and Medical Management
SUMMARY AND IMPLICATIONS FOR CLINICAL PRACTICE
The.optimum.diet.for.GDM.continues.to.be.the.subject.of.ongoing.debate.(Uplinger,.
2009)..Current.trends.in.nutritional.therapy.favor.a.reduction.in.the.total.carbohy- drate.content.of.the.diet.to.30–55.percent.of.energy.to.minimize.postprandial.hyper-glycemia.(Reader,.2007)..Low.glycemic.index.(GI).diets.that.are.high.in.legumes.and.
whole,.unprocessed.grains.have.been.used.with.some.success.in.GDM.(Moses.et.al..
2009),.but.large.clinical.trials.establishing.their.efficacy.are.lacking..We.point.out.that.
the.sweetness.content.of.reduced-carbohydrate.and.low-GI.diets.is.low.due.to.restric- tions.on.the.use.of.carbohydrate.sweeteners.(sucrose,.fructose).as.well.as.the.con-sumption.of.fruit.and/or.fruit.juice.(for.those.women.who.do.not.tolerate.these.foods.
well)..Adherence.to.these.diets.could.be.difficult.to.achieve.for.women.with.GDM.
who.crave.sweets..In.the.United.States,.several.nonnutritive.sweeteners.are.approved.
for.use.by.pregnant.women.(acesulfame.potassium,.aspartame,.neotame,.and.sucra-lose,. although. aspartame. is. restricted. in. women. with. phenyl.ketonuria). (Uplinger.
2009)..Although.these.sweeteners.are.considered.safe.for.use.in.pregnancy,.they.are.
not.broadly.endorsed.by.the.medical.nutrition.community.for.pregnant.women..The.
introduction.of.novel.sweeteners.derived.from.natural.products.may.change.this.per-ception..One.example.is.rebaudioside.A,.an.extract.from.the.leaf.of.the.stevia.plant,.
that.is.Generally.Recognized.as.Safe.(GRAS).and.approved.by.the.U.S..Food.and.
Drug.Administration.(FDA;.2008).for.use.in.specific.products.
Glycemic Control Sweet Cravings Diet Adherence
Negative Diet Perceptions
FIGURE 9.6 (See color insert.).Model.depicting.the.influence.of.negative.diet.perceptions.
on.the.relationship.between.sweet.food.cravings.and.dietary.adherence.in.GDM.
There.are.other.food-based.approaches.that.could.aid.dietary.compliance.in.GDM..
Whole-grain,.breakfast.cereals,.cereal.bars,.and.snacks.containing.slowly.digestible.
starch.may.be.useful.for.limiting.postprandial.glucose.excursions.in.individuals.with.
type.2.diabetes.(Lehmann.and.Robin,.2007),.and.may.be.useful.in.GDM.as.well..
Another.avenue.of.approach.is.the.use.of.probiotics,.specific.strains.of.microorgan-isms.that.are.commonly.found.in.fermented.dairy.products.such.as.yogurt..Probiotics.
modify.the.composition.of.intestinal.microflora.to.regulate.inflammatory.pathways.
involved.in.insulin.resistance.and.glucose.homeostasis,.among.other.mechanisms.
(Shi.et.al..2006;.Shoelson.et.al..2007)..Recent.prospective.studies.in.pregnancy.have.
shown.that.probiotic.supplements.(consumed.as.capsules).have.positive.effects.on.
maternal. glucose. homeostasis. and. reduce. the. incidence. of. GDM. (Laitinen. et. al..
2009;. Luoto. et. al.. 2010).. Whether. probiotic-supplemented. foods. would. be. effica-cious.in.GDM.is.not.known.but.warrants.further.attention.
Better.medical.nutrition.therapies.are.critically.needed.for.GDM..Nutrition.edu-cators.should.be.aware.that.heightened.palatability.for.sweet.foods.may.present.a.
particular. challenge. for. some. women. with. GDM. and. should. be. considered. when.
designing.personalized.diet.plans.for.such.women.
REFERENCES
Abbasi,.A..A..1981..Diagnostic.and.therapeutic.significance.of.taste.impairment..Geriatrics.
36:.73–8.
American.College.of.Obstetrics.and.Gynecology..2001..Clinical.management.guidelines.for.
obstetrician-gynecologists..ACOG Practice Bulletin (30).
American.Diabetes.Association..2007..Nutrition.recommendations.and.interventions.for.diabetes:.
a.position.statement.of.the.American.Diabetes.Association..Diabetes Care 30:S48-S65.
American. Diabetes.Association.. 2009.. Meal. planning. exchange. lists..www.diabetes.org/.
nutrition-and-recipes/nutrition/exchangelist.jsp
American. Diabetes. Association.. 2010a.. Diagnosis. and. classification. of. diabetes. mellitus..
Diabetes Care.33.(suppl..1):.S62–69.
American.Diabetes.Association..2010b..Standards.of.medical.care.in.diabetes:.2010..Diabetes Care,.33.(suppl..1):.S11–61.
Armstrong,.C..L.,.L..P..Brown,.R..York,.D..Robbins,.and.A..Swank..1991..From.diagnosis.
to.home.management:.nutritional.considerations.for.women.with.gestational.diabetes..
Diabetes Educ 17.(6):.455–9.
Barnard,.N..D.,.L..Gloede,.J..Cohen,.D..J..Jenkins,.G..Turner-McGrievy,.A..A..Green,.et.al..
2009..A.low-fat.vegan.diet.elicits.greater.macronutrient.changes,.but.is.comparable.in.
adherence.and.acceptability,.compared.with.a.more.conventional.diabetes.diet.among.
individuals.with.type.2.diabetes..J Am Diet Assoc.109.(2):.263–72.
Belzer,.L..M..2008..Taste.and.endocrine.factors.in.women.with.gestational.diabetes.mellitus..
Doctoral.dissertation..Rutgers,.The.State.University.of.New.Jersey.
Belzer,.L..M.,.J..C..Smulian,.S-E..Lu,.and.B..J..Tepper..2009..Changes.in.sweet.taste.across.
pregnancy.in.mild.gestational.diabetes.mellitus:.relationship.to.endocrine.factors..Chem Senses.34.(7):.595–605.
Belzer,.L..M.,.J..C..Smulian,.S-E..Lu,.and.B..J..Tepper..2010..Food.cravings.and.intake.of.
sweet.foods.in.healthy.pregnancy.and.mild.gestational.diabetes.mellitus:.a.prospective.
study..Appetite.55:.609–615.
Benoit,.S..C.,.D..J..Clegg,.R..J..Seeley,.and.S..C..Woods..2004..Insulin.and.leptin.as.adiposity.
signals..Recent Prog Horm Res 59:.267–85.
Boden,.G..1996..Fuel.metabolism.in.pregnancy.and.in.gestational.diabetes.mellitus..Obstet Gynecol Clin North Am 23:.1–10.
Bowen,.D..J..1992..Taste.and.food.preference.changes.across.the.course.of.pregnancy..Appetite 19.(3):.233–42.
Brown,.J..E.,.and.R..B..Toma..1986..Taste.changes.during.pregnancy..Am J Clin Nutr 43:.414–18.
Butte,.N..F..2000..Carbohydrate.and.lipid.metabolism.in.pregnancy:.normal.compared.with.
gestational.diabetes.mellitus..Am J Clin Nutr 71 (5):.1256S-61S.
Catalano,.P..M.,.J..P..Kirwan,.S..Haugel-de.Mouzon,.and.J..King..2003..Gestational.diabetes.
and.insulin.resistance:.role.in.short-.and.long-term.implications.for.mother.and.fetus..
J Nutr 133.(5.suppl..2):.1674S-83S.
Chu,. S..Y.,.W.. M.. Callaghan,. S..Y.. Kim,. C.. H.. Schmid,. J.. Lau,. L.. J.,. England,. et. al.. 2007..
Maternal.obesity.and.risk.of.gestational.diabetes.mellitus..Diabetes Care.30.(8):.2070–6.
Dabelea,. D.,. J.. K.. Snell-Bergeon,. C.. L.. Hartsfield,. K.. J.. Bischoff,. R.. F.Hamman,. and.
R.. S.. McDuffie.. 2005.. Increasing. prevalence. of. gestational. diabetes. mellitus. (GDM).
over.time.and.by.birth.cohort:.Kaiser.Permanente.of.Colorado.GDM.Screening.Program..
Diabetes Care.28.(3):.579–84.
Dippel,.R..L.,.and.J..W..Elias..1980..Preferences.for.sweet.in.relationship.to.use.of.oral.contra-ceptives.and.pregnancy..Horm Behav 14:.1–6.
Domali,.E.,.and.I..E..Messinis..2002..Leptin.in.pregnancy..J Matern Fetal Neonatal Med 12.
(4):.222–30.
Duffy,.V..B.,.L..M..Bartoshuk,.R..Striegel-Moore,.and.J..Rodin..1998..Taste.changes.across.
pregnancy..Ann N Y Acad Sci 855:.805–9.
Dye,.C..J.,.and.D..A..Koziatek..1981..Age.and.diabetes.effects.on.threshold.and.hedonic.per-ception.of.sucrose.solutions..J Gerontol 36.(3):.310–15.
Fadl,.H..E.,.I..K..Ostlund,.A..F.Magnuson,.and.U..S..Hanson..2010..Maternal.and.neonatal.
outcomes.and.time.trends.of.gestational.diabetes.mellitus.in.Sweden.from.1991.to.2003..
Diabet Med 27.(4):.436–41.
Festa,.A.,.N..Shnawa,.W..Krugluger,.P..Hopmeier,.G..Schernthaner,.and.S..M..Haffner..1999..
Relative.hypoleptinaemia.in.women.with.mild.gestational.diabetes.mellitus..Diabet Med 16.(8):.656–62.
Gilhooly,.C..H.,.S..K..Das,.J..K..Golden,.M..A..McCrory,.G..E..Dallal,.E..Saltzman,.et.al..
2007..Food.cravings.and.energy.regulation:.the.characteristics.of.craved.foods.and.their.
relationship.with.eating.behaviors.and.weight.change.during.6.months.of.dietary.energy.
restriction..Int J Obes (Lond) 31.(12):.1849–58.
Gondivkar,.S..M.,.A..Indurkar,.S..Degwekar,.and.R..Bhowate..2009..Evaluation.of.gustatory.
function.in.patients.with.diabetes.mellitus.type.2..Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108.(6):.876–80.
Harvey,.J.,.R..R..Wing,.and.M..Mullen..1993..Effects.on.food.cravings.of.a.very.low.calorie.
diet.or.a.balanced,.low.calorie.diet..Appetite 21.(2):.105–15.
Henson,.M..C.,.and.V..D..Castracane..2006..Leptin.in.pregnancy:.an.update..Biol Reprod 74:.
218–29.
Herriot,.A..M.,.S..Whitcroft,.and.Y..Jeanes..2008..An.retrospective.audit.of.patients.with.poly-cystic.ovary.syndrome:.the.effects.of.a.reduced.glycaemic.load.diet..J Hum Nutr Diet 21.(4):.337–45.
Highman,.T..J.,.J..E..Friedman,.L..P..Huston,.and.W..W..Wong..1998..Longitudinal.changes.
in.maternal.serum.leptin.concentrations,.body.composition,.and.resting.metabolic.rate.in.
pregnancy..Am J Obstet Gynecol 178:.1010–15.
Hook,.E..B..1978..Dietary.cravings.and.aversions.during.pregnancy..Am J Clin Nutr 1:.1355–62.
Jones,.E..J.,.C..C..Roche,.and.S..J..Appel..2009..A.review.of.the.health.beliefs.and.lifestyle.
behaviors.of.women.with.previous.gestational.diabetes..J Obstet Gynecol Neonatal Nurs 38.(5):.516–26.
Kautzky-Willer,.A.,.G..Pacini,.A..Tura,.et.al..2001..Increased.plasma.leptin.in.gestational.dia-betes..Diabetologia 44:.164–72.
Kawai,.K.,.K..Sugimoto,.K..Nakashima,.H..Miura,.and.Y..Ninomiy..2000..Leptin.as.a.modula-tor.of.sweet.taste.sensitivities.in.mice..Proc Natl Acad Sci USA 97.(20):.11044–9.
Kim,.C.,.D..K..Berger,.and.S..Chamany..2007..Recurrence.of.gestational.diabetes.mellitus:.a. Kolble,.N.,.T..Hummel,.R..von.Mering,.A..Huch,.and.R..Huch..2001..Gustatory.and.olfactory.func-tion.in.the.first.trimester.of.pregnancy..Eur J Obstet Gynecol Reprod Biol 99.(2):.179–83.
Kuga,.M.,.M..Ikeda,.K..Suzuki,.and.S..Takeuchi..2002..Changes.in.gustatory.sense.during.
pregnancy..Acta Otolaryngol Suppl (546):.146–53.
Laitinen,.J..H.,.H..M..Tuorila,.and.M..I..J.Uusitupa..1991..Changes.in.hedonic.reponses.to.
sweet.and.fat.in.recently.diagnosed.non-insulin-dependent.diabetic.patients.during.diet.
therapy..Eur J Clin Nutr 45:.393–400.
Laitinen,.K.,.T..Poussa,.and.E..Isolauri..2009..Probiotics.and.dietary.counselling.contribute.to.
management.of.gestational.diabetes.mellitus..J Matern Fetal Neonatal Med 11.(4):.218–25.
Lappas,. M.,. K..Yee,. M.. Permezel,. and. G.. E.. Rice.. 2005.. Release. and. regulation. of. leptin,.
resistin.and.adiponectin.from.human.placenta,.fetal.membranes,.and.maternal.adipose. Lehmann,.U.,.and.F..Robin..2007..Slowly.digestible.starch—its.structure.and.health.implica-tions:.a.review..Trends in Food Science and Technology 18:.346–55.
Lin,.Y.,.and.Z..Sun..2010..Current.views.on.type.2.diabetes..J Endocrinol 204.(1):.1–11.
Luoto,.R.,.K..Laitinen,.M..Nermes,.and.E..Isolauri..2010..Impact.of.maternal.probiotic-supple-mented.dietary.counselling.on.pregnancy.outcome.and.prenatal.and.postnatal.growth:.a.
double-blind,.placebo-controlled.study..Br J Nutr 103.(12):.1792–9.
Maghbooli,. Z.,. A.. Hossein-Nezhad,. M.. Rahmani,. A.. R.. Shafaei,. and. B.. Larijani.. 2007..
Relationship. between. leptin. concentration. and. insulin. resistance.. Horm Metab Res 39.
(12):.903–7.
Malee,.M..P.,.A..Verma,.G..Messerlian,.R..Tucker,.and.B..R..Vohr..2002..Association.between.
maternal.and.child.leptin.levels.9.years.after.pregnancy.complicated.by.gestational.dia-betes..Horm Metab Res 34.(4):.212–16.
Martin,. C.. K.,. P.. M.. O’Neil,. and. L.. Pawlow.. 2006.. Changes. in. food. cravings. during. low-calorie.and.very-low-calorie.diets..Obesity (Silver Spring) 14.(1):.115–21.
Metzger,.B..E.,.T..A..Buchanan,.D..R..Coustan,.A..de.Leiva,.D..b..Dunger,.D..R..Hadden,.et.al..
2007..Summary.and.recommendations.of.the.Fifth.International.Workshop-Conference.
on.Gestational.Diabetes.Mellitus..Diabetes Care 30.(suppl..2):.S251–60.
Moses,. R.. G.,. M.. Barker,. M..Winter,. P.. Petocz,. and. J.. C.. Brand-Miller,. J.. C.. 2009.. Can. a.
low-glycemic.index.diet.reduce.the.need.for.insulin.in.gestational.diabetes.mellitus?.A.
randomized.trial..Diabetes Care 32.(6):.996–1000.