Could you please help me understand gestational diabetes?
Thank-you! Jolynn Schwartz

GESTATIONAL DIABETES MELLITUS
by Susan Oshel, CPM

One of the common tests recommended by obstetricians during pregnancy is a glucose tolerance test (GTT). Many pregnant women face this test, and many question it's necessity, as ingesting large amounts of glucose after fasting can be uncomfortable, at best. Do we really need this test? What is gestational diabetes? And if our blood sugar levels are high, how does this affect our unborn baby? What can we do to prevent and/or treat it?

Gestational diabetes is a form of diabetes that occurs during pregnancy. It is diagnosed through testing glucose levels in the blood. There are symptoms which are associated with elevated blood sugar: excessive thirst, hunger, frequent urination, and/or weakness. Often the baby will grow large for dates, although some are small due to placental insufficiency. Approximately 70% of gestational diabetes (GDM) occurs in an asymptomatic form, which is why some doctors like to test all women. Some practitioners test only those at risk or with symptoms.

GDM occurs in 2%-6% of all pregnant women, beginning most often in late pregnancy (28-40 weeks).
Factors which place a woman at increased risk are (l) maternal age over 30, (2) obesity, or pre-pregnancy weight more then 20% over ideal weight, (3) family history of diabetes, and (4) obstetric history of polyhydramnios, unexplained stillbirth, or infant with congenital abnormalities.

Women with fasting blood sugar levels of 105mg glucose/dL blood, and two hours after ingesting 50mg (12.5- tablespoons) glucose 120mg/dL, are considered gestationally diabetic. Most labs use 100 mg (25 tablespoons) of glucose, but I work with a doctor who considers 50 mg acceptable. If you find yourself in this scenario during pregnancy, don't spend needless time worrying and labeling yourself high risk, and don't ignore it, either. Educate yourself!

What causes gestational diabetes? During the first trimester of pregnancy, the hormones estrogen and progesterone stimulate the pancreas to increase insulin production, which promotes increased utilization of glucose. Throughout pregnancy, there is an enhanced insulin response to glucose. During second and third trimesters, because of major hormonal changes, the body tolerates glucose less efficiently, has a greater resistance to insulin, and increases it's production of glucose. There is good reason for all of this activity, as insulin resistance is a glucose-sparing mechanism that insures an abundant supply of glucose for the baby and the placental attachment,  needed especially in beginning stages of development. Maternal insulin requirements may double or quadruple by full term pregnancy.

Most pregnant women are capable of increasing insulin production to compensate for the insulin resistance. When the pancreas is unable to produce sufficient insulin, or if the insulin is not utilized effectively, gestational diabetes can result.

From the onset of GDM, the baby faces increased risk of complications which range from mild and transient but often are life-threatening.  During pregnancy the pancreas of the diabetic mother produces insufficient insulin. Consequently, glucose levels, which can damage many organs, rises in the mother's and baby's blood streams. The baby's young, strong pancreas increases it's own insulin production, normalizing it's blood sugar (it is not being normalized by it's mother as insulin DOES NOT cross the placenta.)  Levels stabilize, though at the cost of some compromises to the baby. The baby's own abnormally high insulin levels quickly metabolizes the glucose within it's body, it's blood sugar plummets, and it goes into shock and it cannot live. This can happen during late pregnancy, birth, or shortly thereafter.

This all sounds pretty scary. However, the key to a healthy, safe pregnancy is to keep blood sugar levels within a normal range. Gestational diabetes tends to respond to diet and exercise, the most natural and basic methods of personal health care.  Exercise plays an important role in the utilization of sugars in the bloodstream.  Gestational diabetes is a greater risk undiagnosed and untreated.  I have personally known women who altered their diet, monitored their blood sugar levels, and had safe births and healthy babies.  The avoidance of all processed sugars, processed carbohydrates (white flour, white rice, etc.), and the inclusion of lots of good whole grains and vegetables lends itself well to stabilizing blood sugar.  Processed carbohydrates need to be avoided because they turn into sugar in the bloodstream.  Most women with elevated blood glucose manage it through diet and exercise (any exercise which raises the heart rate assimilates blood glucose that is not otherwise being assimilated, which means even walking helps, especially in the evening).  Very few need to take insulin. The question of improving diet and physical fitness before pregnancy to possibly prevent complications such as GDM IS ongoing.

Eliminating all sugars and processed carbohydrates will eliminate the "problem" of high blood sugar levels. Some women, however, might need to eliminate all sugars, but not all processed carbohydrates (some women can tolerate whole wheat breads purchased from grocery stores.)  By checking blood sugar levels after eating, you are able to determine which foods need to be eliminated, and which foods are acceptable.  Every gestationally diabetic woman is unique in her body's ability to process sugars.  If you do not have access to a glucose monitor (available at most drugstores), following the basic diet will keep blood sugar normal.  However, checking your glucose levels is the most efficient way to know what you should not be eating.

Have your doctor or midwife check glucose regularly throughout pregnancy. A good time to do this is in the morning on a fasting stomach (before eating) and then again one hour after eating breakfast. This will give you a basic check.

It is important to point out that ""cheating" is detrimental.  After eating a candy bar your blood sugar will soar and return to normal when you resume your basic diet.  The baby will receive the effect of the high blood sugar level due to the candy bar and not be without compromise.  If this continues throughout pregnancy off-and-on, the baby could have a reaction in the third trimester, during birth, or after birth. If sugar is ever-so-hard to give up, bake a chocolate cake, wrap it up and freeze it. Get it out after birth and indulge. You can look forward to not having to maintain this diet forever!  But stick to it while you are cradling your little one inside your womb.

It is important to remember that gestational diabetes is a variation of normal pregnancy. Gestationally diabetic women are not sick. Not ignoring it, but MANAGING it is the key!

(Note: Women who were diabetic before pregnancy or are taking insulin to regulate glucose need special care.)

1. MATERNITY & GYNECOLOGIC CARE: THE NURSE and the FAMILY,
5th edition, LBobak and M.Jensen, Mosbey Publisher: 
St. Lewis, 1993, pp.925-926,930,945.
2. MAYE'S MIDWIFERY, 11th edition,
Betty R. Sweet, Bailliere Tindall Publications:
Philadelphia, 1989, p.p.297-301.
3. MOSBY'S Medical, Nursing, & Allied Health DICTIONARY,
3rd edition, Managing Editor W.D. Glanze, Revision
Editor, K.N. Anderson, Consulting Editor L.E. Anderson,
Mosbey Publisher: St. Louis, 1990, p.517

DIET FOR GESTATIONAL DIABETES

The following dietary guidelines for gestational diabetes are basic and can be used by any woman with the exception of those who were diabetic prior to pregnancy and those taking insulin to control their diabetes. These two exceptions need specialized care in dietary management during pregnancy.

FOODS TO AVOID:
ALL SUGARS - White and brown sugar, sucrose, dextrose, molasses, fructose, com syrup, honey, etc. Read labels, as sugar comes in many forms and under numerous names. Check ingredients in canned foods. Peanut butter has sugar in it, as well as breads and numerous other packaged foods. Label reading can be fun and educational. Choose packaged foods free of sugar.
DRIED FRUITS - When a fruit is dried, fruit sugar becomes concentrated.
FRUIT JUICES - Fruit juices are concentrated forms of fructose. An eight ounce glass of apple juice is the equivalent of ten apples in fruit sugars.
PROCESSED CARBOHYDRATES - The farther away from a food's natural state you get, the more processed it is. White flour is a processed carbohydrate as well as white rice. Cream of wheat, if it has been made from wheat stripped of it's hull and germ is a processed carbohydrate. Processed carbohydrates turn to sugar in the bloodstream. The word "processed" is significant here, as some whole wheat breads available in the grocery store behave in the same manner as white flours. These breads have minimal amounts of whole grains in them but enough to bear the title of "whole wheat." One gestationally diabetic woman I worked with found that her blood sugar soared every time she ate any store-bought whole wheat bread. She began grinding her own wheat berries into flour and baking her own breads. Her blood sugars then remained stable. Pastas of all varieties also need to be made of whole grain products. These are available in most health food stores.

FOODS TO EAT:
For breakfast eat a high protein diet avoiding fruit until after lunch. Breakfast could include oatmeal with raisins (raisins are the one acceptable dried fruit), whole grain toast, herbal teas (unsweetened), and other oat cereals and whole grain cereals. Nettles and oatstraw teas are good blood sugar balancers.  Soy and rice milk is good on cereal.  (Remember to read the package and avoid soymilks which contain barley malt sweetener as it is a sugar.) After lunch include some fresh fruits, (apples, oranges, bananas, etc.). Fresh fruit will not affect blood sugar, especially if eaten after noon and not in the morning on a fasting stomach.
Lunches and dinners can include homemade soups of all kinds, (lentil, pea, vegetable, etc.), whole grains such as rice and millet, raw and steamed vegetables, potatoes, cornbread. Books full of wonderful recipes are: THE MCDOUGAL PLAN, by Dr. John McDougal, MAY ALL BE FED, by John Robbins, RECIPES FOR LIFE FROM GOD'S GARDEN by Malkmus, RECIPES FOR LONGER LIFE  by Anne Wigmore and RECIPES FOR LIFE by Anne Wigmore .

Written and submitted by Susan Oshel, CPM