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Basic SS Training Basic SS Training Medical Nutrition TherapyMedical Nutrition Therapy

ByBySharmila Chatterjee Sharmila Chatterjee

Msc,MS,RD,CDEMsc,MS,RD,CDE(CDAPP Coordinator, Region 9)(CDAPP Coordinator, Region 9)

Email: schatterjee@ucsd.eduEmail: schatterjee@ucsd.edu

Basic SS Training Basic SS Training Medical Nutrition TherapyMedical Nutrition Therapy

ByBySharmila Chatterjee Sharmila Chatterjee

Msc,MS,RD,CDEMsc,MS,RD,CDE(CDAPP Coordinator, Region 9)(CDAPP Coordinator, Region 9)

Email: schatterjee@ucsd.eduEmail: schatterjee@ucsd.edu

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Training GoalsTraining GoalsTraining GoalsTraining Goals

Identify the Guidelines for Care as the primary resource

Describe the role of the registered dietitian: medical nutrition therapy

Describe carbohydrate foods and the impact they have on blood sugars

Identify lifestyle modifications for prevention of DM/complications of DM

Identify the Guidelines for Care as the primary resource

Describe the role of the registered dietitian: medical nutrition therapy

Describe carbohydrate foods and the impact they have on blood sugars

Identify lifestyle modifications for prevention of DM/complications of DM

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Medical Nutrition Therapy Medical Nutrition Therapy (MNT) is a key component (MNT) is a key component

of glycemic controlof glycemic control

Medical Nutrition Therapy Medical Nutrition Therapy (MNT) is a key component (MNT) is a key component

of glycemic controlof glycemic control

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Goals of Medical Goals of Medical Nutrition TherapyNutrition Therapy Goals of Medical Goals of Medical Nutrition TherapyNutrition Therapy

Individualized, balanced meal plan Evidence-based recommendations Adequate maternal and fetal nutrition Vitamin/mineral supplementation as

needed Appropriate weight gain Normoglycemia Promotion and support of breastfeeding

Individualized, balanced meal plan Evidence-based recommendations Adequate maternal and fetal nutrition Vitamin/mineral supplementation as

needed Appropriate weight gain Normoglycemia Promotion and support of breastfeeding

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Components of Components of Nutrition Nutrition

Assessment Assessment

Components of Components of Nutrition Nutrition

Assessment Assessment Clinical data

Medical history

Activity level

Plan for infant feeding

Clinical data

Medical history

Activity level

Plan for infant feeding

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Clinical DataClinical Data

Measured height and weight (w/o shoes)

Preconception weight Preconception BMI Weight history

Measured height and weight (w/o shoes)

Preconception weight Preconception BMI Weight history

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Clinical Data (cont.)Clinical Data (cont.)

Available labs Hgb/Hct OGTT A1c

Medical history Post gastric bypass PCOS

Medications: current/historical use

Available labs Hgb/Hct OGTT A1c

Medical history Post gastric bypass PCOS

Medications: current/historical use

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Food Patterns Food Patterns

Food intake history Inadequate intake Overnutrition Food allergies, intolerances Unusual food habits: pica Supplements Complementary medicines Common complaints Dental history Cultural foods

Food intake history Inadequate intake Overnutrition Food allergies, intolerances Unusual food habits: pica Supplements Complementary medicines Common complaints Dental history Cultural foods

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Psychosocial FactorsPsychosocial FactorsPsychosocial FactorsPsychosocial Factors

Limited income/food assistance (WIC) Substance abuse Language/cultural background Religious practices Eating disorders Literacy level Social support Employment

Limited income/food assistance (WIC) Substance abuse Language/cultural background Religious practices Eating disorders Literacy level Social support Employment

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Goals at Initial RD VisitGoals at Initial RD VisitGoals at Initial RD VisitGoals at Initial RD Visit

Treatment initiated Initial individualized meal plan Initial individualized exercise routine Patient comprehension

Assessment completed Weight gain goals determined Weight gain plotted

Treatment initiated Initial individualized meal plan Initial individualized exercise routine Patient comprehension

Assessment completed Weight gain goals determined Weight gain plotted

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Preconception Weight Preconception Weight GoalsGoals

Preconception Weight Preconception Weight GoalsGoals

All women are encouraged to achieve a desirable body weight before conception

Preconception BMI should be used in determining weight category

All women are encouraged to achieve a desirable body weight before conception

Preconception BMI should be used in determining weight category

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Determining Preconception BMI

Determining Preconception BMI

BMI = weight (lbs.) x 703 height (in.) x height

(in.)

BMI = weight (kg.) height (meters) x height (meters)

BMI = weight (lbs.) x 703 height (in.) x height

(in.)

BMI = weight (kg.) height (meters) x height (meters)

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Body Mass Index/Wt Body Mass Index/Wt Gain GoalsGain Goals

(Based on 2009 IOM Guidelines)(Based on 2009 IOM Guidelines)

Body Mass Index/Wt Body Mass Index/Wt Gain GoalsGain Goals

(Based on 2009 IOM Guidelines)(Based on 2009 IOM Guidelines)

CategoryCategory BMIBMI Recommended total wt Recommended total wt gain ranges gain ranges

Singleton TwinsSingleton Twins

Underweight < 18.5 28-40 lbs N/A

Normal 18.5-24.9 25-35 lbs 37-54 lbs

Overweight 25.0-29.9 15-25 lbs 31-50 lbs

Obese ≥ 30 11-20 lbs 25-42 lbs

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Recommended Rate of Recommended Rate of Weight Gain/WeekWeight Gain/Week(Based on 2009 IOM Guidelines)(Based on 2009 IOM Guidelines)

Recommended Rate of Recommended Rate of Weight Gain/WeekWeight Gain/Week(Based on 2009 IOM Guidelines)(Based on 2009 IOM Guidelines)

CategoryCategory BMIBMI Mean (range) in lbs/week Mean (range) in lbs/week (singletons)(singletons)

Underweight < 18.5 1 ( 1-1.3 )

Normal 18.5-24.9 1 ( 0.8 – 1 )

Overweight 25.0-29.9 0.6 ( 0.5 – 0.7 )

Obese ≥ 30 0.5 ( 0.4 – 0.6 )

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Weight Gain GridsWeight Gain GridsWeight Gain GridsWeight Gain Grids

The forms are located at http://www.cdph.ca.gov/pubsforms/forms/Pages/MaternalandChildHealth.aspx

CDPH 4472 B1     Prenatal Weight Gain Grid:  Pre-pregnancy Underweight Range CDPH 4472 B2     Prenatal Weight Gain Grid:  Pre-pregnancy Normal Weight Range CDPH 4472 B3     Prenatal Weight Gain Grid:  Pre-pregnancy Overweight Range CDPH 4472 B4     Prenatal Weight Gain Grid:  Pre-pregnancy Obese Weight Range

The forms are located at http://www.cdph.ca.gov/pubsforms/forms/Pages/MaternalandChildHealth.aspx

CDPH 4472 B1     Prenatal Weight Gain Grid:  Pre-pregnancy Underweight Range CDPH 4472 B2     Prenatal Weight Gain Grid:  Pre-pregnancy Normal Weight Range CDPH 4472 B3     Prenatal Weight Gain Grid:  Pre-pregnancy Overweight Range CDPH 4472 B4     Prenatal Weight Gain Grid:  Pre-pregnancy Obese Weight Range

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Newer Research re Weight Gain for Obese

Women

Newer Research re Weight Gain for Obese

Women Kiel, et al 2007

Obese women w/singleton pregnancy n=120,170

Relationship between weight gain and preeclampsia, C-section, SGA and LGA

Kiel, et al 2007

Obese women w/singleton pregnancy n=120,170

Relationship between weight gain and preeclampsia, C-section, SGA and LGA

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Kiel et al: OutcomesKiel et al: Outcomes

Lowest risk for adverse outcomes:

Lowest risk for adverse outcomes:

BMI Weight Gain

30-34.9 10-25#

35-39.9 0-9#

40+ Wt. loss: 0-9#

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Newer Research re Weight Gain for Obese

Women, Cont’d

Newer Research re Weight Gain for Obese

Women, Cont’d Bodnar et al, 2010

Obese women with singleton pregnancies (n=3254)

Relationship between wt. gain and adverse outcomes (SGA, LGA, spontaneous and medically indicated preterm births)

Bodnar et al, 2010

Obese women with singleton pregnancies (n=3254)

Relationship between wt. gain and adverse outcomes (SGA, LGA, spontaneous and medically indicated preterm births)

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Bodnar, et al Cont’dBodnar, et al Cont’d

Lowest risk for adverse outcomes Lowest risk for adverse outcomes

BMI Weight Gain

30-34.9 20-30#

35-39.9 5-20#

40+ White: 5-10.9#Black: less than 5#

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Preconception Energy Preconception Energy NeedsNeeds

Preconception Energy Preconception Energy NeedsNeeds

Energy needs are based on preconception weight

Calculate energy needs using the Institute of Medicine (IOM) estimated energy requirement (EER) formula

Energy needs are based on preconception weight

Calculate energy needs using the Institute of Medicine (IOM) estimated energy requirement (EER) formula

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EER FormulaEER FormulaEER FormulaEER Formula

14-18 yrs old: EER = [135.3 - (30.8 x A)] + PA x [(10.0 x Wt) + (934 x Ht)]

19 yrs or older: EER = [354 - (6.91 x A)] + PA x [(9.36 x Wt) + (726 x Ht)]

14-18 yrs old: EER = [135.3 - (30.8 x A)] + PA x [(10.0 x Wt) + (934 x Ht)]

19 yrs or older: EER = [354 - (6.91 x A)] + PA x [(9.36 x Wt) + (726 x Ht)]

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EER FormulaEER FormulaEER FormulaEER Formula

A = age (years)

PA = physical activity coefficient

Wt = weight (kg)

Ht = height (meters)

A = age (years)

PA = physical activity coefficient

Wt = weight (kg)

Ht = height (meters)

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Physical Activity Physical Activity CoefficientsCoefficients

Physical Activity Physical Activity CoefficientsCoefficients

Activity Level 14-18 years

≥19 years

Sedentary (only light physical activity associated with typical day-to-day life)

1.0 1.0

Moderate Active (lifestyle includes daily 30 minutes of moderate intensity physical activity)

1.16 1.12

Active (lifestyle includes daily 60 minutes of moderate intensity physical activity)

1.56 1.45

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Prenatal Energy Prenatal Energy NeedsNeeds

Prenatal Energy Prenatal Energy NeedsNeeds

1st trimester (0-12wks) energy needs remain the same as during preconception

2nd and 3rd trimester energy requirements increase

1st trimester (0-12wks) energy needs remain the same as during preconception

2nd and 3rd trimester energy requirements increase

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Energy Needs for Energy Needs for Pregnancy Based on Pregnancy Based on

Gestational AgeGestational Age

Energy Needs for Energy Needs for Pregnancy Based on Pregnancy Based on

Gestational AgeGestational AgeIOM formula to calculate energy needs forpregnant women who have normal

weight pregravid:

1st trimester = Adult EER + 0 2nd trimester = Adult EER + 160 kcal (8 kcal/wk x 20 wk) + 180 kcal 3rd trimester = Adult EER + 272 kcal (8 kcal/wk x 34 wk) + 180 kcal

IOM formula to calculate energy needs forpregnant women who have normal

weight pregravid:

1st trimester = Adult EER + 0 2nd trimester = Adult EER + 160 kcal (8 kcal/wk x 20 wk) + 180 kcal 3rd trimester = Adult EER + 272 kcal (8 kcal/wk x 34 wk) + 180 kcal

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Energy Needs for Overweight and Obese Women

Energy Needs for Overweight and Obese Women

No consensus on determining energy needs for overweight and obese pregnant women

Minimum 1800 kcal for adequate nutrition

Careful clinical monitoring to ensure adequate intake

No consensus on determining energy needs for overweight and obese pregnant women

Minimum 1800 kcal for adequate nutrition

Careful clinical monitoring to ensure adequate intake

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Exercise in PregnancyExercise in Pregnancy Offspring of 20 women who exercised were

compared with offspring of 20 physically active control subjects.

Offspring of the women who exercised weighed less and had less subcutaneous fat mass. Groups had similar motor, integrative and academic

readiness skills. (Clapp JF, 1996)

Offspring of 20 women who exercised were compared with offspring of 20 physically active control subjects.

Offspring of the women who exercised weighed less and had less subcutaneous fat mass. Groups had similar motor, integrative and academic

readiness skills. (Clapp JF, 1996)

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Exercise During PregnancyACOG Committee Opinion

No. 267

Exercise During PregnancyACOG Committee Opinion

No. 267 In the absence of either medical or

obstetric complications, > 30 min of moderate exercise on most, if not all days of the week is recommended

Exercise may be beneficial in primary prevention of GDM

Exercise may be “a helpful adjunctive therapy” for GDM when euglycemia is not achieved by diet alone

(ACOG, 2002)

In the absence of either medical or obstetric complications, > 30 min of moderate exercise on most, if not all days of the week is recommended

Exercise may be beneficial in primary prevention of GDM

Exercise may be “a helpful adjunctive therapy” for GDM when euglycemia is not achieved by diet alone

(ACOG, 2002)

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Macronutrient Recommendations during Pregnancy

Macronutrient Recommendations during Pregnancy

Calories gradually increase from 13+ wks Protein – 1.1 g/kg/day or additional

25g/day (from 2nd trimester) Carbohydrates – min. of 130 gm/day in 1st

trimester and 175 gm/day in 2nd and 3rd Fat – focus on monounsaturated fats as

main source

Calories gradually increase from 13+ wks Protein – 1.1 g/kg/day or additional

25g/day (from 2nd trimester) Carbohydrates – min. of 130 gm/day in 1st

trimester and 175 gm/day in 2nd and 3rd Fat – focus on monounsaturated fats as

main source

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Micronutrient Recommendations during Pregnancy

Micronutrient Recommendations during Pregnancy

Fiber – 25-35 g/day Sodium –

Average Intake (AI) for women under 50 yrs: 1.5g/day

Upper limit: 2.3 g/day Patients with HTN and nephropathy:

no more than 2000mg sodium/day

Fiber – 25-35 g/day Sodium –

Average Intake (AI) for women under 50 yrs: 1.5g/day

Upper limit: 2.3 g/day Patients with HTN and nephropathy:

no more than 2000mg sodium/day

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Micronutrient Recommendations during Pregnancy

Micronutrient Recommendations during Pregnancy Folic acid

Preconception: 400 mcg/day

Pregnancy: 600 mcg/day Hx of NTD: 4000 mcg/day Tolerable upper limit:

14-18yr olds: 800 mcg/day

> 19yrs old: 1000 mcg/day

Folic acid Preconception: 400

mcg/day Pregnancy: 600 mcg/day Hx of NTD: 4000 mcg/day Tolerable upper limit:

14-18yr olds: 800 mcg/day

> 19yrs old: 1000 mcg/day

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Micronutrient Micronutrient Recommendations during Recommendations during

PregnancyPregnancy

Micronutrient Micronutrient Recommendations during Recommendations during

PregnancyPregnancy Vitamin D

Considered a hormone, not a vitamin RDA for pregnancy and lactation:

600 IU/day (15 micrograms/day) Tolerable Upper Limit for

pregnancy and lactation: 4000 IU/day

Vitamin D Considered a hormone, not a vitamin

RDA for pregnancy and lactation: 600 IU/day (15 micrograms/day)

Tolerable Upper Limit for pregnancy and lactation: 4000 IU/day

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Vitamin DVitamin DVitamin DVitamin D

Optimal blood levels of 25(OH)D controversial

IOM: 20 ng/ml sufficient for good bone health

Ginde et al, 2010 (NHANES data)At least 33% of pregnant women

deficient in vitamin D (using 20 ng/ml as target)

Optimal blood levels of 25(OH)D controversial

IOM: 20 ng/ml sufficient for good bone health

Ginde et al, 2010 (NHANES data)At least 33% of pregnant women

deficient in vitamin D (using 20 ng/ml as target)

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Vitamin D Vitamin D Supplementation During Supplementation During

PregnancyPregnancy

Vitamin D Vitamin D Supplementation During Supplementation During

PregnancyPregnancy Wagner, et al 2010 Evaluation of effectiveness of high

doses vitamin D in reducing pregnancy risks

In the group taking 4000 IU/day Lowest rates of preterm labor,

preterm birth, infection Researchers recommendation: 4000

IU/day to maintain level of 40 ng/ml

Wagner, et al 2010 Evaluation of effectiveness of high

doses vitamin D in reducing pregnancy risks

In the group taking 4000 IU/day Lowest rates of preterm labor,

preterm birth, infection Researchers recommendation: 4000

IU/day to maintain level of 40 ng/ml

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CalciumCalciumCalciumCalcium RDA for pregnancy/lactation

14-18yrs old: 1300 mg/day 19-50 y.o.: 1000 mg/day>50 y.o.: 1200 mg/dayPreferable source is food600 mg in most supplements

Maximum absorption: 200-300 mg TID

RDA for pregnancy/lactation14-18yrs old: 1300 mg/day 19-50 y.o.: 1000 mg/day>50 y.o.: 1200 mg/dayPreferable source is food600 mg in most supplements

Maximum absorption: 200-300 mg TID

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Vitamin and Mineral Vitamin and Mineral SupplementsSupplements

Vitamin and Mineral Vitamin and Mineral SupplementsSupplements

Zinc: 15 mg/day Copper: 2 mg/day Folic acid: 600 mcg/day Iron: 30 mg/day at first prenatal visit For vegans, 600 IU vitamin D and 2

mcg vitamin B12

Zinc: 15 mg/day Copper: 2 mg/day Folic acid: 600 mcg/day Iron: 30 mg/day at first prenatal visit For vegans, 600 IU vitamin D and 2

mcg vitamin B12

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Other Substances during Other Substances during PregnancyPregnancy

Other Substances during Other Substances during PregnancyPregnancy

Caffeine- limited to 200 mg/day (2 – 6oz cups of coffee)

Herbs- safety unknown Limit herbal teas.

Potentially contraindicated: gingko biloba,

ginseng, echinacea, St. John’s wort and concentrated herbal garlic extract

Caffeine- limited to 200 mg/day (2 – 6oz cups of coffee)

Herbs- safety unknown Limit herbal teas.

Potentially contraindicated: gingko biloba,

ginseng, echinacea, St. John’s wort and concentrated herbal garlic extract

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Other Substances during Other Substances during Pregnancy: DHAPregnancy: DHA

Other Substances during Other Substances during Pregnancy: DHAPregnancy: DHA

Found in wild fatty fish (salmon, herring, sardines, freshwater trout) and some fortified foods (milk, bread, yogurt)

Inadequate DHA from food: supplement containing at least 200 mg

of DHA Several prenatal supplements include

DHA, either from fish oil or other sources

Found in wild fatty fish (salmon, herring, sardines, freshwater trout) and some fortified foods (milk, bread, yogurt)

Inadequate DHA from food: supplement containing at least 200 mg

of DHA Several prenatal supplements include

DHA, either from fish oil or other sources

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Toxins to AvoidToxins to Avoid Salmonella

Avoid raw eggs Listeriosis

Avoid raw sprouts, unpasteurized milk and cheeses

Cook all meat, fish and poultry thoroughly Heat deli and luncheon meats until steaming

Drugs and alcohol Avoid If questions contact CTIS at

www.ctispregnancy.org

Salmonella Avoid raw eggs

Listeriosis Avoid raw sprouts, unpasteurized milk and

cheeses Cook all meat, fish and poultry thoroughly Heat deli and luncheon meats until steaming

Drugs and alcohol Avoid If questions contact CTIS at

www.ctispregnancy.org

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Toxins to AvoidToxins to Avoid

Mercury and PCBs Avoid shark, swordfish, king

mackerel and tilefish Limit other fish and shellfish to 12

oz/wkAlbacore tuna – limit to 6 oz/wk

Mercury and PCBs Avoid shark, swordfish, king

mackerel and tilefish Limit other fish and shellfish to 12

oz/wkAlbacore tuna – limit to 6 oz/wk

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Nonnutritive SweetenersNonnutritive SweetenersNonnutritive SweetenersNonnutritive Sweeteners

FDA approved Saccharin Aspartame

Acceptable daily intake: 50 mg/kg body wtActual intake @ 90th percentile: 2-3 mg/kg BW

Acesulfame potassium (acesulfame K) Sucralose

Pregnancy and lactation: no adverse effects in animals

FDA approved Saccharin Aspartame

Acceptable daily intake: 50 mg/kg body wtActual intake @ 90th percentile: 2-3 mg/kg BW

Acesulfame potassium (acesulfame K) Sucralose

Pregnancy and lactation: no adverse effects in animals

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Stevia and Rebaudioside AStevia and Rebaudioside AStevia and Rebaudioside AStevia and Rebaudioside A

Rebaudioside A aka Reb ATruvia, PureViaHighly processed derivative of stevia

Received GRAS status from FDA Stevia: Natural Medicines

Comprehensive Database indicates there is insufficient evidence for its safety in pregnancy

Rebaudioside A aka Reb ATruvia, PureViaHighly processed derivative of stevia

Received GRAS status from FDA Stevia: Natural Medicines

Comprehensive Database indicates there is insufficient evidence for its safety in pregnancy

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Comparisons Comparisons ADI

mg/kg BW

Avg amt in 12-oz can of soda (mg)

Cans of soda = ADI for 60 kg person

Amt in packet of sweetener (mg)

Packets= ADI for 60 kg person (132#)

Acesul-fame K

15 40 25 50 18

Aspar-tame

50 200 15 35 86

Saccharin 5 140 2 40 7.5

Sucralose 5 70 4.5 5 60

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Acceptable Daily Intake (ADI) ofNon-nutritive Sweeteners

Acceptable Daily Intake (ADI) ofNon-nutritive Sweeteners

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Nutritive SweetenersNutritive SweetenersNutritive SweetenersNutritive Sweeteners

Agave CHO/kcal content similar to table sugar Sweeter than table sugar Possibly lower glycemic index Likely safe when consumed in usual

amounts Likely unsafe during pregnancy due to

contraceptive effects that could lead to miscarriage

Agave CHO/kcal content similar to table sugar Sweeter than table sugar Possibly lower glycemic index Likely safe when consumed in usual

amounts Likely unsafe during pregnancy due to

contraceptive effects that could lead to miscarriage

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Sugar Alcohols/PolyolsSugar Alcohols/PolyolsSugar Alcohols/PolyolsSugar Alcohols/Polyols

GRAS Reduced risk dental caries Laxative effect

Half the kcal of sucrose Calculating the CHO of foods

containing polyols: subtract half the sugar alcohol grams from the total CHO grams

GRAS Reduced risk dental caries Laxative effect

Half the kcal of sucrose Calculating the CHO of foods

containing polyols: subtract half the sugar alcohol grams from the total CHO grams

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Working the Meal Plan into Working the Meal Plan into

Real LifeReal Life

Working the Meal Plan into Working the Meal Plan into

Real LifeReal Life

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Sweet Success Sweet Success Nutrition Guidelines Nutrition Guidelines

for GDMfor GDM

Sweet Success Sweet Success Nutrition Guidelines Nutrition Guidelines

for GDMfor GDM Spread carbohydrate load over 3 small meals and 3 or more snacks. CHO not well tolerated at breakfast. Flexible CHO intake

with the use of insulin

Fruit: 2 or more servings daily, not at breakfast

Milk: 3-4 servings daily, not at breakfast; 2%, 1% fat or nonfat in portion sizes of 4-8 oz during meals or snacks

Bread/starch: as low as 15-20 gms at breakfast; a minimum of 7 gms of protein and 15-30 gms of carb at bedtime snack

Spread carbohydrate load over 3 small meals and 3 or more snacks. CHO not well tolerated at breakfast. Flexible CHO intake

with the use of insulin

Fruit: 2 or more servings daily, not at breakfast

Milk: 3-4 servings daily, not at breakfast; 2%, 1% fat or nonfat in portion sizes of 4-8 oz during meals or snacks

Bread/starch: as low as 15-20 gms at breakfast; a minimum of 7 gms of protein and 15-30 gms of carb at bedtime snack

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Refined sugars, juices, processed breakfast cereal, instant potatoes and noodles – limit or avoid

Vegetables: liberal amounts of non-starchy vegetables

Fats: at least 6 or more portions/day. Limit saturated fat and emphasize monounsaturated.

Avoid trans fats. Include an individualized realistic meal plan

Refined sugars, juices, processed breakfast cereal, instant potatoes and noodles – limit or avoid

Vegetables: liberal amounts of non-starchy vegetables

Fats: at least 6 or more portions/day. Limit saturated fat and emphasize monounsaturated.

Avoid trans fats. Include an individualized realistic meal plan

Sweet Success Sweet Success Nutrition Guidelines Nutrition Guidelines

for GDM cont.for GDM cont.

Sweet Success Sweet Success Nutrition Guidelines Nutrition Guidelines

for GDM cont.for GDM cont.

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RecommendationsRecommendationsRecommendationsRecommendations

3 meals + 3-4 snacks Consistent schedule Avoid more than 10 hours between bedtime

snack and breakfast Synchronize meals, snacks and glyburide/insulin Adequate nutrient intake Reading labels for carbohydrates Encourage pattern management

Food records

3 meals + 3-4 snacks Consistent schedule Avoid more than 10 hours between bedtime

snack and breakfast Synchronize meals, snacks and glyburide/insulin Adequate nutrient intake Reading labels for carbohydrates Encourage pattern management

Food records

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Recommendations: Foods to Recommendations: Foods to LimitLimit

Recommendations: Foods to Recommendations: Foods to LimitLimit

Cold/instant hot cereals Elevated glycemic index → elevated BG

Beverages Sports drinks Energy drinks Drinks sweetened with sugar/high fructose corn

syrup

Fruit juice

Cold/instant hot cereals Elevated glycemic index → elevated BG

Beverages Sports drinks Energy drinks Drinks sweetened with sugar/high fructose corn

syrup

Fruit juice

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CarbohydratesCarbohydratesCarbohydratesCarbohydrates

Impact blood sugars more than proteins or fats

Recommended dietary allowance (RDA) Adequate for 97-98% of women Pregnancy: 175g/day Lactation: 210 g/day

Estimated Average Requirement (EAR): Adequate for 50% of women Pregnancy: 135g/day Lactation: 160g/day

Impact blood sugars more than proteins or fats

Recommended dietary allowance (RDA) Adequate for 97-98% of women Pregnancy: 175g/day Lactation: 210 g/day

Estimated Average Requirement (EAR): Adequate for 50% of women Pregnancy: 135g/day Lactation: 160g/day

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Sources of CarbohydratesSources of Carbohydrates

Include Starch

Half of all starch should be whole grain

Fruit Fresh

Milk Soymilk: read the labels

Vegetables: emphasize dark green, leafy vegetables

Sweets, desserts and other carbohydrates

Include Starch

Half of all starch should be whole grain

Fruit Fresh

Milk Soymilk: read the labels

Vegetables: emphasize dark green, leafy vegetables

Sweets, desserts and other carbohydrates

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Exchange InformationExchange InformationExchange InformationExchange Information

Group CHO (g) Pro (g) Fat (g) Kcal

Starch 15 3 .75 80

Fruit 15 0 0 60

Milk (2%) 15 10 5 145

Vegetables

5 2 0 25

Meat (med fat)

0 7 5 75

Fat 0 0 5 45

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Serving SizesServing SizesServing SizesServing Sizes

1 Starch = 1 slice bread, 1 6” tortilla, 6 saltines

1 Milk = 8 oz. milk, ¾ cup yogurt (no sugar added)

1 Fruit = 1 small fresh fruit

1 Starch = 1 slice bread, 1 6” tortilla, 6 saltines

1 Milk = 8 oz. milk, ¾ cup yogurt (no sugar added)

1 Fruit = 1 small fresh fruit

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Carbohydrate CountingCarbohydrate CountingCarbohydrate CountingCarbohydrate Counting

1 carb = 1 bread = 1milk = 1fruit = 15 grams of carbohydrate

Label reading Serving size Total carbohydrate in grams Fiber Kcal/Fat

1 carb = 1 bread = 1milk = 1fruit = 15 grams of carbohydrate

Label reading Serving size Total carbohydrate in grams Fiber Kcal/Fat

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Carb GuidelinesCarb GuidelinesCarb GuidelinesCarb Guidelines

Breakfast: 15-30 grams (1-2 carbs)

Lunch: 30 - 60 grams (2-4 carbs)

Dinner: 30- 60grams (2-4 carbs)

Snacks: 15-30 grams (1-2 carbs)

Breakfast: 15-30 grams (1-2 carbs)

Lunch: 30 - 60 grams (2-4 carbs)

Dinner: 30- 60grams (2-4 carbs)

Snacks: 15-30 grams (1-2 carbs)

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A Carb is a Carb is a Carb?A Carb is a Carb is a Carb?A Carb is a Carb is a Carb?A Carb is a Carb is a Carb?

American Diabetes Association: “ The available evidence from clinical studies demonstrates that dietary sucrose does not increase glycemia more than isocaloric amounts of starch.”

Foods high in sucrose Lower nutrient density Higher fat content Replace more nutritious foods Limit intake

American Diabetes Association: “ The available evidence from clinical studies demonstrates that dietary sucrose does not increase glycemia more than isocaloric amounts of starch.”

Foods high in sucrose Lower nutrient density Higher fat content Replace more nutritious foods Limit intake

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Glycemic IndexGlycemic IndexGlycemic IndexGlycemic Index

Use of low-glycemic index diet Reduced need for insulin in women with

GDM No compromise of obstetric or fetal

outcomes Well-tolerated

Use of low-glycemic index diet Reduced need for insulin in women with

GDM No compromise of obstetric or fetal

outcomes Well-tolerated

(Moses RG et al, 2009 )

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What about Fats and Protein?What about Fats and Protein?What about Fats and Protein?What about Fats and Protein?

Fats: Slow down stomach emptying Potential source excess calories

Protein: Insulin secretion similar to carbohydrate Glucose from ingested protein- doesn’t

appear in general circulation

Fats: Slow down stomach emptying Potential source excess calories

Protein: Insulin secretion similar to carbohydrate Glucose from ingested protein- doesn’t

appear in general circulation

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Carbs, Proteins and FatsCarbs, Proteins and FatsCarbs, Proteins and FatsCarbs, Proteins and Fats

Some foods fall into more than one group Milk (8 oz, 2% milkfat): 15g Carb, 10g protein,

5g fat Peanut butter (2 T): 6g Carb, 8g protein, 16g fat Cottage cheese (1 cup, 2% milkfat) 8g Carb,

31g protein, 4g fat Greek yogurt (7 oz, plain): 8g Carb, 17g protein,

4g fat

Some foods fall into more than one group Milk (8 oz, 2% milkfat): 15g Carb, 10g protein,

5g fat Peanut butter (2 T): 6g Carb, 8g protein, 16g fat Cottage cheese (1 cup, 2% milkfat) 8g Carb,

31g protein, 4g fat Greek yogurt (7 oz, plain): 8g Carb, 17g protein,

4g fat

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Sweets, Desserts and Other Sweets, Desserts and Other CarbohydratesCarbohydrates

Sweets, Desserts and Other Sweets, Desserts and Other CarbohydratesCarbohydrates

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Goals of ReassessmentGoals of ReassessmentGoals of ReassessmentGoals of Reassessment

Weight gain within recommended rates

Balanced meal plan

Meal plan comprehension

Schedule appropriate

Weight gain within recommended rates

Balanced meal plan

Meal plan comprehension

Schedule appropriate

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ReassessmentReassessmentReassessmentReassessment

Weight gain measured and plotted Weight loss common after first visit

Food intake patterns Food records 24-hr. recall Compare w/original meal plan

Weight gain measured and plotted Weight loss common after first visit

Food intake patterns Food records 24-hr. recall Compare w/original meal plan

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Inadequate Weight GainInadequate Weight GainInadequate Weight GainInadequate Weight Gain

Inadequate weight gain

<2#/mo for women of normal pregravid BMI

Women who have already gained excessively may not need to continue gaining

Inadequate weight gain

<2#/mo for women of normal pregravid BMI

Women who have already gained excessively may not need to continue gaining

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Causes of Inadequate Causes of Inadequate Weight GainWeight Gain

Causes of Inadequate Causes of Inadequate Weight GainWeight Gain

Inadequate weight gain Initial dietary changes Fear of elevated blood sugars→↓CHO intake Insulin/OHA needed

Remedy Encourage initial meal plan Increase kcal level beyond initial estimate Insulin/OHA; increase in insulin/OHA

Inadequate weight gain Initial dietary changes Fear of elevated blood sugars→↓CHO intake Insulin/OHA needed

Remedy Encourage initial meal plan Increase kcal level beyond initial estimate Insulin/OHA; increase in insulin/OHA

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Ketone TestingKetone TestingKetone TestingKetone Testing

Ketone testing daily is encouraged for the first two weeks of nutrition counseling. In the event of persistent weight loss or inadequate food intake, ketone testing is strongly advised

Ketone testing daily is encouraged for the first two weeks of nutrition counseling. In the event of persistent weight loss or inadequate food intake, ketone testing is strongly advised

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Recommendations to Recommendations to Avoid Starvation KetosisAvoid Starvation Ketosis

Recommendations to Recommendations to Avoid Starvation KetosisAvoid Starvation Ketosis

Avoid long periods of fastingAssure adequate calories and CHO

intake throughout the daySchedule snacks about 2-3 hours after

mealsSchedule bedtime snacks no more than 10 hours away from the next mealtimeProvide a minimum of 7gm of protein and 15-30gm of CHO in the bedtime snack

Avoid long periods of fastingAssure adequate calories and CHO

intake throughout the daySchedule snacks about 2-3 hours after

mealsSchedule bedtime snacks no more than 10 hours away from the next mealtimeProvide a minimum of 7gm of protein and 15-30gm of CHO in the bedtime snack

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Weight LossWeight LossWeight LossWeight Loss

Fear of carbs

Lack of understanding

Insulin/OHA needed?

Clarify kcal/nutrition needs

Fear of carbs

Lack of understanding

Insulin/OHA needed?

Clarify kcal/nutrition needs

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Excess Weight GainExcess Weight GainExcess Weight GainExcess Weight Gain

Defined as 6.5lbs or more/month for all women not underweight at the time of conception

Use clinical judgment for women in overweight and obese categories

Defined as 6.5lbs or more/month for all women not underweight at the time of conception

Use clinical judgment for women in overweight and obese categories

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Excess Weight GainExcess Weight GainExcess Weight GainExcess Weight Gain

Evaluate for edemaEvaluate activity levelReview food records for excess

kcal/fatRevise meal plan if necessaryAvoid “feeding” insulin/OHAPreeclampsia??

Evaluate for edemaEvaluate activity levelReview food records for excess

kcal/fatRevise meal plan if necessaryAvoid “feeding” insulin/OHAPreeclampsia??

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InsulinInsulinInsulinInsulin

Insulin initiationChanges in schedule to

accommodate insulin actionHypoglycemia treatment

Insulin follow-up24-hr recall:

AmountTypeTime

Insulin initiationChanges in schedule to

accommodate insulin actionHypoglycemia treatment

Insulin follow-up24-hr recall:

AmountTypeTime

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Insulin, ContinuedInsulin, ContinuedInsulin, ContinuedInsulin, Continued

NPH and hypoglycemia preventionBedtime snackMidmorning snack

NPH and hypoglycemia preventionBedtime snackMidmorning snack

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Hypoglycemia and Hypoglycemia and GlyburideGlyburide

Hypoglycemia and Hypoglycemia and GlyburideGlyburide

Glyburide: long half-life for some metabolites?

Risk of post-breakfast hyperglycemia Common scenario Elevated BG post-breakfast Hypoglycemia to follow almost immediately

Tx: earlier morning snack

Glyburide: long half-life for some metabolites?

Risk of post-breakfast hyperglycemia Common scenario Elevated BG post-breakfast Hypoglycemia to follow almost immediately

Tx: earlier morning snack

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HypoglycemiaHypoglycemiaHypoglycemiaHypoglycemia

Signs and symptoms Confirm with BG check Treatment

15 grams carbohydrate15 grams glucose tabs + water1/2 cup fruit juice or soda

Recheck in 15 minutes Retreat if necessary

Signs and symptoms Confirm with BG check Treatment

15 grams carbohydrate15 grams glucose tabs + water1/2 cup fruit juice or soda

Recheck in 15 minutes Retreat if necessary

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Causes of HypoglycemiaCauses of HypoglycemiaCauses of HypoglycemiaCauses of Hypoglycemia

↑Activity

↓CHO

Skipping snack

↑Insulin/OHA

↑Activity

↓CHO

Skipping snack

↑Insulin/OHA

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Sick Day ManagementSick Day ManagementSick Day ManagementSick Day Management

Substitute easily digested CHO foods as a replacement With N/V, add caffeine free liquids to preventing dehydration If BG > 200 mg/dl, the usual amt of carbs is not needed Frequent urine ketone testing for women with

DM1 Contact health care provider if BG values out of range > 2 times

Substitute easily digested CHO foods as a replacement With N/V, add caffeine free liquids to preventing dehydration If BG > 200 mg/dl, the usual amt of carbs is not needed Frequent urine ketone testing for women with

DM1 Contact health care provider if BG values out of range > 2 times

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BreastfeedingBreastfeedingBreastfeedingBreastfeeding

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Benefits to the MotherBenefits to the MotherBenefits to the MotherBenefits to the Mother

Enhances bonding with infant

Mobilizes fat stores Reduces risk of

premenopausal breast and ovarian cancer

May improve BG control

Enhances bonding with infant

Mobilizes fat stores Reduces risk of

premenopausal breast and ovarian cancer

May improve BG control

Protective role against chronic diseases (diabetes and osteoporosis)HDL ratio increasesEconomicalNo preparationReduced healthcare costs an absenteeism

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Benefits to the InfantBenefits to the InfantBenefits to the InfantBenefits to the Infant

Enhances bonding with mother

Reduces incidence and severity of ear infections

Reduces incidence of respiratory infections

Transfers growth factors

Enhances bonding with mother

Reduces incidence and severity of ear infections

Reduces incidence of respiratory infections

Transfers growth factors

Decreases risk of baby tooth decayDigests easilyReduces incidence of diarrheaProtects against infant botulismMay reduce lifetime risk of diabetes

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Breastfeeding and Risk of DM2 Breastfeeding and Risk of DM2 in Womenin Women

Breastfeeding and Risk of DM2 Breastfeeding and Risk of DM2 in Womenin Women

Longer duration of BF decreases incidence DM2

Independent of physical activity and BMI later in life Exclusive breastfeeding for ≥1 month

decreases DM2

(Schwarz et al, 2010)

Longer duration of BF decreases incidence DM2

Independent of physical activity and BMI later in life Exclusive breastfeeding for ≥1 month

decreases DM2

(Schwarz et al, 2010)

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Breastfeeding and Risk of Breastfeeding and Risk of Maternal Type 2 DiabetesMaternal Type 2 DiabetesBreastfeeding and Risk of Breastfeeding and Risk of Maternal Type 2 DiabetesMaternal Type 2 Diabetes

Mothers who did not breastfeed had an increased risk of about 50% of developing DM2

Each year of breastfeeding reduced risk by 14%

Breastfeeding longer than 3 months reduced risk more

Liu et al, 2010

Mothers who did not breastfeed had an increased risk of about 50% of developing DM2

Each year of breastfeeding reduced risk by 14%

Breastfeeding longer than 3 months reduced risk more

Liu et al, 2010

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Breastfeeding and Breastfeeding and Development of DM2 in Development of DM2 in

YouthYouth

Breastfeeding and Breastfeeding and Development of DM2 in Development of DM2 in

YouthYouth Breastfeeding protective against

development of DM2 in youth Mediated by current weight status

in childhood

Mayer-Davis et al, 2008

Breastfeeding protective against development of DM2 in youth

Mediated by current weight status in childhood

Mayer-Davis et al, 2008

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Postpartum TopicsPostpartum TopicsPostpartum TopicsPostpartum Topics

Prevention of type 2 DM

Breastfeeding issues/encouragement

Weight loss

Prevention of type 2 DM

Breastfeeding issues/encouragement

Weight loss

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Postpartum Guidelines for Postpartum Guidelines for Women with Previous GDMWomen with Previous GDMPostpartum Guidelines for Postpartum Guidelines for Women with Previous GDMWomen with Previous GDM

Follow a low fat, low sugar, high fiber diet RD to provide meal plan to attain and maintain

a healthy weight Exercise daily after doctor gives approval 6 week Postpartum 75 gm OGTT Yearly follow up on FBG and 2h OGTT every

3 years Carefully plan any further pregnancies

Follow a low fat, low sugar, high fiber diet RD to provide meal plan to attain and maintain

a healthy weight Exercise daily after doctor gives approval 6 week Postpartum 75 gm OGTT Yearly follow up on FBG and 2h OGTT every

3 years Carefully plan any further pregnancies

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Postpartum Weight LossPostpartum Weight LossPostpartum Weight LossPostpartum Weight Loss

Reasonable weight loss: 10% of body weight

Rapid weight loss after delivery Breastfeeding

Normal weight: 1-2 #/monthOverweight/obese: up to 4.5#/month

Reasonable weight loss: 10% of body weight

Rapid weight loss after delivery Breastfeeding

Normal weight: 1-2 #/monthOverweight/obese: up to 4.5#/month

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Diabetes Prevention Diabetes Prevention ProgramProgram

Diabetes Prevention Diabetes Prevention ProgramProgram

Women with a history of GDM ~12 years earlier + current IGT

Lifestyle recommendations: 150 min moderate activity/week + 7% wt loss

or Metformin 850mg bid

Ratner et al

Women with a history of GDM ~12 years earlier + current IGT

Lifestyle recommendations: 150 min moderate activity/week + 7% wt loss

or Metformin 850mg bid

Ratner et al

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Outcomes of DPP for Women Outcomes of DPP for Women with Hx of GDMwith Hx of GDM

Outcomes of DPP for Women Outcomes of DPP for Women with Hx of GDMwith Hx of GDM

Metformin: 50% risk reduction in development of DM2

Lifestyle: 53% risk reduction By year 3

GDM women had reduced activity to <30 min/wk

Wt loss - ~3.5 lb

Metformin: 50% risk reduction in development of DM2

Lifestyle: 53% risk reduction By year 3

GDM women had reduced activity to <30 min/wk

Wt loss - ~3.5 lb

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Utilize Sweet Success Utilize Sweet Success ResourcesResources

Utilize Sweet Success Utilize Sweet Success ResourcesResources

Educational tools CA Diabetes & Pregnancy Program

Materials Resource Center (858) 536-5090

Regional Consultants Sweet Success Directory

www.cdph.ca.gov/programs/CDAPP

Educational tools CA Diabetes & Pregnancy Program

Materials Resource Center (858) 536-5090

Regional Consultants Sweet Success Directory

www.cdph.ca.gov/programs/CDAPP

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ResourcesResourcesResourcesResources

Steps to Take: Gestational Diabetes (CPSP Guidelines) http://www.cdph.ca.gov/programs/CPSP/Pages/StepstoTakeHandbook.aspx

Daily Food Pyramid for Gestational Diabetes http://www.cdph.ca.gov/programs/cdapp/Documents/MO-CDAPP-FoodPyramidEng.pdf

First Step in Diabetes Meal Planning (ADA/ADA)

Steps to Take: Gestational Diabetes (CPSP Guidelines) http://www.cdph.ca.gov/programs/CPSP/Pages/StepstoTakeHandbook.aspx

Daily Food Pyramid for Gestational Diabetes http://www.cdph.ca.gov/programs/cdapp/Documents/MO-CDAPP-FoodPyramidEng.pdf

First Step in Diabetes Meal Planning (ADA/ADA)

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Resources Cont’d…Resources Cont’d…Resources Cont’d…Resources Cont’d…

American Dietetic Association www.eatright.org

California Dietetic Association www.dietitian.org

Diabetes education materials in different languages www.monarch.gsu.edu/multiculturalhealth

Nutrition education materials www.nutrition.gov

Food safety during pregnancy www.fsis.usda.gov

American Dietetic Association www.eatright.org

California Dietetic Association www.dietitian.org

Diabetes education materials in different languages www.monarch.gsu.edu/multiculturalhealth

Nutrition education materials www.nutrition.gov

Food safety during pregnancy www.fsis.usda.gov

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ResourcesResources ResourcesResources

California Diabetes Program: http://www.diabetescoaltionofcalifornia.org/

Diabetes Information Resource Center: http://www.caldiabetes.org/dirc.cfm

MyPyramid for pregnancy and breastfeeding: http://www.mypyramid.gov/mypyramidmoms/index.html

California Diabetes Program: http://www.diabetescoaltionofcalifornia.org/

Diabetes Information Resource Center: http://www.caldiabetes.org/dirc.cfm

MyPyramid for pregnancy and breastfeeding: http://www.mypyramid.gov/mypyramidmoms/index.html

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ReferencesReferencesReferencesReferences

Bodnar LM et al. Severe obesity, gestational weight gain, and adverse birth outcomes. AJCN 2010 91: 1642-48.

Ginde AA et al. Vitamin D insufficiency in pregnant and nonpregnant women of childbearing age in the United States. Obstet Gynecol May 2010, 436.e1-436.e8.

Kiel DW et al. Gestational Weight Gain and Pregnancy Outcomes in Obese Women. Obstet Gynecol 2007 Oct; 110 (4): 752-8.

ACOG Committee Opinion, Obstet Gynecol 2002 Jan; 99(1): 171-3

Bodnar LM et al. Severe obesity, gestational weight gain, and adverse birth outcomes. AJCN 2010 91: 1642-48.

Ginde AA et al. Vitamin D insufficiency in pregnant and nonpregnant women of childbearing age in the United States. Obstet Gynecol May 2010, 436.e1-436.e8.

Kiel DW et al. Gestational Weight Gain and Pregnancy Outcomes in Obese Women. Obstet Gynecol 2007 Oct; 110 (4): 752-8.

ACOG Committee Opinion, Obstet Gynecol 2002 Jan; 99(1): 171-3

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ReferencesReferencesReferencesReferences

Clapp JF. Morphometric and neurodevelopmental outcome at age five years of the offspring of women who continued to exercise regularly throughout pregnancy. J Pediatrics 1996; 129(6): 856-863

Jensen DM et al. Gestational Weight Gain and Pregnancy Outcomes in 481 Obese Glucose-Tolerant Women. Diab Care 2005; 28: 2118-2122

Wagner CL et al. “Vitamin D supplementation during Pregnancy Par 2 NICHD/CTSA Randomized Clinical Trial (RCT): Outcomes” Pediatric Academic Societies 2010; Abstract 1665.6

Clapp JF. Morphometric and neurodevelopmental outcome at age five years of the offspring of women who continued to exercise regularly throughout pregnancy. J Pediatrics 1996; 129(6): 856-863

Jensen DM et al. Gestational Weight Gain and Pregnancy Outcomes in 481 Obese Glucose-Tolerant Women. Diab Care 2005; 28: 2118-2122

Wagner CL et al. “Vitamin D supplementation during Pregnancy Par 2 NICHD/CTSA Randomized Clinical Trial (RCT): Outcomes” Pediatric Academic Societies 2010; Abstract 1665.6

3/4/11 98

ReferencesReferencesReferencesReferences

Moses RG et al. Can a Low-Glycemic Index Diet reduce the Need for Insulin in Gestational Diabetes? A randomized trial. Diabetes Care 2009; 32(6): 996-1000

Dornhurst A et al. Calorie restriction for treatment of gestational diabetes. Diabetes 1991; 40: ((Suppl 2)) 161-164.

Stuebe AM et al. Duration of Lactation and Incidence of Type 2 Diabetes. JAMA 2005; 294: 2601-2610

Moses RG et al. Can a Low-Glycemic Index Diet reduce the Need for Insulin in Gestational Diabetes? A randomized trial. Diabetes Care 2009; 32(6): 996-1000

Dornhurst A et al. Calorie restriction for treatment of gestational diabetes. Diabetes 1991; 40: ((Suppl 2)) 161-164.

Stuebe AM et al. Duration of Lactation and Incidence of Type 2 Diabetes. JAMA 2005; 294: 2601-2610

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ReferencesReferencesReferencesReferences

CDC Grand Rounds: vitamin D. www.cdc.gov/about/grand-rounds/archives/2010/08-August.htm

Schwarz BE et al. Lactation and maternal Risk of Type 2 Diabetes: A Population-based Study, Am J Med 2010: 863.e1-863.e6

Liu B et al, Parity, Breastfeeding, and the Subsequent Risk of Maternal Type 2 Diabetes, Diabetes Care 2010; 33: 1239-1241

CDC Grand Rounds: vitamin D. www.cdc.gov/about/grand-rounds/archives/2010/08-August.htm

Schwarz BE et al. Lactation and maternal Risk of Type 2 Diabetes: A Population-based Study, Am J Med 2010: 863.e1-863.e6

Liu B et al, Parity, Breastfeeding, and the Subsequent Risk of Maternal Type 2 Diabetes, Diabetes Care 2010; 33: 1239-1241

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ReferencesReferencesReferencesReferences

Mayer-Davis EJ et al. Breast-Feeding and Type 2 Diabetes in the Youth of Three Ethnic Groups. Diabetes Care 2008; 31: 470-475

Ratner RE et al. Prevention of Diabetes in Women with a History of Gestational Diabetes: Effects of Metformin and Lifestyle Interventions. J Clin Endocrinol Metab 2008; 93: 4774-4779

Mayer-Davis EJ et al. Breast-Feeding and Type 2 Diabetes in the Youth of Three Ethnic Groups. Diabetes Care 2008; 31: 470-475

Ratner RE et al. Prevention of Diabetes in Women with a History of Gestational Diabetes: Effects of Metformin and Lifestyle Interventions. J Clin Endocrinol Metab 2008; 93: 4774-4779