A group of Israeli dietitians from the Israeli Dietetic Association (IDA), experts in diabetes, joined a multidisciplinary medical team in updating the national protocol for follow-up after delivery in Gestational Diabetes Mellitus (GDM) cases, with the purpose of delaying/inhibiting risk of future diabetes.
The Diabetes Prevention Program (DPP) showed - over 10 years - that women with a history of GDM assigned to placebo had a 48% higher risk of developing diabetes, as compared with women without a history of GDM, while Intensive Life Style (ILS) reduced diabetes risk in post-GDM by 35%, and by 30% among women without a history of GDM. According to these results, and based on local Israeli experience, the diabetes-expert dietitians designed a follow-up nutritional preventive program and specified their professional role, which is now accepted and included in the revised national post-GDM prevention program.
Dietitian’s role in tracking women previously diagnosed with GDM is to provide guidelines for maintaining proper body weight (BMI ≤25 kg/m2) or advising weight loss (of at least 5-7%) in women with higher BMI (>25 kg/m2) with intensive nutritional surveillance on individual/personalized and/or group basis - emphasizing healthy carbohydrates and related risks, as well as physical activity (PA).
Adhering to the high consumption of fruits and vegetables, high fiber whole grains, legumes and nuts; high protein in the form of fish, and low-fat dairy products; high MUFA oils (i.e. canola and olive oil) and foods rich with essential fatty acids (PUFA), especially omega-3 long-chain (n-3LCPUFA); reducing consumption of red meat (especially well-done and processed), sugar sweetened drinks and fried and 'junk' foods.
DASH and Mediterranean diet
Dietary Approaches to Stop Hypertension (DASH) and Mediterranean Diet are appropriate and relatively easy to implement along with maintaining physical activity. These constitute an effective prevention program against diabetes development.
Exercise – the rational physical activity (PA)
Beyond contributing to the prevention of type 2 diabetes, PA during pregnancy has physical and psychological advantages, especially in women with GDM. Following delivery with GDM, combining PA with adequate nutrition, may reduce incidence for future diabetes (up-to 80%) and further risk factors i.e. for cardiovascular diseases.
The 'pyramid' of PA includes increasing the NEAT (Non-exercise activity and related thermogenesis) or "spontaneous" activity/exercise throughout the daily living (i.e. use stairs instead of the elevator, walking one bus-stop, gardening etc.), reducing sitting time, aerobic-training of at least 150 minutes a week of moderate-intensity, and resistance (strength) training 2-3 times/week. The right prescription for women during and after pregnancy should consider relative and absolute contraindications.
The summary of essential recommendations: 1. Encourage breast feeding beyond 3 months; 2. Avoid weight gain after birth, especially central obesity, which raises the risk of diabetes later in life; and overweight women are advised to lose weight. 3. Promote a healthy lifestyle that includes proper exercise and nutrition (prescribed by Dietitians). 4. Carbohydrate tolerance evaluation to be applied at 6-12 weeks after birth – first priority - oral glucose tolerance test (OGTT, with 75 gm glucose), or second priority - checking fasting blood sugar combined with HbA1C test.
The long-term disease prevention and glucose tolerance follow-up program further includes regular biochemical tests and matching of dietary and PA recommendations, with a strong emphasis on the importance of healthy body weight and optimal glycemic management before getting into future pregnancies, and raising awareness to the fact that another pregnancy will raise the risk of developing diabetes in the future.
The above protocol is now being presented and is in the process of adoption by the multidisciplinary team of national diabetes prevention and management program, including emphasis on dietitians' trans-professional interaction and cooperation.
Niva Shapira, Ph.D.,R.D., Agr. Karen Hershkop, Ph.D.,R.D., Gila Fayman, BSc. R.D., Michal Gillon, Ph.D., R.D., Shelly Meshel, MSc. R.D, Amit Sapir, BSc. R.D, and Naama Constantini, Prof. , MD, DFM, FACSM, Dip. Sport Med. (CASM)