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Nutritional management of the obese gestational diabetic pregnant woman. 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
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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 . In addition, truncal obesity is a risk factor for a macrosomic infant . 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 . 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 . Glucose intolerance is assessed by the glucose tolerance test (GTT) . The 50 g glucose challenge test , 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 , and that it is associated with a 20% increase in risk of infantile macrosomia . 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 . 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% . 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 . Fetuses of such women are at risk of macrosomia, hypoglycemia, birth trauma, and possibly adult obesity . 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 , 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 . Truncal obesity directly correlates with an elevated fasting blood glucose . 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
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.
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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 . Our own data using mag netic resonance imaging to evaluate the degree of adiposity of the mother and the fetus in the third trimester  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") . Obese women have a higher fasting plasma glucose (90-100 mg/dl) than do normal weight women (60-70 mg/dl) . Women with fasting plasma glucose levels >90 mg/dl have a 20% risk of delivering a macrosomic infant . 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 . 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  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 . 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 . 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 . 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 .
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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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