Review Article

Management of Gestational Diabetes Mellitus with Medical

Nutrition Therapy: A Comprehensive Review
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Sheryl Salis1, Natasha Vora1, Shefa Syed1, Uma Ram2, Viswanathan Mohan3
1
Nurture Health Solutions, Mumbai, Maharashtra, India, 2Seethapathy Clinic and Hospital, Chennai, Tamil Nadu, India, 3Madras Diabetes Research Foundation,
Chennai, Tamil Nadu, India
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Abstract
Gestational diabetes mellitus (GDM) also referred to as hyperglycemia during pregnancy is posing to be a big health concern for
women and is emerging as a major public health problem in India. Early diagnosis and tight glycemic control during pregnancy play a
pivotal role in improving pregnancy outcomes in women with GDM. Once diagnosis is made, lifestyle behavioral changes with medical
nutrition therapy (MNT) and physical activity form the first choice of therapy for the management of GDM. Failure to meet glycemic
goals with these requires the addition of medication/insulin. Regular blood glucose monitoring and record keeping must be encouraged
to improve adherence and review treatment efficacy. MNT for GDM is defined as a “carbohydrate-controlled” meal plan that provides
adequate nutrition along with appropriate weight gain and fetal well-being to meet increased requirements of energy, protein, and
micronutrients, achieve normoglycemia, and prevent nutritional ketosis. Choosing nutrient-dense carbohydrate sources which are low
to moderate in glycemic index and glycemic load with focus on the correct amount and distribution of carbohydrates at meals helps
control postprandial glucose excursions which is the biggest challenge in GDM. Blood glucose levels can be difficult to control in the
morning due to increased insulin resistance secondary to dawn phenomenon seen in women with GDM. Splitting meals at breakfast
has shown to improve post-breakfast blood glucose levels. This article is a comprehensive review of guidelines and scientific literature
for the dietary management of GDM aimed at achieving normoglycemia, ensuring fetal and maternal wellbeing, and preventing
adverse outcomes in pregnancy. The literature has been retrieved from various databases such as “Google Scholar,” “PubMed,” and
“Cochrane Database of Systematic Reviews” using relevant keywords related to the topics discussed in this manuscript.

Keywords: Fetal growth and development, gestational diabetes, glucose monitoring, medical nutrition therapy, postpartum, pregnancy
outcomes

Introduction problem. The prevalence of GDM in different parts of

India varies from 3.8% to 17.9% which is much higher
Gestational diabetes mellitus (GDM) also referred
than the west.[3]
to as hyperglycemia in pregnancy (HIP) is defined as
“glucose intolerance with onset or first recognition during The Women in India with GDM Strategy (WINGS)
pregnancy.”[1] project of the IDF study carried out in the city of Chennai
and rural antenatal clinics in Tamil Nadu in southern
The International Diabetes Federation (IDF) Atlas, ninth
India between January 2013 and December 2014 showed
edition, 2019, revealed an alarming increase in the global
that there were no urban–rural differences, suggesting that
prevalence of HIP with women having some form of it, of
GDM prevalence rate in the rural areas in South India is
which GDM amounted to 83.6%.[2]
also rising. Thus, it is recommended that all women be
There is an exceptionally high estimated prevalence of
GDM in India, and it is emerging as a major public health
Address for correspondence: Ms. Sheryl Salis,
Received: 09-April-2021, Revised: 19-April-2021, Accepted: 03-May-2021, 504, Navsmruti, Kalina, Mumbai 400098, Maharashtra, India.
Published: 20-July-2021 E-mail: sheryl@nurturehealthsolutions.com

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DOI: How to cite this article: Salis S, Vora N, Syed S, Ram U, Mohan
10.4103/jod.jod_44_21 V. Management of gestational diabetes mellitus with medical nutrition
therapy: A comprehensive review. J Diabetol 2021;12:S52-8.

      
S52 52  
© 2021 Journal of Diabetology | Published by Wolters Kluwer ‑ Medknow
 Salis, et al.: Management of GDM with MNT

screened for GDM even if they do not show symptoms. Medical Nutrition Therapy (MNT) in GDM
Emphasis must be on increasing awareness and taking
According to American Diabetes Association (ADA)
steps to prevent GDM.[4,5]
2021 guidelines, lifestyle behavioral change is an essential
component in the management of GDM.[7]
Glycemic Goals
All national and international guidelines suggest MNT,
Management of blood glucose levels plays a pivotal role together with weight management and physical activity
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in reducing the risk of complications that may occur (PA), as the initial mainstay for the management of
during pregnancy. The aim should be to target the infant’s GDM.[10,11]
birth weight appropriate for gestational age to prevent
the offspring developing non-communicable diseases in An overview of Cochrane systematic reviews elucidated
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the future. Early diagnosis and stringent maternal blood that lifestyle changes (MNT, PA) and SMBG were the
glucose control during pregnancy similar to glycemic level only interventions that showed positive health outcomes
in a normal pregnancy are therefore necessary to reduce for women and their offspring.[12]
risk of adverse pregnancy outcomes. Glycemic goals are Counseling by a qualified dietitian familiar with the
HbA1c ≤6% achieved without significant hypoglycemia, management of GDM must be done to initiate MNT
fasting plasma glucose ≤90 mg/dL (5.0 mmol/dL), 1-h once diagnosis of GDM is confirmed. PA of 30 min a day
postprandial glucose ≤140 mg/dL (7.8 mmol/dL), and is recommended.[7,10,11] Evidence has shown that lifestyle
2-h postprandial plasma glucose ≤120 mg/dL (6.7 mmol/ modification alone is sufficient to control blood glucose
dL). Women with GDM must monitor their blood glucose in 70–85% of the women who are diagnosed with GDM.[7]
levels at least four times each day: fasting and either 1 or Failure to meet glycemic goals with appropriate MNT and
2 h after each meal.[6-8] PA requires the addition of medication/insulin.[6,13]
Continuous glucose monitoring (CGM) when used in The WINGS Model of Care (MOC) has shown that
addition to self-monitoring of blood glucose (SMBG) can following a structured program with focussed counseling
help achieve HbA1c targets in pregnancy associated with and regular follow-up helps achieve good pregnancy
diabetes.[7] Recent data suggest that even more stringent outcomes in women with GDM.[14] The management
targets may be necessary to improve outcomes in women protocol includes MNT to be followed for 2 weeks after
with GDM. The goal in pregnancy is to safely increase time diagnosis with GDM, following which screening for
in range as quickly as possible, while reducing glycemic fasting blood glucose (FBG) and postprandial blood
variability and time above range [Figure 1]. However, as glucose (PPBG) testing is done. If FBG is <5.5 mmol/L
shown in Table 1, evidence is lacking on CGM targets and (<90 mg/dL) or 1-h PPBG <7.7 mmol/L (<140 mg/dL) or
percentages of time spent in range for women with GDM.[9] 2-h PPBG <6.6 mmol/L (<120 mg/dL) in the follow-up
visit, then MNT can be continued. If blood glucose levels
are not in the desired range after 2 weeks, then insulin is
indicated.[15]
MNT for GDM is defined as a “carbohydrate-controlled”
meal plan which provides adequate nutrition with
appropriate weight gain and fetal well-being, keeping
cultural preferences in mind to achieve normoglycemia
and prevent nutritional ketosis.[16-19]
Monitoring weight changes is important to ensure
adequacy of MNT and to gain weight within the
recommended limits as shown in Table 2.[11]
For twin pregnancy, a gestational weight gain of 16.8–
24.5 kg for women of normal weight, 14.1–22.7 kg for
overweight women, and 11.3–19.1 kg for obese women is
recommended by the Institute of Medicine (IOM).[20]
Interventions need to begin in the first trimester for
women at high risk for excessive weight gain.[17]

Energy Recommendations
MNT should allow sufficient calories for optimum growth
Figure 1: CGM-based targets for gestational diabetes populations[9] and development of the fetus, while avoiding postprandial

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 Salis, et al.: Management of GDM with MNT

Table 1: Targets for assessment of glycemic control during GDM[9]

Diabetes group Time in range (TIR) Time below range (TBR) Time above range (TAR)
% of readings, time Target range % of readings, time Below target level % of readings, time Above target
per day per day per day level
GDM Lack of evidence on 63–140 mg% Lack of evidence on <63 mg% Lack of evidence on >140 mg%
CGM targets for women (3.5– CGM targets for women (<3.5 mmol/L) CGM targets for women (>7.8 mmol/L)
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with GDM 7.8 mmol/L) with GDM with GDM

<54 mg%
(<3.0 mmol/L)
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macronutrient as they have the greatest impact on post-

Table 2: Recommended weight gain in pregnancy[11] meal blood glucose levels. Post-meal blood glucose
Prepregnancy BMI Total weight gain (range in kg) concentrations are directly dependent on the amount,
Underweight (<18.5 kg/m2) 12.7–18.1 type, digestion, and absorption of the carbohydrate
Normal weight (18.5–24.9 kg/m2) 11.3–15.9 content of the meal or snack.[7,17]
Overweight (25.0–29.9 kg/m2) 6.8–11.3
Obese(≥30 kg/m2) 5–9 The quantity and distribution of carbohydrates will vary
depending on the caloric requirement, glycemic targets,
and pre-meal blood glucose levels. The ICMR NIN 2020
hyperglycemia and excessive weight gain in the mother.
guidelines suggest that the estimated average requirements
The energy requirement depends on factors such as
(EARs) for carbohydrate for pregnant women should be
preconception weight, stage of pregnancy, PA levels, and
135 g/day plus the additional requirement of 35 g/day
blood glucose levels.[21]
for the fetus during the last trimester. The recommended
As per the ICMR-National Institute of Nutrition (ICMR- dietary allowance (RDA) for carbohydrate for pregnant
NIN) 2020 guidelines, there should be no increase in calorie women is set at a minimum of 175 g/day for appropriate
intake in the first trimester and an average recommendation fetal growth and cerebral development and function.[7,11,22]
of an additional 350 kcal/day through the second and
Most guidelines recommend carbohydrate intake of
third trimesters.[22] Pre-pregnancy BMI adjustment calorie
33–45% of the total energy. This should be distributed
requirements during pregnancy are detailed in Table 3.
over three main meals and 2–4 snacks/day. This will
Restricting calories has been a strategy for controlling help suppress hunger pangs, control postprandial
weight gain in obese women, or women who have already glucose excursions, and improve pregnancy outcomes in
achieved the recommended weight gain to control glucose GDM.[11,21,27-32]
levels and avoid macrosomia in babies of women with
GDM.[17] A modest calorie restriction of 30–33% or Nutrient-dense carbohydrate sources which are low to
between 1600 and 1800 kcal/day may be advisable to help moderate in GI and glycemic load (GL) such as non-
control weight gain and glucose levels in obese women starchy vegetables, whole fruits, dairy products, whole
without leading to ketosis.[11,17] pulses and sprouts, whole grain cereals such as barley,
rolled/steel cut oats, millets should be preferred over high
Calorie restriction of <1500 calories/day or 50% restriction is GI and GL foods such as polished rice, bread, refined
not recommended as it may increase the chances of ketosis.[17] flour and its products, cornflakes, potato, sugar, fruit
Ketosis has been associated with lower mental or motor juices, etc.[21,27-31,33,34]
function in the offspring and hence should be avoided.[23]
For twin pregnancy, an increased energy intake with an Dietary fiber
average of 700 kcal/day in the second and third trimesters Several studies have shown that including fiber in the diet
in comparison to the first trimester is necessary to support aids in improving satiety, stabilizing blood glucose levels,
rise in energy expenditure and gestational weight gain of and preventing constipation which is commonly observed
twin pregnancy. Luke et al.[24-26] suggested 20% of energy in pregnancy. Most guidelines recommend fiber intake of
intake derived from protein, 40% from low glycemic index 25–40 g/day.[21,22,27,28,30]
(GI) carbohydrates, and 40% from fat. Adequate protein
The WINGS-MOC project, which was one of the first
intake is emphasized as essential to normal fetal growth in
studies to show the beneficial effect of a low-cost, well-
twin gestations.
structured dietary intervention on neonatal outcomes,
showed that women with a higher healthy “dietary score”
Carbohydrate Recommendations derived from higher intake of whole grains, dairy, and
Since the biggest challenge in GDM is management dietary fiber had beneficial effects on neonatal outcomes
of high PPBG levels, carbohydrates become a vital in women with GDM. This type of dietary intervention

      
S54 54  Journal of Diabetology ¦ Volume 12 ¦ Supplement 5 ¦ July 2021
 Salis, et al.: Management of GDM with MNT

Table 3: Prepregnancy BMI adjustment calorie requirements during pregnancy[21]

Prepregnancy BMI 1st trimester (kcal/kg) 2nd trimester (kcal/kg) 3rd trimester (kcal/kg)
Underweight (<18.5 kg/m2) 30 36–40 36–40
Normal weight (18.5–24.9 kg/m2) 30 36 36–38
Overweight (25–29.9 kg/m2) 24
Morbidly obese (>30 kg/m2) 12–14
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therefore has a huge potential in public health applications Protein Recommendations

in low-resource settings.[13]
During pregnancy, protein requirement increases due to
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its role in the synthesis of placental, maternal, and fetal

Splitting Meals at breakfast tissues.[11]
Blood glucose levels can be difficult to control in the Most guidelines suggest that protein intake should be
morning due to increased insulin resistance secondary 20% of the total calories. Protein intake with every meal
to dawn phenomenon seen in women with GDM. As the is recommended as it flattens the glycemic response of
pregnancy progresses, insulin resistance increases. Refined food helping control postprandial glucose spikes.[21,27-31] As
cereals and breads may lead to rise in blood glucose per the ICMR-NIN 2020 guidelines, the suggested EAR
levels and hence may not be a good option for breakfast. for protein for pregnant women is an additional protein
A decreased carbohydrate load, high protein breakfast is of 7.6 g/day in the second trimester and 17.6 g/day in the
recommended to prevent undue spikes in post-breakfast third trimester. The RDA for protein for pregnant women
blood glucose levels. An egg/paneer whole wheat wrap or is an additional 9.5 g protein/day in the second trimester
a pesarrattu/dal dosa (adai)/chilla are an ideal choice at and 22 g protein/day in the third trimester.[22]
breakfast.
On an average, 1.1 g protein/kg ideal body weight is
Studies have shown that distribution of carbohydrates needed which is 60–70 g of protein/day. Protein sources
especially at breakfast helps to improve post-meal such as curd/yogurt, paneer, egg, pulses, sprouts, soybean,
excursions.[21] The suggested recommendation is 10–20% nuts, lean-meat (fish and chicken breast), etc. are
carbohydrates of total calories at breakfast divided into recommended. Whole pulses provide both protein and
two meals and taken 2 h apart, 30% carbohydrates of total fiber, thus blunting the post-meal blood glucose spikes.
calories at lunch, 30% carbohydrates of total calories at Change in the pulse: cereal ratio from 1:7 in the standard
dinner with two small meals comprising 10% carbohydrates diet to about 1:5 and 1:3 in the 2nd and 3rd trimesters,
of total calories at each meal. Eating in portioned amounts respectively, helps improve the protein quality.[22,34,36] The
at timely intervals makes the carbohydrates easier for the recipes of traditional Indian foods can be modified to
body to process, thus requiring lesser insulin. A bedtime increase the fiber and protein content of the meal and
high-protein snack may be recommended to prevent lower the GI, e.g., adding a pulse flour to the chapatti
accelerated ketosis overnight.[1,16,18,21] flour can help improve the protein and fiber content while
reducing the GI of the chapati.
Meal Planning for Women with GDM on Insulin Studies have shown that a meal with low GI not only
Therapy lowers the postprandial glycemic response after the
If post-meal blood glucose levels continue to rise, then first meal but also lowers the glycemic response after a
bolus insulin (rapid-acting or regular insulin) should be standardized second meal. Hence, adding a low GI, low
started before that meal. If both fasting and postprandial carbohydrate protein source like egg, nuts, curd, yogurt,
glucose levels are elevated, multiple daily injection insulin paneer in the morning at breakfast may help in reducing
therapy which is bolus insulin at mealtimes and basal post-meal glucose spikes and improve satiety.[37]
insulin once or twice a day needs to be started.[31]
Studies have shown that if protein and fiber are consumed
Indian data on insulin therapy in women with first followed by carbohydrates or starch, the post-meal blood
pregestational type 2 diabetes mellitus revealed that glucose spikes are lower. For example, if you have chicken, fish,
insulin requirement was highest at dinner time which was paneer, or dal with vegetables first followed by rice or chapatti,
further co-related significantly with higher calorie intake the post-meal blood glucose level spike is blunted.[38,39]
at dinner versus breakfast and lunch.[35]
Women with GDM should be trained in carbohydrate Fat Recommendations
counting, hypoglycemia management, and advised Most guidelines suggest that the fat intake should be
to keep a record of food intake, activity, and insulin 35–40% of the total calories.[21,27-31] As per the ICMR-NIN
dosage.[17,18] 2020 guidelines, the minimum level of total fat should

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 Salis, et al.: Management of GDM with MNT

be 20% of energy, of which 30 g can be visible fat. It is women and could reduce the risk of GDM. A meta-analysis
recommended to increase proportion of polyunsaturated showed that probiotic supplementation reduced fasting
fats including n-3 and monounsaturated fats (MUFA), serum insulin levels and insulin resistance (HOMA-IR)
limit proportion of saturated fats (SFA), and avoid trans significantly in women with GDM when compared with
fats. It is recommended to choose lean meat and low women with normal pregnancy. Effectiveness of probiotic
fat dairy products to limit SFA consumption. Bakery food supplements is dependent on various factors such as
products, margarine, vanaspati/dalda, ready-to-eat foods, anaerobic storage conditions, temperature, initial dose of
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deep fried foods, high fat sweets, and takeaway foods the strain, and its quality.[11,45]
should be avoided as they are sources of trans fat.[22]
Whether modification of gut microbiota is an effective
Co-relation between low levels of n-3 and n-6 during tool in improving glycemic outcomes is inconclusive.[11]
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pregnancy and preterm birth or fetal growth retardation

have been observed. The recommendations by IOM are
5–10 E% n-6 and 0.6–1.2 E% n-3 with a minimum of 13 g/
Micronutrients
day of n-6 fatty acids. Emphasis should be on ensuring Kozlowska et al.[46] found no statistically significant
sufficient intake of n-3 fatty acids with a minimum of differences for most of the vitamin and mineral intakes
1.4 g/day and up to 2.7 g/day. About 200 mg/day of DHA among women with normal pregnancy, pregnant
is recommended for optimal adult health, fetal, and infant women with GDM, and pregnant women with
development and to prevent preeclampsia.[11,22] pregestational T1DM.

Walnuts, chia seeds, and fish are good sources of omega Increased calcium needs may be met by MNT alone (1.2 g/
3 fatty acids. A minimum intake of 350 g of fish/week is day recommended); however, in women with low dietary
recommended of which 200 g should be fatty fish.[11] Low calcium intake (<1 g/day), supplementation of 0.3–2.0 g/
mercury fishes such as Indian salmon, anchovy, catfish, day is advised to preserve bone density, maternal calcium
pomphret, etc. can be consumed.[34] balance, and support fetal development.[47]

Nuts while being low in carbohydrates are a good source Evidence supporting vitamin D supplementation for
of MUFA, protein, fiber, and antioxidants. Studies have improving pregnancy outcomes is limited.[46]
shown that when a snack containing carbohydrate and The demand for iron increases in pregnancy, from 0.8
SFA are replaced with raw unsalted nuts, it helps improve to up to 7.5 mg/day of absorbed ferritin. The risk of
glycemic control in individuals with T2DM. This may also developing iron deficiency anemia increases in pregnancy;
hold true in women with GDM.[40,41] hence, supplementation with 30–60 mg/day of elemental
iron is recommended.[46]
Sugar Substitutes Zhang and Rawal[48] reviewed that there is a potential link
The use of sugar substitutes during pregnancy has increased between increased risk of GDM with higher iron status.
in the recent decades with approximately 30% of the pregnant As iron supplementation is often prescribed to prevent or
women reporting intentional sugar substitute consumption.[42] treat iron deficiency anemia, the potential association of
Sucralose and stevia are safest for consumption in a higher GDM risk with higher iron status warrants more
pregnant women. There is limited research on the safety research.
of acesulfame-K and polyols during pregnancy. Saccharin Total intake of ~600 μg/day of folic acid is recommended
is not recommended for pregnant women as placenta for all reproductive age women from at least 1 month
concentrates saccharin avidly. Aspartame must be prior to conception until at least 12 weeks of gestation.[47]
restricted in pregnant women with hyperphenylalaninemia.
Plows et al.[49] found limited evidence for nutritional
In the recent times, there are growing concerns that sugar supplementation of myo-inositol, vitamins D and B6,
substitutes cause gut dysbiosis. While there is some evidence, magnesium, selenium, zinc, fatty acids, and probiotics in
further studies are needed to elucidate the potential impact improvement of glycemic control or to prevent GDM.
of sugar substitutes on intestinal microbiota.[43,44]
Since data concerning the use of sugar substitutes during Physical Activity
pregnancy are limited, caution must be exercised for their
The WINGS-MOC study by Anjana et al.[50] showed that
use well within the recommended acceptable daily intake
PA levels are inadequate among pregnant women with
standards.
and without GDM. The study indicated that a low-cost,
culturally appropriate MOC can result in significant
Probiotics improvements in PA in women with GDM and is
Studies have shown that the use of probiotics is associated associated with improved glycemic control and pregnancy
with improved lipid and glucose metabolism in pregnant outcomes.

      
S56 56  Journal of Diabetology ¦ Volume 12 ¦ Supplement 5 ¦ July 2021
 Salis, et al.: Management of GDM with MNT

In women with GDM who have no medical or obstetric Conflicts of interest

contraindications to PA, most guidelines suggest planned There are no conflicts of interest.
PA of moderate intensity for at least 30 min per day or
150 min weekly, as this may contribute to improved
glycemic control. Brisk walking, recumbent bicycling,
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