Comparison of nutrient intakes of women with and without gestational diabetes(Nutritional Management of Gestational Diabetes Mellitus )
Instructions:
dissection part of dissertation I have already start write the dissection part and i wrote the main information but I need to re-write and add more and reorganize the structure .. please reword the red text in the file attached
Discussion structure updating the main finding of this study  that pre-pregnancy overweight or obese woman is at high risk to develop Gestational diabetes Miletus. The association between weight and the risk of develop GDM was more obvious among overweight women . depend on  Nice recommended the woman who have BMI  more than 27kg/m2 should seek for weight management adviser in order to achieve healthy BMI  , However  in this study we found that the relation between  nutritional intake including energy ,macronutrient and micronutrient and  develop GDM   is  not  significant in addition the social factors  such as smoking and alcoholic has the same result
1-advantage of study and  method  food diary “study use information for   nutritional intake ,weight , life social factors and biomedical test    the original sample size is 1639 ,food diary advantage ….
the strength of this study include collected information background for multiable  area like social factor background like matrial statue  ,number of children ,breast feeding ,smoking, and alcoholic and anthropometric background  like weight ,high, age ,and BMI  in addition a biomedical test including 1,2hours blood glucose ,and HAb1c the original sample size is 1639 which give the study advantage of have large number of  cases and enough to support the evidence   ,that will decrease the limitation of have misreport or incomplete 7 days  food dairy  , however only 120 cases of the total number  has included in this study
2-On the other hand disadvantage of study was the pre-pregnancy weight was estimated, because of the study data collection start in 28weeks of pregnancy and we had no information before that . One of the limmetation The rates of under-reporting were substantially higher than in other studies looking at nutrition in pregnant women with a range of BMI, for example the ALSP AC study on11,923 women in the South West of England had a rate of under-reporting 11% lower than in this”investigation (Rogers et al. 1998)he rates of under-reporting were substantially higher than in other studies
one of common  of food diary limitation  is under-reporting which will effect negatively on the accuracy of the collected  data practically in obese or over weight woman ,The researcher was faced with a significant amount of difficulty while trying to gather and analyse the information taken from the food diaries. First, there were some instances in which the researcher encountered unknown kinds of foods that were recorded in the food diaries. There were also some cases in which the research participants failed to record the portion size of their food intake. Other research study limitations included the use of home food measurement and the risk of the research participants’ misreporting the kind of food they ate and the portion size they had consumed throughout each meal.    Finally, we lacked information on some potential confounders, such as physical activity, so we were not able to assess the association between pre-pregnancy weight and GDM independent of these factors.,
finelly No data for physical activety Regular physical activity is key to ensure a healthy life for diabetic woman whether before conception, during pregnancy or after (Mottola, 2007)
weight discussion
Being overweight or obese immediately before getting pregnant may result in the development of gestational diabetes (Clerisme & Rand, 2009).study showed that pregnant women should gain 7-15kgs depending on their body weight before pregnancy and their height (Connor et al, 2003).and the The American Institute of Medicine (2008) recommendation  that women with a pre-pregnancy BMI that is greater than 30kglm2 should gain 11-20 pounds. In this study we found that the GDM group are heavier than Non-GDM group.
for Non GDM characteristics for the women mention in the descriptive statistics clarify that the pre-pregnancy weight of participant is (62.31 kg) and BMI (23.51kg/m2) the weight after 28 weeks (73.31 kg)  with BMI (27.62kg/m2) shows that the participant gain 11kg in average.
While for GDM the gain more weight during the pregnancy period with pre-pregnancy weight of participant is (78.52 kg) with BMI (29.98 kg/m2)the weight after 28 weeks (91.06 kg) with BMI(34.88 kg/m2).The weight  gain 13kg  in average.
From this we conclude that the GDM gain 2 kilos more than The NON-GDM.
The extra gained weight affects not only the mother but also the baby with increased risk of developing complications. (Maicon, 2012). For Example In a study examining 1092 woen, it was established that material weight was the factor affected baby’s birth weight by raising it. This was linked to macrosomia which is a symptom of GDM in a mother (Dawes et al, 1991).
Glucose result discussion
The Gold standard test for diagnosing gestational diabetes is considered to be the oral glucose tolerance test. There is a range of recommendations and guidelines for the identification and diagnosis of women with gestational diabetes (WHO 1999, Expert Committee 2000, NICE  2008 and ADA Metzger et al 2007)  The ADA guidelines are in the process of changing following the Hyperglycaemic and Adverse Pregnancy Outcome (HAPO) study. New diagnostic criteria for GDM as a result of this study have been recommended but are not yet universally adopted (Metzger et al 2008; 2010;add the range   NON GDM The mean value of 1 hour glucose (7.437) and 2 hours glucose (5.841) shows the difference of two points, for GDM The mean value of 1 hour glucose (10.3) and 2 hours glucose (8.508) shows the difference of two points
HAb1c  GDM The mean value of HBA1c at 28 weeks (5.13)
FOR NON GDM The mean value of HBA1c at 28 weeks (4.83)
AGE GDM The age of participants at 28 weeks is around (32.67 years) with 16 year of education which shows the good maturity level. The participants serve the breast feeding to child for 28.14 days.while in NON GDM The age of participants at 28 weeks is around (29.8 years) with 16 year of education which shows the good maturity level
7–there is no relation between social factor like smoke and employed years of eduction with rick of GDM” please see result section file and add the resul
Nutrients intake discussion
8-  during the pregnancy energy requirements increase due to the physiological change in the body to meet the mother and the fetus requirements in relation to that We found that No significant association between nutrient intake and  risk of  develop GDM ,
The energy consume by each percipients (2052.60 Kcal) on average the total fat and carbohydrate  shows the mean value (73.52g) and( 286.33g) .The usage of englyst fibre (15.92g), protein (80.41g) and vitamin D (2.94u) shows the mean value at large extent. The height of participants mentioned in meters i.e. (1.62 m) which is (5.31 feet) on average. The value shows the estimated pre-pregnancy weight and group wise classification of GDM and non-GDM.
the  distribution on energy depend on  nutrient intake within GDM group and Non GDM  group   :
In GDM  group 54% of total energy intake for carbohydrates  with mean (291.2g)while in NON GDM 56.8% , with mean (283.9g)
GDM total fat intake is 33.7% of total energy with the mean value (80.97g) ,while  NON GDM  total fat intake 31% with mean value (69.81g), depend on the total daily allowance of fat intake for those with GDM should not be more than 35% of the total daily energy intake(ADA, 2006).the Total fat intake is not above the allowance level  ,
protein consumption should be approximately 15% of the daily calorific intake (0.8-1g/1kg of the ideal body weight) (ADA, 2006)  in GDM group was  15.8% with the mean value (85.68) while  the protein intake  slightly lower in non GDM  group  with 15.5% mean value (77.77g) . However both group are above the recommendation  level .
Non GDM   energy consume by each percipients is 1998 Kcal. On the other hand, the total fat and carbohydrate shows the and (283.9). The mean value of, Vitamin D (2.888), and t fibre (15.61) shows the consumption level.
While the energy consume in GDM Group by each percipients is 2158 Kcal. On the other hand, the total fat and sugar shows and (119.3). The mean value of starch (171.1), Vitamin D (3.05), Cholesterol (291.2) and fibre (16.59) shows the consumption level.
Better education on the risks of beingoverweight and pregnant is necessary, as well as simple ways for women to estimate their calorie intakes, such as portion size aids.
This is example of the discussion similar what I’m looking for
DISCUSSION
In this study, we found that greater gestational weight gain in early pregnancy, particularly during the first trimester, was associated with an increased risk of GDM. Exceeding the 2009 IOM recommendations for gestational weight gain was also associated with an increased risk of developing GDM. All of these associations were independent of important confounders, including age, race/ethnicity, pregravid BMI, and parity. However, the association between gestational weight gain and the risk of GDM was more pronounced among overweight and nonwhite women.
Strengths of this study include the representative population, the robustness of the results after several sensitivity analyses, and the biologic plausibility of a stronger association between gestational weight gain during the first trimester and the risk of GDM.7 However, several limitations should be considered when interpreting the results of this study. First, we used prepregnancy weights that were (for most women) self-reported. Although we and other investigators have observed that self-reported prepregnancy weight approximates the true value,19,23 we may have underestimated or overestimated the association with GDM. However, our sensitivity analyses restricted to women with measured weights were encouraging. We have no reason to believe that the women who developed GDM would have underreported their prepregnancy weight more than control women because none of the women included had a history of GDM. Thus, we expect that any bias attributable to the misclassification of prepregnancy BMI would be nondifferential and would therefore bias our results toward the null. We were also missing data on weights recorded in the medical charts for approximately 15% of the women. If women with missing data were more or less likely to gain excessive weight, we could have underestimated or overestimated the risk of GDM associated with gestational weight gain. We did not have information on the composition of pregnancy weight gain, and it is plausible that gaining fat mass compared with lean mass could have differential effects on GDM risk. Finally, we lacked information on some potential confounders, such as diet and physical activity, so we were not able to assess the association between gestational weight gain and GDM independent of these factors.
Three prior studies have found that excessive gestational weight gain is associated with an increased risk of impaired glucose tolerance during pregnancy that did not meet the strict criteria for GDM.9–11 Similar to our finding that the association was stronger among overweight and obese women, one study found that a higher observed-to-expected gestational weight gain ratio increased the risk of impaired glucose tolerance only among overweight women,10 and another study found that exceeding the 1990 IOM recommendations increased the risk of impaired glucose tolerance, but only among obese women.9 A recent study11 found no association between gestational weight gain before the GDM screening and risk of GDM, but they did find a borderline association between a high rate of weight gain in the first trimester and risk of GDM (OR 1.70, 95% CI 0.98–2.94). The smaller sample size of these previous studies may explain some of the discrepancies, but overall prior studies support our findings. We tested and found an interaction between gestational weight gain and race/ethnicity, suggesting that excessive gestational weight gain may have a greater effect on the risk of GDM in nonwhite women than in white women.
We found that the association between gestational weight gain and risk of GDM was mainly attributable to excessive weight gain in the first trimester. Rapid gestational weight gain in early pregnancy may result in an early increase in insulin resistance that leads to the “exhaustion” of the B cell. This could reduce the capacity of the B cells to secrete adequate levels of insulin to compensate for the insulin resistance induced by the progression of pregnancy and therefore lead to the development of GDM. Although we were unable to measure the components of gestational weight gain (eg, maternal fat mass, fat-free mass, mass of the fetus), weight gain in early pregnancy has been found to consist of more maternal body fat.7,8 Large gains in maternal fat mass in early pregnancy could have a stronger influence on subsequent insulin resistance and, consequently, GDM risk than later gains in lean tissue or fetal mass. Catalano et al24 found an inverse association between maternal fat accretion and insulin sensitivity from before conception through 12 to 14 weeks of gestation, but not from early to late pregnancy. The authors speculated that at 12 to 14 weeks of gestation they were primarily estimating changes in maternal metabolism, and only a small proportion of the change was attributable to increased fetal or placental tissue.
The 2009 IOM pregnancy weight gain report suggested that more evidence was needed to determine whether gestational weight gain plays a role in the cause of GDM.12 Our study is one of the first to support a direct association between gestational weight gain and the risk of GDM. These findings need to be replicated in other racial/ethnically diverse populations. Clinicians should be aware that high rates of weight gain during early pregnancy may increase a woman’s risk of GDM, particularly among overweight or obese women. Avoidance of excessive weight gain early in pregnancy may be an effective strategy for prevention of GDM, but randomized studies are needed to determine the feasibility of such an early intervention and the best methods to help women meet the IOM recommendations for gestational weight gain

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