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Journal of the American College of Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uacn20
Nutritional management of the obese gestational diabetic pregnant woman. a
a
L Jovanovic-Peterson & C M Peterson a
Sansum Medical Research Foundation, Santa Barbara, CA 93105. Published online: 02 Sep 2013.
To cite this article: L Jovanovic-Peterson & C M Peterson (1992) Nutritional management of the obese gestational diabetic pregnant woman., Journal of the American College of Nutrition, 11:3, 246-250, DOI: 10.1080/07315724.1992.10718223 To link to this article: http://dx.doi.org/10.1080/07315724.1992.10718223
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
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Guest Editorial: Nutritional Management of the Obese Gestational Diabetic Pregnant Woman
distribution relate independently to the fasting plasma glucose and indices of carbohydrate tolerance even in normal pregnancy [14]. In addition, truncal obesity is a risk factor for a macrosomic infant [15]. Truncal obesity can be easily estimated by calculating the ratio of the waist measurement at the umbilicus and the hip measurement at the level of the superior iliac spine using a flexible tape with the subject vertical [16]. This measurement is predic tive of truncal obesity up to the 12th gestational week. A waist/hip ratio (measurement of the waist circumference divided by the measurement of the hip circumference) above 1.00 significantly increases the risk of glucose intol erance in pregnancy [14]. Glucose intolerance is assessed by the glucose tolerance test (GTT) [17]. The 50 g glucose challenge test [17], recommended for all pregnant women at 24-28 weeks of gestation, is not sufficient to evaluate the glycémie levels of an obese woman, because it does not measure the fasting glucose level. It has recently been suggested that fasting hyperglycemia may be the only abnormality of carbohy drate metabolism in the obese pregnant woman [18], and that it is associated with a 20% increase in risk of infantile macrosomia [19]. Thus, either a fasting glucose should be obtained on all glucose challenge tests for all overweight pregnant women or these women should be given the diagnostic test of a 100 g GTT at 24-28 weeks gestation regardless of the results of the 50 g glucose challenge test (Table 1). Proceeding immediately with the 100 g GTT might eliminate the need to retest the woman if the chal lenge is abnormal, a cost savings in a population with a high prevalence of disease [20]. Because both fasting and the postprandial glucose elevations increase the risk for macrosomia [21,22], the nutritional management strategy must take into account the degree of glucose intolerance based on the GTT. If only those women with morbid, gross, debilitating obesity (>150% ideal body weight) are studied, the preva lence of obesity during pregnancy is 6-10% [21]. These women tend to be older and of greater parity than non-
Obesity is the most common and serious nutritional disorder of adults in the Western world. When obese women become pregnant, particularly when they consume a caloric intake that results in excessive weight gain, they are at high risk of gestational diabetes mellitis (GDM) and hypertension [1]. Fetuses of such women are at risk of macrosomia, hypoglycemia, birth trauma, and possibly adult obesity [2]. Despite the assumption that dietary prevention of excessive weight gain by an already obese pregnant woman should decrease the risks to mother and infant, "caloric-restricted" diets during even obese preg nancy remain controversial [3-8]. Because of the wide variation in clinicians' practice of prescribing diets for the obese GDM woman, a symposium during the National Meeting of The American College of Nutrition, 1990, presented a panel to "debate" the safety and utility of caloric-restricted diets for these women dur ing pregnancy. Although it was anticipated that the views expressed would be polar, the speakers reached a consen sus. If safety and efficacy is defined as that diet which produces a healthy baby, then the ideal diet for obese GDM women was agreed upon by the panel to be approx imately 33% less than a diet for a normal weight woman (1500-1800 kcal/day or 24-25 kcal/kg present pregnant weight) [9-11]. This editorial 1) reviews the risks associated with preg nancy complicated by obesity, 2) presents one approach to the management of obese GDM, 3) reviews pertinent data from our own studies [9], and 4) sets the stage for the other papers presented in this consensus conference [10,11].
DEFINITIONS AND EPIDEMIOLOGY Recent studies have indicated that central obesity as opposed to total body fatness, puts a woman at a higher risk for GDM [12]. Truncal obesity directly correlates with an elevated fasting blood glucose [13]. Fatness and fat
Presented at the American College of Nutrition Annual Meeting, Albuquerque, NM, 1990. Address reprint requests to Lois Jovanovic-Peterson, MD, Sansum Medical Research Foundation, 2219 Bath St., Santa Barbara, CA 93105.
Journal of the American College of Nutrition, Vol. 11, No. 3, 246-250 (1992) Published by the American College of Nutrition
246
Diets for Obese Gestational Diabetic Women obese pregnant women. Less severe obesity during preg nancy may also increase risk to mother and infant, but good data on prevalence or risk are not yet available.
Downloaded by [Temple University Libraries] at 14:05 10 January 2015
MATERNAL RISKS SECONDARY TO OBESITY All previous studies have shown an increased risk of medical complications in obese (>150% ideal body weight) pregnant women [1,2,21-24] (Table 2). Obesity increases the risk for GDM tenfold over the risk for nonobese patients. GDM and obesity independently contribute to fetal growth. In some studies, maternal obesity has the predominant influence on fetal growth, rather than abnor mal glucose homeostasis [25]. Our own data using mag netic resonance imaging to evaluate the degree of adiposity of the mother and the fetus in the third trimester [26] also reveals that maternal adiposity correlates better than ma ternal glucose levels with infant size. There is evidence that fetal macrosomia associated with obesity is mediated in part through even moderately ele vated glucose levels (i.e., at marginally "normal glucose tolerance") [27]. Obese women have a higher fasting plasma glucose (90-100 mg/dl) than do normal weight women (60-70 mg/dl) [27]. Women with fasting plasma glucose levels >90 mg/dl have a 20% risk of delivering a macrosomic infant [19]. In addition, obese women may constantly be in the "postprandial" state, with resultant frequent eating. It is hypothesized that a normal woman eating three tim,es/day has a peak blood glucose of 120 mg/dl three times/day, with a lower mean glycémie level over 24 hours; she will have a smaller baby than a woman who eats six times/day with the same peak response to each meal. An additional problem in obese women is the occur rence of both chronic hypertension and the development of superimposed pre-eclampsia. Seven percent of obese women begin pregnancy with chronic hypertension, whereas leaner patients have a 1.7% prevalence rate of hypertension [28]. The management of a pregnancy com plicated by obesity must include intensive blood pressure surveillance using a large cuff.
Table 2. Pregnancy Risks Associated with Obesity [41] Gestational diabetes Hypertension (chronic and pre-eclampsia) Twins Dysfunctional labor pattern Anaesthesia/operative risks Postpartum hemorrhage Thrombophlebitis Wound infection/dehiscence
Table 2 lists other problems of delivery for the obese pregnant woman.
INFANT RISKS Infants born to obese mothers have risks, most of which are secondary to the neonate's large size (Table 3). Multiple factors contribute to fetal growth, including parity, mater nal age, fetal sex, uterine size, genetics, placental size and function, adverse disease states, and nutrition.
LIMITING WEIGHT GAIN IN THE OBESE PREGNANT WOMAN Two significant factors related to maternal nutrition and enhancement of fetal growth are prepregnant weight and pregnancy weight gain, which are mutually independ ent [25]. Since the obese pregnant woman begins preg nancy with one factor predisposing to high infant birthweight, management strategies should focus on limiting maternal weight gain during pregnancy. All the presenta tions at the symposium came to this same conclusion [911]. Despite a high risk of chronic hypertension in obese pregnant women, the feared complication of intrauterine growth retardation (IUGR) of infants born to normal weight hypersensitive women, does not occur in obese women [2]. IUGR is also a risk of normal weight women who gain weight poorly during pregnancy, but not of obese pregnant women who either have lost weight or gained 140 mg/dl, we further decrease kilocalories. If ketonuria occurs, we begin insulin therapy. In some women, morning ketonuria may be prevented by a 3 a.m. snack (a glass of milk) without subsequent hyperglycemia or the need for insulin. All of the speakers [9-11] at the symposium presented data consistent with the following conclusion: The "con sensus ideal diet" for the obese GDM woman is composed of a 33% reduction in caloric intake compared to the kilocalories allowed for a normal weight woman or 24-25 kcal/kg present pregnant weight per day (about 1500-1800 kcal/day). In summary, nutritional management for the obese pregnant woman includes a diet which minimizes further weight gain and prevents postprandial elevations of glu cose. Attention to both variables is important if neonatal macrosomia is to be avoided. We suggest that all obese women need a 100 g GTT at 24-28 weeks of gestation, because the prevalence of GDM is high and even fasting hyperglycemia increases the risk for neonatal macrosomia. If diabetes is present, all meals need to be monitored with self blood glucose monitoring. If fasting and postprandial hyperglycemia is documented despite caloric restriction, then insulin should be prescribed [17].
REFERENCES 1. King JC: Obesity in pregnancy. In Frankle RT, Dwyer J, Morangne L, Owen A (eds): "Dietary Treatment and Preven tion of Obesity." London: John Libbey, pp 185-192, 1985. 2. Kleigman RM, Gross T: Perinatal problems of the obese mother and her infant. Obstet Gynecol 66:299-305, 1985. 3. Algeri S, Shragg P, Hollingsworth DR: Moderate caloric restriction in obese women with gestational diabetes. Obstet Gynecol 65:487-491, 1985. 4. Herrera E, Knopp RH, Freinkel N: Carbohydrate metabolism in pregnancy VI. Plasma fuels, insulin, liver composition, gluconeogenesis and nitrogen metabolism during gestation in the fed and fasted pregnant rat. J Clin Invest 48:2260-2272, 1969. 5. Felig P, Lynch V: Starvation in human pregnancy: hypoglycemia, hypoinsulinemia, and hyperketonemia. Science 170:490-492, 1970. 6. Knopp RH, Herrera E, Freinkel N: Carbohydrate metabolism in pregnancy VIII. Metabolism of adipose tissue isolated from fed and fasted pregnant rats during late gestation. J Clin Invest 49:1438-1446, 1970. 7. Freinkel N: Of pregnancy and progeny. Diabetes 29:10231035, 1980.
Diabetic
Women
8. Morrow PG, Marshall WP, Hak-Joong K, Kalkhoff R: Met abolic response to starvation. I. Relative effects of pregnancy and sex steroid administration in the rat. Metabolism 30:268278, 1981. 9. Jovanovic-Peterson L, Peterson CM: Dietary manipulation as a primary strategy for pregnancies complicated by diabetes. J Am Coll Nutr 9:320-325, 1990. 10. Knopp RH, Magee MS, Raisys V, Benedetti T, Bonet B: Hypocaloric diets and ketogenesis in the management of obese gestational diabetic women. J Am Coll Nutr, in press, 1991. 11. Hollingsworth DR, Ney DM: Caloric restriction in pregnant diabetic women: a review of maternal obesity, glucose and insulin relationships as investigated at the University of Cali fornia, San Diego. J Am Coll Nutr, in press, 1991. 12. Lean MEJ, Sutherland F, Bruce P, Sutherland HW, Garthwaite PH: Body mass index, waist/hip ratio and carbohydrate tolerance in pregnancy. Diabetes Nutr Metab 2:291-297, 1989. 13. Sparrow D, Borkan GA, Gerzof SG, Wisniewski C, Silbert CK: Relationship of fat distribution to glucose tolerance. Diabetes 35:411-415, 1986. 14. Deans HE, Smith FW, Lloyd DJ, Sutherland HW: Fetal fat measurement by magnetic imaging. Br J Radiol 62:603-607, 1989. 15. Larsen CE, Serdula MK, Sullivan KM: Macrosomia: influ ence of maternal overweight among a low-income population. Am J Obstet Gynecol 161:490-494, 1990. 16. Haftner SM, Stern MP, Hazuda HP, Pugh J, Patterson JK: Do upper-body and centralized adiposity measure different aspects of regional body-fat distribution? Diabetes 36:43-51, 1987. 17. Summary and Recommendations of the Second International Gestational Diabetes Workshop. Diabetes 34(Suppl 2): 123126, 1985. 18. Scott A, Moar V, Ounsted M: The relative contribution of different maternal factors in large for gestational age pregnan cies. Eur J Obstet Gynecol Reprod Biol 13:269-277, 1982. 19. Miller JM, Brown HL, Pastorek JG, Gabert HA: Fetal over growth: diabetic versus nondiabetic. J Ultrasound Med 7:577579, 1988. 20. Kissebah AH, Vydelingum N, Murray R, Evans DJ, Hartz AJ, KalkhoffRK, Adams PW: Relation of body distribution to metabolic complications of obesity. J Clin Endocrinol Metab 54:254-260, 1982. 21. Edwards LE, Dickers WF, Alton IR, Hakanson EY: Preg nancy in the massively obese: course, outcome and obesity prognosis of the infant. Am J Obstet Gynecol 131:479-484, 1978. 22. Jovanovic-Peterson L, Peterson CM, Reed GF, Metzger BE, Mills JL, Knopp RH, Aarons JH: Maternal post prandial glucose levels and infant birth weight: The Diabetes and Early Pregnancy Study. Am J Obstet Gynecol 164:103-111, 1991. 23. Boyd ME, Usher RH, McLean FH: Fetal macrosomia: pre diction, risks, preposed management. Obstet Gynecol 61:715722, 1983. 24. "Nutrition During Pregnancy, Part I: Weight Gain." Wash ington, DC: National Academy Press, 1990.
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Diets for Obese Gestational Diabetic Women 25. Abrams BF, Laros RK: Prepregnancy weight, weight gain and birth weight. Am J Obstet Gynecol 154:503-509, 1986. 26. Jovanovic-Peterson L, Durak E, Peterson CM, Crues J: The utility of magnetic resonance imaging to detect fetal fat in gestational diabetic women. Presented at the Satellite Sym posium of the International Diabetes Federation, Rhode Is land, 1991. 27. Roberts SB, Savage J, Coward WA, Chew B, Lucas A: energy expenditure and intake in infants born to lean and overweight mothers. N Engl J Med 318:461-466, 1988. 28. Spellacy WN, Miller S, Winegar A, Peterson PQ: Macrosomia—maternal characteristics and infant complications. Obstet Gynecol 66:158-161, 1985. 29. Luke B, Dickenson C, Pétrie RH: Intrauterine growth: cor relations of maternal nutritional status and rate of gestational weight gain. Eur J Obstet Gynecol Reprod Biol 12:113-121, 1981. 30. Papoz L, Eschwege E, Pequignot G, Barrat J: Dietary behavior during pregnancy: The St. Antoine Maternity Hospital Study in Paris. In Dobbing J (ed): "Maternal Nutrition in Pregnancy. Eating for Two?" New York: Academic, 1981. 31. Churchill JA, Berendes HW: Intelligence of children whose mothers have acetonuria in pregnancy. In: "Perinatal Factors Affecting Development." Washington, DC: Pan Am Health Org, 1969 (Sci Pubi. no. 185). 32. Naeye RL, Chez RA: Effects of maternal acetonuria and low pregnancy weight gain on children's psychomotor develop ment. Am J Obstet Gynecol 1139:189-193, 1981. 33. Stebhens JA, Baker GI, Kitchell M: Outcome at ages 1, 3, and 5 years of children born to diabetic mothers. Am J Obstet Gynecol 127:108-112, 1981. 34. Naeye RL: The outcome of diabetic pregnancies. A prospec tive study. In: "Pregnancy Metabolism, Diabetes and the
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36. 37.
38.
39.
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Fetus." Ciba Foundation Symposium 63, Amsterdam, 1979, Exerpta Medica. Coetzee EJ, Jackson WPU, Berman PA: Ketonuria in preg nancy with special reference to kilocalorie-restricted food intake in obese diabetics. Diabetes 29:177-181, 1980. Chez RA, Curcio III FD: Ketonuria in normal pregnancy. Obstet Gynecol 69:272-274, 1987. Jovanovic L, Peterson CM: Optimal insulin delivery for the pregnant diabetic patient. Diabetes Care 5(Suppl l):24-37, 1982. American Diabetes Association: Nutritional recommenda tions and principles for individuals with diabetes mellitus. Diabetes Care 10:126-132, 1986. Peterson CM, Jovanovic-Peterson L: Percent carbohydrate and glycémie response to breakfast, lunch, and dinner in women with gestational diabetes. Diabetes 40(Suppl 2): 172174, 1991. Jenkins DJ A, Jenkins DM, Wolever TMS, Taylor RA, Barker H, Fieden H, Baldwin JM, Bowling AC, Newman HC, Jen kins AL, Gaff DV: Glycémie index of foods: a physiological basis for carbohydrate exchange. Am J Clin Nutr 34:362366, 1981. Tracy TA, Miller GL: Obstetric problems of the massively obese woman. Obstet Gynecol 33:204-209, 1969.
Lois Jovanovic-Peterson, MD Charles M. Peterson, MD Sansum Medical Research Foundation 2219 Bath St. Santa Barbara, CA 93105 Received June 1991.
VOL. 11, NO. 3
Journal of the American College of Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uacn20
Nutritional management of the obese gestational diabetic pregnant woman. a
a
L Jovanovic-Peterson & C M Peterson a
Sansum Medical Research Foundation, Santa Barbara, CA 93105. Published online: 02 Sep 2013.
To cite this article: L Jovanovic-Peterson & C M Peterson (1992) Nutritional management of the obese gestational diabetic pregnant woman., Journal of the American College of Nutrition, 11:3, 246-250, DOI: 10.1080/07315724.1992.10718223 To link to this article: http://dx.doi.org/10.1080/07315724.1992.10718223
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Downloaded by [Temple University Libraries] at 14:05 10 January 2015
Guest Editorial: Nutritional Management of the Obese Gestational Diabetic Pregnant Woman
distribution relate independently to the fasting plasma glucose and indices of carbohydrate tolerance even in normal pregnancy [14]. In addition, truncal obesity is a risk factor for a macrosomic infant [15]. Truncal obesity can be easily estimated by calculating the ratio of the waist measurement at the umbilicus and the hip measurement at the level of the superior iliac spine using a flexible tape with the subject vertical [16]. This measurement is predic tive of truncal obesity up to the 12th gestational week. A waist/hip ratio (measurement of the waist circumference divided by the measurement of the hip circumference) above 1.00 significantly increases the risk of glucose intol erance in pregnancy [14]. Glucose intolerance is assessed by the glucose tolerance test (GTT) [17]. The 50 g glucose challenge test [17], recommended for all pregnant women at 24-28 weeks of gestation, is not sufficient to evaluate the glycémie levels of an obese woman, because it does not measure the fasting glucose level. It has recently been suggested that fasting hyperglycemia may be the only abnormality of carbohy drate metabolism in the obese pregnant woman [18], and that it is associated with a 20% increase in risk of infantile macrosomia [19]. Thus, either a fasting glucose should be obtained on all glucose challenge tests for all overweight pregnant women or these women should be given the diagnostic test of a 100 g GTT at 24-28 weeks gestation regardless of the results of the 50 g glucose challenge test (Table 1). Proceeding immediately with the 100 g GTT might eliminate the need to retest the woman if the chal lenge is abnormal, a cost savings in a population with a high prevalence of disease [20]. Because both fasting and the postprandial glucose elevations increase the risk for macrosomia [21,22], the nutritional management strategy must take into account the degree of glucose intolerance based on the GTT. If only those women with morbid, gross, debilitating obesity (>150% ideal body weight) are studied, the preva lence of obesity during pregnancy is 6-10% [21]. These women tend to be older and of greater parity than non-
Obesity is the most common and serious nutritional disorder of adults in the Western world. When obese women become pregnant, particularly when they consume a caloric intake that results in excessive weight gain, they are at high risk of gestational diabetes mellitis (GDM) and hypertension [1]. Fetuses of such women are at risk of macrosomia, hypoglycemia, birth trauma, and possibly adult obesity [2]. Despite the assumption that dietary prevention of excessive weight gain by an already obese pregnant woman should decrease the risks to mother and infant, "caloric-restricted" diets during even obese preg nancy remain controversial [3-8]. Because of the wide variation in clinicians' practice of prescribing diets for the obese GDM woman, a symposium during the National Meeting of The American College of Nutrition, 1990, presented a panel to "debate" the safety and utility of caloric-restricted diets for these women dur ing pregnancy. Although it was anticipated that the views expressed would be polar, the speakers reached a consen sus. If safety and efficacy is defined as that diet which produces a healthy baby, then the ideal diet for obese GDM women was agreed upon by the panel to be approx imately 33% less than a diet for a normal weight woman (1500-1800 kcal/day or 24-25 kcal/kg present pregnant weight) [9-11]. This editorial 1) reviews the risks associated with preg nancy complicated by obesity, 2) presents one approach to the management of obese GDM, 3) reviews pertinent data from our own studies [9], and 4) sets the stage for the other papers presented in this consensus conference [10,11].
DEFINITIONS AND EPIDEMIOLOGY Recent studies have indicated that central obesity as opposed to total body fatness, puts a woman at a higher risk for GDM [12]. Truncal obesity directly correlates with an elevated fasting blood glucose [13]. Fatness and fat
Presented at the American College of Nutrition Annual Meeting, Albuquerque, NM, 1990. Address reprint requests to Lois Jovanovic-Peterson, MD, Sansum Medical Research Foundation, 2219 Bath St., Santa Barbara, CA 93105.
Journal of the American College of Nutrition, Vol. 11, No. 3, 246-250 (1992) Published by the American College of Nutrition
246
Diets for Obese Gestational Diabetic Women obese pregnant women. Less severe obesity during preg nancy may also increase risk to mother and infant, but good data on prevalence or risk are not yet available.
Downloaded by [Temple University Libraries] at 14:05 10 January 2015
MATERNAL RISKS SECONDARY TO OBESITY All previous studies have shown an increased risk of medical complications in obese (>150% ideal body weight) pregnant women [1,2,21-24] (Table 2). Obesity increases the risk for GDM tenfold over the risk for nonobese patients. GDM and obesity independently contribute to fetal growth. In some studies, maternal obesity has the predominant influence on fetal growth, rather than abnor mal glucose homeostasis [25]. Our own data using mag netic resonance imaging to evaluate the degree of adiposity of the mother and the fetus in the third trimester [26] also reveals that maternal adiposity correlates better than ma ternal glucose levels with infant size. There is evidence that fetal macrosomia associated with obesity is mediated in part through even moderately ele vated glucose levels (i.e., at marginally "normal glucose tolerance") [27]. Obese women have a higher fasting plasma glucose (90-100 mg/dl) than do normal weight women (60-70 mg/dl) [27]. Women with fasting plasma glucose levels >90 mg/dl have a 20% risk of delivering a macrosomic infant [19]. In addition, obese women may constantly be in the "postprandial" state, with resultant frequent eating. It is hypothesized that a normal woman eating three tim,es/day has a peak blood glucose of 120 mg/dl three times/day, with a lower mean glycémie level over 24 hours; she will have a smaller baby than a woman who eats six times/day with the same peak response to each meal. An additional problem in obese women is the occur rence of both chronic hypertension and the development of superimposed pre-eclampsia. Seven percent of obese women begin pregnancy with chronic hypertension, whereas leaner patients have a 1.7% prevalence rate of hypertension [28]. The management of a pregnancy com plicated by obesity must include intensive blood pressure surveillance using a large cuff.
Table 2. Pregnancy Risks Associated with Obesity [41] Gestational diabetes Hypertension (chronic and pre-eclampsia) Twins Dysfunctional labor pattern Anaesthesia/operative risks Postpartum hemorrhage Thrombophlebitis Wound infection/dehiscence
Table 2 lists other problems of delivery for the obese pregnant woman.
INFANT RISKS Infants born to obese mothers have risks, most of which are secondary to the neonate's large size (Table 3). Multiple factors contribute to fetal growth, including parity, mater nal age, fetal sex, uterine size, genetics, placental size and function, adverse disease states, and nutrition.
LIMITING WEIGHT GAIN IN THE OBESE PREGNANT WOMAN Two significant factors related to maternal nutrition and enhancement of fetal growth are prepregnant weight and pregnancy weight gain, which are mutually independ ent [25]. Since the obese pregnant woman begins preg nancy with one factor predisposing to high infant birthweight, management strategies should focus on limiting maternal weight gain during pregnancy. All the presenta tions at the symposium came to this same conclusion [911]. Despite a high risk of chronic hypertension in obese pregnant women, the feared complication of intrauterine growth retardation (IUGR) of infants born to normal weight hypersensitive women, does not occur in obese women [2]. IUGR is also a risk of normal weight women who gain weight poorly during pregnancy, but not of obese pregnant women who either have lost weight or gained 140 mg/dl, we further decrease kilocalories. If ketonuria occurs, we begin insulin therapy. In some women, morning ketonuria may be prevented by a 3 a.m. snack (a glass of milk) without subsequent hyperglycemia or the need for insulin. All of the speakers [9-11] at the symposium presented data consistent with the following conclusion: The "con sensus ideal diet" for the obese GDM woman is composed of a 33% reduction in caloric intake compared to the kilocalories allowed for a normal weight woman or 24-25 kcal/kg present pregnant weight per day (about 1500-1800 kcal/day). In summary, nutritional management for the obese pregnant woman includes a diet which minimizes further weight gain and prevents postprandial elevations of glu cose. Attention to both variables is important if neonatal macrosomia is to be avoided. We suggest that all obese women need a 100 g GTT at 24-28 weeks of gestation, because the prevalence of GDM is high and even fasting hyperglycemia increases the risk for neonatal macrosomia. If diabetes is present, all meals need to be monitored with self blood glucose monitoring. If fasting and postprandial hyperglycemia is documented despite caloric restriction, then insulin should be prescribed [17].
REFERENCES 1. King JC: Obesity in pregnancy. In Frankle RT, Dwyer J, Morangne L, Owen A (eds): "Dietary Treatment and Preven tion of Obesity." London: John Libbey, pp 185-192, 1985. 2. Kleigman RM, Gross T: Perinatal problems of the obese mother and her infant. Obstet Gynecol 66:299-305, 1985. 3. Algeri S, Shragg P, Hollingsworth DR: Moderate caloric restriction in obese women with gestational diabetes. Obstet Gynecol 65:487-491, 1985. 4. Herrera E, Knopp RH, Freinkel N: Carbohydrate metabolism in pregnancy VI. Plasma fuels, insulin, liver composition, gluconeogenesis and nitrogen metabolism during gestation in the fed and fasted pregnant rat. J Clin Invest 48:2260-2272, 1969. 5. Felig P, Lynch V: Starvation in human pregnancy: hypoglycemia, hypoinsulinemia, and hyperketonemia. Science 170:490-492, 1970. 6. Knopp RH, Herrera E, Freinkel N: Carbohydrate metabolism in pregnancy VIII. Metabolism of adipose tissue isolated from fed and fasted pregnant rats during late gestation. J Clin Invest 49:1438-1446, 1970. 7. Freinkel N: Of pregnancy and progeny. Diabetes 29:10231035, 1980.
Diabetic
Women
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Lois Jovanovic-Peterson, MD Charles M. Peterson, MD Sansum Medical Research Foundation 2219 Bath St. Santa Barbara, CA 93105 Received June 1991.
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