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15 - Interventional strategies to improve outcome in obese pregnancies: insulin resistance and gestational diabetes

from Section 4 - Interventions

Published online by Cambridge University Press:  05 August 2012

By
Scott M. Nelson  and
Lucilla Poston
Edited by
Matthew W. Gillman  and
Lucilla Poston
Matthew W. Gillman
Affiliation:
Harvard Medical School
Lucilla Poston
Affiliation:
King's College London
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Summary

Introduction

In this chapter we address the metabolic sequelae of maternal obesity, and by detailing effects on glucose, lipid, and protein metabolism, parallels with type 2 diabetes are highlighted. These similarities and the success of lifestyle intervention strategies for the prevention of type 2 diabetes may provide a road map for the development of strategies to modify maternal hyperglycemia – a key determinant of pregnancy complications.

Maternal metabolism

Lipid metabolism

Lipid metabolism undergoes major adjustment during pregnancy as although there is no change in either basal carbohydrate oxidation or non-oxidizable carbohydrate metabolism there is a significant 50% to 80% increase in basal fat oxidation during pregnancy and also in response to glucose [1]. There is also a marked hyperlipidemia in pregnancy [2–4]. Specifically very low-density lipoprotein (VLDL) triglyceride concentrations increase three-fold from 14 weeks gestation to term [5], with concomitant decreases in hepatic lipase activity [2]. This increase in plasma triglyceride concentration results may drive in the appearance of small, dense low-density lipoprotein (LDL) particles, particularly in late pregnancy [6]. Plasma cholesterol levels rise to a lesser degree due to an early decrease in LDL followed by a modest continuous rise in high-density lipoprotein (HDL) (particularly the HDL-2 subfraction) by over 40% after 14 weeks gestation [5]. HDL cholesterol exhibits a triphasic profile, rising to a peak at 25 weeks, and then declining to 32 weeks with maintenance at this level until term [7]. These changes in lipoprotein concentrations are associated with the progressive increases in estradiol, progesterone, and human placental lactogen [7], and estrogens are known to enhance VLDL production and decrease hepatic lipase activity and may play a key role in the accumulation of triglycerides in lipoproteins of higher density than VLDL [8].

Keywords

gestational diabetesglucose homeostasisinsulin sensitivityprotein metabolismtype 2 diabetespregnancylipid metabolismmaternal obesity
Type
Chapter
Information
Maternal Obesity , pp. 179 - 198
Publisher: Cambridge University Press
Print publication year: 2012

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References

Okereke, N C Huston-Presley, L Amini, S B Kalhan, S Catalano, P M 2004 Longitudinal changes in energy expenditure and body composition in obese women with normal and impaired glucose tolerance Am J Physiol Endocrinol Metab 287 e472 Google Scholar
Alvarez, J J Montelongo, A Iglesias, A Lasuncion, M A Herrera, E. Longitudinal study on lipoprotein profile, high density lipoprotein subclass, and postheparin lipases during gestation in women J Lipid Res 1996 37 299 Google Scholar
Knopp, R H Warth, M R Carrol, C J. Lipid metabolism in pregnancy. I. Changes in lipoprotein triglyceride and cholesterol in normal pregnancy and the effects of diabetes mellitus J Reprod Med 1973 10 95 Google Scholar
Warth, M R Arky, R A Knopp, R H. Lipid metabolism in pregnancy. III. Altered lipid composition in intermediate, very low, low, and high-density lipoprotein fractions J Clin Endocrinol Metab 1975 41 649 Google Scholar
Fahraeus, L Larsson-Cohn, U Wallentin, L. Plasma lipoproteins including high density lipoprotein subfractions during normal pregnancy Obstet Gynecol 1985 66 468 Google Scholar
Sattar, N Greer, I A Louden, J Lipoprotein subfraction changes in normal pregnancy: threshold effect of plasma triglyceride on appearance of small, dense low density lipoprotein J Clin Endocrinol Metab 1997 82 2483 Google Scholar
Desoye, G Schweditsch, M O Pfeiffer, K P Zechner, R Kostner, G M. J Clin Endocrinol Metab 1987 64 704
Sacks, F M Walsh, B W Sex hormones and lipoprotein metabolism Curr Opin Lipidol 1994 5 236 Google Scholar
Merzouk, H Meghelli-Bouchenak, M el-Korso, N Belleville, J Prost, J. Low birth weight at term impairs cord serum lipoprotein compositions and concentrations Eur J Pediatr 1998 157 321 Google Scholar
Ramsay, J E Ferrell, W R Crawford, L Maternal obesity is associated with dysregulation of metabolic, vascular, and inflammatory pathways J Clin Endocrinol Metab 2002 87 4231 Google Scholar
Rajasingam, D Seed, P T Briley, A L Shennan, A H Poston, L. A prospective study of pregnancy outcome and biomarkers of oxidative stress in nulliparous obese women Am J Obstet Gynecol 2009 200 395e391 Google Scholar
Sivan, E Homko, C J Chen, X Reece, E A Boden, G. Effect of insulin on fat metabolism during and after normal pregnancy Diabetes 1999 48 834 Google Scholar
Catalano, P M Nizielski, S E Shao, J Downregulated IRS-1 and PPARgamma in obese women with gestational diabetes: relationship to FFA during pregnancy Am J Physiol Endocrinol Metab 2002 282 e522 Google Scholar
Sanchez-Vera, I Bonet, B Viana, M Changes in plasma lipids and increased low-density lipoprotein susceptibility to oxidation in pregnancies complicated by gestational diabetes: consequences of obesity Metabolism 2007 56 1527 Google Scholar
Sattar, N Tan, C E Han, T S Associations of indices of adiposity with atherogenic lipoprotein subfractions Int J Obes Relat Metab Disord 1998 22 432 Google Scholar
Bevier, W C Fischer, R Jovanovic, L. Treatment of women with an abnormal glucose challenge test (but a normal oral glucose tolerance test) decreases the prevalence of macrosomia Am J Perinatol 1999 16 269 Google Scholar
Enquobahrie, D A Williams, M A Butler, C L Maternal plasma lipid concentrations in early pregnancy and risk of preeclampsia Am J Hypertens 2004 17 574 Google Scholar
Lorentzen, B Drevon, C A Endresen, M J Henriksen, T Br J Obstet Gynaecol 1995 102 530
Potter, J M Nestel, P J The hyperlipidemia of pregnancy in normal and complicated pregnancies Am J Obstet Gynecol 1979 133 165 Google Scholar
Ramsay, J E Ferrell, W R Crawford, L Divergent metabolic and vascular phenotypes in pre-eclampsia and intrauterine growth restriction: relevance of adiposity J Hypertens 2004 22 2177 Google Scholar
Rajasingam, D Seed, P T Briley, A L Shennan, A H Poston, L. A prospective study of pregnancy outcome and biomarkers of oxidative stress in nulliparous obese women Am J Obstet Gynecol 2009 200 395e391 Google Scholar
Sattar, N Greer, I A Louden, J Lipoprotein subfraction changes in normal pregnancy: threshold effect of plasma triglyceride on appearance of small, dense low density lipoprotein J Clin Endocrinol Metab 1997 82 2483 Google Scholar
Vadachkoria, S Woelk, G B Mahomed, K Elevated soluble vascular cell adhesion molecule-1, elevated homocyst(e)inemia, and hypertriglyceridemia in relation to preeclampsia risk Am J Hypertens 2006 19 235 Google Scholar
Hubel, C A Shakir, Y Gallaher, M J McLaughlin, M K Roberts, J M Low-density lipoprotein particle size decreases during normal pregnancy in association with triglyceride increases J Soc Gynecol Investig 1998 5 244 Google Scholar
Llurba, E Casals, E Domínguez, C Atherogenic lipoprotein subfraction profile in preeclamptic women with and without high triglycerides: different pathophysiologic subsets in preeclampsia Metabolism 2005 54 1504 Google Scholar
Griffin, B A Freeman, D J Tait, G W Role of plasma triglyceride in the regulation of plasma low density lipoprotein (LDL) subfractions: relative contribution of small, dense LDL to coronary heart disease risk Atherosclerosis 1994 106 241 Google Scholar
Institute of Medicine, National Research Council Weight Gain During Pregnancy: Reexamining the Guidelines Washington, DC The National Academies Press 2009
Sebire, N J Jolly, M Harris, J P Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London Int J Obes Relat Metab Disord 2001 25 1175 Google Scholar
Duggleby, S L Jackson, A A Higher weight at birth is related to decreased maternal amino acid oxidation during pregnancy Am J ClinNutr 2002 76 852 Google Scholar
deBenoist, B Jackson, A A Hall, J S Persaud, C Whole-body protein turnover in Jamaican women during normal pregnancy Hum Nutr Clin Nutr 1985 39 167 Google Scholar
Jackson, A A Measurement of protein turnover during pregnancy Hum Nutr Clin Nutr 1987 41 497 Google Scholar
Thompson, G N Halliday, D Protein turnover in pregnancy Eur J Clin Nutr 1992 46 411 Google Scholar
Willommet, L Schutz, Y Whitehead, R Jequier, E Fern, E B. Whole body protein metabolism and resting energy expenditure in pregnant Gambian women Am J Physiol Endocrinol Metab 1992 263 e624 Google Scholar
Duggleby, S L Jackson, A A Relationship of maternal protein turnover and lean body mass during pregnancy and birth length Clin Sci (Lond) 2001 101 65 Google Scholar
Chevalier, S Marliss, E B Morais, J A Lamarche, M Gougeon, R Whole-body protein anabolic response is resistant to the action of insulin in obese women Am J Clin Nutr 2005 82 355 Google Scholar
Chevalier, S P Burgess, S C Malloy, C R The greater contribution of gluconeogenesis to glucose production in obesity is related to increased whole-body protein catabolism Diabetes 2006 55 675 Google Scholar
Mills, J L Jovanovic, L Knopp, R Physiological reduction in fasting plasma glucose concentration in the first trimester of normal pregnancy: the diabetes in early pregnancy study Metabolism 1998 47 1140 Google Scholar
Catalano, P M Tyzbir, E D Wolfe, R R Longitudinal changes in basal hepatic glucose production and suppression during insulin infusion in normal pregnant women Am J Obstet Gynecol 1992 167 913 Google Scholar
Kalhan, S C D’Angelo, L J Savin, S M Adam, P A Glucose production in pregnant women at term gestation. Sources of glucose for human fetus J Clin Invest 1979 63 388 Google Scholar
Assel, B Rossi, K Kalhan, S. Glucose metabolism during fasting through human pregnancy: comparison of tracer method with respiratory calorimetry Am J Physiol Endocrinol Metab 1993 265 e351 Google Scholar
Kalhan, S Rossi, K Gruca, L Burkett, E O’Brien, A. Glucose turnover and gluconeogenesis in human pregnancy J Clin Invest 1997 100 1775 Google Scholar
Cousins, L Rigg, L Hollingsworth, D The 24-hour excursion and diurnal rhythm of glucose, insulin, and C-peptide in normal pregnancy Am J Obstet Gynecol 1980 136 483 Google Scholar
Butte, N F Hopkinson, J M Mehta, N Moon, J K Smith E, O Adjustments in energy expenditure and substrate utilization during late pregnancy and lactation Am J Clin Nutr 1999 69 299 Google Scholar
Catalano, P M Tyzbir, E D Roman, N M Amini, S B Sims, E A Longitudinal changes in insulin release and insulin resistance in nonobese pregnant women Am J Obstet Gynecol 1991 165 1667 Google Scholar
Catalano, P M Tyzbir, E D Wolfe, R R Carbohydrate metabolism during pregnancy in control subjects and women with gestational diabetes Am J Physiol Endocrinol Metab 1993 264 e60 Google Scholar
Meier, J J Gallwitz, B Askenas, M Secretion of incretin hormones and the insulinotropic effect of gastricinhibitory polypeptide in women with a history of gestational diabetes Diabetologia 2005 48 1872 Google Scholar
Cypryk, K Vilsbøll, T Nadel, I Normal secretion of the incretin hormones glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 during gestational diabetes mellitus Gynecol Endocrinol 2007 23 58 Google Scholar
Ryan, E A O’Sullivan, M J Skyler, J S Insulin action during pregnancy. Studies with the euglycemic clamp technique Diabetes 1985 34 380 Google Scholar
Catalano, P M Drago, N M Amini, S B Longitudinal changes in pancreatic beta-cell function and metabolic clearance rate of insulin in pregnant women with normal and abnormal glucose tolerance Diabetes Care 1998 21 403 Google Scholar
Agardh, C D Aberg, A Norden, N E Glucose levels and insulin secretion during a 75 g glucose challenge test in normal pregnancy J Intern Med 1996 240 303 Google Scholar
Endo, S Maeda, K Suto, M Differences in insulin sensitivity in pregnant women with overweight and gestational diabetes mellitus Gynecol Endocrinol 2006 22 343 Google Scholar
Kirwan, J P Huston-Presley, L Kalhan, S C Catalano, P M. Clinically useful estimates of insulin sensitivity during pregnancy: validation studies in women with normal glucose tolerance and gestational diabetes mellitus Diabetes Care 2001 24 1602 Google Scholar
Sivan, E Chen, X Homko, C J Reece, E A Boden, G. Longitudinal study of carbohydrate metabolism in healthy obese pregnant women Diabetes Care 1997 20 1470 Google Scholar
Di Cianni, G Miccoli, R Volpe, L Maternal triglyceride levels and newborn weight in pregnant women with normal glucose tolerance Diabet Med 2005 22 21 Google Scholar
Kalkhoff, R K Kandaraki, E Morrow, P G Relationship between neonatal birth weight and maternal plasma amino acid profiles in lean and obese nondiabetic women and in type I diabetic pregnant women Metabolism 1988 37 234 Google Scholar
Nolan, C J Riley, S F Sheedy, M T Walstab, J E Beischer, N A Maternal serum triglyceride, glucose tolerance, and neonatal birth weight ratio in pregnancy Diabetes Care 1995 18 1550 Google Scholar
Schaefer-Graf, U M Graf, K Kulbacka, I Maternal lipids as strong determinants of fetal environment and growth in pregnancies with gestational diabetes mellitus Diabetes Care 2008 31 1858 Google Scholar
HAPO Study Cooperative Research Group Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study: associations with maternal body mass index BJOG 2010 117 575 Google Scholar
Catalano, P M Roman-Drago, N M Amini, S B Sims, E A Longitudinal changes in body composition and energy balance in lean women with normal and abnormal glucose tolerance during pregnancy Am J Obstet Gynecol 1998 179 156 Google Scholar
Sivan, E Homko, C J Whittaker, P G Free fatty acids and insulin resistance during pregnancy J Clin Endocrinol Metab 1998 83 2338 Google Scholar
Homko, C J Cheung, P Boden, G. Effects of free fatty acids on glucose uptake and utilization in healthy women Diabetes 2003 52 487 Google Scholar
Crowther, C A Hiller, J E Moss, J R Effect of treatment of gestational diabetes mellitus on pregnancy outcomes N Engl J Med 2005 352 2477 Google Scholar
Landon, M B Spong, C Y Thom, E 2009 A multicenter, randomized trial of treatment for mild gestational diabetes N Engl J Med 361 Google Scholar
Metzger, B E Lowe, L P Dyer, A R Hyperglycemia and adverse pregnancy outcomes N Engl J Med 2008 358 1991 Google Scholar
International Association of Diabetes and Pregnancy Study Groups Consensus Panel International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy Diabetes Care 2010 33 676 Google Scholar
Leary, J Pettitt, D J Jovanovic, L Gestational diabetes guidelines in a HAPO world Best Pract Res Clin Endocrinol Metab 2010 24 673 Google Scholar
Round, J A Jacklin, P Fraser, R B Screening for gestational diabetes mellitus: cost-utility of different screening strategies based on a woman’s individual risk of disease Diabetologia 2011 54 256 Google Scholar
Savvidou, M Nelson, S M Makgoba, M First-trimester prediction of gestational diabetes mellitus: examining the potential of combining maternal characteristics and laboratory measures Diabetes 2010 59 3017 Google Scholar
Nanda, S Savvidou, M Syngelaki, A Akolekar, R Nicolaides, K H Prenat Diagn 2011 31 135
Graham, I Atar, D Borch-Johnsen, K European guidelines on cardiovascular disease prevention in clinical practice: executive summary Eur Heart J 2007 28 2375 Google Scholar
Rydén, L Standl, E Bartnik, M Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD) Eur Heart J 2007 28 88 Google Scholar
Lindstrom, J Louheranta, A Mannelin, M The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity Diabetes Care 2003 26 3230 Google Scholar
Eriksson, K F Lindgarde, F. Prevention of type 2 (non-insulin-dependent) diabetes mellitus by diet and physical exercise. The 6-year Malmo feasibility study Diabetologia 1991 34 891 Google Scholar
Pan, X R Li, G W Hu, Y H Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance Diabetes Care 1997 20 537 Google Scholar
Ramachandran, A Snehalatha, C Mary, S The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1) Diabetologia 2006 49 289 Google Scholar
Diabetes Prevention Program Research Group Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin N Engl J Med 2002 346 393 Google Scholar
Spinnewijn, W E Lotgering, F K Struijk, P C Wallenburg, H C Fetal heart rate and uterine contractility during maternal exercise at term Am J Obstet Gynecol 1996 174 43 Google Scholar
Kennelly, M M Geary, M McCaffrey, N Exercise-related changes in umbilical and uterine artery waveforms as assessed by Doppler ultrasound scans Am J Obstet Gynecol 2002 187 661 Google Scholar
Bonen, A Campagna, P Gilchrist, L Young, D C Beresford, P. Substrate and endocrine responses during exercise at selected stages of pregnancy J Appl Physiol 1992 73 134 Google Scholar
Madsen, M Jorgensen, T Jensen, M L Leisure time physical exercise during pregnancy and the risk of miscarriage: a study within the Danish National Birth Cohort BJOG 2007 114 1419 Google Scholar
Misra, D P Strobino, D M Stashinko, E E Nagey, D A Nanda, J. Effects of physical activity on preterm birth Am J Epidemiol 1998 147 628 Google Scholar
Berkowitz, G S Kelsey, J L Holford, T R Berkowitz, R L Physical activity and the risk of spontaneous preterm delivery J Reprod Med 1983 28 581 Google Scholar
Evenson, K R Siega-Riz, A M Savitz, D A Leiferman, J A Thorp, J M Vigorous leisure activity and pregnancy outcome Epidemiology 2002 13 653 Google Scholar
Hatch, M Levin, B Shu, X O Susser, M. Maternal leisure-time exercise and timely delivery Am J Public Health 1998 88 1528 Google Scholar
Rizzo, T Metzger, B E Burns, W J Burns, K. Correlations between antepartum maternal metabolism and child intelligence N Engl J Med 1991 325 911 Google Scholar
Rizzo, T A Dooley, S L Metzger, B E Prenatal and perinatal influences on long-term psychomotor development in offspring of diabetic mothers Am J Obstet Gynecol 1995 173 1753 Google Scholar
Lokey, E A Tran, Z V Wells, C L Myers, B C Tran, A C Effects of physical exercise on pregnancy outcomes: a meta-analytic review Med Sci Sports Exerc 1991 23 1234 Google Scholar
Kramer, M S McDonald, S W Cochrane Database Syst Rev 2006 3 CD000180
Leet, T Flick, L. Effect of exercise on birthweight Clin Obstet Gynecol 2003 46 423 Google Scholar
Bell, R J Palma, S M Lumley, J M The effect of vigorous exercise during pregnancy on birth-weight Aust N Z J Obstet Gynaecol 1995 35 46 Google Scholar
Clapp, J F Dickstein, S. Endurance exercise and pregnancy outcome Med Sci Sports Exerc 1984 16 556 Google Scholar
Alderman, B W Zhao, H Holt, V L Watts, D H Beresford, S A Maternal physical activity in pregnancy and infant size for gestational age Ann Epidemiol 1998 8 513
Langer, O Yogev, Y Most, O Xenakis, E M Gestational diabetes: the consequences of not treating Am J Obstet Gynecol 2005 192 989 Google Scholar
Gillman, M W Oakey, H Baghurst, P A Diabetes Care 2010 33 964
Reece, EA Leguizamón, G Wiznitzer, A. Gestational diabetes: the need for a common ground Lancet 2009 373 1789 Google Scholar
American Diabetes Association Gestational diabetes mellitus Diabetes Care 2003 26 s103 Google Scholar
Major, C A Henry, M J De Veciana, M Morgan, M A The effects of carbohydrate restriction in patients with diet-controlled gestational diabetes Obstet Gynecol 1998 91 600 Google Scholar
Franz, M J Horton, E S Bantle, J P Nutrition principles for the management of diabetes and related complications Diabetes Care 1994 17 490 Google Scholar
Moses, R G Barker, M Winter, M Petocz, P Brand-Miller, J C Can a low glycemic index diet reduce the need for insulin in gestational diabetes mellitus? Diabetes Care 2009 32 996 Google Scholar
Tuffnell, D J West, J Walkinshaw, S A Cochrane Database Syst Rev 2003 3
Rowan, J A Hague, W M Gao, W Battin, M R Moore, M P Metformin versus insulin for the treatment of gestational diabetes N Engl J Med 2008 358 2003 Google Scholar
Fougner, K J Vanky, E Carlsen, S M Metformin has no major effects on glucose homeostasis in pregnant women with PCOS: results of a randomized double-blind study Scand J Clin Lab Invest 2008 68 771 Google Scholar
Ratner, R E Christophi, C A Metzger, B E Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions J Clin Endocrinol Metab 2008 93 4774 Google Scholar
Jovanovic-Peterson, L Durak, E P Peterson, C M Randomized trial of diet versus diet plus cardiovascular conditioning on glucose levels in gestational diabetes Am J Obstet Gynecol 1989 161 415 Google Scholar
Avery, M D Walker, A J Acute effect of exercise on blood glucose and insulin levels in women with gestational diabetes J Matern Fetal Med 2001 10 52 Google Scholar
Brankston, G N Mitchell, B F Ryan, E A Okun, N B Resistance exercise decreases the need for insulin in overweight women with gestational diabetes mellitus Am J Obstet Gynecol 2004 190 188 Google Scholar
Garcia-Patterson, A Martin, E Ubeda, J Evaluation of light exercise in the treatment of gestational diabetes Diabetes Care 2001 24 2006 Google Scholar
Clapp, J F Rokey, R Treadway, J L Exercise in pregnancy Med Sci Sports Exerc 1992 24 s294 Google Scholar
Clapp, J F Capeless, E L The changing glycemic response to exercise during pregnancy Am J Obstet Gynecol 1991 165 1678 Google Scholar
Dempsey, J C Butler, C L Sorensen, T K A case-control study of maternal recreational physical activity and risk of gestational diabetes mellitus Diabetes Res Clin Pract 2004 66 203 Google Scholar
Dempsey, J C Sorensen, T K Williams, M A Prospective study of gestational diabetes mellitus risk in relation to maternal recreational physical activity before and during pregnancy Am J Epidemiol 2004 159 663 Google Scholar
Weissgerber, T L Wolfe, L A Davies, G A Mottola, M F Exercise in the prevention and treatment of maternal-fetal disease: a review of the literature Appl Physiol Nutr Metab 2006 31 661 Google Scholar
Oostdam, N van Poppel, M N Eekhoff, E M Wouters, M G van Mechelen, W Design of FitFor2 study: the effects of an exercise program on insulin sensitivity and plasma glucose levels in pregnant women at high risk for gestational diabetes BMC Pregnancy Childbirth 2009 9 1 Google Scholar
Dornhorst, A Frost, G. The principles of dietary management of gestational diabetes: reflection on current evidence J Hum Nutr Diet 2002 15 145 Google Scholar
Thomas, D Elliott, E J Cochrane Database Syst Rev 2009 1
Moses, R G Luebcke, M Davis, W S Effect of a low-glycemic-index diet during pregnancy on obstetric outcomes Am J Clin Nutr 2006 84 807 Google Scholar
Fraser, R B Ford, F A Milner, R D A controlled trial of a high dietary fibre intake in pregnancy – effects on plasma glucose and insulin levels Diabetologia 1983 25 238 Google Scholar
Clapp, J F Maternal carbohydrate intake and pregnancy outcome Proc Nutr Soc 2002 61 45 Google Scholar
Tieu, J Crowther, C A Middleton, P. Dietary advice in pregnancy for preventing gestational diabetes mellitus Cochrane Database Syst Rev 2008 2 Google Scholar
Thomas, D E Elliott, E J Baur, L. Cochrane Database Syst Rev 2007 3
Rasmussen, K M Yaktine, A L Weight Gain During Pregnancy: Reexamining the Guidelines Washington DC National Academies Press 2009
Stuebe, A M Oken, E Gillman, M W Associations of diet and physical activity during pregnancy with risk for excessive gestational weight gain Am J Obstet Gynecol 2009 201 58e1 Google Scholar
Kramer, M S Kakuma, R. Cochrane Database Syst Rev 2003 4 CD000032
Olafsdottir, A S Skuladottir, G V Thorsdottir, I Hauksson, A Steingrimsdottir, L. Maternal diet in early and late pregnancy in relation to weight gain Int J Obes (Lond) 2006 30 492 Google Scholar
Deierlein, A L Siega-Riz, A M Herring, A. Dietary energy density but not glycemic load is associated with gestational weight gain Am J Clin Nutr 2008 88 693 Google Scholar
Stehbens, J A Baker, G L Kitchell, M. Outcome at ages 1, 3, and 5 years of children born to diabetic women Am J Obstet Gynecol 1977 127 408 Google Scholar
Gardner, B Wardle, J Poston, L Croker, H. Changing diet and physical activity to reduce gestational weight gain: a meta-analysis Obesity Rev 2011 12 e602 Google Scholar
Laraia, B A Siega-Riz, A M Dole, N London, E. Obesity (Silver Spring) 2009 17 550
Webb, J B Siega-Riz, A M Dole, N. Psychosocial determinants of adequacy of gestational weight gain Obesity (Silver Spring) 2009 17 300 Google Scholar
Evenson, K R Moos, M K Carrier, K Siega-Riz, A M Matern Child Health J 2008 13
Rifas-Shiman, S L Rich-Edwards, J W Kleinman, K P Oken, E Gillman, M W Dietary quality during pregnancy varies by maternal characteristics in Project Viva: a US cohort J Am Diet Assoc 2009 109 1004 Google Scholar
Craig, P Dieppe, P Macintyre, S Developing and evaluating complex interventions: the new Medical Research Council guidance BMJ 2008 337 a1655 Google Scholar
Kinnunen, T I Aittasalo, M Koponen, P Feasibility of a controlled trial aiming to prevent excessive pregnancy-related weight gain in primary health care BMC Pregnancy Childbirth 2008 8 37 Google Scholar
North, R A McCowan, L M Dekker, G A BMJ 2011 342

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