Dietary fiber intakes and insulin requirements in pregnant women with type 1 diabetes

Management of type 1 diabetes in pregnancy: update on lifestyle, pharmacological treatment, and novel technologies for achieving glycaemic targets

Glucose concentrations within target, appropriate gestational weight gain, adequate lifestyle, and, if necessary, antihypertensive treatment and low-dose aspirin reduces the risk of pre-eclampsia, preterm delivery, and other adverse pregnancy and neonatal outcomes in pregnancies complicated by type 1 diabetes. Despite the increasing use of diabetes technology (ie, continuous glucose monitoring and insulin pumps), the target of more than 70% time in range in pregnancy (TIRp 3·5-7·8 mmol/L) is often reached only in the final weeks of pregnancy, which is too late for beneficial effects on pregnancy outcomes. Hybrid closed-loop (HCL) insulin delivery systems are emerging as promising treatment options in pregnancy. In this Review, we discuss the latest evidence on pre-pregnancy care, management of diabetes-related complications, lifestyle recommendations, gestational weight gain, antihypertensive treatment, aspirin prophylaxis, and the use of novel technologies for achieving and maintaining glycaemic targets during pregnancy in women with type 1 diabetes. In addition, the importance of effective clinical and psychosocial support for pregnant women with type 1 diabetes is also highlighted. We also discuss the contemporary studies examining HCL systems in type 1 diabetes during pregnancies.

Self-management education among women with pre-existing diabetes in pregnancy: A scoping review

BACKGROUND

Education is a cornerstone of self-management for adults with diabetes. Self-management is particularly important during pregnancy for women with type 1 and type 2 diabetes, as perinatal outcomes are affected by maternal glycemic control. To our knowledge, literature describing the provision of diabetes education and support during pregnancy for women with type 1 and type 2 diabetes has not been synthesized, nor examined within its context as a complex intervention.

OBJECTIVES AND DESIGN

This scoping review aims to synthesize the evidence regarding prenatal diabetes education and support for women with type 1 and type 2 diabetes and to apply the Medical Research Council framework for complex interventions where appropriate.

DATA SOURCES AND METHODS

We searched EMBASE, CINAHL, and MEDLINE from inception to February 2019 for primary studies focused on prenatal diabetes education among women with type 1 and type 2 diabetes. Two independent reviewers screened eligible studies against inclusion criteria. A narrative synthesis of the included studies was conducted.

RESULTS

Of 511 identified citations, 30 studies were included in the final review. Approximately 44% of the pooled sample were women with type 1 diabetes, 46% had gestational diabetes mellitus, and 10% had type 2 diabetes. Education focused on self-monitoring of blood glucose, attaining glycemic targets, and following a healthy diet. Many studies included educational elements that went beyond traditional didactic teaching and promoted self-management skills and self-management support. The majority of education was delivered via one-on-one outpatient appointments every one to three weeks. About half of the reviewed studies used a multidisciplinary team approach, with most including a combination of physicians, nurses, dietitians, and midwives. Application of the Medical Research Council framework revealed that most studies were limited in methods (i.e., randomization) and few examined process evaluation or intervention cost-effectiveness.

CONCLUSION

We identified a lack of studies centred on educational interventions for women with type 2 diabetes in pregnancy. As pregnancy for women with type 2 diabetes involves significant changes, including the transition from oral hypoglycemics to insulin therapy, often without exposure to diabetes-specific preconception care and counselling, future research may focus on optimizing preconception and prenatal education and support for this high-risk group. This is particularly relevant as the prevalence of type 2 diabetes is increasing worldwide. Future research ought to also design, implement and evaluate interventions in accordance with the Medical Research Council framework for complex interventions.

Dietary intakes of women with Type 1 diabetes before and during pregnancy: a pre-specified secondary subgroup analysis among CONCEPTT participants

AIM

To describe the dietary intakes of women with Type 1 diabetes before and during pregnancy.

METHODS

This was a pre-specified subgroup analysis of CONCEPTT involving 63 women planning pregnancy and 93 pregnant women from 14 sites in England, Scotland and Ireland. Two hundred and forty-six 3-day food diaries (104 planning pregnancy, 142 pregnant) were matched to data source and food reference codes, and analysed using dietary software. Participants were informed that food diaries would be de-identified and used only for research purposes.

RESULTS

Mean (sd) daily energy intake was 1588 (346) kcal and 1673 (384) kcal in women planning pregnancy and pregnant women respectively. Total carbohydrate intake was consistent with dietary guideline recommendations [180 (52) g planning pregnancy, 198 (54) g pregnant], but non-recommended sources (e.g. sugars, preserves, confectionery, biscuits, cakes) contributed to 46% of total daily carbohydrate intake. Fat consumption exceeded guideline recommendations [70 (21) g planning pregnancy, 72 (21) g pregnant]. Fibre [15.5 (5.3) g planning pregnancy, 15.4 (5.1) g pregnant], fruit and vegetable intakes [3.5 (2.2) and 3.1 (1.8) serves/day] were inadequate. Twelve women planning pregnancy (19%) and 24 pregnant women (26%) did not meet micronutrient requirements.

CONCLUSIONS

The diets of pregnant women from England, Scotland and Ireland are characterized by high fat, low fibre and poor-quality carbohydrate intakes. Fruit and vegetable consumption is inadequate, with one in four women at risk of micronutrient deficiencies. Further research is needed to optimize maternal nutrition for glycaemic control and for maternal and offspring health.

Pregnant women have inadequate fiber intake while consuming fiber-rich diets in low-income rural setting: Evidences from Analysis of common "ready-to-eat" stable foods

The intake of fiber-rich foods during pregnancy has several health benefits to the pregnant woman including lowering the risks of diabetes, preeclampsia, and constipation. However, little is known about the content, daily intake levels, and adequacy of fiber among pregnant women in many low-income settings. We aimed to identify common food items and determine adequacy of dietary fiber intake levels among pregnant women in rural Ethiopia. Dietary data were collected from a subsample (n = 55) of pregnant women enrolled to a larger prospective cohort study (n = 414). Dietary intake level was measured using repeated 24-hr dietary recall method and weighing the total amount of daily food. Fiber content was determined using the Weende method supplemented by other sources.The mean [±SD] dietary fiber intake level was 25.89 [±5.09 mg/g] per day, which declined across pregnancy trimester from 26.01 [±9.18 mg/g] to 22.67 [±9.01 mg/g] and 24.56 [±9.98 mg/g] during the first, to second and third pregnancy trimesters, respectively. Boiled cereals and coffee contributed to nearly two-thirds (63.2%) of the daily fiber intake, while the major bulk of daily food, enjera, contributed to less than a quarter (24.3%) of the fiber intake. Though dietary patterns favor diversified intake for fiber, the mean intake levels below the recommended levels and proportion of women getting adequate to the physiologic stages of pregnancy were inadequate compared to the standard. Mothers, in such community, could benefit from increasing overall intake of existing food to satisfy their fiber needs during pregnancy.

Dietary roles of non-starch polysaccharides in human nutrition: a review

Nonstarch polysaccharides (NSPs) occur naturally in many foods. The physiochemical and biological properties of these compounds correspond to dietary fiber. Nonstarch polysaccharides show various physiological effects in the small and large intestine and therefore have important health implications for humans. The remarkable properties of dietary NSPs are water dispersibility, viscosity effect, bulk, and fermentibility into short chain fatty acids (SCFAs). These features may lead to diminished risk of serious diet related diseases which are major problems in Western countries and are emerging in developing countries with greater affluence. These conditions include coronary heart disease, colo-rectal cancer, inflammatory bowel disease, breast cancer, tumor formation, mineral related abnormalities, and disordered laxation. Insoluble NSPs (cellulose and hemicellulose) are effective laxatives whereas soluble NSPs (especially mixed-link β-glucans) lower plasma cholesterol levels and help to normalize blood glucose and insulin levels, making these kinds of polysaccharides a part of dietary plans to treat cardiovascular diseases and Type 2 diabetes. Moreover, a major proportion of dietary NSPs escapes the small intestine nearly intact, and is fermented into SCFAs by commensal microflora present in the colon and cecum and promotes normal laxation. Short chain fatty acids have a number of health promoting effects and are particularly effective in promoting large bowel function. Certain NSPs through their fermented products may promote the growth of specific beneficial colonic bacteria which offer a prebiotic effect. Various modes of action of NSPs as therapeutic agent have been proposed in the present review. In addition, NSPs based films and coatings for packaging and wrapping are of commercial interest because they are compatible with several types of food products. However, much of the physiological and nutritional impact of NSPs and the mechanism involved is not fully understood and even the recommendation on the dose of different dietary NSPs intake among different age groups needs to be studied.

The impact of gestational weight gain and diet on abnormal glucose tolerance during pregnancy in Hispanic women

OBJECTIVE

To examine the association of gestational weight gain and dietary factors with abnormal glucose tolerance (AGT).

METHODS

We conducted a prospective cohort study among 813 Hispanic prenatal care patients in Massachusetts. Gestational weight gain and oral glucose tolerance test results were abstracted from medical records. Dietary intake was assessed using a semi-quantitative food frequency questionnaire. Target weight gain was based on BMI-specific weekly weight gain rates established by the Institute of Medicine (IOM).

RESULTS

We observed a statistically significant interaction between prepregnancy BMI and weight gain in relation to AGT (P < 0.01). Class II/III (BMI > or = 35 kg/m2) obese women who had a high rate of weight gain (>0.30 kg/week) or who exceeded target weight were 3-4 times as likely to develop AGT compared to women who gained within IOM ranges (OR = 4.2, 95% CI 1.1-16.0, OR = 3.2 95% CI 1.0-10.5, respectively). Decreasing levels of saturated fatty acids and energy-dense snack foods and increasing levels of fiber and polyunsaturated:saturated fat ratio were significantly associated with decreased risk of AGT, independent of gestational weight gain [corrected].

CONCLUSIONS

Weight gain among class II/III obese women and certain dietary components may represent modifiable risk factors for AGT.

High-methoxyl pectin has greater enhancing effect on glucose uptake in intestinal perfused rats

OBJECTIVE

Pectins have been known to decrease blood glucose levels. However, the mechanism of this effect is unclear. The direct action of various pectins (high- or low-methoxyl pectins) on the intestinal absorption of glucose was investigated in gut-perfused rats.

METHODS

After equilibrium, jejunal and ileal segments were simultaneously perfused with an isotonic electrolyte solution (pH 7.4) containing glucose (10 mM/L) and high- or low-methoxyl pectins (10 g/L). Each test or control solution was perfused in a random sequence, with perfusion times of 30 min. Changes in glucose concentration of perfusate solution reservoir were determined over the experimental period.

RESULTS

High- and low-methoxyl pectins in the perfusate significantly inhibited jejunal uptake of glucose compared with the control (P < 0.05). High-methoxyl pectins had greater inhibitive effect on intestinal absorption of glucose than low-methoxyl pectins. The observed changes in glucose and water absorptions caused by high- or low-methoxyl pectins were reversible by switching to a pectin-free perfusate. In addition, net water absorption changed to secretion after addition of high- or low-methoxyl pectins.

CONCLUSIONS

These results suggest that the decrease in intestinal absorption of glucose observed after perfusion of high- or low-methoxyl pectins may be caused by viscosity-related increases in mucosal unstirred layer thickness.

Position of the American Dietetic Association: health implications of dietary fiber

Dietary fiber consists of the structural and storage polysaccharides and lignin in plants that are not digested in the human stomach and small intestine. A wealth of information supports the American Dietetic Association position that the public should consume adequate amounts of dietary fiber from a variety of plant foods. Recommended intakes, 20-35 g/day for healthy adults and age plus 5 g/day for children, are not being met, because intakes of good sources of dietary fiber, fruits, vegetables, whole and high-fiber grain products, and legumes are low. Consumption of dietary fibers that are viscous lowers blood cholesterol levels and helps to normalize blood glucose and insulin levels, making these kinds of fibers part of the dietary plans to treat cardiovascular disease and type 2 diabetes. Fibers that are incompletely or slowly fermented by microflora in the large intestine promote normal laxation and are integral components of diet plans to treat constipation and prevent the development of diverticulosis and diverticulitis. A diet adequate in fiber-containing foods is also usually rich in micronutrients and nonnutritive ingredients that have additional health benefits. It is unclear why several recently published clinical trials with dietary fiber intervention failed to show a reduction in colon polyps. Nonetheless, a fiber-rich diet is associated with a lower risk of colon cancer. A fiber-rich meal is processed more slowly, which promotes earlier satiety, and is frequently less calorically dense and lower in fat and added sugars. All of these characteristics are features of a dietary pattern to treat and prevent obesity. Appropriate kinds and amounts of dietary fiber for the critically ill and the very old have not been clearly delineated; both may need nonfood sources of fiber. Many factors confound observations of gastrointestinal function in the critically ill, and the kinds of fiber that would promote normal small and large intestinal function are usually not in a form suitable for the critically ill. Maintenance of body weight in the inactive older adult is accomplished in part by decreasing food intake. Even with a fiber-rich diet, a supplement may be needed to bring fiber intakes into a range adequate to prevent constipation. By increasing variety in the daily food pattern, the dietetics professional can help most healthy children and adults achieve adequate dietary fiber intakes.