5 carbohydrate choices equal to ∼75 grams carbohydrate
½ c. oatmeal (1 choice)
1 slice toast (1 choice)
1 egg
1 c. fat-free milk (1 choice)
1 Tbsp. regular jelly (1 choice)
1 tsp. soft margarine
coffee
½ c. oatmeal
1 slice toast
1 egg
1 c. fat-free milk
1 Tbsp. jelly
1 tsp. soft margarine
coffee
5 carbohydrate choices equal to ∼75 grams carbohydrate
½ c. mashed potatoes/gravy (1 choice)
½ c. mixed vegetables (without corn or peas)
1 dinner roll (1 choice)
2 tsp. soft margarine
2 x 2 brownie/frosting (2 choices)
1 c. fat-free milk (1 choice)
coffee
½ c. mashed potatoes/gravy
½ c. mixed vegetables
1 dinner roll
2 tsp. soft margarine
2 x 2 brownie/frosting
1 c. fat-free milk
coffee
5 carbohydrate choices equal to ∼75 grams carbohydrate
1 cup tomato soup with 2 crackers (1 choice)
½ c. fruit cocktail (1 choice)
1 c. fat-free milk (1 choice)
coffee
1 cup tomato soup
2 crackers
½ c. fruit cocktail
1 c. fat-free milk
coffee
1–2 carbohydrate choices equal to 15–30 grams carbohydrate
½ c. cubed cantaloupe ( ½ choice)
3 cups popcorn (1 choice)
½ c. cubed cantaloupe
3 cups popcorn (1 choice)
Gestational Diabetes Meal Plan
The meal plan for a woman with gestational diabetes follows the same principles as the Consistent Carbohydrate Diet. Total carbohydrate intake is usually 40 to 45% of total calories. (4,7) Some researchers advocate lower carbohydrate intakes, however, the minimum amount of carbohydrate recommended daily in pregnancy is 175 grams according to the DRIs. (8) Care must be taken to provide enough calories in the meal plan to promote proper weight gain and prevent starvation ketosis; extra protein and fat foods at each meal and snack time can aid in meeting calorie needs. An evening snack is necessary to prevent ketosis. Women are advised to check ketones before breakfast.
Generally, the meal pattern for breakfast is reduced in carbohydrates due to hormonal surges and insulin resistance in the morning hours. The carbohydrate allowance for breakfast is limited to two choices (30 grams) to help promote optimal blood glucose levels.
Table 6.3 Suggested Menu Plan for Gestational Diabetes ∼2000 Calories
| (Select from foods described) |
| Breakfast: Two carbohydrate choices (30 grams) |
| 1 slice whole wheat toast (1 choice) |
| 1 egg or 1 Tbsp. peanut butter |
| 1 tsp. soft margarine |
| 8 oz. low-fat milk (1 choice) |
| Snack: Two carbohydrate choices (30 grams) |
| 3 graham cracker squares (1 choice) |
| 8 oz. fat-free milk (1 choice) |
| Lunch or Supper: Three to four carbohydrates (45–60 grams) |
| 2 slices bread (2 choices) |
| ½ medium banana (1 choice) |
| 6 oz. light yogurt (1 choice) |
| 1 c. carrot and celery sticks |
| 2-3 oz. roast beef |
| 2 tsp. soft margarine |
| Snack: Two carbohydrate choices (30 grams) |
| 3 c. popcorn, lower fat (1 choice) |
| 1 c. cantaloupe (1 choice) |
| 1 unsweetened beverage |
| Dinner: Three to four carbohydrates (45–60 grams) |
| 3 oz. chicken breast |
| 1 small baked potato (1 choice) |
| ½ c. broccoli |
| ½ c. peaches (1 choice) |
| 1 small dinner roll (1 choice) |
| 8 oz. fat-free milk (1 choice) |
| 1 tsp. margarine |
| Snack: Two carbohydrate choices (30 grams) |
| 6 whole wheat crackers (1 choice) |
| 1 oz. cheese |
| 8 oz. fat-free milk (1 choice) |
Once the meal plan is in place, blood glucose is checked on a regular basis. If the blood sugars show a trend of acceptable readings, the meal plan may be adjusted to a higher carbohydrate allowance. This generally does not occur with many women with gestational diabetes due to hormonal changes during pregnancy.
Full and Clear Liquid Substitutions
When an individual with diabetes cannot eat solid food, it may be necessary to offer the Clear Liquid or Full Liquid Diet. Carbohydrate counting still plays a role with meal planning. The use of regular products is acceptable to maintain the level of carbohydrate in the meal plan. Individuals should receive approximately 200 grams of carbohydrate daily. Sugar-free products should be limited on a liquid diet due to the decreased caloric value. The following table shows carbohydrate values for selected foods that could be offered on a Full or Clear Liquid Diet.
Table 6.4
| Food | Amount |
| 15 gram carbohydrate portions | |
| Carbonated regular soda | ½ cup |
| Cooked cereal | ½ cup |
| Creamed soup | 1 cup |
| Custard, soft | ½ cup |
| Eggnog | ½ cup |
| Flavored gelatin, regular | ½ cup |
| Ice cream, regular | ½ cup |
| Light ice cream, vanilla | ½ cup |
| Pudding, sugar-free | ½ cup |
| Pudding, regular | ¼ cup |
| Sherbet | ¼ cup |
| Sugar | 1 Tbsp |
| Yogurt, flavored low-fat, sugar sweetened |  cup |
Hypoglycemia
Hypoglycemia or low blood sugar can be caused by taking too much diabetes medication, eating too few carbohydrates at meal time, skipping meals, or getting more exercise than usual. Symptoms may vary among individuals. Common signs are feeling shaky, sweaty, tired, hungry, crabby or confused, rapid heart rate, blurred vision or headaches, and numbness or tingling in the mouth and lips. In severe cases, the person may lose consciousness.
The treatment for low blood sugar is the “Rule of 15.” This means once a low blood sugar is recognized, 15 grams of carbohydrate are given. It is recommended to use only carbohydrate to treat hypoglycemia and not to use foods high in protein or fat. Protein can stimulate the pancreas to release insulin and does not prevent a repeat low blood sugar. Fat slows down the absorption of carbohydrate leading to a delay in raising blood glucose.
Table 6.5 Treatment of Low Blood Sugar “Rule of 15”
| Good Choices 15 gram carbohydrate portions | Poor Choices |
| ½ cup fruit juice 4 glucose tablets ½ cup regular soda 1 cup fat-free or low-fat (1%) milk 1 Tbsp. honey 1 Tbsp. sugar | Donuts Ice cream Candy bars Sandwiches Pies, cakes, cookies Milkshakes |
The blood sugar should be rechecked in 15 minutes. If the blood sugar remains low, then retreat with 15 grams of carbohydrate. Recheck the blood sugar again in 15 minutes and repeat as necessary until the blood sugar is within normal limits. If the next meal is more than one hour away, serve a snack consisting of 30 grams of carbohydrate. If the next meal is less than one hour away, continue to monitor blood glucose levels until mealtime. A repeat low blood sugar may occur if not treated properly.
Effective treatment for hypoglycemia in the healthcare setting is essential. Historically the addition of table sugar to juice or other liquids has been used to elevate blood glucose levels. This is not recommended as it may over treat the low blood sugar. A high blood sugar may be the result, causing a roller coaster effect.
Herbal Therapy and Vitamin or Mineral Supplementation
Herbal therapy is becoming more common to aid in the treatment of disease states. The herbal industry is not regulated by the Food and Drug Administration (FDA) and therefore does not uphold the same standards as other conventional therapies. Persons with diabetes need to exercise extreme caution with herbal therapies because some may interfere with diabetes medication or may cause the body to become more insulin resistant. Contact a physician or pharmacist for more information.
There is no clear data that shows benefit from the use of any vitamin or mineral supplement for persons with diabetes who do not have underlying deficiencies. In fact, regular supplementation with antioxidants, such as vitamins A, C, or E, is not recommended due to safety concerns associated with long-term use. Certain populations may need supplementation for reasons unrelated to diabetes including the elderly, pregnant and lactating women and those on low calorie diets.
Gastroparesis
Gastroparesis (delayed stomach emptying) is a complication of diabetes that may require diet modification. Offer individuals six or more small meals daily as large meals slow stomach emptying. (6) Fat, fiber, and solid foods slow down stomach emptying. If a person has severe nausea and vomiting, then a Clear Liquid Diet (see Chapter 4) is recommended. Once clear liquids are tolerated, the next step is a Full Liquid Diet (see Chapter 4). Some people do not tolerate high fat liquids such as whole milk, cream soup, and milkshakes. Once full liquids are tolerated, a low-fat, low-fiber diet is the next step. Some high fiber foods may cause bezoar formation and may need to be avoided (6).
Table 6.6 Low-Fat, Low-Fiber Diet for Gastroparesis
| Food Group | Recommended | Restrict |
| Vegetables | Choose cooked or canned vegetables without skins or seeds except those not recommended. May have potatoes without skins; tomato juice, sauce, and paste. | Raw, deep-fried and lightly cooked vegetables; creamed vegetables; tomato seeds and skins; avocado, broccoli, Brussels sprouts, corn, green beans, peas, potato skins, sauerkraut, dried beans and peas; cooked spinach and greens. |
| Fruits | Choose cooked or canned fruits without skin or seeds (e.g., applesauce, peaches, or pears); ripe banana or melons; fruit juice without pulp. | Fresh fruit except ripe banana or melon; dried fruits; canned fruit with skin or seeds; juice with pulp; jam, and marmalade |
| Grains | White bread, rolls, pasta and rice; refined cereals including cream of wheat and crispy rice; soda crackers | Whole grain breads, cereals, pasta; wild and brown rice; graham crackers; bran; high fat breads including biscuits, cornbread, croissants, donuts, muffins, pancakes, and waffles |
| Dairy Products | Fat-free or low-fat milk, low-fat yogurt, fat-free or low-fat cheese; fat-free or low-fat cottage cheese. | Whole or reduced fat milk; cheese or cottage cheese made with whole or reduced fat milk |
| Protein Foods | Choose tender lean meats which are baked, broiled or grilled and trimmed of fat. Beef (round, flank and loin cuts), pork (loin), ham, skinless chicken and turkey, fish, canned tuna in water, eggs, egg substitutes, 97% fat-free deli meats. If not tolerated, try ground meat. Smooth peanut butter or nut butters (2 Tbsp/day) | Tough, gristly or deep fried meats, bacon, hot dogs, luncheon meats, pork steak, prime rib, ribs, sardines, sausage; dried beans and peas Crunchy peanut butter or nut butters |
| Oils/Solid Fats May need to limit to 1 serving per meal or snack if not tolerated. | Butter, margarine, mayonnaise, oil (1 teaspoon) Reduced-fat margarine or mayonnaise (1 Tbsp.) Cream, salad dressing, cream cheese (1 Tbsp.) Sour cream (2 Tbsp.) May use fat-free condiments as desired | Avocado, bacon, coconut, and nuts |
| Added Sugars/Misc. | Plain pudding made with skim milk, gelatin, fat-free ice cream, sherbet, popsicles, angel food cake, sugar, brown sugar, clear jelly, honey, syrup, marshmallows, hard candy, coffee, tea, soft drinks, catsup, mustard, lemon juice, and vinegar | High fat desserts (cake, pie, cookies, pastries), desserts with coconut, nuts, raisins; seeds, popcorn, pickles, and whole spices |
| Fluids | Clear carbonated beverages, Gatorade, clear fruit drinks, coffee, and tea (hot and iced) | Juice with pulp; smoothies with pieces of fruit not allowed |
| Soup | Fat-free broth or bouillon, soups made with skim milk, broth soup made with allowed vegetables and pasta | Soups made with whole milk or cream; soups made with vegetables not allowed |
Symptoms of gastroparesis wax and wane, therefore, an individual’s ability to tolerate foods may change over time.
REFERENCES
1. American Diabetes Association. Clinical practice recommendations. Diabetes Care. 2008;31(Supplement 1):S61–S78.
2. American Diabetes Association. Standards of medical care in diabetes—2010. Diabetes Care. 2010;33(Supplement 1):S11–S61.
3. American Dietetic Association and American Diabetes Association. Choose Your Foods: Exchange Lists for Diabetes. Chicago: ADA, 2008.
4. American Dietetic Association Evidence Analysis Library. GDM Macronutrient and Micronutrient Intake. 2010. Available at: http://www.adaevidencelibrary.com/template.cfm?template=guide_summary&key=2178.
5. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008.
6. Parrish CR, Pastors JG. Nutritional management of gastroparesis in people with diabetes. Diabetes Spectrum. 2007;20(4):231–35.
7. Setji TL, Brown AJ, Feinglos MN. Gestational diabetes mellitus. Clinical Diabetes. 2005;23(1):17–24.
8. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Washington DC: The National Academies Press, 2002/2005.
ADDITIONAL RESOURCES
American Association of Diabetes Educators. The Art and Science of Diabetes Self-Management Education Desk Reference, 2nd ed. 2010. www.diabeteseducator.org.
American Diabetes Association. 2009. Therapy for Diabetes Mellitus and Related Disorders, Fifth Edition. Chicago: American Diabetes Association, 2009. www.diabetes.org.
International Diabetes Association. Staged Diabetes Management Quick Guide: Prevention, Detection and Treatment of Diabetes in Adults. 2009. www.parknicollet.com/healthinnovations.
International Diabetes Association. 2008. My Food Plan. Patient handout. www.parknicollet.com/healthinnovations
St. Luke’s Hospital Diabetes Education. 2008. Carbohydrate Counting Placemat for Meal Planning. Patient handout. www.stlukescr.org/our-services/all-other-services/diabetes-education/
St. Luke’s Hospital Nutrition Center. 2010. Diet Progression for Gastroparesis www.stlukescr.org/our-services/all-other-services/digestive-health/diet-information/
Study Guide Questions
A. Differentiate between the following:
Type 1 diabetes
Type 2 diabetes
Gestational diabetes
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