A Holistic Look at Gestational Diabetes
Pregnancy is a time for excitement; for hopes and dreams. We hope for a healthy pregnancy and a healthy baby. We dream of a future for our developing child where we can give them every advantage for a fulfilling and productive life. But pregnancy can also be a time for concerns. One of the most concerning phrases that can come up during a pregnancy is "gestational diabetes." While there certainly can be some serious health outcomes involved, there are also things we can do both to minimize our risks of developing it and to manage it should we be diagnosed with gestational diabetes.
What is gestational diabetes?
Let's start with diabetes. Traditionally, diabetes (type 2) has been viewed through the lens of blood sugar. If one's blood sugar is consistently too high, they are diagnosed with diabetes. The measurement that is most commonly used for diagnosis is hemoglobin(Hg) A1C. In essence, this measures how much sticky sugar from the blood is sticking to the red blood cells. If the HgA1C is between 5.7 and 6.4, a person is considered pre-diabetic. If it hits 6.5, they are deemed diabetic. But how do we get there?
In a healthy body, when a person eats, as the carbohydrate from what they have eaten is absorbed into the blood as glucose, the pancreas releases a hormone called insulin. Insulin has various effects on every cell in the body, but it is best known for unlocking the cells to allow blood sugar to get inside. As the sugar leaves the blood and goes into the cell, the pancreas stops releasing insulin, and over time, insulin drops back to fasting levels.
However, if a person eats a diet that is heavy in carbohydrates, as many do, blood sugar levels increase and the pancreas has to release copious amounts of insulin to keep the body safe from the dangers of too much blood sugar, like damage to the blood vessels in the eyes, kidney, and brain. However, over time, the cells become "resistant" to the insulin, and the pancreas has to release more and more to get the job done. This situation can continue for years, maybe decades, and the blood sugar levels and HgA1C will all look normal because the pancreas is able to release enough insulin to keep ushering the sugar into the cells. Until it can't.
At some point, the pancreas just can't produce enough insulin to keep up with the blood sugar and the fact that the cells keep requiring more insulin to do the job. At this point, the blood sugar will start to rise and the person will eventually get a diagnosis of pre-diabetes or diabetes.
Gestational diabetes is when this happens or is first identified during pregnancy.
In functional medicine, insulin resistance, pre-diabetes and type 2 diabetes are also known as "carbohydrate intolerance" because it is the body's inability to deal with the escalating blood sugar that results from constant and excessive ingestion of carbohydrates.
How does gestational diabetes affect you and your baby?
Diabetes can affect a pregnant woman by increasing her blood pressure, risk of cardiovascular disease, and kidney disease and puts her at greater risk for developing type 2 diabetes after the pregnancy is over. Depending on where she has chosen to give birth, she may have to be transferred out of care and seen by a specialist. She may need insulin or other medication to manage her blood sugar throughout the pregnancy.
High insulin levels also carry serious risks like migraines, PCOS, high blood pressure, and double the risk of developing cancer or Alzheimer’s disease.
There are risks to the baby, too. Women with poorly controlled gestational diabetes have children who face a 6 fold higher risk of obesity and/or type 2 diabetes in their lifetime (Nichols, 2019). This means childhood obesity just may start in the womb. Gestational diabetes also carries with it a risk for various birth defects. Further, according to the HAPO study, chronically high maternal blood sugar, even if it is below the cutoff for gestational diabetes, causes babies to be bigger, more likely to be delivered via c-section, and at greater risk to develop neonatal hypoglycemia. (NEJM 2004)
Who is at risk for gestational diabetes?
If a woman was diagnosed with gestational diabetes in a previous pregnancy, it increases her risk in subsequent pregnancies. If a woman is already insulin resistant before she gets pregnant, this also increases her risk. As it is actually quite common for pre-diabetes and diabetes to go undiagnosed, let's spend a moment discussing how you might know if you may be insulin resistant. As mentioned above, insulin resistance can develop years, and sometimes decades before blood sugar levels start to rise. Prior to pregnancy, or early in pregnancy, a patient can request a fasting insulin blood test to keep an eye on this important indicator. During pregnancy, insulin levels naturally rise as the pregnancy progresses, with third trimester numbers being the highest, and therefore, depending on how far along you are, this should be taken into consideration. A measurement of 6 mIU/mL is ideal. As the number gets higher, say into the teens, it is a warning that the person is headed toward diabetes.
Insulin resistance is synonymous with a condition called metabolic syndrome, which affects about 88% of the US population to some degree according to the most recent NHANES study. The tell-tale signs of metabolic syndrome are having 3 of the following 5 characteristics: high waist circumference, high blood pressure, high blood sugar, high triglycerides, and low HDL cholesterol. Functional medicine practitioners frequently identify insulin resistance if the triglyceride: HDL ratio is over 1.5. If you are headed into your pregnancy with metabolic syndrome, your risk of developing gestational diabetes is increased. Insulin resistance also tends to make someone crave carbohydrates. If before your pregnancy, you needed to eat every couple of hours to avoid feeling shaky or "hangry" (angry because you're hungry), then you may have been experiencing some degree of insulin resistance.
It is important to note that pregnancy is a time of increased insulin resistance by design, even in women who enter their pregnancy in a state of insulin sensitivity. It is the body's way of making sure that nutrients are directed to the developing baby. But if this natural and expected insulin resistance is compounded by already high blood sugar, high insulin, and desensitized cells, a woman can be headed for trouble.
How is gestational diabetes diagnosed?
The gold standard for diagnosing gestational diabetes is a 3-hour glucose tolerance test. The patient fasts through the night and in the morning goes to the lab/clinic. Her fasting blood glucose level is tested. She then drinks a 75-gram glucose mixture. Her blood glucose is then tested after 1, 2, and 3 hours. If her blood sugar levels are too high, she is diagnosed with gestational diabetes.
In my experience, if a woman is already struggling with insulin resistance, it is very difficult for her body to process 75 grams of liquid sugar. As an alternative, after she has learned how to keep her blood sugar levels under control, she can test her post-meal blood sugar either with a continuous glucose monitor or a standard glucometer (finger stick) to show her practitioner that she is keeping her blood sugar at levels that are safe for her and her baby.
How is gestational diabetes treated?
Like so many other conditions, gestational diabetes is often treated with medication. Sometimes, despite our best efforts, this is completely necessary, and in those situations, we can be very grateful that these medications exist. However, in many, many cases some very simple dietary changes can help a woman manage her blood sugar levels without medication.
When I work with anyone with insulin resistance, we always start with diet. I love the way Ben Bikman, one of the world's preeminent insulin researchers puts it:
Control Carbs
Prioritize Protein
Fill with Fat
Control Carbs
Remember that we said another term for insulin resistance or diabetes is "carbohydrate intolerance." A person's body is not able to process the carbohydrates they are putting into it. Some carbohydrates are more problematic than others. For example, sugar, refined and even whole grains, and even fruit juice or fruit smoothies tend to make the blood sugar rise quickly. In other words, they have a high glycemic index. Vegetables, on the other hand, especially those that grow above the ground, tend to absorb much more slowly and are considered low glycemic foods. These are the foods we want to prioritize.
Glycemic load is also important to consider. This means that we need to pay attention not only to how quickly the sugars absorb, but also the total amount of carbohydrate we consume. If the amount of sugar in the blood stream is what causes insulin to go up, and the large and constant amounts of insulin in the blood are what make our cells resistant to it, creating a vicious cycle, then it only makes sense that reducing the amount of carbohydrate will reverse the cycle.
Prioritize Protein
Each meal should contain a palm sized portion of protein, preferably animal protein. Animal protein contains bioavailable (easily absorbed and used) amino acids in the proper ratio to be used in building a little human. They are full of micronutrients like vitamins and minerals, and they tend to be much lower in toxic heavy metals like arsenic and cadmium than proteins concentrated from vegetable or grain sources. Animal sources of protein only create a very modest bump in insulin, and they help a person stay full longer.
Fill with Fat
Most of the time, the animal protein is packaged with healthy fat that will be used to build your baby's brain, nerves and the membrane that goes around every one of their trillions of cells. Adding grass-fed butter or full-fat cream or cheese to veggies makes them taste better and adds to our sense of fullness. Fats also help us to make better use of the other nutrients we are consuming.
A typical meal might be a palm-sized serving of salmon, a salad with an olive oil based dressing and a cup of steamed broccoli with a pat of butter, or perhaps a palm-sized portion of steak with some roasted Brussels sprouts and a salad. It is particularly important to start the day right with plenty of protein. Bacon and eggs is my favorite breakfast, but eggs and smoked salmon, a veggie and cheese omelette, or even left-over dinner will keep blood sugar in check.
Snacks should also contain protein and fat. Veggies dipped in hummus or guacamole, nuts and cheese are all good choices.
Monitoring your progress
I recommend that all women at high risk of developing gestational diabetes ask their practitioner to prescribe a continuous glucose monitor so that they can learn how the foods they eat affect their blood sugar. Please be aware that these are not always covered by insurance and can cost several hundred dollars. If the continuous glucose monitor is not feasible, a simple glucometer ($40-50 with all the supplies), which requires a finger stick, will do the trick. You can measure your fasting blood sugar (when you wake in the morning) and then 1 hour after your meals/snacks. Fasting blood sugar below 90 and post-meal measurements under 120 are ideal.
Often times, my patients will ask me if they can eat certain foods. Some things are just a bad idea...like most anything that comes in a package including almost all "low-carb" or "gluten-free" foods. Other foods are specific to the individual. Full fat yogurt with berries and almond slivers may be fine for one person, but cause a sugar spike in another. One patient found she did fine with steel cut oats with a splash of heavy cream and a pat of butter. Someone else may not be able to tolerate even a slice of whole grain toast. Another patient found that on occasion, she could have 2 slices of thin-crust pizza, but 1 slice of regular crust pizza shot her numbers too high.
So my recommendation is that a patient eats the meal plan as outlined above for 2 - 3 weeks, or until their blood sugars are at a healthy level. After that, once a week or so, they can try a meal or snack that they would really like to eat if their body tolerates it.
Is lowering carbohydrates during pregnancy safe?
Yes it is. Remember, we aren't talking about eliminating all carbohydrates. Admittedly, there is an increasing number of women who are reporting that they adhered to a ketogenic (very low carbohydrate)or even carnivore (zero carbohydrate) diet and had a healthy pregnancy and a thriving baby. The plan detailed above is much more moderate, likely providing between 100 and 150 grams of carbohydrates per day.
And what does science say about this? In 2005, the Institute of Medicine released a paper. In it, they estimate that a woman needs approximately 175 grams of carbohydrates daily during pregnancy. This was not based on any type of scientific experiment, mind you. They just estimated that the average adult needs 100 grams of carbohydrates, threw in 30 grams for mom's increased energy needs during pregnancy and another 30 grams for the baby's energy needs and then rounded up to 175. They later state, however, that "The lower limit of dietary carbohydrate compatible with life is apparently zero provided that adequate amounts of protein and fats are consumed." After all, let's not forget that the body is able to make glucose if it needs to in a process called gluconeogenesis.
Interestingly enough, a typical meal plan from the Nutrition and Lifestyle for a Healthy Pregnancy Outcome (2014) contains about 300 grams of carbohydrate per day. According to Lily Nichols, Registered Dietician and Certified Diabetes Educator, on plans like this, her patients required insulin to manage their gestational diabetes roughly half the time. She has experienced far better blood sugar management for her patients with a lower carbohydrate approach.
Other important considerations
Carbohydrates are not the only thing that can push a patient into insulin resistance. Stress is a huge factor that is often overlooked. Cortisol is the hormone released during stress and it directly antagonizes insulin, causing insulin resistance. The stress can be emotional or physical (think infection or chronic pain). Even missing one night of restful sleep can cause cortisol to spike and insulin to be elevated the whole next day. Managing stress to the best of our ability and prioritizing sleep can make a big difference. I have often received calls from patients telling me that they ate the same exact thing as yesterday and their sugars are 10 or 15 points higher than they were the day before. It is very common that they admit to staying up late or having a very stressful day leading up to the higher numbers.
On the other hand, something as simple as exercise can be very helpful in lowering blood sugar. You see, even though the muscles can become insulin resistant, there is a "back door" where glucose from the blood can get in without the use of insulin. In fact, our muscles use approximately 80% of the glucose in our blood. This happens especially when the muscles are in use. A walk after a meal is a good start. Building more muscle by strength training will move things in the right direction even faster. Please be sure to discuss your exercise plans with your practitioner.
Getting the help you need
If you read the description above about insulin resistance and feel you might be at risk, please bring it up with your practitioner right away. The sooner you implement a plan to get your blood sugar under control, the better off you and your baby will be.
Other Helpful Resources
Lily Nichols, Real Food for Pregnancy and Real Food for Gestational Diabetes https://lilynicholsrdn.com/
Ben Bikman, Why We Get Sick and any of his numerous YouTube videos
About the author:
Julie Disser is an Acupuncture Physician with a specialty in Holistic Nutrition, practicing in the Tampa Bay area. She loves helping people take control of their health through diet and lifestyle choices. Julie is currently accepting new patients who are committed to learning how to live well.
juliedisser@yahoo.com
727-743-6372