Mastering Diabetes: My Empowered Pregnancy

Mastering Diabetes: My Empowered Pregnancy

MASTERING GESTATIONAL D I A B E T E S

MY EMPOWERED PREGNANCY

KYL IE BUCKNER R.N

WELCOME

Kylie Buckner, RN, MSN has over 18 years of nursing experience and is a Mastering Diabetes coach and the Director of Lifestyle Change. Prior to working for Mastering Diabetes, Kylie spent 18 years working in different areas of women's health care including NICU, pediatrics, high-risk OB, labor and delivery, and reproductive endocrinology.

Kylie has been following a plant-based diet since 2011 and loves using her background to support people reversing insulin resistance through a low-fat, plant-based, whole-food lifestyle. She uses all of her experience to teach about the connection between lifestyle choices and health. She has an in-depth understanding of the challenges of adopting a plant-based lifestyle and is committed to empowering people to make simple lifestyle changes.

Currently, Kylie loves to coach women who are pregnant or trying to conceive to help them achieve their healthiest pregnancy outcomes.

Kylie Buckner R.N

N U R S E

E D U C A T O R

B U S I N E S S O W N E R

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19 09 28 58 49

Part One Congrats you're expecting Nutritional Needs during pregnancy

Part Two What to eat each Trimester

Part Three Gestational Diabetes Mastering Diabetes Method

Healthy Recipes 30 day Challange 4 Ways to Improve your Blood Glucose

Resources

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VISION & MISSION

My vision is to support women during such a special time in life by offering education and guidance to make sustainable

changes to improve blood glucose values and overall health.

If you’re a mom, you’re a superhero. Period. -Rosie Pope

My mission is to support and educate pregnant women to achieve their healthiest outcomes in pregnancy by reversing insulin resistance.

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PROGRAM MODULES 01 02 03

Laying the Foundation

You Can't Track What You Don't Measure

To Whole or Not to Whole?

06

04

05

Buying, Preparing and Sharing Food

Intermittent Fasting for Increased Insulin Sensitivity

Exercice for Increased Insulin Sensitivity

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08

09

Understanding Gestational Diabetes and how to prevent and reverse it

Pregnancy, Hormones and Insulin Resistance

Nutritional Needs throughout Pregnancy (1st-3rd Trimester)

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Weekly Review Journal

At the end of every week, you’ll have the opportunity to reflect and plan your next week. Use this section of the workbook each week for learning more about your progress over the course of time. When you're making lifestyle changes, it can be very helpful to pause at the end of each week to check in on your progress, goals, and areas that you want to improve as you’re learning the Mastering Diabetes Method. Weekly Gratitude: List one or a few things that you’re feeling grateful for today or about the past week. This is a wonderful way to start the week off with some positive feelings. Studies show that gratitude practice helps to reduce anxiety and stress which is important for reducing blood glucose values. Weight Tracker: If you’re monitoring your weight, this is a good opportunity to check and log your weight. We recommend weekly weight checks to understand your progress over time. This will help you track your weight goals over the course of time. Weekly Wins: This is the place to identify areas that you feel successful about from the prior week. What do you feel great about? What did you enjoy about this week? What are you proud that you accomplished as you progress toward your short- or long-term goals? Did you accomplish any of your goals? Needs Improvement: Use this section to identify previous week’s plans that could use some improvement. Examples include shopping for green light foods, food preparation, keeping your Decision Tree with you, or logging your food in Cronometer. You can include any green light activities that you want to build consistency with to ensure you bring your focus to areas that you want to continue to improve. Notes: Use the notes area to write down any other information that is helpful to you in your progress. Write down questions you would like to address, reflections or insights that you gained about your blood glucose,

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To-Do List

To-Do List: Pick a few specific and measurable goals that you can achieve by the end of the following week. Try to stay focused on one thing that you want to accomplish. These weekly goals can be individualized and small actions that will help you make big gains in your insulin sensitivity. Exercise: Use this area to document important information about your movement and exercise. Write what exercise you enjoyed performing and what you want to include in the week ahead. You can reflect on the ways you moved your body and what felt good. You can also write your specific exercise plan and include the days and times that you will be performing the exercise. Having a plan can help you to stay accountable and motivated to your activity. Daily movement is an important way to reduce blood glucose, improve insulin sensitivity, and feel great every day. Healthy Sleep Habits: Sleep is an incredibly important part of a healthy lifestyle. When you’re making lifestyle changes to make improvements in your health, your body also needs rest so you have the energy to focus on your health goals during the day. Consistent sleep is shown to improve blood glucose levels, decrease cortisol levels and improve your stress, as well as improves your brain health and immune system functioning.

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STEPS TO SUCCESS 4

01 02 03 04 Take it slowly Make changes to 1 meal at a time- you will get results and build habits. Measure and Document You can’t monitor what you don’t measure. Find small ways to make changes in your daily habits. Invite in patience to the process

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Congrats you´re expecting!

For most women, pregnancy is a time of anticipation, excitement, joy and expectations. It is also a time of great changes and shifts in a woman’s body as it is providing a nourishing space for a baby to grow. As your body changes with the growing baby inside of you, your body also experiences shifts in nutritional needs. So the question becomes, what is the best food to eat and how do I meet the nutritional needs of myself and my baby. If you are someone who has been eating a plant-based diet, or chooses a low fat plant based whole foods (LFPBWF) diet for the management of diabetes or reversal of insulin resistance, this time of your life could become very confusing. Many questions arise- how do I ensure a healthy pregnancy, maintain my weight, avoid gestational diabetes, and other complications and still ensure my baby’s needs are met? Unfortunately, you may not receive much nutrition education during prenatal OB visits or during preconception consultation. Oftentimes the nutrition advice will focus on prescription of a prenatal vitamin and a brief discussion of foods best to avoid during pregnancy. Most physicians and OB health providers are not able to provide adequate nutrition counseling by reviewing your diet and making suggestions. But, why the need for a prenatal vitamin? What is contained in this supplement that you are not getting from your food? We are going to break down your nutritional needs during pregnancy and help you understand why a plant-based diet is an amazing option for optimal nutrition at any time during your life, but especially during the time of preconception, throughout pregnancy and when breastfeeding.

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Breakdown

Calories

1.

Calorie needs do change during pregnancy to ensure your body has the energy it needs to grow as your body adapts and your baby grows throughout pregnancy. However, calorie needs actually are not that much different than pre- pregnancy calorie needs. During the first trimester, your body doesn’t really need more calories than pre-pregnancy. In your Second trimester, you need 200-300 extra calories per day and in your third trimester, 400 calories more than pre-pregnancy caloric intake. After pregnancy, if you are planning to breastfeed your baby, you will actually require the most energy to produce energy-rich food for your baby. Increasing your caloric intake to 500 calories per day over pre-pregnancy calorie intake is important. So- how many actual calories do you need? The best way to learn this is to start by logging your “pre-pregnancy” calorie intake based on your typical diet. Learn how many calories you were consuming before you became pregnant and also think about where you were in relation to your ideal weight. Most women require a minimum of 1200-1500 calories to achieve their ideal weight and maintain it on a daily basis. Carefully planning a diet that is balanced in nutrition will inevitably be rich in carbohydrates. A diet that contains 80% carbohydrate from whole plant-based foods is the recommended nutrient content for the Mastering Diabetes Method to reverse insulin resistance. During pregnancy, protein and fat needs are important to consider. The World Health Organization (WHO) recommends a minimum of 20% of total calories from fat during pregnancy. By minimizing fat intake to 20%, the recommended carbohydrate intake would be 60-70% of total calories Carbohydrate and Fat

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Protein When in a non-pregnant state, the best way to understand your protein needs each day is to multiply your Ideal weight by .3. So, if your ideal body weight is 120, multiply this by .3 and your protein needs are 36g per day. There are many sources of dietary protein from plant sources such as- beans, whole grains, vegetables and fruits. These all contain adequate amounts of protein and with a variety of whole fresh foods, you will easily meet this need. During pregnancy, your protein needs increase by about 50% of your non-pregnant state. So again, if your pre-pregnancy body weight is 120, multiply this by .3 and your protein needs are 36g per day and then add 50% more giving you about 54g of protein per day. Calcium While Calcium needs don’t change during pregnancy, it’s important to bring up this vital nutrient. Calcium plays a crucial role in bone development mineralization which leads to strong bones in your baby. 1000mg of Calcium is recommended during pregnancy to ensure adequate levels. It’s also important to achieve adequate Vitamin D intake to help with Calcium absorption in your body. Supplementation with a prenatal vitamin will help you meet both your calcium and Vitamin D levels on a daily basis. But some foods that are rich in calcium include sweet potatoes, broccoli, leafy green vegetables and almonds or almond milk. Eating a variety of plant-based foods will help you meet this important mineral intake each day Breakdown

Iron

1.

Iron is a very important nutrient during pregnancy to prevent anemia and promote the growth and development of your baby. Green light foods like beans, whole grains, leafy green vegetables and even fruits contain sufficient amounts of iron to meet your daily intake. When eating an abundance of green light foods, you will often meet or exceed the recommended nutrient needs, however, iron is also included in most prenatal vitamins as well.

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Fat Currently, the American College of Obstetrics and Gynecology (ACOG) recommends a total fat intake of 20-35% per day (1), which is a very wide range of fat intake. The most important reason for fat intake is for omega 3 fatty acids and DHA/EPA. These micronutrients are important in infant brain and neurological development and function. For some perspective, 2 TBSP of ground flax seeds will provide you with over 100% of your daily Omega 3 requirements. Investing in a quality vegan DHA/EPA supplement will ensure you meet that requirement without having to ingest high amounts of dietary fat. If you’re someone who maintains a LFPBWF diet and currently eat between 10-15% of your total calories from fat, then during pregnancy adjusting to 20% will keep you within the recommendations of the ACOG. However, going much above this number will place you at greater risk for insulin resistance. A diet that consists of 35% of your calories from fat on a daily basis is by definition, a high fat diet. Eating plant based foods that contain more fat, like nuts, seeds, avocado and coconuts can help you reach the recommended limit of 20% fat, however, add these foods with caution because a little bit can go a long way. If you are someone who is managing their blood glucose and insulin resistance using a LFPBWF approach, the small addition of more fat- rich foods can impact your management. Finding a balance here is key. Insulin resistance is the root cause of many inflammatory conditions and can contribute to the development of diabetes, heart disease, cancer and other health conditions even during pregnancy. Insulin Resistance is caused by a high-fat diet and is defined as the storage of fat in tissues that are not designed to store fat, such as muscle tissue, organs and excess adipose tissue. Breakdown

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Breakdown

It is very difficult to get adequate vitamin D from any food source or diet. The very best place to get Vitamin D is actually from direct sunlight as our skin is the primary absorber for Vitamin D. If you are unable to get adequate sun exposure then supplementing with Vitamin D is important, especially in pregnancy. Vitamin D plays a critical role in calcium absorption, immune support and in glucose uptake into the cells. Monitoring your Vitamin D levels before, during and after pregnancy is important Vitamin D 1. 2. 3. 4. Folate Start enjoying folate-rich foods!! This is one of the most important nutrients that you can offer your body in preparation for pregnancy. Folate helps with very early cell growth as well as the baby’s brain and nervous system development. Folate deficiency can lead to spinal cord defects and neurological developmental delays. Folic acid found in prenatal vitamins is recommended, but folic acid is a synthetic version of the actual nutrient folate and does not convert completely for proper absorption. Unlike folate found in whole foods which provides a whole source of this very important nutrient inside your body. What if you could eat your daily folate requirements in the form of whole foods? The pre-pregnancy recommendation is 400mcg daily and during pregnancy, it increases to 600 mcg. (cite Brenda Davis). Where do I find folate in my food? Folate is found in the following: leafy green vegetables, legumes like beans, whole grains, citrus fruits like oranges (bonus- citrus fruit helps in the absorption of dietary iron!). 1 cup of black beans provides 256 mcg of folate alone, which is almost half of the folate recommended during pregnancy!

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MYWEEK

PLANNER

Dates

Monday

Priorities

Tuesday

Wednesday

Thursday

Saturday / Sunday

Friday

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JOURNAL

I am g r a t e f u l f o r . . .

L a s t we e k :

We i g h t T r a c k e r

C u r r e n t we e k :

My We e k l y W i n s

N e e d s I mp r o v eme n t

E x t r a N o t e s

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TO DO

ACT I ON ST EPS / PR I OR I T Y TASKS 1 .

2 .

3 .

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NOTES

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You never understand life until it grows inside of you. -Sandra Chami Kassis

1st Trimester

Each trimester will bring along different experiences for you, and you may start to feel different symptoms each week. Don’t worry, that’s very normal. Here are some suggestions to help you navigate the changes in your body throughout the trimesters and beyond. Carbohydrate-rich foods can help with nausea, as they “settle the stomach”. Remember how the school nurse or your mom would give you a cracker when you had a stomach ache as a child? This is the same philosophy, with intact whole grains, fruits or starchy vegetables. Feel free to blend, puree or mash whole grains and starchy vegetables, including mashed potatoes, mashed cauliflower, blended or pureed soups including squash, potato or corn.

Other foods to maximize during the first trimester include:

Leafy greens, beans, lentils and beets Starchy vegetables for nausea and morning sickness (eat small, frequent meals) Oatmeal, quinoa, rice, beans, hummus, potatoes, squash and bananas Eat 3-5 servings of fruit per meal to dramatically increase your energy levels

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It is the most powerful creation to have life that is growing inside of you. There is no bigger gift. -Beyonce

2nd Trimester

In this trimester, most women feel great! It’s common to feel very energized in your second trimester, especially since morning sickness has subsided. Keep up your plan from the first trimester, and celebrate with some creative plant-based meals. Of note, your calorie and protein needs do increase during the second trimester to meet the needs of your growing baby. Please consider logging your food to get a good idea of how many calories you’re eating and how much protein you are eating each day. All plant-based foods contain protein, but to maximize your protein intake, look for protein-rich whole foods like beans, lentils, whole grains, etc. During the second trimester, your protein needs increase by 15% of your pre-pregnancy protein intake. You may find yourself feeling more energized to perform more exercise, and this may also increase your appetite. If you’re feeling hungrier, add more carbohydrate-rich foods from the green light list. As with any change in your exercise routine, consult your OB/GYN to discuss the safest ways to add exercise into your day.

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Being pregnant means every day is another day closer to meeting the other love of your life. -Unknown

3rd Trimester

This pressure can make it difficult to eat large meals, so eating small and frequent meals (every 2 hours or so) that are high in fiber can help with digestion and feeling comfortable after your meal. During your third trimester, you’ll want to focus on smaller, more frequent meals. As your uterus expands and your baby grows, it will begin to place pressure on your stomach. During the 3rd trimester, your digestion can be affected due to slowed gastrointestinal motility, and fiber helps move food material through your large intestine. We recommend adding soups or blended soups, hummus, green smoothies, fruit smoothies, mashed potatoes, squash, cauliflower, and bananas eaten in small frequent meals. In addition, protein and calorie needs also increase once again during the 3rd trimester above your pre-pregnancy intake. It is recommended to increase protein by 25% of pre-pregnancy protein intake from protein-rich whole foods. Pro tip: Eat dates! Dates are associated with healthy labor and birthing, and can make a highly nutritious snack during your third trimester.

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There's no way to be a perfect mother and a million ways to be a good one. -Jill Churchill

Beyond Birth and Lactation

After the birth of your baby, you will likely be very busy, so having foods available that are quick, easy to eat in one hand, or drink from a glass will make this time much easier. If you are planning on breastfeeding, you will actually need more calories than you did in each of the trimesters of pregnancy. Producing breast milk and recovering from birth can consume between 500-1000 calories per day, so high-energy carbohydrate-rich foods will be especially important to eat. Pro tip: To make up for this calorie deficit, eat either 5 whole pieces of fruit, 2 large potatoes, a large smoothie containing bananas, mangoes, and berries, or eat about 2 cups of beans in addition to your regular meals.

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MYWEEK

PLANNER

Dates

Monday

Priorities

Tuesday

Wednesday

Thursday

Saturday / Sunday

Friday

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JOURNAL

I am g r a t e f u l f o r . . .

L a s t we e k :

We i g h t T r a c k e r

C u r r e n t we e k :

My We e k l y W i n s

N e e d s I mp r o v eme n t

E x t r a N o t e s

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TO DO

ACT I ON ST EPS / PR I OR I T Y TASKS 1 .

2 .

3 .

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NOTES

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WHAT IS GESTATIONAL DIABETES?

Gestational diabetes mellitus (GDM) is a condition that is discovered during pregnancy, which is caused by insulin resistance and can cause pregnancy- related complications in the baby including elevated blood glucose levels, excess birth weight, underdeveloped lungs, stillbirth, postpartum hypoglycemia and maternal pre-eclampsia (high blood pressure). For many pregnant women, gestational diabetes is temporary, treatable, results in a healthy pregnancy and a healthy baby and resolves after childbirth. However, there are many women unaware that they are living with insulin resistance, prediabetes or type 2 diabetes prior to pregnancy who then develop gestational diabetes during pregnancy. Oftentimes, pregnancy is the first time many women are comprehensively tested for metabolic conditions like diabetes, high blood pressure (hypertension), high cholesterol and obesity. In this workbook, we’ll discuss the connection between gestational diabetes and insulin resistance, and explain key strategies that can dramatically prevent and reverse it altogether.

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Motherhood is the greatest thing and the hardest thing. -Ricki Lake

What causes Gestational Diabetes?

Similar to prediabetes and type 2 diabetes, gestational diabetes most often results from uncontrolled insulin resistance. It’s important to understand that pregnant women develop insulin resistance as a natural byproduct of being pregnant, however, the diet that a woman eats during pregnancy is also incredibly important.

The following risk factors can increase your risk for GDM:

An elevated body mass index (BMI >25) Low physical activity Family history of diabetes mellitus History of developing gestational diabetes in the past Polycystic Ovary Syndrome (PCOS) Previously delivering a baby weighing more than 9 pounds (4.1 kg) Low HDL cholesterol An A1c greater than 5.7% Living with preexisting insulin resistance or prediabetes

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Laboratory testing typically done at around 24 weeks can become an important time to learn about underlying conditions that may be developing in the mother which increases the risk for pregnancy-related complications. Between 24-28 weeks, pregnant women are asked to take an oral glucose tolerance test (OGTT). The OGTT is standard care for pregnant women in their late 2nd or early 3rd trimester to screen for gestational diabetes. During an OGTT, you’ll typically fast for 8 to 12 hours before arriving at a medical clinic. Then, you’ll drink a solution containing glucose and provide blood samples to a medical technician according to a timed schedule. Once the results of your OGTT are analyzed, you’ll be notified of whether you’re safe, whether you should go for follow up testing, or whether your results indicate that you have gestational diabetes. Unfortunately, there is no consensus on how to analyze an OGTT, and as a result, diagnosing gestational diabetes varies from institution to institution. The amount of glucose in the solution, the timing of blood samples, and the threshold for high blood glucose differ between institutions, making it extremely challenging to come to a research-based consensus. How typically you will find out?

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The International Association of Diabetes and Pregnancy Study Group IADPSG “one-step strategy” has been adopted internationally, but conflicting recommendations by multiple expert groups make it challenging to determine objective criteria for the diagnosis of gestational diabetes. Despite this difference in diagnosis criteria, our diet and treatment recommendations are an extremely powerful way to improve the health of both mom and baby, and are specifically designed to reverse insulin resistance and reduce the risk of complications during and after pregnancy.

A mother's love endures through all. - Washington Irving

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Insulin Resistance and Gestational Diabetes

Th e g r oundwo r k o f a l l ha pp i ne s s i s h e a l t h . - Le i gh Hun t

Simply put, insulin resistance results from the accumulation of excess fat in tissues that are not designed to store large quantities of fat and it is the underlying condition that increases your risk for complications in all forms of diabetes. If you have been diagnosed with gestational diabetes, this indicates that you were likely either insulin resistant prior to pregnancy, or developed insulin resistance during pregnancy. This can result from the many risk factors above, it can result from shifts in hormones, or you could already be living with insulin resistance and not even know it.

So the key to preventing, treating and reversing gestational diabetes is really focused on reversing insulin resistance – the root cause of blood glucose variability and elevated blood glucose values. Because insulin resistance results from the accumulation of excess fat in tissues like muscle, liver and adipose the key to reversing insulin resistance is to reduce your dietary fat intake. Dietary fat is the key contributor to developing insulin resistance. As you reduce excess dietary fat and burn through the stored fat in your cells and tissues, you can reverse insulin resistance and improve your glucose tolerance.

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Does Gestational Diabetes Go Away?

Most doctors aren’t comfortable using the word “reverse” when it comes to gestational diabetes because it’s considered a temporary form of diabetes that resolves after delivery. However, if you develop gestational diabetes during pregnancy, scientific research indicates that you have a 35- 60% increased risk of developing type 2 diabetes within 10 to 20 years after pregnancy. Multiple studies have found similar results, which indicate that it’s important to treat gestational diabetes as a potential warning sign and respond accordingly. Fortunately, making smart changes to your diet can not only help reverse insulin resistance, but also help improve you and your baby’s overall health. The amazing thing about becoming a parent is that you will never again be your own first priority. -Olivia Wilde

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How Does Gestational Diabetes Affect the Baby?

When you are diagnosed with gestational diabetes, the primary concern is to ensure a healthy pregnancy for you and your baby, which means managing your blood glucose with precision. Glucose in maternal blood passes through the placenta and into the baby’s bloodstream. Maternal insulin, however, doesn't cross the placenta. This happens because glucose is a small molecule that is small enough to pass through the placenta, but maternal insulin is a much larger molecule that cannot pass through. Your baby will begin producing its own insulin at 12 weeks gestation. When the fetus is exposed to excess glucose from the mother’s blood, the baby secretes its own excess insulin in utero, greatly increasing the risk for complications for both mom and baby. What this means is that your baby’s glucose level will likely remain stable throughout pregnancy even though your blood glucose may be elevated.

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Some Possible Effects of Gestational Diabetes

Insulin affects your baby’s entire body. It acts as a glucose transporter but is also a potent growth factor that stimulates the growth of all tissues and can increase your baby’s body weight. Babies who are producing large amounts of insulin to keep their blood glucose stable in the womb have a risk of growing at an accelerated rate. This can cause your baby to gain excess weight, which can cause complications during delivery, including requiring a Cesarean birth. Additional insulin exposure for your baby also increases the risk for underdeveloped fetal lung tissue, which causes respiratory distress after birth, often requiring immediate respiratory support. Another common problem for a newborn producing excess insulin in utero occurs when the umbilical cord is cut. When your baby has high levels of endogenous (self-made) insulin, they can become hypoglycemic within 1-48 hours after birth when the umbilical cord is cut and the baby is no longer exposed to excess glucose frommaternal blood. Both of these problems can be treated, often through care in the newborn intensive care unit (NICU) by administration of intravenous glucose, which adds stress to what can already be a stressful and complicated time. It’s also worth noting that GDM does increase the chance of stillbirth by 34%, up to 17.1 per 10,000 deliveries as compared with 12.7 per 10,000 deliveries for women without diabetes.

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Other Effects of Gestational Diabetes

Aside from many of the effects that come with any form of insulin resistance (unpredictable energy, weight fluctuations, excessive hunger, urination or thirst) gestational diabetes can also result in a condition called pre-eclampsia. Pre-eclampsia is characterized by high blood pressure and can result in liver and kidney damage, which may prompt an emergency Cesarean birth, decreased blood supply to your baby and premature delivery. Note: If you have had pre-eclampsia in a previous pregnancy, you are at an increased risk for GDM. Fortunately, almost all of the effects of GDM can be counteracted by monitoring your blood glucose levels and adopting a lifestyle guaranteed to keep your blood glucose in range in the long-term.

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Does Gestational Diabetes Go Away

One thing you can do to be proactive in your health is to request to have your A1C, blood glucose, blood pressure and cholesterol levels monitored during your postpartum follow-up appointments. Most OBGYN physicians do not routinely monitor or measure these values after delivery of the baby, so speak with your primary care provider about getting this testing done. This will give you valuable information to track over time so you understand your level of insulin resistance and can take steps to reverse it and prevent T2 diabetes from developing in the future.

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How to Manage Gestational Diabetes: Action Plan

Wh a t y ou p l an t now , y ou w i l l h a r v e s t l a t e r . -Og Mand i no

The first step to effectively managing gestational diabetes starts with monitoring your blood glucose (blood sugar) and regularly taking insulin when needed to help supplement your body’s insulin production. Remaining physically active during pregnancy can certainly help keep your blood glucose well controlled. A recent systematic review and meta-analysis analyzed >Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50 Page 51 Page 52 Page 53 Page 54 Page 55 Page 56 Page 57 Page 58 Page 59 Page 60 Page 61 Page 62 Page 63 Page 64

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