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Meal planning

Dr Mohammad Altamimi

m.altamimi@najah.edu

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Important of food

• Why we need food.• What parts of food do we need.• What is nutrition? nutrition science?• What are nutrients? Essential nutrients?• The six categories of nutrients• Food security?

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• Poor nutrition.• Malnutrition.• Groups at risk of in adequate nourishment. • Healthy diet• Are there goo foods and bad foods?• RDI, RDA• Diet reference intake DRI.• glycemic index GI

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Carbohydrate • Recommended intake of carbohydrates is

based on their contribution to total energy intake.

• It is recommended that 45–65% of calories come from carbohydrates.

• Added sugar should constitute no more than 25% of total caloric intake.

• It is recommended that adult females consume between 21 and 25 grams, and males 30–38 grams of total dietary fiber daily.

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Protein • Recommended Protein Intake • In general, proteins should contribute 10–35%

of total energy intake.• High quality protein, low quality protein.

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Fats (Lipids)

• In the past, it was recommended that Americans aim for diets providing less than 30% of total calories from fat.

• Evidence indicating that the type of fat consumed is more important to health than is total fat intake has changed this advice.

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Vitamins and Minerals

• Water

• Quantity of any nutrient is important to obtain optimal function.

• Optimal function during one stage most likely to affect performance in later stages.

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The Life-Course Approach to Nutrition and Health

• for example Lack of adequate nutrition during pregnancy,, can program gene functions for life in ways that set the stage for life-long metabolic changes that increase the risk of chronic-disease development.

• Iron deficiency experienced by young children can decrease intellectual capacity later in life.

• Vitamin D intake during childhood decrease incidence of type 1 diabetes.

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Meeting Nutritional Needs Across the Life Cycle

• Healthy individuals require the same nutrients through-out life.

• amounts of nutrients needed vary based on gender, growth and development and activities.

• Nutrient needs during each stage of the life cycle can be met through a variety of foods and food practices.

• There is no one best diet for everyone.

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Nutritional Assessment

• Nutritional status may be assessed for a population group or for an individual.

1. Community-Level Assessment:• key nutrition concerns and issues related to

food can be assessed by statistical data (level of obesity, infant mortality rate, heart disease) or for targeted group by school meals, family income, observation and direct questionnaire.

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2. Individual-Level Nutritional Assessment:• Nutritional assessment of individuals has four

major components:Clinical/physical assessment Dietary assessmentAnthropometric assessmentBiochemical assessment.All of these assessments are required to get clear picture about the nutritional state of an individual.

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• for example Data on height and weight provide information on weight status (BMI).

• knowledge of blood iron levels tells you something about iron status.

• On the other side It cannot be concluded that people who are normal weight or have good iron status are “well nourished.”

• Single measures do not describe a person’s nutritional status.

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• Clinical/physical Assessment A clinical/physical assessment involves visual inspection of a person by a trained dietitian or other qualified professional to note features that may be related to malnutrition.

• Excessive or inadequate body fat, paleness, bruises, and brittle hair are examples of features that may suggest nutrition-related problems.

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• Dietary Assessment:There different ways to assess diet such as :1. 24-Hour Dietary Recalls and Food records are completed by clients themselves. These are more accurate if the client has also received some training. Generally, the purpose of assessing an individual’s diet is to estimate the person’s overall diet quality so that strengths and weak-nesses can be identified, or to assess intake of specific nutrients that may be involved in disease states.

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2. Dietary History.Interview clients asking questions about food, types, most frequents, size of portions and last 24 hour intake.3. Food Frequency Questionnaires.Usually used in epidemiological studies.These tools are considered semiquantitative because they force people into describing food intake based on a limited number of food choices and portion sizes.

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• Anthropometric Assessment: • It is the science of measuring human body and

parts.• height, weight, percent body fat, bone density,

and head and waist circumferences, for example) are useful in the assessment of nutritional status—if done correctly.

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• Biochemical Assessment.• Nutrient and enzyme levels, DNA characteristics,

and other biological markers are components of a biochemical assessment of nutritional status.

• Which nutrition biomarkers are measured depends on what problems are suspected, based on other evidence.

• For example, a young child who tires easily, has a short attention span, and does not appear to be consuming sufficient iron based on dietary assessment results may have blood taken for analyses of hemoglobin and serum ferritin (markers of iron status).

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Guidelines

• MyPyramid.gov: • The Website A large assortment of

educational and assessment tools are available at the MyPyramid website (www.mypyramid.gov).

• Here are a few examples of the types of resources you can find:

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1. For Professionals link will • connect you to detailed information about using

MyPyramid educational materials and provides seven days of sample menus that correspond to MyPyramid recommendations for a 2000-calorie food pattern.

2. Inside the Pyramid • explains each food group, calories, and physical activity

recommendations. • It provides information on which foods are within the

various groups and food measure equivalents so you can convert food amounts into cups and ounces, and oils into teaspoons.

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3. MyPyramid Tracker is a dietary and physical activity assessment tool that provides information on your diet quality, physical activity status, and links to nutrient and physical activity information.4. MyPyramid Menu Planner • can be used to develop menus based on food preferences and calorie need.

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Homework

• Visit mypyramid web site and prepare a one day menu for a male 30 years, active. Weight 78 kg and height 168 cm.

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Preconception NutritionKeys :• Fertility is achieved and maintained by carefully

balanced, complex processes that can be disrupted by a number of factors related to body composition and dietary intake.

• Oral contraceptives and contraceptive implants can adversely affect some aspects of nutritional status.

• Optimal nutritional status prior to pregnancy enhances the likelihood of conception and helps ensure a healthy pregnancy and robust newborn.

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Sources of Disruptions in Fertility

• factors including adverse nutritional exposures, contraceptive use, severe stress, infection, tubal damage and other structural problems, and chromosomal abnormalities will partially or completely produce infertility.

Nutrition-Related Disruptions in Fertility• Nutrition and other lifestyle changes are now

viewed as a core component of the prevention and treatment of many cases of infertility.

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• Nutrient intake from food and dietary supplements, and body fat, affect fertility primarily by

• 1) altering the environment in which eggs and sperm develop.

• 2) modifying levels of hormones involved in reproductive processes.

• Nutrient intake and body fat before conception also influence the mother’s health during pregnancy and the growth and development of the fetus.

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1) Undernutrition and Fertility• Chronic Undernutrition (long term) • The primary effect of chronic undernutrition on

reproduction in women is the birth of small and frail infants who have a high likelihood of death in the first year of life.

• Acute Undernutrition (short term).• In 1st WW, Famine in Holland led to drop of birth

rate by 53%.• the 1974–1975 famine in Bangladesh resulted in

a 40% decline in births.

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2) Body Fat and Fertility• Excessive and inadequate levels of body fat are

related to declines in fertility in women and men.

• Body fat–related declines in fertility are primarily related to changes in hormone concentrations.

• In obese individuals, increased levels of oxidative stress and exposure of eggs and sperm to oxidative damage are also related to infertility.

• Most obese women and men are not infertile.

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• Obese women tend to have higher levels of estrogen, androgens, and leptin than non–obese women.

• These hormonal changes favor the development of menstrual-cycle irregularity (it occurs in 30 to 47% of overweight and obese women), ovulatory failure and anovulatory cycles, and amenorrhea.

• Obesity in men is associated with lower levels of testosterone and increased estrogen and leptin levels.

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Cystic fibrosis• Cystic fibrosis is a disease causes thick, sticky mucus

to build up in the lungs, digestive tract, and other areas of the body. It is one of the most common chronic lung diseases in children and young adults. It is a life-threatening disorder.

• Causes• Cystic fibrosis (CF) is caused by a defective gene

which causes the body to produce abnormally thick and sticky fluid, called mucus.

• The disease may also affect the sweat glands and a man's reproductive system.

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What is polycystic ovary syndrome (PCOS)?

• Polycystic ovary syndrome (PCOS) is a health problem that can affect a woman's:

• Menstrual cycle, Ability to have children, Hormones, Heart, Blood vessels, and Appearance.

• What causes PCOS?• hormonal imbalance, Researchers also

think insulin may be linked to PCOS. Excess insulin appears to increase production of androgen

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• The existence of excessive body fat is generally indicated by body mass index values over 30kg/m2

• Infertility treatments, such as the use of drugs to induce ovulation, are less effective in obese than in normal-weight women.

• Loss of body fat is related to improvements in hormone levels, reduced oxidative stress, and improved conception rates.

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• level of body fat usually indicated by a body mass index over 20 kg/m2 is needed to trigger and sustain normal reproductive functions in women.

• Weight Loss and Fertility in Normal-Weight Women and Men:

• It is estimated that about 30% of cases of impaired fertility are related to simple weight loss.

• Weight gain is the recommended first-line treatment for amenorrhea related to low body weight

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Homework

• What is amenorrhea.• Case study 2.1 Weight loss and amenorrhea Page 59

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Caffeine and Fertility• Two studies showed:• women who consumed over 4 cups of coffee

per day (>500 mg caffeine)were less by 50% to be pregnant.

• Another study reported that intake of over 300 mg of caffeine daily from coffee, sodas, and tea decreased the chance of conceiving by 27%.

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Recommended Dietary Intakes for Preconceptional Women

• It is recommended that women who may become pregnant to:

(1) consume 400 mcg of folate from fortified grain products, vegetables, fruits, or supplements(2) take no more than 5000 IU of vitamin A (retinol or retinoic acid) from supplements daily.(3) limit or omit alcohol-containing beverages.

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Eating Disorders and Fertility

• Anorexia Nervosa (anorexia = poor appetite; nervosa = mental disorder)

• A disorder characterized by extreme underweight, malnutrition, amenorrhea, low bone density, irrational fear of weight gain, restricted food intake, hyperactivity, and disturbances in body image.

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• Bulimia Nervosa (bulimia = ox hunger) • A disorder characterized by repeated bouts of

uncontrolled, rapid ingestion of large quantities of food (binge eating) followed by self-induced vomiting, laxative or diuretic use, fasting, or vigorous exercise in order to prevent weight gain.

• Binge eating is often followed by feelings of disgust and guilt.

• Menstrual cycle abnormalities may accompany this disorder.

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Nutritional Management of Women with Anorexia Nervosa or Bulimia Nervosa

• The primary therapeutic goal for anorexia nervosa is normalization of body weight, and for bulimia nervosa, normalization of eating behaviors.

• Recommended treatment for anorexia nervosa involves long-term, multidisciplinary services.

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Disorders of Metabolism1. Phenylketonuria (PKU):• Phenylketonuria (also called hyperphenyl

alaninemia) is the most frequently inherited disorder of amino-acid metabolism and one of the few preventable causes of mental retardation.

• It occurs in roughly 1 in 10,000 individuals.• It is important that infants born with PKU be

identified and started on low-phenylalanine formula as soon after birth as possible.

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Nutritional Management of PKU• PKU can be successfully managed by a low-

phenylalanine diet, instituted and monitored with the help of an experienced dietitian.

• PKU diets are individualized based on blood phenylalanine response to protein foods.

• Successful PKU diets maintain blood concentrations of phenylalanine in the range of 120–360 μmol/L (2–6 mg/dL).

• High phenylalanine protein foods such as meat, fish, eggs, and wheat are excluded from the diet

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• The formulated products are generally fortified with tyrosine, vitamins, and minerals.

• Vegetables, fruits, fats, sugars and high-carbohydrate foods, and phenylalanine-free breads, flour, and pasta are included in the diet.

• Milk is allowed if needed to maintain a minimal blood phenylalanine level.

• The PKU diet should be followed throughout life. It takes 4-6 months to lower down Phenylalanine level in the blood.

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Celiac

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2) Celiac Disease:

• An autoimmune disease that causes malabsorption due to an inherited sensitivity to the gliadin portion of gluten in wheat, rye, and barley.

• It is often responsible for iron, folate, zinc, and other deficiencies.

• In females, untreated celiac disease is associated with amenorrhea, increased rates of miscarriage, fetal growth restriction, low birth-weight deliveries, and a short duration of lactation.

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Nutritional Management of Celiac Disease

• Treatment of celiac disease centers on the goals of elimination of gluten from the diet, correction of vitamin and mineral deficiencies, and the long-term maintenance of health.

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Nutrition During PregnancyKey Nutrition Concepts:• Many aspects of nutritional status, such as dietary intake,

supplement use, and weight change, influence the course and outcome of pregnancy.

• The fetus is not a parasite; it depends on the mother’s nutrient intake to meet its nutritional needs.

• Periods of rapid growth and development of fetal organs and tissues occur during specific times throughout pregnancy. Essential nutrients must be available in required amounts during these times for fetal growth and development to proceed optimally.

• The risk of heart disease, diabetes, hypertension, and other health problems during adulthood may be influenced by maternal nutrition during pregnancy.

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Terminology

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Physiology of Pregnancy• Changes in maternal physiology during pregnancy

are so profound that they were previously considered abnormal and in need of correction.

• We now know that what is considered normal physiological status of non-pregnant women cannot be considered normal for women who are pregnant.

• Changes in maternal body composition and functions occur in a specific sequence during pregnancy. The order of the sequence is absolute because the successful completion of each change depends on the one before it.

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Normal Physiological Changes During Pregnancy

• Physiological changes in pregnancy can be divided into two basic groups:

• those occurring in the first half of pregnancy and those in the second half.

• In general, physiological changes in the first half are considered “maternal anabolic” changes because they build the capacity of the mother’s body to deliver relatively large quantities of blood, oxygen, and nutrients to the fetus in the second half of pregnancy.

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• The second half is a time of “maternal catabolic” changes in which energy and nutrient stores, and the heightened capacity to deliver stored energy and nutrients to the fetus.

• Approximately 10% of fetal growth is accomplished in the first half of pregnancy, and the remaining 90% occurs in the second half.

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• Body Water Changes • A woman’s body gains a good deal of water

during pregnancy, primarily due to in-creased volumes of plasma and extracellular fluid, as well as amniotic fluid.

• Total body water increases in pregnancy range from 7 to 10 liters.

• Birth weight is strongly related to plasma volume: generally, the greater the expansion, the greater the newborn size.

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• Hormonal Changes • Many physiological changes in pregnancy are

modulated by hormones produced by the placenta.

• The placenta is also the main supplier of many other hormones needed to support the physiological changes of pregnancy.

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• Maternal Nutrient Metabolism• Many of the metabolic adjustments are

directed toward ensuring that nutrients will be available to the fetus during periods of high nutrient need.

• Because normal fetal tissue growth and development are genetically timed, nutrients must be available at the same time that genes controlling fetal growth and development are expressed.

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• Carbohydrate Metabolism:• Adjustments are made to make sure the

availability of glucose to the fetus. • Glucose is the fetus’s preferred fuel, even though

fats can be utilized for energy.• Continued availability of a fetal supply of glucose

is accomplished primarily through metabolic changes that promote maternal insulin resistance.

• These changes, sometimes referred to as the diabetogenic effect of pregnancy, make normal pregnant women slightly carbohydrate intolerant in the third trimester of pregnancy.

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• Protein Metabolism:• There is no evidence, however, that the

mother’s body stores protein early in pregnancy in order to meet fetal needs for protein later in pregnancy.

• Maternal and fetal needs for protein are primarily fulfilled by the mother’s intake of protein during pregnancy.

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• Fat Metabolism • changes in lipid metabolism promote the

accumulation of maternal fat stores in the first half of pregnancy and enhance fat mobilization in the second half.

• In addition to seeing increasing maternal reliance on fat stores for energy as pregnancy progresses.

• we see blood levels of many lipoproteins increase dramatically.

• Plasma triglyceride levels increase first and most dramatically, reaching three times nonpregnant levels by term.

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• High concentrations of cholesterol and triglycerides observed during pregnancy do not promote the development of atherosclerosis.

• By the third trimester of pregnancy, most women have a lipid profile that would be considered atherogenic, if not for pregnancy.

• These blood lipid changes are normal, however, which is why blood lipid screening is not recommended during pregnancy.

• Normal changes in blood lipid levels during pregnancy appear to be unrelated to maternal dietary intake

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• Mineral Metabolism • Impressive changes in mineral metabolism occur

during pregnancy.• Calcium metabolism is characterized by an

increased rate of bone turn-over and reformation.

• Elevated levels of body water and tissue synthesis during pregnancy are accompanied by increased requirements for sodium and other minerals.

• High blood pressure may occur due to sodium retention.

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• Sodium restriction (by diet) may overstress mechanisms that act to conserve sodium and lead to functional and growth impairments due to sodium depletion.

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Embryonic and Fetal Growth and Development

• Growth and development during gestation is the fastest in the human life.

• Growth• Increase in an organism’s size through cell

multiplication (hyperplasia) and enlargement of cell size (hypertrophy).

• Development• Progression of the physical and mental capabilities

of an organism through growth and differentiation of organs and tissues, and integration of functions

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Critical Periods of Growth and Development

• Why is it crucial to know them?• critical periods represent a “one-way street,”

because it is not possible to reverse directions and correct errors in growth or development that occurred during a previous critical period.

• Consequently, adverse effects of nutritional and other insults occurring during critical periods of growth and development persist throughout life.

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• The brain is the first organ that develops in humans, and along with the rest of the central nervous system, it is given priority access to energy, nutrient, and oxygen supplies.

• Thus, in conditions of low energy, nutrient, and oxygen availability, the needs of the central nervous system will be met before those of other fetal tissues such as the liver or muscles.

• The heart and adrenal glands come next after the central nervous system in the hierarchy of targets for preferential nutrient delivery

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• Deficits or excesses in nutrients supplied to the embryo and fetus during critical periods of cell multiplication can produce lifelong defects in organ and tissue structure and function.

• The organ or tissue undergoing critical periods of growth at the time of the adverse exposure will be affected most.

• For example, the neural tube develops into the brain and spinal cord during weeks 3 and 4 after conception.

• If folate supplies are inadequate during this critical period of growth, permanent defects in brain or spinal cord formation occur, regardless of folate availability at other times

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Nutrition, Miscarriages, and Preterm Delivery

Miscarriages • Over 30% of implanted embryos are lost by

reabsorption into the uterus or expulsion before 20 weeks of conception. Roughly a third of these losses are recognized as a miscarriage.

• Women who enter pregnancy under-weight are at higher risk of miscarriage than are normal and overweight women.

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Preterm Delivery• Infants born preterm are at greater risk than

other infants of death, neurological problems reflected later in low IQ scores, congenital malformations, and chronic health problems such as cerebral palsy.

Cerebral Palsy A group of disorders characterized by impaired muscle activity and coordination present at birth or developed during early childhood.

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• Underweight women who gain less than the recommended amount of weight during pregnancy are at particularly high risk for preterm delivery.

• Women entering pregnancy obese are also at increased risk, but to a lesser extent than is the case for underweight women.

• Studies have identified a protective effect of multivitamin supplement use before pregnancy on preterm delivery.

• Additionally, it appears that women who exercise during pregnancy are at lower risk of preterm delivery than are women who do not exercise.

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Pregnancy Weight Gain• Weight gain during pregnancy is an indicator

of plasma volume expansion and positive calorie balance, and provides a rough index of dietary adequacy.

• 7 kg weight gain will give 3.1 kg baby while 13.6 kg weight gain will give 3.6 kg baby.

• Psychological and sociological factors play major role on how much weight to be gained.

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Pregnancy Weight Gain Recommendations

• Current recommendations for weight gain in pregnancy are based primarily on gains associated with the birth of healthy-sized newborns (approximately 3500–4500 g or 7 lb 13 oz to 10 lb).

• Mother’s weight affect the relationship on how much weight gain is recommended.

• The higher the weight before pregnancy, the lower the weight gain needed to produce healthy-sized infants.

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Nutrient Needs During Pregnancy

• Nutrient requirements during pregnancy are not static.

• They vary during the course of pregnancy depending on prepregnancy nutrient stores, body size and composition, physical activity levels, stage of pregnancy, and health status.

• studies showed that diet quality during pregnancy was strongly related to newborn health status.

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The Need for Energy

• Approximately one-third of the increased calorie need in pregnancy is related to increased work of the heart, and another third to increased energy needs for respiration and accretion of breast tissue, uterine muscles, and the placenta.

• The fetus accounts for about a third of the increased energy needs of pregnancy.

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• The DRIs for energy intake for pregnancy are +340 kcal per day for the second trimester and +452 kcal per day for the third trimester of pregnancy.

• Approximately 50–60% of total caloric intake during pregnancy should come from carbohydrates.

• Women should consume a minimum of 175 grams carbohydrates to meet the fetal brain’s need for glucose.

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• Basic foods such as vegetables, fruits, and whole-grain products containing fiber and a variety of other nutrients are good choices for high-carbohydrate foods.

• sources of carbohydrates that do not con-tain added sugars and fat tend to be less energy-dense than foods that do and may help women manage pregnancy weight gain.

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Homework

• Are artificial sweeteners good or bad for pregnant woman?

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• The recommended protein intake for pregnancy is +25 grams per day, or 71 grams daily (total protein), and as 1.1 gram/kg body weight, for females aged 14 and older.

• Protein requirements in vegetarians whose main source of protein is cereals and legumes may be 30% higher than for non-vegetarians due to the low digestibility of protein in these foods.

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• It is estimated that pregnant women consume, on average, 33% of total calories from fat.

• It is recommended that pregnant women consume 13 grams of the essential fatty acid linoleic acid daily (omega-6), and 1.4 grams of the other essential fatty acid, alpha-linolenic acid (omega-3).

• Omega-3 is converted to EPA DHA.• An adequate intake of EPA and DHA during

pregnancy is estimated to be 250 mg or more per day.

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The Need for Water• On average, women consume about 9 cups of

fluid daily during pregnancy.• Women who engage in physical activity in hot

and humid climates should drink enough to keep urine light-colored and normal in volume.

• Water, diluted fruit juice, iced tea, and other un-sweetened beverages are good choices for staying hydrated.

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The Need for Vitamins and Minerals During Pregnancy

• It is now well accepted that inadequate availability of folate between 21 and 27 days after conception (when the embryo is only 2–3 mm in length) can interrupt normal cell differentiation and cause Neural-tube defects NTDs.

• Recommended Intake of Folate:• DFE : dietary folate equivalent. Due to

variability in bioavailability.

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One DFE equals any of the following:• 1 mcg food folate. (50% bioavalability).• 0.6 mcg folic acid consumed in fortified foods or a

supplement taken with food.• 0.5 mcg of folic acid taken as a supplement on an

empty stomach. (100% bioavailabilty).• It is recommended that women consume 600 mcg

DFE of folate per day during pregnancy which include:• 400 mcg folic acid from fortified foods or

supplements.• The remaining 200 mcg DFE should be obtained from

vegetables and fruits.

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• Vitamin A • Vitamin A is a key nutrient in pregnancy

because it plays important roles in reactions involved in cell differentiation.

• Due to the potential toxicity of retinol, it is recommended that women take no more than 5,000 IU of vitamin A as retinol from supplements during pregnancy.

• excessive intakes of vitamin A in the form of retinol or retinoic acid 10,000 IU cause fetal abnormalities.

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• Vitamin D • Vitamin D supports fetal growth, the addition of

calcium to bone, and tooth and enamel formation.

• Lack of a sufficient supply of vitamin D during pregnancy compromises fetal as well as childhood bone development.

• An intake of 5 mcg (200 IU) vitamin D daily is officially recommended for pregnancy.

• The current upper limit for vitamin D intake from foods and supplements is 50 mcg (2000 IU) daily

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The DRI for• Calcium 1000 mg• Iron• women require about 1000 mg (1 g) of additional

iron for pregnancy. 300 mg is used by the fetus and placenta. 250 mg is lost at delivery. 450 mg is used to increase red blood cell mass.• average iron consumption of 27 mg per day will

meet the iron needs of pregnancy. • The Upper Limit for iron intake during pregnancy is

set at 45 mg per day

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• iodine 220 mcg daily.

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Healthy Diets for Pregnancy

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Effect of Taste and Smell Changes on Dietary Intake During Pregnancy

• Changes in the way certain foods taste, and the odor of foods and other substances, affect two out of three women during pregnancy.

• Pica: An eating disorder characterized by the compulsion to eat substances that are not food. It affects half of pregnant women.

• Women experiencing pica are more likely to be iron deficient than those who don’t.

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Assessment of Nutritional Status During Pregnancy

• nutrition assessment in pregnancy includes an evaluation of dietary intake, weight status, biomarkers of nutrient status, food preferences and resources, previous pregnancy and health history, and dietary supplement use.

• Dietary assessment:• Dietary assessment in pregnancy should cover

usual dietary intake, dietary supplement use, and weight-gain progress

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• Nutrition Biomarker Assessment• Nutrition assessment of pregnant women

usually includes laboratory tests of iron status, and will include tests to determine the status of other nutrients as indicated.

• Blood nu-trient concentrations change with time during pregnancy, so no one value per nutrient for all of pregnancy accurately reflects status.

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Nutritional Management of Women with Gestational Diabetes

• Management of blood glucose concentrations with diet and exercise is considered successful when fasting blood glucose values remain at 95 mg/dL or less, or when 1-hour postprandial values are 140 mg/dL or less and 2-hour postprandial levels are 120 mg/dL or less.

• Insulin is recommended when fasting glucose levels or when 1- and 2-hour postprandial glucose values exceed these cut-points.

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• The following are components of the nutritional management of women with gestational diabetes:

• Assessing dietary habits and exercise habits. • Developing an individualized diet and exercise

plan for blood glucose control• Monitoring weight gain, dietary intake.• Interpreting blood glucose and urinary ketone

results. • Ensuring follow-up during pregnancy and

postpartum.

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The Diet Plan:• In general, diets developed for women with

gestational diabetes emphasize:• Whole-grain breads and cereals, vegetables,

fruits and high-fiber foods.• Limited intake of simple sugars and foods and

beverages that contain them.• Low-GI foods, or high fiber carbohydrate foods

that do not greatly raise glucose levels• Unsaturated fats• Three regular meals and snacks daily

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Nutritional Recommendations for Women with Multifetal Pregnancy

• caloric needs for twin pregnancy can be extrapolated from weight gain.

• Theoretically, to achieve a 40-pound (18.2 kg) weight gain, or 10 pounds (4.5 kg) more than in singleton pregnancy, women with twins would need to consume about 150 cal per day above the level for singleton pregnancy.

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