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Meta-Analysis
. 2017 Jan 3;1(1):CD006674.
doi: 10.1002/14651858.CD006674.pub3.

Dietary advice interventions in pregnancy for preventing gestational diabetes mellitus

Joanna Tieu  1 , Emily Shepherd  1 , Philippa Middleton  2 , Caroline A Crowther  3
Affiliations
Meta-Analysis

Dietary advice interventions in pregnancy for preventing gestational diabetes mellitus

Joanna Tieu et al. Cochrane Database Syst Rev. .

Abstract

Background: Gestational diabetes mellitus (GDM) is a form of diabetes occurring during pregnancy which can result in short- and long-term adverse outcomes for women and babies. With an increasing prevalence worldwide, there is a need to assess strategies, including dietary advice interventions, that might prevent GDM.

Objectives: To assess the effects of dietary advice interventions for preventing GDM and associated adverse health outcomes for women and their babies.

Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (3 January 2016) and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs assessing the effects of dietary advice interventions compared with no intervention (standard care), or to different dietary advice interventions. Cluster-RCTs were eligible for inclusion but none were identified.

Data collection and analysis: Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.

Main results: We included 11 trials involving 2786 women and their babies, with an overall unclear to moderate risk of bias. Six trials compared dietary advice interventions with standard care; four compared low glycaemic index (GI) with moderate- to high-GI dietary advice; one compared specific (high-fibre focused) with standard dietary advice. Dietary advice interventions versus standard care (six trials) Considering primary outcomes, a trend towards a reduction in GDM was observed for women receiving dietary advice compared with standard care (average risk ratio (RR) 0.60, 95% confidence interval (CI) 0.35 to 1.04; five trials, 1279 women; Tau² = 0.20; I² = 56%; P = 0.07; GRADE: very low-quality evidence); subgroup analysis suggested a greater treatment effect for overweight and obese women receiving dietary advice. While no clear difference was observed for pre-eclampsia (RR 0.61, 95% CI 0.25 to 1.46; two trials, 282 women; GRADE: low-quality evidence) a reduction in pregnancy-induced hypertension was observed for women receiving dietary advice (RR 0.30, 95% CI 0.10 to 0.88; two trials, 282 women; GRADE: low-quality evidence). One trial reported on perinatal mortality, and no deaths were observed (GRADE: very low-quality evidence). None of the trials reported on large-for-gestational age or neonatal mortality and morbidity.For secondary outcomes, no clear differences were seen for caesarean section (average RR 0.98, 95% CI 0.78 to 1.24; four trials, 1194 women; Tau² = 0.02; I² = 36%; GRADE: low-quality evidence) or perineal trauma (RR 0.83, 95% CI 0.23 to 3.08; one trial, 759 women; GRADE: very low-quality evidence). Women who received dietary advice gained less weight during pregnancy (mean difference (MD) -4.70 kg, 95% CI -8.07 to -1.34; five trials, 1336 women; Tau² = 13.64; I² = 96%; GRADE: low-quality evidence); the result should be interpreted with some caution due to considerable heterogeneity. No clear differences were seen for the majority of secondary outcomes reported, including childhood/adulthood adiposity (skin-fold thickness at six months) (MD -0.10 mm, 95% CI -0.71 to 0.51; one trial, 132 children; GRADE: low-quality evidence). Women receiving dietary advice had a lower well-being score between 14 and 28 weeks, more weight loss at three months, and were less likely to have glucose intolerance (one trial).The trials did not report on other secondary outcomes, particularly those related to long-term health and health service use and costs. We were not able to assess the following outcomes using GRADE: postnatal depression; maternal type 2 diabetes; neonatal hypoglycaemia; childhood/adulthood type 2 diabetes; and neurosensory disability. Low-GI dietary advice versus moderate- to high-GI dietary advice (four trials) Considering primary outcomes, no clear differences were shown in the risks of GDM (RR 0.91, 95% CI 0.63 to 1.31; four trials, 912 women; GRADE: low-quality evidence) or large-for-gestational age (average RR 0.60, 95% CI 0.19 to 1.86; three trials, 777 babies; Tau² = 0.61; P = 0.07; I² = 62%; GRADE: very low-quality evidence) between the low-GI and moderate- to high-GI dietary advice groups. The trials did not report on: hypertensive disorders of pregnancy; perinatal mortality; neonatal mortality and morbidity.No clear differences were shown for caesarean birth (RR 1.27, 95% CI 0.79 to 2.04; two trials, 201 women; GRADE: very low-quality evidence) and gestational weight gain (MD -1.23 kg, 95% CI -4.08 to 1.61; four trials, 787 women; Tau² = 7.31; I² = 90%; GRADE: very low-quality evidence), or for other reported secondary outcomes.The trials did not report the majority of secondary outcomes including those related to long-term health and health service use and costs. We were not able to assess the following outcomes using GRADE: perineal trauma; postnatal depression; maternal type 2 diabetes; neonatal hypoglycaemia; childhood/adulthood adiposity; type 2 diabetes; and neurosensory disability. High-fibre dietary advice versus standard dietary advice (one trial) The one trial in this comparison reported on two secondary outcomes. No clear difference between the high-fibre and standard dietary advice groups observed for mean blood glucose (following an oral glucose tolerance test at 35 weeks), and birthweight.

Authors' conclusions: Very low-quality evidence from five trials suggests a possible reduction in GDM risk for women receiving dietary advice versus standard care, and low-quality evidence from four trials suggests no clear difference for women receiving low- versus moderate- to high-GI dietary advice. A possible reduction in pregnancy-induced hypertension for women receiving dietary advice was observed and no clear differences were seen for other reported primary outcomes. There were few outcome data for secondary outcomes.For outcomes assessed using GRADE, evidence was considered to be low to very low quality, with downgrading based on study limitations (risk of bias), imprecision, and inconsistency.More high-quality evidence is needed to determine the effects of dietary advice interventions in pregnancy. Future trials should be designed to monitor adherence, women's views and preferences, and powered to evaluate effects on short- and long-term outcomes; there is a need for such trials to collect and report on core outcomes for GDM research. We have identified five ongoing studies and four are awaiting classification. We will consider these in the next review update.

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Conflict of interest statement

Joanna Tieu: none known.

Emily Shepherd: none known.

Philippa Middleton: none known.

Caroline A Crowther: none known.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 1 Gestational diabetes.
1.2
1.2. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 2 Hypertensive disorders of pregnancy (pregnancy‐induced hypertension).
1.3
1.3. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 3 Hypertensive disorders of pregnancy (pre‐eclampsia).
1.4
1.4. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 4 Perinatal mortality.
1.5
1.5. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 5 Caesarean section.
1.6
1.6. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 6 Induction of labour.
1.7
1.7. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 7 Perineal trauma (anal sphincter injury).
1.8
1.8. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 8 Postpartum haemorrhage.
1.9
1.9. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 9 Postpartum infection.
1.10
1.10. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 10 Breastfeeding (at 3 months).
1.11
1.11. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 11 Breastfeeding (at 6 months).
1.12
1.12. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 12 Gestational weight gain (kg).
1.14
1.14. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 14 Behaviour changes associated with the intervention: health behaviours at 3 months postpartum.
1.15
1.15. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 15 Fasting glucose at 28 weeks (mmol/L).
1.16
1.16. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 16 Fasting glucose at 28 weeks ≥ 5.1 mmol/L.
1.17
1.17. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 17 OGCT at 28 weeks (mmol/L).
1.18
1.18. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 18 OGCT at 28 weeks > 7.8 mmol/L.
1.19
1.19. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 19 Fasting glucose at 28 weeks ≥ 5.1 mmol/L or OGCT at 28 week s> 7.8 mmol/L.
1.20
1.20. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 20 Sense of well‐being: score (% score between 14 to 28 weeks).
1.21
1.21. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 21 Postpartum weight loss at 6 weeks (kg).
1.22
1.22. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 22 Postnatal weight retention: change in weight from late pregnancy to 3 months postpartum (kg).
1.23
1.23. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 23 Return to pre‐pregnancy weight: change in weight from baseline to 3 months postpartum (kg).
1.25
1.25. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 25 Stillbirth.
1.26
1.26. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 26 Neonatal mortality.
1.27
1.27. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 27 Preterm birth (less than 37 weeks' gestation).
1.28
1.28. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 28 Preterm birth (less than 32 weeks' gestation).
1.29
1.29. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 29 Apgar score less than 7 at 5 minutes.
1.30
1.30. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 30 Macrosomia (> 4000 g).
1.31
1.31. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 31 Macrosomia (> 4500 g).
1.32
1.32. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 32 Shoulder dystocia.
1.33
1.33. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 33 Gestational age at birth (weeks).
1.34
1.34. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 34 Birthweight (g).
1.35
1.35. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 35 Head circumference at birth (cm).
1.36
1.36. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 36 Length at birth (cm).
1.37
1.37. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 37 Ponderal index at birth.
1.38
1.38. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 38 Adiposity at birth: skin‐fold thickness (mm).
1.39
1.39. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 39 Weight at 3 months (kg).
1.40
1.40. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 40 Weight at 6 months (kg).
1.41
1.41. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 41 Length at 6 months (cm).
1.42
1.42. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 42 Head circumference at 6 months (cm).
1.43
1.43. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 43 Skinfold thickness at 6 months (mm).
1.44
1.44. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 44 Systolic blood pressure at 6 months (mmHg).
1.45
1.45. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 45 Diastolic blood pressure at 6 months (mmHg).
1.46
1.46. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 46 Mean blood pressure at 6 months (mmHg).
1.47
1.47. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 47 Heart rate at 6 months (bpm).
1.48
1.48. Analysis
Comparison 1 Dietary advice interventions versus standard care, Outcome 48 Clinical complications (gestational diabetes, pre‐eclampsia, low birthweight, prematurity).
2.1
2.1. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 1 Gestational diabetes.
2.2
2.2. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 2 Large‐for‐gestational age.
2.3
2.3. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 3 Caesarean birth.
2.4
2.4. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 4 Operative vaginal birth.
2.5
2.5. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 5 Gestational weight gain (kg).
2.6
2.6. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 6 Adherence to the intervention.
2.7
2.7. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 7 Fasting glucose at 24‐28 weeks (mmol/L).
2.8
2.8. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 8 Fasting glucose at 32‐36 weeks (mmol/L).
2.9
2.9. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 9 Views of the intervention.
2.10
2.10. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 10 Apgar score less than 7 at 5 minutes.
2.11
2.11. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 11 Macrosomia (> 4000 g).
2.12
2.12. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 12 Macrosomia (> 4500 g).
2.13
2.13. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 13 Small‐for‐gestational age.
2.14
2.14. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 14 Gestational age at birth (weeks).
2.15
2.15. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 15 Birthweight (g).
2.16
2.16. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 16 Birthweight (z score).
2.17
2.17. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 17 Head circumference at birth (cm).
2.18
2.18. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 18 Length at birth (cm).
2.19
2.19. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 19 Ponderal index at birth.
2.20
2.20. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 20 Adiposity at birth: % body fat.
2.21
2.21. Analysis
Comparison 2 Low‐GI dietary advice versus moderate‐ to high‐GI dietary advice, Outcome 21 Neonatal intensive care unit admission.
3.1
3.1. Analysis
Comparison 3 High‐fibre dietary advice versus ‘standard’ dietary advice, Outcome 1 OGTT at 35 weeks (mmol/L).
3.2
3.2. Analysis
Comparison 3 High‐fibre dietary advice versus ‘standard’ dietary advice, Outcome 2 Birthweight centile.
See this image and copyright information in PMC

Update of

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Luoto 2011 {published data only}
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    1. Maitland RA, Patel N, Sherry C, Marriage B, Barr S, Lopez JM, et al. A pilot study to evaluate the effects of a dietary supplement with slow digesting‐low GI carbohydrates in obese pregnant women using continuous glucose monitoring. The Power of Programming 2014: International Conference on Developmental Origins of Adiposity and Long‐Term Health; 2014 March 13‐15; Munich, Germany. 2014.
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Mike O'Callaghan Federal Hospital 2011 {published data only}
    1. NCT01302756. The effect of high dose folic acid versus placebo on the rate of gestational diabetes or gestational hypertension in pregnant women: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT01302756 Date first received: 17 February 2011.
Min 2014 {published data only}
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Poston 2015 {published data only}
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    1. NCT00364403. A low glycemic load diet during pregnancy in overweight women. clinicaltrials.gov/ct2/show/NCT00364403 Date first received: 14 August 2006.
    1. Rhodes ET, Pawlak DB, Takoudes TC, Ebbeling CB, Feldman HA, Lovesky MM, et al. Effects of a low‐glycemic load diet in overweight and obese pregnant women: a pilot randomized controlled trial. American Journal of Clinical Nutrition 2010;92(6):1306‐15. - PMC - PubMed
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References to studies awaiting assessment

Angel 2011 {published data only}
    1. Angel MD, Haene J, Perez M, Hernandez G, Castaneda D, King JC. Dietary patterns associated with gestational weight gain and fat mass gain in overweight and obese pregnant women. FASEB Journal 2011;25:783.15.
Parat 2015 {published data only}
    1. NCT00804765. Impact of education during pregnancy in overweight pregnant women (ETOIG). clinicaltrials.gov/ct2/show/NCT00804765 Date first received: 8 December 2008.
    1. Parat S, Negre V, Baptiste A, Tauber M‐T, Valensi P, Bertrand A‐M, et al. A randomized trial of the effects of prenatal education of overweight or obese pregnant women to prevent childhood overweight: The ETOIG study. Diabetes 2015;64:A375. - PubMed
Simmons 2015 {published data only}
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References to ongoing studies

NCT01056406 {published data only}
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NCT01105455 {published data only}
    1. NCT01105455. The effect of a low glycemic index diet on blood sugar control in pregnant women at risk for gestational diabetes. clinicaltrials.gov/ct2/show/NCT01105455 Date first received: 9 April 2010.
NCT01628835 {published data only}
    1. NCT01628835. Low glycemic index diet management for pregnant women with overweight. clinicaltrials.gov/ct2/show/NCT01628835 Date first received: 10 May 2012.
NCT01894139 {published data only}
    1. NCT01894139. An optimized programming of healthy children (APPROACH). clinicaltrials.gov/ct2/show/NCT01894139 Date first received: 3 July 2013.
NCT02218931 {published data only}
    1. NCT02218931. Effect of simple, targeted diet in pregnant women with metabolic risk factors on pre‐eclampsia (ESTEEM): a randomised trial. clinicaltrials.gov/ct2/show/NCT02218931 Date first received: 11 July 2014.

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References to other published versions of this review

Tieu 2007
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Publication types