Dietary Intervention in Patients With Gestational Diabetes Mellitus: A Systematic Review and Meta-analysis of Randomized Clinical Trials on Maternal and Newborn Outcomes

Luciana Verçoza Viana; Jorge Luiz Gross; Mirela Jobim Azevedo

doi:10.2337/dc14-1530

Meta-analysis

Dietary Intervention in Patients With Gestational Diabetes Mellitus: A Systematic Review and Meta-analysis of Randomized Clinical Trials on Maternal and Newborn Outcomes

Luciana Verçoza Viana⇑,
Jorge Luiz Gross and
Mirela Jobim Azevedo

Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

Corresponding author: Luciana Verçoza Viana, vercoza{at}yahoo.com.

Diabetes Care 2014 Dec; 37(12): 3345-3355. https://doi.org/10.2337/dc14-1530

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Figure 1
Flow diagram of literature search to identify RCTs evaluating the effect of diet in patients with GDM.
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Figure 2
Forest plots of dietary intervention for patients with GDM: low GI diet (A), energy restriction diet (B), and low carbohydrate diet (C).

Tables

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Table 1

Characteristics of the studies according to dietary intervention in GDM

Author, year	Sample characteristics	GDM criteria	Diet characteristics	Maternal outcomes	Newborn outcomes
Dietary intervention: low GI
Perichart-Perera, 2012	n = 48 Age = 33.2 ± 5.1 years GDM diagnoses: 24.12 ± 4.6 weeks BMI = 31.4 ± 4.8 kg/m² (pregestational)	ADA, 2004	Intervention (n = 27): LGI diet^* Energy: 1,477.4 ± 400.8 kcal/day CHO: 49.3 ± 6.8%; Prot: 24.1 ± 4.5%; Lip: 28 ± 5.8% GI: 47.5 ± 6.5 GL: NA Fiber: NA	Intervention Total weight gain: 4.1 ± 4.9 kg Cesarean: 20 (83.3%) Labor induction: NA Insulin use: 8 patients (30%)	Intervention Birth weight: 2,954 ± 649 g Macrosomia: 1 Prematurity: 3 Birth trauma: NA Hypoglycemia: NA SGA: 1

			Control (n = 21): all types of CHO^* Energy: 1,485.4 ± 26.4 kcal/day CHO: 46.2 ± 6.2%; Prot: 24.4 ± 4.55%; Lip: 30.8 ± 6.1% GI: 47.0 ± 9.9 GL: NA Fiber: NA	Control Total weight gain: 3.3 ± 3.9 kg Cesarean: 16 (76.2%) Labor induction: NA Insulin use: 9 patients (43%)	Control Birth weight: 3,115 ± 469 g Macrosomia: 1 Prematurity: 2 Birth trauma: NA Hypoglycemia: NA SGA: 1
Grant, 2011	n = 47 Age = 34 ± 4 years GDM diagnoses: 27 ± 2.9 weeksNonwhite: 85% BMI = 26.5 ± 4.8 kg/m² (pregestational)	Canada, 2008	Intervention (n = 23): LGI diet^* Energy: NA CHO: NA; Prot: NA; Lip: NA GI: 49 ± 0.8 GL: 98.2 ± 5.1 Fiber: 30 ± 1.6 g/day	Intervention Weight gain: 0.35 ± 0.05 kg/week Cesarean: NA Labor induction: NA Insulin use: 13 patients (62%)	Intervention Birth weight: 3,124 ± 124 g Macrosomia: 1 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 1

			Control (n = 24): intermediate/high GI diet^* Energy: NA CHO: NA; Prot: NA; Lip: NA GI: 58 ± 0.5 GL: 125 ± 8.8 Fiber: 23 ± 1 g/day	Control Weight gain: 0.37 ± 0.07 kg/week Cesarean: NA Labor induction: NA Insulin use: 12 patients (55%)	Control Birth weight: 330 ± 220 g Macrosomia: 2 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 0
Moses, 2009	n = 63 Age = 31.1 ± 4.2 years GDM diagnoses: 30.1 ± 1.1 weeks Nonwhite: 1.6% BMI = 32.4 ± 7.3 kg/m² (at enrollment)	ADIPS	Intervention (n = 31): LGI^* Energy: 1,713 ± 66 kcal/day CHO: 36.7 ± 1.1%; Prot: 23.9 ± 0.7%; Lip: 33.4 ± 1.2% GI: 48.0 ± 0.9 GL: NA Fiber: 25.6 ± 1.6 g/day	Intervention Total weight gain: 8.9 ± 5.0 kg Cesarean: 5 (16%) Labor induction: NA Insulin use: 9 patients (29%)	Intervention Birth weight: 3,279 ± 464.5 g Macrosomia: 1 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 2

			Control (n = 32): high GI diet^* Energy: 1,664 ± 79 kcal/day CHO: 37.8 ± 1.1%; Prot: 23.5 ± 0.8%; Lip: 34.0 ± 1.8% GI: 56.0 ± 1.1 GL: NA Fiber: 22.9 ± 1.1 g/day	Control Total weight gain: 10.6 ± 7 0.0 kg Cesarean: 8 (25%) Labor induction: NA Insulin use: 19 patients (59%)	Control Birth weight: 3,334 ± 431.5 g Macrosomia: 2 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 0
Louie, 2011	n = 99 Age = 33.2 ± 4.3 years GDM diagnoses: 26.1 ± 4.12 weeks Nonwhite: 64.1% BMI = 24 ± 5 kg/m² (pregestational)	ADIPS	Intervention (n = 47): LGI; target GI ≤50^* Energy: 1,834 ± 425 kcal/day CHO: 39%; Prot: 23%; Lip: 35% GI: 47 ± 1 GL: 84 ± 3 Fiber: 27 ± 1 g/day	Intervention Total weight gain: 11.9 ± 0.7 kg Cesarean: 10 (21%) Labor induction: NA Insulin use: 25 patients (53.2%)	Intervention Birth weight: 3.3 ± 0.1 kg Macrosomia: 1 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 5

			Control (n = 45): moderate GI and high fiber diet; target GI ∼60^* Energy: 1,932 ± 476.3 kcal/day CHO: 40%; Prot: 22%; Lip: 35% GI: 53 ± 1 GL: 105 ± 4 Fiber: 25 ± 1 g/day	Control Total weight gain: 13.1 ± 0.9 kg Cesarean: 5 (11%) Labor induction: NA Insulin use: 29 patients (65.1)	Control Birth weight: 3.3 ± 0.1 g Macrosomia: 3 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 4
Dietary intervention: total energy restriction
Garner, 1997	n = 300 Age = 30.7 ± 4.6 years GDM diagnoses: 24–30 weeks	Hatem criteria	Intervention (n = 149): calorie-restricted diet^§ Energy: 35 kcal/ideal body weight (kg)/day	Intervention Weight gain: 12.54 kg Cesarean: 30 (20.1%) Labor induction: NA Insulin use: 36 patients (24.2%)	Intervention Birth weight: 3,437 ± 575 g Macrosomia: 24 (16.1%) Prematurity: NA Birth trauma: 0 Hypoglycemia: 21 (14.1%) SGA: NA

			Control (n = 150): Canada Food Guide recommendations	Control Weight gain: 13.37 kg Cesarean: 28 (18.6%) Labor induction: NA Insulin use: NA	Control Birth weight: 3,544 ± 601 g Macrosomia: 28 (18.7%) Prematurity: NA Birth trauma: 0 Hypoglycemia: 13 (8.7%) SGA: NA

Rae, 2000	n = 125 Age = 30.4 years GDM diagnoses: 28.2 ± 5.3 weeks BMI = 38 ± 0.7 kg/m² (at enrollment)	OGTT fasting >100 mg/dL and/or 2 h >145 mg/dL	Intervention (n = 66): moderate energy restriction (30%): 1,590–1,776 kcal^* Energy: 1,566 kcal/day CHO: 42 ± 0.7%; Prot: 25 ± 0.3%; Lip: 31 ± 0.7%	Intervention Weight gain: 11.56 ± 10.7 kg Cesarean: 36 (40%) Labor induction: 26 (46%) Insulin use: 11 patients (17.5%)	Intervention Birth weight: 3,461 g Macrosomia: 11 (16.7%) Prematurity: 14 (22.2%) Birth trauma: NA Hypoglycemia: 25 (37.3%) SGA: NA

			Control (n = 58): not energy-restricted diet; 2,010–2,220 kcal^* Energy: 1,630 kcal/day CHO: 41 ± 0.6%; Prot: 24 ± 0.3%; Lip: 34 ± 0.7%	Control Weight gain: 9.68 ± 11.04 kg Cesarean: 19 (33.9%) Labor induction: 23 (45.2%) Insulin use: 9 patients (16.75%)	Control Birth weight: 3,267 g Macrosomia: 6 (10.7%) Prematurity: 13 (22.1%) Birth trauma: NA Hypoglycemia: 29 (50%) SGA: NA
Dietary intervention: low carbohydrate
Moreno-Castilla, 2013	n = 152 Age = 32.8 ± 4.1 years GDM diagnoses: 30.3 ± 3.3 weeks Nonwhite 5% BMI = 26 ± 5.6 kg/m² (pregestational)	National Diabetes Group criteria	Intervention (n = 75): low carbohydrate diet (40%) Energy: >1,800 kcal/day CHO: 40%; Prot: 20%; Lip: 40%	Intervention Weight gain: 1.4 ± 2 kg Cesarean: 25 (33.8%) Labor induction: NA Insulin use: 41 (54.7%)	Intervention Birth weight: NA Macrosomia: 1 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 12

			Control (n = 75): high carbohydrate diet (∼60%)^§ Energy: >1,800 kcal/day CHO: 55%; Prot: 20%; Lip: 25%	Control Weight gain: 2.3 ± 2.1 kg Cesarean: 20 (26.7%) Labor induction: NA Insulin use: 41 (54.7%)	Control Birth weight: NA Macrosomia: 4 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 8
Cypryk, 2007	n = 30 Age = 28.7 ± 3.7 years GDM diagnoses: 29.2 ± 5.4 weeks All white	WHO criteria	Intervention (n = 15): low carbohydrate diet (∼45%)^§ Energy: NA CHO: 45%; Prot: 25%; Lip: 30%	Intervention Weight gain: NA Cesarean: 7 (47%) Labor induction: NA Insulin use: 2 (13%)	Intervention Birth weight: 3,407 ± 309 g Macrosomia: 0 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: NA

			Control (n = 15): high carbohydrate diet (∼60%)^§ Energy: NA CHO: 60%; Prot: 25%; Lip: 15%	Control Weight gain: NA Cesarean: 5 (33%) Labor induction: NA Insulin use: 1 (7%)	Control Birth weight: 3,385 ± 418 g Macrosomia: 2 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: NA
Dietary intervention: others
Valentini, 2012	n = 20 Age = 29.6 ± 4 years GDM diagnoses: 24.2 ± 6.9 weeks BMI = 24.9 ± 4.2 kg/m²(pregestational)	Fourth International Workshop Conference on GDM	Intervention (n = 10): ethnic meal plan^§ Energy: 1,800–2,200 kcal/day CHO: 55%; Prot: 17%; Lip: 28% Fiber: 21 g/day	Intervention Weight gain: 12.1 ± 4.3 kg Cesarean: 6 Labor induction: NA Insulin use: 2 (20%)	Intervention Birth weight: 3,064 ± 626 g Macrosomia: 0 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 1

			Control (n = 10): ADA recommendations^§ Energy: 1,800–2,200 kcal/day CHO: 53%; Prot: 18%; Lip: 28% Fiber: 26 g/day	Control Weight gain: 14.3 ± 6.9 kg Cesarean: 5 Labor induction: NA Insulin use: 1 (10%)	Control Birth weight: 3,434 ± 649 g Macrosomia: 2 Prematurity: NA Birth trauma: NA Hypoglycemia: NA SGA: 0

ADIPS, Australasian Diabetes in Pregnancy Society; CHO, carbohydrates; GL, glycemic load; Lip, lipids; LGI, low GI; OGTT, oral glucose tolerance test; Prot, protein; WHO, World Health Organization.
↵*Actual intake.
↵§Dietary prescription.