Basic SS Training Medical Nutrition Therapy By Sharmila Chatterjee Msc,MS,RD,CDE (CDAPP Coordinator, Region 9) Email: [e-mail]

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Basic SS Training Medical Nutrition
TherapyBySharmila Chatterjee Msc,MS,RD,CDE(CDAP
P Coordinator, Region 9)Email
schatterjee_at_ucsd.edu
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Training 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

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• Medical Nutrition Therapy (MNT) is a key
  component of glycemic control

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Goals of Medical Nutrition 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

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Components of Nutrition Assessment

• Clinical data
• Medical history
• Activity level
• Plan for infant feeding

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Clinical Data

• Measured height and weight (w/o shoes)
• Preconception weight
• Preconception BMI
• Weight history

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Clinical Data (cont.)

• Available labs
• Hgb/Hct
• OGTT
• A1c
• Medical history
• Post gastric bypass
• PCOS
• Medications current/historical use

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Food Patterns

• 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 Factors

• 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 Visit

• 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 Goals

• 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

• 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 Gain Goals(Based on 2009 IOM
Guidelines)
Category BMI Recommended total wt gain ranges Singleton Twins
Underweight lt 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 Weight Gain/Week(Based on
2009 IOM Guidelines)
Category BMI Mean (range) in lbs/week (singletons)
Underweight lt 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 Grids

• The forms are located at http//www.cdph.ca.gov/pu
  bsforms/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

• Kiel, et al 2007
• Obese women w/singleton pregnancy n120,170
• Relationship between weight gain and
  preeclampsia, C-section, SGA and LGA

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Kiel et al 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,
Contd

• Bodnar et al, 2010
• Obese women with singleton pregnancies (n3254)
• Relationship between wt. gain and adverse
  outcomes (SGA, LGA, spontaneous and medically
  indicated preterm births)

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Bodnar, et al Contd

• 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 Needs

• 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 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)

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EER Formula

• A age (years)
• PA physical activity coefficient
• Wt weight (kg)
• Ht height (meters)

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Physical Activity Coefficients
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 Needs

• 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 Pregnancy Based on Gestational
Age

• IOM formula to calculate energy needs for
• pregnant 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

• 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 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)

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Exercise During PregnancyACOG Committee Opinion
No. 267

• In the absence of either medical or obstetric
  complications, gt 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

• 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

• 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

• 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
• gt 19yrs old 1000 mcg/day

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Micronutrient Recommendations during Pregnancy

• 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 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)

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Vitamin D Supplementation During Pregnancy

• 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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Calcium

• RDA for pregnancy/lactation
• 14-18yrs old 1300 mg/day
• 19-50 y.o. 1000 mg/day
• gt50 y.o. 1200 mg/day
• Preferable source is food
• 600 mg in most supplements
• Maximum absorption 200-300 mg TID

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Vitamin and Mineral Supplements

• 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 Pregnancy

• Caffeine- limited to 200 mg/day
• (2 6oz cups of coffee)
• Herbs- safety unknown
• Limit herbal teas.
• Potentially contraindicated gingko
  biloba,
• ginseng, echinacea, St. Johns wort and
• concentrated herbal garlic extract

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Other Substances during Pregnancy 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

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Toxins 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
  

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Toxins to Avoid

• Mercury and PCBs
• Avoid shark, swordfish, king mackerel and
  tilefish
• Limit other fish and shellfish to 12 oz/wk
• Albacore tuna limit to 6 oz/wk

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Nonnutritive Sweeteners

• FDA approved
• Saccharin
• Aspartame
• Acceptable daily intake 50 mg/kg body wt
• Actual intake _at_ 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 A

• Rebaudioside A aka Reb A
• Truvia, PureVia
• Highly 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

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Nutritive 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

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Sugar 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

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• Working the Meal Plan into
• Real Life

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Sweet Success Nutrition Guidelines for 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

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Sweet Success Nutrition Guidelines for GDM cont.

• 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

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Recommendations

• 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 Limit

• 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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Carbohydrates

• 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 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 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 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

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Carbohydrate Counting

• 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 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)

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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

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Glycemic Index

• 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?

• Fats
• Slow down stomach emptying
• Potential source excess calories
• Protein
• Insulin secretion similar to carbohydrate
• Glucose from ingested protein- doesnt appear in
  general circulation

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Carbs, 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

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Sweets, Desserts and Other Carbohydrates
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Goals of Reassessment

• Weight gain within recommended rates
• Balanced meal plan
• Meal plan comprehension
• Schedule appropriate

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Reassessment

• 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 Gain

• Inadequate weight gain
• lt2/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 Weight 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

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Ketone 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

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Recommendations to Avoid Starvation Ketosis

• Avoid long periods of fasting
• Assure adequate calories and CHO intake
  throughout the day
• Schedule snacks about 2-3 hours after meals
• Schedule bedtime snacks no more than
• 10 hours away from the next mealtime
• Provide a minimum of 7gm of protein and
• 15-30gm of CHO in the bedtime snack

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Weight Loss

• Fear of carbs
• Lack of understanding
• Insulin/OHA needed?
• Clarify kcal/nutrition needs

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Excess 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

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Excess Weight Gain

• Evaluate for edema
• Evaluate activity level
• Review food records for excess kcal/fat
• Revise meal plan if necessary
• Avoid feeding insulin/OHA
• Preeclampsia??

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Insulin

• Insulin initiation
• Changes in schedule to accommodate insulin action
• Hypoglycemia treatment
• Insulin follow-up
• 24-hr recall
• Amount
• Type
• Time

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Insulin, Continued

• NPH and hypoglycemia prevention
• Bedtime snack
• Midmorning snack

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Hypoglycemia and Glyburide

• 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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Hypoglycemia

• Signs and symptoms
• Confirm with BG check
• Treatment
• 15 grams carbohydrate
• 15 grams glucose tabs water
• 1/2 cup fruit juice or soda
• Recheck in 15 minutes
• Retreat if necessary

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Causes of Hypoglycemia

• ?Activity
• ?CHO
• Skipping snack
• ?Insulin/OHA

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Sick Day Management

• Substitute easily digested CHO foods as
• a replacement
• With N/V, add caffeine free liquids to
• preventing dehydration
• If BG gt 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 gt 2 times

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Breastfeeding
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Benefits to the Mother

• 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 increases
• Economical
• No preparation
• Reduced healthcare costs an absenteeism

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Benefits to the Infant

• Enhances bonding with mother
• Reduces incidence and severity of ear infections
• Reduces incidence of respiratory infections
• Transfers growth factors

• Decreases risk of baby tooth decay
• Digests easily
• Reduces incidence of diarrhea
• Protects against infant botulism
• May reduce lifetime risk of diabetes

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Breastfeeding and Risk of DM2 in 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)

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Breastfeeding and Risk of Maternal 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

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Breastfeeding and Development of DM2 in Youth

• 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 Topics

• Prevention of type 2 DM
• Breastfeeding issues/encouragement
• Weight loss

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Postpartum Guidelines for Women 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

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Postpartum Weight Loss

• Reasonable weight loss 10 of body weight
• Rapid weight loss after delivery
• Breastfeeding
• Normal weight 1-2 /month
• Overweight/obese up to 4.5/month

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Diabetes Prevention Program

• 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 with Hx of GDM

• Metformin 50 risk reduction in development of
  DM2
• Lifestyle 53 risk reduction
• By year 3
• GDM women had reduced activity to lt30 min/wk
• Wt loss - 3.5 lb

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Utilize Sweet Success Resources

• Educational tools
• CA Diabetes Pregnancy Program
• Materials Resource Center
• [phone]
• Regional Consultants
• Sweet Success Directory
• www.cdph.ca.gov/programs/CDAPP

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Resources

• Steps to Take Gestational Diabetes (CPSP
  Guidelines) http//www.cdph.ca.gov/programs/CPSP/P
  ages/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 Contd

• 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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Resources

• California Diabetes Program http//www.diabetesco
  altionofcalifornia.org/
• Diabetes Information Resource Center
  http//www.caldiabetes.org/dirc.cfm
• MyPyramid for pregnancy and breastfeeding
  http//www.mypyramid.gov/mypyramidmoms/index.html

96
References

• 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

97
References

• 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

98
References

• 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

99
References

• CDC Grand Rounds vitamin D. www.cdc.gov/about/gr
  and-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

100
References

• 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