NUT 5031

Gestational Diabetes and Pregnancy Case Study

Maria is a 30-year old referred by an obstetrician to you after being diagnosed with
gestational diabetes at 24 weeks gestation. The appointment is made with you 1
week after the diagnosis.
Social and Medical History
Maria has been married for 5 years, is a mother of two, and works as a teacher at an
elementary school. The school is located within walking distance of her home.
Maria’s physical activity level is sedentary. She is 63 inches tall, and her current
weight is 158 lbs. Her prepregnancy weight was 138 lb. She did not develop GDM in
her two previous pregnancies, although she has a family history of diabetes. Her
mother has type 2 diabetes and developed GDM in her second and third
pregnancies. Maria has never met an RDN and is feeling anxious. She believes the
RDN will completely change what and how she eats, so she informs you that any
changes to her eating habits must fit into her lifestyle. She eats breakfast and
dinner at home and eats lunch at work. Occasionally, dinner is skipped due to her
fatigue from work. She indicates that her favorite foods are sweet breads, refried
beans, and red enchiladas with cheese. She rarely eats vegetables because she
has little time to prepare fresh vegetables.
Recent lab results
Blood pressure: 128/72 mm Hg
Hemoglobin: 13.2 g/dl
Hematocrit: 36.5%
Ultrasound: consistent with 24 weeks’ gestation
Oral glucose tolerance test:
Fasting blood glucose: 83 mg/dl
1-hour: 192 mg/dl
2-hour: 155 mg/dl
Hemoglobin A1c at 12 weeks gestation: 5.3%

Questions:
Assessment
1. What additional information is needed to complete a comprehensive
nutrition assessment?
Additional information that is needed is a food recall or food frequency
questionnaire to get an understanding of what exactly she eats throughout the
day. Food that she doesn't like, any foods she might be allergic to, as well as
exactly the amount of carbohydrates consumed. In regards to
anthropometrics, calculating her BMI and how much weight she has gained
throughout her pregnancy would be useful to assess her weight gain. Asking
Maria about her family history outside of her mother having GDM as well as
her own medical history and if she is taking any medications. It's also
beneficial to ask her what she is expecting to get out of working with a RDN,
and the goals she has for herself regarding her diagnosis.
Perform a 24-hour food recall for 3 days to get an understanding of
typical meals and portions. Have Maria do 2 non-consecutive days ( a
weekend and 2 school days) to get a better idea of her meals and meal
timing. We also would want to know any food allergies or intolerances and
nutrition related goals or things she wants to discuss. We would also want her
medical history and if she is taking any supplements. This would include
vitamins or herbal supplements, why she is taking them, the dosage, when
she takes them, and how she may tolerate them. Other information we may
want would be lifestyle assessment to understand stressors, food security,
cultural habits, or what cooking looks like in her house. Also to discuss any
types of physical activity she may take part in or would want to include in her
day. Discuss her previous pregnancy experience with weight gain or any
nausea, constipation, heart burn, diarrhea during past and her current
pregnancy. We would want to do a nutrition focused physical assessment,
including dentition or swallowing issues that could impact her food intake.

2. Based on the information provided, how would you approach working with
Maria to manage her GDM?
Maria states that she is anxious about meeting with a Dietitian, and has
never done so before. As a RDN, I would approach working with Maria in a
patient centered, relationship centered approach. I want Maria to be
comfortable opening up to me and I want the meeting to be about helping her
overcome her diagnosis. The focus of the consult would be around
motivational interviewing and for Maria to determine the problem and
ultimately set her own goals. Since Maria stated that she doesn't want to
make any drastic changes, it will be important to find change that she is
willing to do, and comfortable with. It is my job as a RDN to listen to her
concerns and answer any questions that she has regarding her nutrition.
I would let her choose the direction for the meeting and that everything
is her choice and the RDN is there to help her achieve her goals. Asking
open-ended questions, in hopes Maria would be able to lead the visit. Since
 she is anxious about the visit, making her feel comfortable and emphasize we
are here to help her.

3. Based on the information provided, what is your assessment of her weight

gain during pregnancy – is it adequate? Inadequate?
Based on her current and prepregnancy weight, her BMI pre pregnancy is
24.4 which is normal weight range. Based on the total recommended weight
gain for her weight and height, she should gain around 25-35lbs. Her current
weight is 158lbs and her prepregnancy weight was 138lbs, therefore she has
gained 20lbs since pregnancy. Based on the information provided, her weight
gain during pregnancy is adequate. As she reaches her third trimester, she
wants to watch her weight gain to ensure she doesn't gain more than 35 lbs.

4. Calculate her calorie and macronutrient needs. What is your assessment

– is she meeting her estimated needs?
158lbs=71.66kg
138lbs=62.59kg
63in = 1.6m
EER(pre pregnancy/first trimester)
354- ((6.91 x 30) + (1.2x9.36x63) +(726 x 1.6)) = 1722kcals 1st trimester
1600 + 340 = 1941kcals EER 2nd trimester 2,062 kcals
1600+452 = 2052 kcals EER 3rd trimester 2,174 kcals
Within the 2nd trimester, she should get 2062kcals a day. 35-50% should be
coming from CHO which is around 721 kcals-1031 kcals. 15-30% should be
from protein sources which is around 309 kcals- 619 kcals. Lastly, 20-35%
should be from fat sources which is 412 kcals-721 kcals. It seems like Maria
is gaining the right amount of weight, but not meeting her macronutrient
needs. Her favorite food consists of processed foods that do not contain
enough nutritious ingredients. More information is needed from Maria to
assess if her needs are being met on a more accurate basis.
Without seeing her food log, we would not know her protein, carbohydrate,
fat, or calorie consumption.
Nutrition Diagnosis
1. Please write one or more PES statements based on your assessment.
 ● Excessive carbohydrate intake related to family history of GDM, as evidenced
by abnormal lab value of 155 mg/dl of 2 hour fasting blood glucose.
● Excessive carbohydrate intake related to sweetened food preference as
evidenced by diet history
● Inconsistent carbohydrate intake related to GDM as evidenced by high blood
glucose levels
● Food and nutrition knowledge deficit related to lack of prior nutrition education
as evidenced by clients report of first time meeting with RDN, nutrition
diagnosis of GDM, physical activity, and limited vegetable intake.

Nutrition Prescription and Intervention

2. Prepare a food plan that addresses macronutrient needs for Maria based
on the GDM guidelines for carbohydrates, protein, and fat. Address how
many servings of carbohydrates she should have and the distribution
throughout the day.

The ACOG recommends 40-50 % of calories come from carbohydrates. This breaks
down to:
Breakfast: 30-45g
Lunch: 45-60g
Dinner: 45-60g
Snacks: 15g

Carbohydrates could also range from 35-50% of total calories, which would be 721
kcals-1031 kcals or 180-258g/day

As far as protein, we are aiming for 15-30% of total calories, which would be 309
kcals- 619 kcals or about 77-155g/ day.

As far as fat, we are aiming for 20-35% of total calories, which would be 412 kcals-
721 kcals or about 47-80g/day.

Using Maria’s weight, height, and macronutrient calculations, she could divide up
her carbohydrates by:
Breakfast: 30-35g
Lunch: 60g
Dinner: 60g
3 Snacks: 25-30g
 3. Based on the information provided, prepare a possible food plan for Maria
to review with you.

A food plan for Maria could look like:

Breakfast: 2 slices of whole wheat toast (corn tortillas instead of toast could be used)
with 1 tsp of butter and 2 eggs or 1oz of cheese
Lunch: ½ cup of black beans, ½ cup of corn, a baked/ grilled 4oz chicken breast,
grilled veggies, 2 corn tortillas and small cup of fresh fruit, water or sugar free
beverage
Dinner: 2 corn tortillas (6”) with 4oz of grilled beef with peppers and onions, small
salad with oil (1 tsp) and red wine vinegar dressing, sugar free lemonade, ½ cup of
corn, some cabbage, salsa, jalapenos, ½ cup refried beans
Snack: 1) greek yogurt with mixed nuts and 3 graham crackers, 2) A serving of
crackers with cheese and 8oz of milk, or 3) fruit smoothie with 2 tbsp peanut butter,
½ a frozen banana, 8oz nonfat milk

4. Prepare a nutrition education plan that you could propose to Maria.

For Maria, I would propose for her to start eating dinner on a regular basis. I would
encourage her to meal prep some items she could easily heat up when she gets
home from work. I would also suggest limiting the sweet breads she has and to eat
them in moderation. She stated one of her favorite foods or foods she eats regularly
are refried beans, so I would suggest swapping those out for black beans or another
type of bean she likes. Maria also mentioned she does not eat a lot of vegetables
due to the time it takes to prepare them. I would suggest trying frozen vegetables
that are easier to prepare, or preparing a large batch of vegetables to keep in her
fridge to grab at her convenience. Due to the concern with GDM, I would propose for
her to increase the amount of fruits and vegetables she eats and to have moderate
amounts of lean proteins, like chicken, turkey, and fish. She should consume 8-12oz
of fish low in methyl mercury per week and to consume moderate amounts of whole
grains.
Our number 1 goal would be blood glucose control and how her foods can help her
manage that.
Monitoring and Evaluation
1. What would you need to follow-up on regarding Maria’s GDM at future
appointments?
The dietitian would need to follow up on Maria’s blood glucose levels, as well as her
food plan. Maria is consuming an excess of carbohydrates and will often skip dinner.
The dietitian will need to follow up with Maria on starting to eat dinner more often
and finding a balance between foods.