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If you’re diagnosed with gestational diabetes mellitus (GDM), it means you have elevated blood glucose levels (translation: glucose stays in the blood too long rather than being used up as an energy source). The incidence of gestational diabetes has risen dramatically in recent years, closely paralleling the obesity epidemic and growing numbers of type 2 diabetes, generally.
Why?
Insulin is the hormone (produced by the pancreas) the body uses to regulate blood-sugar levels, and go figure, pregnant women need more of it — up to 2-3 times more of it — to keep their blood-sugar levels “normal.” It’s possible that some women, for whatever reason, don’t produce enough insulin over the course of their pregnancies.
Another component of GDM is increased insulin resistance, courtesy of the placenta; basically, placental outputs (namely, hormones that help your baby and body grow healthily) almost all impede your body’s ability to actually use insulin. Result: unregulated (high) blood-sugar levels. Since the placenta produces more and more of these insulin-impairing hormones as your baby grows, these effects can worsen over the course of your pregnancy.
To make the problem worse, many women crave high-sugar and high-carb foods during pregnancy (am I right??) or already have a high-carb/high-sugar diet to begin with (as most Americans do…).
Good news: though our insulin production may not be in our control, our diets totally are.
Risks with Gestational Diabetes
Unfortunately, GDM comes with risks for both mother and baby. If a pregnant woman has high blood glucose, that flows through the placenta and is passed on to the baby. In response, the baby’s pancreas produces more insulin to get rid of the extra blood glucose. Since the baby is getting more energy than s/he is using, the extra energy is stored as fat, which can lead to a condition called macrosomia — the medical term for an oversized baby.
Babies with macrosomia face health problems of their own. For starters, a bigger baby (9 pounds and heavier) is more difficult to get… out of… your body. Hence, macrosomia can put babies (and moms) at risk for certain delivery traumas, such as a shoulder dystocia or an emergency C-section. Babies born to mothers with GDM face other risks, such as preterm birth, respiratory distress syndrome (RDS), hypoglycemia after delivery (low blood-sugar), jaundice, NICU admission, and even stillbirth.
Mothers with GDM are at a higher risk for preeclampsia and some will go on to develop full-blown type 2 diabetes after birth (estimates vary: between 15 and 70%).
In the long-term, babies with excess insulin are at a higher risk for obesity and type 2 diabetes.
Symptoms of Gestational Diabetes
Most women with gestational diabetes exhibit no symptoms, which is part of why it’s so important to get screened, though some may experience increased thirst, increased urination, fatigue, nausea and vomiting, bladder infection, yeast infections, and blurred vision.
Here, Drink This
GDM is diagnosed with an oral glucose tolerance test (OGTT). (This first step is a screening, sometimes called the glucose challenge test, and there’s nothing special you need to do to prepare.) Your doctor or midwife will send you to a clinic (alternatively, some offices do it in-house) where you’ll drink this delicious orange concoction (kidding! It’s a little gross… but it’s not really that bad — it tastes like Tang or Sunny-D) that contains exactly 50 grams of sugar. (You have to drink it in less than five minutes, just FYI.)
Then, precisely one hour later, you’ll have your blood drawn to measure your blood-sugar level.
*Bring your book, magazines, or an iPad to kill time — most offices won’t “let” you leave for the hour.
If the lab reading is in the range of 130-140 mg/dl, you might have gestational diabetes (below this is considered “normal”). *Note that there is no uniform magic number in terms of “failing” this test. Every office determines its own threshold for the screening — in some places, it might only be 130 mg/dl, but in others that number is 135 or 140.
If your numbers are elevated: deep breath, relax. That was just a screening, and you might still “pass” the next phase (a 3-hour test), though you should take notice and cut back on carbs/sugar. Remember, this is all a continuum: it’s not like a woman with 129 mg/dl is doing just fine and one with 132 mg/dl is in big trouble.
Somewhere between 15 and 25% of women fail this initial screen, but the actual estimated incidence of GDM in the US is only 7% on average. If you do move on to round 2 of testing, you’ll need to return for the glorious 3-hour glucose tolerance test.
The protocol is roughly the same, except you’ll have to fast overnight before coming in, drink a 100-gram sugar cocktail this time, and then have your blood drawn for a baseline reading before it’s taken again at 1, 2, and 3 hours afterward. If 2 out of 4 of these readings are abnormal, you’ll be officially diagnosed with GDM. (Again, there is no universal consensus on the “normal” readings — every practice selects its own screening threshold levels. Medline lists normal values at <95 mg/dL (fasting), <180 mg/dL (one hour), <155 mg/dL (two hours), and <140 mg/dL (three hours).)
Then What?
This can be scary, we know, but there is good news. Treating GDM appropriately reduces risks for baby and mom, and — as a team of authors writing in the New England Journal of Medicine concluded — “may also help improve the woman’s health-related quality of life.”
It’s worth noting here that many women are totally caught off guard by GDM — it can and does happen to women who have none of the classic risk factors (overweight, history of large babies, family history of diabetes).
Regardless of your personal medical history, you should know that healthy eating and exercise (emphasis on the healthy eating) are typically effective in managing GDM. In the minority of cases where these kinds of lifestyle changes don’t “work,” your doctor will probably discuss insulin with you, but this is the exception rather than the rule.
Managing Gestational Diabetes
Many women diagnosed with GDM will meet and work with a nutritionist or dietician for the duration of their pregnancies (in fact, we highly recommend it).
Regarding diet, let’s talk basics. None of this is even unique to GDM; it’s just how everyone should be eating. Unfortunately, this is a national issue. In the land of plenty, childhood obesity is a devastating social problem, and it’s still trending upward for people in all socioeconomic categories. So is diabetes.
Houston, we have a problem
There are multiple factors contributing to this crisis.
Americans, on average, work more hours than any others in the world. When we work more, we cook less. On top of that, many of us parents have stopped teaching our kids to cook.
Furthermore, those who don’t earn much find their dollar goes much farther on fast food, cheap carbs, and unhealthy oils. And thanks to farming subsidies, the market is flooded with products made from the highly subsidized crops (corn, wheat and soybeans), including sweeteners in the form of high-fructose corn syrup (HFCS), fats in the form of hydrogenated fats made from soybeans, and feed for cattle and pigs. This flood, in turn, drives down the prices of fattening fare such as prepackaged snacks, ready-to-eat meals, fast food, corn-fed beef and pork, and soft drinks.
Meanwhile, the “Big Food” industry has mastered the art of marketing to us and to our children – they’ve also mastered the science of creating the most addictive kinds of foods – and we, as a culture, have succumbed to it.
I wanted to throw this in to give a little context into what’s happened to us as a people and how our “food culture” has deteriorated — and continues to do so. This is also to say that it’s not all our fault, per se — most of us are simply products of our environment.
According to the American Heart Association, the average American adult consumes a about 60 lbs of sugar per year. Holy sh*t! Our bodies simply were not designed to eat this way! This amount of sugar is literally toxic to the pancreas and, over time, will most likely cause insulin resistance. In fact, more than half of American adults have diabetes or pre-diabetes.
This is completely insane.
Once we recognize that the food culture we live in is super fucked up — we can see it for what it is and take steps to change our habits.
Something Has to Change
Big picture: there is no one single way to “eat right.” We can do it in all kinds of different ways. You may have heard a lot about people eating paleo, vegetarian, vegan, “keto,” gluten-free… the list goes on and on. You don’t have to subscribe to any of these, but here are the things you should know about carbs, sugar, and various types of fat.
We all need to throw out some of our deeply-entrenched — and totally incorrect — ideas about fat, carbs, and sugar that were impressed upon us in the 80s and 90s (namely, that carbs are your friend and fat is the enemy).
In fact, when we talk about diabetes, we need to primarily look at carbs.
The Thing about Carbs, Sugar and Fat
When we eat carbohydrates, the digestive system breaks them down into sugar (glucose), which enters the blood. As blood-sugar levels rise, the pancreas produces insulin, a hormone that prompts cells to absorb blood-sugar for energy or storage.
Type 2 diabetes occurs when the body can’t make enough insulin or can’t properly use the insulin it makes.
When managing diabetes, the goal is to keep your blood-sugar stable and low. Here’s a look at how your blood-sugar responds (roughly) to various types of foods:
Gary Taubes explains some of this in painstaking detail in Good Calories, Bad Calories, but the gist is: our culture’s addiction to processed carbs — breads, pastas, cereals, crackers, etc. — is a big part of the problem. Maybe the biggest part. Eating carbs such as these causes spikes in insulin and blood-sugar, which at best will make you feel crappy an hour afterward (pancake coma), and at worst can cause metabolic syndrome (diabetes, heart disease, certain cancers).
When you consume meals high in refined carbohydrates that are not balanced with respect to protein and good fat, you may continually crave carbohydrates and get stuck in the “carb craving cycle.”
When creating meal plans for controlling diabetes, tracking/controlling total carbs per day is key. For example, a person with type 2 diabetes might be instructed to keep their total carbs per day under 130 grams/day (which is actually quite a lot). Because everyone’s needs/bodies are different, this is where a personal dietician can really help. (Also: there’s calculating “net carbs,” which is total carbs minus fiber intake. As you can see, this can get a little technical, so it’s best to create a personal plan with a trained professional.)
Sugar is a type of carb you should especially steer clear of. Eating simple sugar is the easiest way to spike your blood-sugar (obviously).
Fat
For years, fat was a four-letter word. We were urged to banish it from our diets wherever possible. We switched to low-fat foods, but that shift made us more unhealthy because we replaced healthy fats with carbs, sugars, and unhealthy fats.
Trans fats create inflammation, which is linked to heart disease, stroke, diabetes, and other chronic conditions. They also contribute to insulin resistance, which increases the risk of developing type 2 and gestational diabetes. Even small amounts of trans fats can harm health: for every 2% of calories from trans fat consumed daily, the risk of heart disease rises by 23%. Luckily, most people have banished trans fats from their diet (except for my grandmother, who insisted on cooking with Crisco ’til the day she died… and yes, it was delicious). Use of these oils dropped dramatically after the FDA required trans fats to be listed on nutrition labels in 2006, and then in 2015 it formally announced that partially hydrogenated oils (PHOs) are NOT “Generally Recognized as Safe.” Now, companies aren’t allowed to add PHOs to foods anymore, which includes added trans fats. So that’s one good thing.
Looking at an example, it’s far better to have, say, whole-fat dairy rather than fat-free yogurt, especially if the latter is loaded up with flavor additives, sugar, etc.
For example, the average low-fat yogurt contains about 25g of sugar, roughly the same amount of sugar found in a Snickers Bar 😱. And because all the fat is stripped out, you won’t ever feel full. Furthermore, your blood-sugar will spike and you’ll be craving more sweets in an hour or two. Foods that are stripped of fat and loaded with sugar are definitely ones you should avoid. *Note — now food labels are also required to specify added sugars, which is great, because you can easily see whether or not extra sugar was added in.
When people eat fat and protein, they feel full (or satiated) and naturally eat less — because they feel full!
Many studies have found that the combination of fat + simple carbs (think donuts and cookies) isn’t satiating at all. In fact, it’s the opposite. High fat + high sugar (especially if you also add high salt) is a perfect recipe for compulsive and addictive overeating.
Thus, if you’re trying to cut your carb, sugar, and unhealthy oil intake, cutting out processed foods is a great place to start.
Sadly, processed foods have become the mainstay of most people’s diets (including our kids’) and cutting them out is super hard for busy people who don’t have time to cook. What’s more: processed foods are cheap, yummy, portable and they have a long shelf-life. No wonder so many of us eat more processed foods than we care to admit, especially busy parents!
Let’s face it: most people aren’t preparing fresh meals at home. Again, this is a cultural problem – and one that is not easily overcome.
There is no easy advice here. There’s no pill we can take to make this problem go away, despite all the ads you may see on daytime TV – ha! All we can say is carving out more time to shop and prepare fresh foods will pay dividends in your long-term health and wellbeing.
At the end of the day, every woman’s nutritional plan is going to be unique, depending on her own body’s response to certain kinds of foods, but the above-mentioned “principles” essentially apply universally for everyone (pregnant or not, GDM or not, adult or child, man or woman). Although, note that experts especially stress limiting simple carbohydrate consumption when it comes to diabetes.
Being diagnosed with GDM is scary and serious, and we don’t want to trivialize that in any way, but the good news is that addressing and confronting the problem head on by changing your diet will absolutely help, so perhaps the GDM screening might serve as an opportunity for everyone to step back and reflect on the way we’re all eating, and make positive changes for yourself, your partner and your baby to be.
Thank you for reading. We’ve found that it’s super hard to discuss this topic without striking a nerve in people. We get more emails about this than any other topic because the sensitivities that surround weight and health are like no other.
And yet… we hope you agree that we must talk about it. In the last two years, maternal mortality has increased, especially among women of color, and Americans’ life expectancy in general is also shrinking (even before the pandemic) — let’s do what we can to change things.
I just had my first baby 5 weeks early (5 weeks ago). I really appreciate you, and your emails literally got me through some tough times. Your down-to-earth advice is incredible and I’ve recommended you to everyone I know! Keep up the amazing work, lady!!
Cassie Smith
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