Maternal Nutrition and Fetal Growth in GDM

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It is well known that the state of maternal nutrition (both macro- and micronutrient) before and during pregnancy is a critical factor influencing fetal growth and pregnancy outcome. Guidelines for optimal weight gain and recommendations for daily intake of micronutrients during pregnancy have for many years been offered by bodies such as the FAO/WHO/UNU [9] and the Institute of Medicine of the National Academy of Science [10]. However, the benefit of specific supplementations during pregnancy is, in most cases, uncertain (iodine and iron excepted). In April 2004, an entire Nestlé Nutrition Workshop was devoted to the topic [11]. Studies addressing these issues in pregnancy complicated by diabetes are very sparse. Nevertheless, these same guidelines for maternal nutrient intake and weight gain are generally used in the presence of diabetes (type 1, type 2 or GDM).

Influences of Obesity

Insulin Resistance

Maternal weight prior to pregnancy, weight gain during pregnancy, maternal height, number of previous pregnancies, and gender of the fetus all influence infant size at birth. Women who are obese prior to pregnancy tend to gain less weight and give birth to heavy babies (large for gestational age) more frequently than those whose pre-gravid weight is normal [12]. Catalano et al. [13] found that insulin sensitivity prior to pregnancy is an important predictor of birth weight and may account for the association between maternal pre-gravid weight and birth weight. In women with GDM, there is little if any correlation between maternal weight gain and birth weight; however, studies that examine associations with the weight of babies born to mothers with GDM are all potentially confounded by treatment of hyperglycemia. As indicated above, obesity is associated with an increased risk of large for gestational age (macrosomic) babies even when glucose levels remain normal [12]. Nevertheless, a collaborative study in Chicago, Ill., and Seoul, Korea, found that GDM was associated with a similar increment in the number of large babies above that of the general population in the more obese subjects in Chicago and in the mostly non-obese Korean population [14].

Nutrient Delivery

Circulating concentrations of micro- and macronutrients (lipids, glucose and free amino acids) are altered during pregnancy and they are further modified by the presence of diabetes. More than 25 years ago, GDM was first characterized as a 'panfuel' metabolic disturbance with alterations in lipids (free

Meals at time (h)

Fig. 1. Diurnal patterns of plasma free fatty acids (FFA), triglycerides and individual amino acids (serine and isoleucine) in the third trimester of normal pregnancy (•) and 'mild' gestational diabetes (A; fasting plasma glucose <105mg/dl [5.8mmol/l]). Adapted from Metzger et al. [15].

Meals at time (h)

Fig. 1. Diurnal patterns of plasma free fatty acids (FFA), triglycerides and individual amino acids (serine and isoleucine) in the third trimester of normal pregnancy (•) and 'mild' gestational diabetes (A; fasting plasma glucose <105mg/dl [5.8mmol/l]). Adapted from Metzger et al. [15].

fatty acids (FFAs), triglycerides, lipoproteins), amino acids (especially branched chain amino acids) and other glucose-regulating hormones as well as glucose [15] (fig. 1). Obesity is also associated with changes in the circulating concentration of multiple nutrients (glucose, FFAs, triglycerides, cholesterol, branched chain amino acids), and it is likely that insulin resistance also plays a central role in these changes. For example, it is well known that normal pregnancy is associated with a decline in the fasting plasma glucose (FPG) concentration of approximately 0.5-0.6 mmol/l, and most of the change has occurred by the end of the first trimester. However, Mills et al. [16] found no decline in FPG in obese pregnant women (pre-pregnancy body mass index >30) with normal glucose tolerance. Yogev et al. [17] performed continuous glucose monitoring of subcutaneous interstitial fluid via a glucose sensor for 72 h in normal weight and obese non-diabetic pregnant women in the third trimester [17]. Compared to the normal weight subjects, the obese group had higher postprandial and mean values during the day, lower values during the night and similar fasting and pre-meal glucose concentrations.

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