SUBJECTIVE:,  This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy.  Patient reports that she had gestational diabetes with her first pregnancy.  She did use insulin at that time as well.  She does not fully understand what ketones are.  She walks her daughter to school and back home each day which takes 20 minutes each way.  She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:,  Weight is 238.3 pounds.  Weight from last week’s visit was 238.9 pounds.  Prepregnancy weight is reported at 235 pounds.  Height is 62-3/4 inches.  Prepregnancy BMI is approximately 42-1/2.  Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time.  Blood sugar records for the last week reveal the following:  Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116.  Overall average is 140.  A diet history was obtained.  Expected date of confinement is May 1, 2005.  Instructed the patient on dietary guidelines for gestational diabetes.  A 2300 meal plan was provided and reviewed.  The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:,  Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day.  Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day.  Her diet history reveals that she is eating three meals a day and three snacks.  The snacks were just added last week following presence of ketones in her urine.  We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most.  We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget.  We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy.  We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars.  While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day.  Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis.  At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:,  Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate.  Breakfast:  Three carbohydrate servings.  Morning snack:  One carbohydrate serving.  Lunch:  Four carbohydrate servings.  Afternoon snack:  One carbohydrate serving.  Supper:  Four carbohydrate servings.  Bedtime snack:  One carbohydrate serving.  Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack.  Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy.  Recommend patient include a fruit or a vegetable with most of her meals.  Also recommend including solid protein with each meal as well as with the bedtime snack.  Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment:  Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units.  Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial.  Provided my name and number should there be additional dietary questions.consult - history and phy., diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks