important intervention for women with GDM. In standard practice, three visits to the registered dietician (RD) are suggested and carbohydrate counting is the preferred method of choice employed to obtain strict control over blood glucose. The amount of insulin intake can be monitored and customized by regulating the carbohydrate intake. A weight gain of 0 to 7 lbs for women with GDM and obesity has been recommended by some experts as there is data to demonstrate that weight gain within this range is associated with a reduced risk of macrosomia. An eating plan called DASH (Dietary Approaches to Stop Hypertension) was tested using a randomized controlled clinical trial approach on a group of GDM patients. Intake of the DASH diet comprising higher amounts of whole grains, fruits, vegetables and lower amounts of refined grains, cholesterol and saturated fat was shown to be associated with improved pregnancy outcomes like lower weight, head circumference, ponderal index and a lower frequency of cesarean deliveries (Asemi et al 68: 490-495). Pharmacotherapy During pregnancy, insulin is the only anti-diabetic medication recommended for managing blood glucose levels when medical nutrition therapy proves to be ineffective in achieving the glycemic targets (Langer 43:106–115). In general oral hypoglycemic agents are not used in GDM management. But some recent reports have demonstrated that women with GDM on metformin or glyburide therapy were able to lose more weight, had better control of hyperglycemia and good perinatal outcomes that were comparable to the insulin treated women (Faraci et al 5: 63-64). Monitoring blood glucose and ketone bodies Monitoring of blood glucose occupies an integral part in the management of GDM. Self monitoring of the blood glucose levels is the best method recommended to achieve the glycemic targets. The appropriate goal should be towards maintaining the level of blood sugar in the range of 80- 110 mg/dl. Monitoring of ketone bodies in urine is would aid in identifying inadequate carbohydrate intake in women undergoing calorie restriction (Langer 43:106–115). Hypertension and fetal monitoring Blood pressure and urine protein levels should be monitored for detecting hypertension as normal blood pressure maintenance facilitates normal fetal growth and prevents end organ damage. Beta blockers and calcium channel blockers are some of the safe drug classes recommended during pregnancy. Furthers assessments include, screening for asymmetrical growth of the fetus using ultrasonography during the third trimester and surveying the risk of fetal demise when pregnancy progresses past term or at elevated fasting glucose levels beyond 105 mg/dl. Furhter, monitoring of fetal kick counts, epigastric pain, headaches etc could identify the presence of fetal abnormalities (Carpenter Suppl 2: S246-50). Moderate physical exercise Maternal hyperglycemia has been shown to be controlled by moderate physical activity programs. Tobias et al have shown that a 30 minute engagement in moderate physical activity can lead to effective management of GDM. Moderate physical activity has also been proved to be an important preventive strategy against GDM (34: 223-229). Stress management and counseling Since stress has been known to augment glucose levels and contribute to hyperglycemia, women with GDM should be taught coping techniques for management of stress. Also, counseling on the importance of vitamin intake towards fetal growth and maintaining normal blood glucose levels during and prior to pregnancy could help in management of GDM (Kim 2: 339-51.). Post-pregnancy Management GDM increases the susceptibility towards the development of type 2 diabetes in future. A systemic review has shown that in a ten year follow up period, over 60 % of individuals with GDM had developed type 2 diabetes. Even after attaining normal postpartum blood glucose levels, the risk of developing GDM in the subsequent pregnancies was found to be higher in women with a previous history of GDM and obesity (Lawrence et al 33: 569-576). One of the essential elements of postpartum care in women with GDM should be placing higher emphasis on breast feeding (Gunderson, 30: S161–S168) and undergoing an oral glucose tolerance test (OGTT) at 6 weeks. Further, ophthalmology examinations, counseling for prevention or progression to type 2 diabetes and family planning contribute towards better post pregnancy management. Outcomes GDM which is untreated could lead to many adverse health outcomes in the mother and the neonate. An increase in cesarean deliveries, higher risk for the development of future type 2 diabetes and hypertension in women with GDM and macrosomia, polycythemia, and brachial plexus injury in neonates born to GDM mother has been reported. On the other hand, interventions like diet and physical activity have been shown to impart many positive outcomes on the mother and infant. In case of obese women with a body mass index > 30 kg/m2, a reduction in triglycerides and glucose levels and improved fetal and maternal outcomes were achieved as a result of calorie restriction by 30 to 40% (American Diabetes Associaiton 4). Similarly, as mentioned earlier, physical activity and insulin therapy and blood pressure monitoring have been shown to reduce negative obstetric outcomes in pregnancy associated with GDM. Conclusions In order to reduce maternal weight gain and control hyperglycemia associated with GDM, diet and physical activity are important therapeutic options that contribute to positive health outcomes in the mother and the infant. Administration of Insulin and oral hypoglycemic agents with continuous self monitoring of blood glucose would aid in achieving the glycemic targets. A balanced diet with moderate intensity exercises for about 30 minutes per day would be the appropriate weight reduction strategy and this approach has not been shown to result in neonates with low birth weight or small for gestational age. REFERENCES American Diabetes Association. “Gestational diabetes mellitus.” Diabetes Care 26. Suppl 1(2003):S103-5. Asemi Zatollah, Samimi Mansooreh, Tabassi Zohreh et al. “The effect of DASH diet on pregnancy outcomes in gestational diabetes: a randomized controlled clinical trial.” Eur J Clin Nutr 68.4 (2010):490-5. Print Carpenter, MarshallW. “Gestational diabetes, pregnancy hypertension, and late vascular disease.” Diabetes Care. Suppl 2(2007): S246-50. Print Faraci, Marianna, Di Prima, Fosca A.F, Valenti Oriana et al. “Treatment of gestational diabetes: oral hypoglycemic agents or insulin?” J Prenat Med 5.3( 2011):63-4. Print Gunderson, Erica-P. “Breastfeeding after gestational diabetes pregnancy: subsequent obesity and type 2 diabetes in women and their offspring.” Diabetes Care 30.2 (2007):S161–S168. Print Hone Jennifer, Jovanovic Lois. “Approach to the Patient with Diabetes during Pregnancy.” Journal of Clinical Endocrinology & Metabolism 95.8 (2010): 3578-3585.Print Kim, Catherine. “Gestational diabetes: risks, management, and treatment options.” Int J Womens Health 2 (2010):339-51. Langer, Oded. “Management of gestational diabetes.” Clin Obstet Gynecol 43(2000):106–15. Print Lawrence Jean M, Black, Mary Helen, Hsu, Jin-Wen et al. “Prevalence and Timing of Postpartum Glucose Testing and Sustained Glucose Dysregulation after Gestational Diabetes Mellitus.” Diabetes Care 33.3( 2010):569-576. Print Tobias, Deirdre K, Zhang, Cuilin and van Dam, Rob M, et al. “Physical activity before and during pregnancy and risk of gestational diabetes mellitus: a meta-analysis.” Diabetes Care 34.1(2011):223-9. 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