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Guidelines for Medical Nutrition Therapy in Gestational Diabetes Mellitus: Systematic Review and Critical Appraisal



      Medical nutrition therapy is the cornerstone of gestational diabetes mellitus treatment. However, guidelines often present contradictory guidance to health care practitioners.


      To systematically review and critically appraise medical nutrition therapy guidelines for treating patients with gestational diabetes mellitus.


      We searched Medline, the Cochrane Library, Guidelines International Network, and Google Scholar to retrieve clinical practice guidelines (CPGs) for medical nutrition therapy in gestational diabetes mellitus from professional or governmental organizations, published in English, between January 1, 2007, and November 24, 2018. CPGs were reviewed and appraised using the Appraisal of Guidelines, Research, and Evaluation II instrument.


      Of 1,286 retrieved articles, 21 CPGs fulfilled the inclusion criteria. CPGs of the Academy of Nutrition and Dietetics, Diabetes Canada, and Malaysia Health Technology Assessment Section received the greatest overall scores and the highest scores concerning rigor of recommendations development. Many CPGs failed to involve multidisciplinary teams in their development, including patients, and often, dietitians. Applicability of the recommendations was low, lacking facilitators and tools to enhance implementation. Many CPGs demonstrated low editorial independence by failing to disclose funding and competing interests. More medical nutrition therapy recommendations were incorporated in the Academy of Nutrition and Dietetics and Malaysia Health Technology Assessment Section CPGs. The Malaysia Health Technology Assessment Section, Diabetes Canada, Academy of Nutrition and Dietetics, and Endocrine Society guidelines were recommended by the review panel herein without modifications. Overall, the CPGs suggested the consumption of adequate protein and the selection of foods with low glycemic index, divided into three main meals and two to four snacks. Weight gain recommendations were mostly based on the Institute of Medicine body mass index thresholds.


      With few exceptions, the main developmental limitations of the appraised CPGs involved low rigor of recommendations development, lack of multidisciplinary stakeholder involvement, low applicability, and inadequate editorial independence. This indicates a need for developing more clear, unbiased, practical, and evidence-based CPGs.


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      E. Tsirou is an endocrinology resident and a doctoral degree candidate, Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece.


      D. Savvaki is a doctoral degree candidate, Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece.


      D. G. Goulis is an associate professor of Reproductive Endocrinology, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece.


      M. G. Grammatikopoulou is a senior lecturer, Department of Nutrition and Dietetics, Alexander Technological Educational Institute, and a scientific associate, Laboratory of Hygiene, Social and Preventive Medicine, and Medical Statistics, Aristotle University of Thessaloniki, Thessaloniki, Greece.


      K. Gkiouras is a scientific associate, Laboratory of Clinical Pharmacology, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.


      X. Theodoridis is a postgraduate student, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece; at the time of the study, he was a postgraduate student, Medical School, Faculty of Health Sciences, University of Thessaly, Larissa, Greece.


      A. Petalidou is a postgraduate student, Medical School, Faculty of Health Sciences, University of Thessaly, Larissa, Greece.


      E. Taousani is a doctoral degree candidate, Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece, and a senior lecturer, Department of Midwifery, Alexander Technological Educational Institute, Thessaloniki, Greece.


      A. Tsapas is an associate professor of medicine and lead investigator, Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece, and head, Diabetes Centre, Second Medical Department, Ippokration General Hospital, Thessaloniki, Greece.