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Dietary Advice to Support Glycaemic Control and Weight Management in Women with Type 1 Diabetes during Pregnancy and Breastfeeding. Nutrients 2022; 14:nu14224867. [PMID: 36432552 PMCID: PMC9692490 DOI: 10.3390/nu14224867] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022] Open
Abstract
In women with type 1 diabetes, the risk of adverse pregnancy outcomes, including congenital anomalies, preeclampsia, preterm delivery, foetal overgrowth and perinatal death is 2-4-fold increased compared to the background population. This review provides the present evidence supporting recommendations for the diet during pregnancy and breastfeeding in women with type 1 diabetes. The amount of carbohydrate consumed in a meal is the main dietary factor affecting the postprandial glucose response. Excessive gestational weight gain is emerging as another important risk factor for foetal overgrowth. Dietary advice to promote optimized glycaemic control and appropriate gestational weight gain is therefore important for normal foetal growth and pregnancy outcome. Dietary management should include advice to secure sufficient intake of micro- and macronutrients with a focus on limiting postprandial glucose excursions, preventing hypoglycaemia and promoting appropriate gestational weight gain and weight loss after delivery. Irrespective of pre-pregnancy BMI, a total daily intake of a minimum of 175 g of carbohydrate, mainly from low-glycaemic-index sources such as bread, whole grain, fruits, rice, potatoes, dairy products and pasta, is recommended during pregnancy. These food items are often available at a lower cost than ultra-processed foods, so this dietary advice is likely to be feasible also in women with low socioeconomic status. Individual counselling aiming at consistent timing of three main meals and 2-4 snacks daily, with focus on carbohydrate amount with pragmatic carbohydrate counting, is probably of value to prevent both hypoglycaemia and hyperglycaemia. The recommended gestational weight gain is dependent on maternal pre-pregnancy BMI and is lower when BMI is above 25 kg/m2. Daily folic acid supplementation should be initiated before conception and taken during the first 12 gestational weeks to minimize the risk of foetal malformations. Women with type 1 diabetes are encouraged to breastfeed. A total daily intake of a minimum of 210 g of carbohydrate is recommended in the breastfeeding period for all women irrespective of pre-pregnancy BMI to maintain acceptable glycaemic control while avoiding ketoacidosis and hypoglycaemia. During breastfeeding insulin requirements are reported approximately 20% lower than before pregnancy. Women should be encouraged to avoid weight retention after pregnancy in order to reduce the risk of overweight and obesity later in life. In conclusion, pregnant women with type 1 diabetes are recommended to follow the general dietary recommendations for pregnant and breastfeeding women with special emphasis on using carbohydrate counting to secure sufficient intake of carbohydrates and to avoid excessive gestational weight gain and weight retention after pregnancy.
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Kachaner A, Rives-Lange C, Radu A, Czernichow S, Ranque B, Pouchot J, Lafont E. Ketoacidosis in a non-diabetic lactating woman: A case report and literature review. Eur J Clin Nutr 2021; 76:775-777. [PMID: 34675399 DOI: 10.1038/s41430-021-01013-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 09/15/2021] [Indexed: 11/09/2022]
Abstract
We report the case of a 36-year-old woman who developed non-diabetic ketoacidosis following a low carbohydrate diet in order to lose weight while actively breast feeding her newborn. She was admitted in intensive care unit because of severe metabolic acidosis. She rapidly recovered after refeeding process. Lactation ketoacidosis, a special condition that occurs in non-diabetic breastfeeding women, is rare and life-threatening. This report highlights the importance of nutritional education of lactating women in the post-partum period.
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Affiliation(s)
- Alexandra Kachaner
- Université de Paris, Paris, France.,Service de médecine interne, Hôpital Européen Georges-Pompidou, Paris, France
| | - Claire Rives-Lange
- Université de Paris, Paris, France.,Service de nutrition, Hôpital Européen Georges-Pompidou, Paris, France
| | - Alina Radu
- Université de Paris, Paris, France.,Service de nutrition, Hôpital Européen Georges-Pompidou, Paris, France
| | - Sebastien Czernichow
- Université de Paris, Paris, France.,Service de nutrition, Hôpital Européen Georges-Pompidou, Paris, France
| | - Brigitte Ranque
- Université de Paris, Paris, France.,Service de médecine interne, Hôpital Européen Georges-Pompidou, Paris, France
| | - Jacques Pouchot
- Université de Paris, Paris, France.,Service de médecine interne, Hôpital Européen Georges-Pompidou, Paris, France
| | - Emmanuel Lafont
- Université de Paris, Paris, France. .,Service de médecine interne, Hôpital Européen Georges-Pompidou, Paris, France.
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Alsomali M. Severe ketoacidosis in a lactating woman on a ketogenic diet. Intern Med J 2021; 51:144-145. [PMID: 33572013 DOI: 10.1111/imj.15149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 06/28/2020] [Accepted: 06/28/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Mona Alsomali
- Department of Internal Medicine, Middlemore Hospital, Auckland, New Zealand
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Watanabe M, Tuccinardi D, Ernesti I, Basciani S, Mariani S, Genco A, Manfrini S, Lubrano C, Gnessi L. Scientific evidence underlying contraindications to the ketogenic diet: An update. Obes Rev 2020; 21:e13053. [PMID: 32648647 PMCID: PMC7539910 DOI: 10.1111/obr.13053] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/31/2022]
Abstract
First identified as a feasible treatment for intractable epilepsy, the ketogenic diet (KD) has recently gained popularity thanks to growing evidence on applications such as weight loss, most importantly, but also NAFLD, cancer, neurologic conditions and chronic pain. As with any treatment, whether pharmacologic or not, the KD might not be an appropriate intervention for every individual, and a number of contraindications have been proposed, now deeply rooted into clinical practice, excluding de facto many patients that could benefit from its use. However, many of these concerns were expressed due to the absence of clinical studies conducted on fragile populations, and an assessment of lately emerged evidence relative to KD safety is currently lacking and much needed. We herein provide a critical revision of the literature behind each safety alert, in order to guide through the treatment options in the case of subjects with an indication to the KD and a borderline safe situation. Based on available evidence, the possible use of this diet as a therapeutic intervention should be assessed on a patient-to-patient basis by adequately skilled medical doctors, keeping in mind current recommendations, but reading them through the knowledge of the current state of the art.
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Affiliation(s)
- Mikiko Watanabe
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Dario Tuccinardi
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Ilaria Ernesti
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy.,Department of Surgical Sciences, Surgical Endoscopy Unit, Sapienza University of Rome, Rome, Italy
| | - Sabrina Basciani
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Stefania Mariani
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Alfredo Genco
- Department of Surgical Sciences, Surgical Endoscopy Unit, Sapienza University of Rome, Rome, Italy
| | - Silvia Manfrini
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Carla Lubrano
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Lucio Gnessi
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
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Marzban S, Arbee M, Vorajee N, Richards GA. Non-diabetic ketoacidosis associated with a low carbohydrate, high fat diet in a postpartum lactating female. Oxf Med Case Reports 2020; 2020:omz026. [PMID: 32793371 PMCID: PMC7416821 DOI: 10.1093/omcr/omz026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/21/2019] [Accepted: 03/02/2019] [Indexed: 12/18/2022] Open
Abstract
A 31-year old non-diabetic woman presented to our hospital with symptoms of dehydration, drowsiness, fatigue, shortness of breath and vomiting present for two consecutive days prior to admission. She had started a low carbohydrate, high fat (LCHF) diet to induce weight loss while breastfeeding her 4-month-old child 2 weeks prior to admission. The patient was found to have a severely high anion gap metabolic acidosis. It was determined to be due to ketoacidosis, which was as a result of carbohydrate restriction in the presence of increased metabolic demands related with the synthesis and secretion of milk. She denied alcohol use or ingestion of any drugs prior to admission. The patient underwent dialysis and received insulin, 5% dextrose water alongside a well-balanced diet with adequate calories. All abnormal laboratory results normalized and follow-up visits were done. Lactating women are at risk of developing ketoacidosis due to high metabolic demands of the body to produce milk. LCHF diets may exacerbate the body's demand to meet its milk production requirement and result in ketoacidosis. Health professionals need to be aware of the complications of LCHF diet in this population to prevent mortality associated with this condition.
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Affiliation(s)
- Saba Marzban
- Clinical Pharmacy, Netcare Christiaan Barnard Memorial Hospital, Cape Town, South Africa
| | - Mohamed Arbee
- Clinical Haematology, Netcare Garden City Hospital, Johannesburg, Gauteng, South Africa
| | - Naseema Vorajee
- Division of Pathology, National Institute for Occupational Health, National Health Laboratory Services, Johannesburg, Gauteng, South Africa
| | - Guy A Richards
- Division of Critical Care Charlotte Maxeke Hospital and University of the Witwatersrand, Faculty of Health Sciences
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Ringholm L, Stougaard EB, Nørgaard SK, Damm P, Mathiesen ER. Diabetes Management During Breastfeeding in Women with Type 1 Diabetes. Curr Diab Rep 2020; 20:34. [PMID: 32562097 DOI: 10.1007/s11892-020-01315-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW To provide an update on glycemic management of type 1 diabetes during breastfeeding with focus on diet and insulin treatment to prevent hypoglycemia, ketoacidosis, and weight retention. Recommendations for insulin pump settings are given. RECENT FINDINGS Women with type 1 diabetes are encouraged to breastfeed. Hypoglycemia is a concern in the breastfeeding period among women with type 1 diabetes, and ketoacidosis may also occur. The usual goals for glucose values for persons with diabetes also apply during breastfeeding. The recommended minimum daily carbohydrate intake is 210 g during breastfeeding, and this may contribute to prevention of hypoglycemia and ketoacidosis while aiming for gradual weight loss. Insulin requirements are 21% lower during breastfeeding than before pregnancy. Diabetes management in breastfeeding women with type 1 diabetes includes the same goals for glucose values as in other persons with diabetes, sufficient carbohydrate intake, and adequate reduction in insulin dose.
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Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, DK-2820, Gentofte, Denmark.
| | | | - Sidse Kjærhus Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Lactation Ketoacidosis: A Systematic Review of Case Reports. ACTA ACUST UNITED AC 2020; 56:medicina56060299. [PMID: 32560535 PMCID: PMC7353886 DOI: 10.3390/medicina56060299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/29/2022]
Abstract
Background and Objective: Lactation ketoacidosis is a rare cause of high anion gap metabolic acidosis affecting breastfeeding mothers. We aim to review and analyze all cases of lactation ketoacidosis reported. Materials and Methods: A systematic search of PubMed/MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL), identifying relevant case reports published from 1 January 1970 to 31 December 2019. We extracted the following data: the first author, country, year of publication, age of the mother, age of the child, weight/body mass index (BMI) of the mother, precipitating factors, presenting symptoms, biochemical results, treatment, breastfeeding, and time from presentation to the resolution of ketoacidosis. Results: Sixteen case reports and 1 case series reporting 18 cases of lactation ketoacidosis were found. Presenting symptoms were nausea (72%, 13/18), vomiting (67%, 12/18), malaise (56%, 10/18), abdominal pain (44%, 8/18), dyspnea (33%, 6/18), headache (22%, 4/18), and palpitation (11%, 2/18). Dieting and physical exercise to lose weight were reported in 76% (14/18). The treatments included IV dextrose, sodium bicarbonate, insulin, rehydration, monitoring and replacement of electrolytes, and resumption of a balanced diet. The prognoses were good, with no mortalities. Conclusions: lactation ketoacidosis should be suspected in unwell breastfeeding women with high anion gap metabolic acidosis, after excluding other causes.
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Al Alawi AM, Al Amri U, Falhammar H. Lactation Ketoacidosis: A case series. Sultan Qaboos Univ Med J 2019; 19:e359-e363. [PMID: 31897320 PMCID: PMC6930031 DOI: 10.18295/squmj.2019.19.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/23/2019] [Accepted: 10/24/2019] [Indexed: 11/25/2022] Open
Abstract
Lactation ketoacidosis is an extremely rare type of high anion gap metabolic acidosis. We report two lactating women who were diagnosed with lactation ketoacidosis. The first patient presented to the Emergency Department at Royal Darwin Hospital, Darwin, Australia, in 2018 with lethargy, nausea and abdominal pain after she commenced a new diet regimen based on three meals of protein per day and free of glucose, gluten and dairy products. The second patient presented to the Emergency Department at Sultan Qaboos University Hospital, Muscat, Oman, in 2018 with headache, severe malaise, epigastric pain and worsening of gastroesophageal symptoms. Blood investigation results showed that both patients had high anion gap metabolic acidosis, ketosis and hypoglycaemia. The patients responded well to intravenous dextrose and resumption of a balanced diet. Both patients were able to continue breastfeeding and remained well on follow-up.
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Affiliation(s)
| | - Usama Al Amri
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Henrik Falhammar
- Division of Medicine, Royal Darwin Hospital, Darwin, Australia.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.,Menzies School of Health Research, Darwin, Australia
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