No Gestational Diabetes!
The takeaway
My glucose tolerance test came back normal--no gestational diabetes!
Dietary changes, supplements and exercise likely contributed to my improved insulin response
Gestational diabetes is caused by pregnancy-induced or chronic insulin resistance resulting from defects in insulin production or signaling
The risk of gestational diabetes increases with each pregnancy, especially after previous gestational diabetes
Read on for all the details!
A couple weeks ago, I went for the prenatal oral glucose tolerance test. As you may know, I have been preparing for this test since the end of February. Because I had gestational diabetes mellitus (GDM) during my first pregnancy, I wanted to see if some lifestyle changes could help prevent it this time around. Spoiler alert: it worked!
Granted, as I mentioned previously, I will of course never know if the changes I made had any influence, or if this pregnancy was just different. As my midwife said, “It’s an entirely different placenta.” However, early on in the pregnancy, I was already getting high fasting blood glucose numbers, which naturally set off my alarm bells and incentivized the changes.
I started by changing my diet, following a combination of The Microbiome Diet and Whole 30 (overview of both here). The goal was to promote a healthy gut and balanced gut microbiota while lowering overall inflammation. I have been focusing on eating whole foods, like vegetables, fruits, quality meats/poultry/fish, nuts, seeds, and healthy fats. For the first 30 days I avoided all grains, dairy, potatoes, legumes, corn, refined sugar and processed foods; now I eat them in moderation.
I also started taking probiotics, which have been shown to help prevent GDM, but not treat it. I like to use a probiotic that provides 20-50 billion cells and at least 10 strains of bacteria, if not more.
Additionally, I began using natural approaches to control blood sugar, including inositols, apple cider vinegar, cinnamon and green tea. As I discussed previously, these supplements have been shown to help regulate blood sugar by various mechanisms. I also began exercising more regularly and at times that I thought would specifically help with insulin sensitivity and glucose utilization, like before breakfast and after dinner.
My blood sugar control regimen is as follows.
Microbiome Diet: high-fiber vegetable-centric, high protein, low-ish carbohydrate (mostly from fruits and starchy vegetables, occasional whole grains and legumes)
Probiotics: 50 billion CFU, 16 strains, once daily
Myo-inositol: 2 g (2/3 tsp powder) in liquid twice daily
D-chiro inositol: 500 mg capsule twice daily
Apple cider vinegar: 1 Tbs in ~1 cup water, twice daily
Green tea: approximately 5 cups per week (regular or decaffeinated)
Cinnamon: generous sprinkles on chia seed yogurt, seed/nut granola (recipes here), or fruit, or ¼ tsp blended in coffee
Water: I aim to drink 3-4 liters of water each day and much more if I've indulged, especially in carbohydrates or sugar.
Exercise: I exercise 30-60 min daily, broken down as follows:
25-35 min strength/bodyweight before breakfast 2-4 times/week,
30 min run or walk 2-4 times/week,
30 min stationary bike after dinner 5-7 times/week
Although it may seem like a lot, it all just became part of my new routine. Challenges like gestational diabetes provide a wonderful opportunity to learn and adopt new healthy habits. For example, in my last pregnancy, I realized that my meals were either carb-overloaded or carb-deficient and learned how to balance them to maintain steady blood sugar levels. I also improved my carbohydrate choices, like substituting lower-glycemic items like steel-cut oatmeal, Ezekial sprouted bread or corn tortillas for seemingly-healthy options that are overly processed and high-glycemic like instant oats, shredded wheat and whole grain bread. I had never really considered dairy as a source of carbohydrates, but the natural lactose sugar in dairy products, particularly milk and yogurt, must be included in the daily carb count.
Figuring out your personal optimal diet is a learning process that can take years, but is so rewarding when you realize and feel the immense health benefits.
Now let's move on to discuss some details of gestational diabetes.
How is gestational diabetes diagnosed?
The glucose challenge tests to diagnose GDM vary, but the test I did was recommended by the International Association of Diabetes and Pregnancy Study [1]. In this test, you fast for 10-12 hours; only water is allowed during that time. You arrive at a lab, and blood is drawn. Then you drink a solution containing 75 grams of glucose (this is approximately the amount of sugar in 2 cans of Coke!) and blood is drawn 1 hour and 2 hours after that.
Blood sugar is then measured and compared it to the following cutoffs:
fasting 91 mg/dL
1 hour 179 mg/dL
2 hr 152 mg/dL.
If your numbers are lower than these thresholds, you are considered normal; if any value is higher, you’re diagnosed with GDM.
My results
*values expressed as milligrams of glucose per deciliter of blood (mg/dL)
As you can see, in my first pregnancy, my body did not process the glucose properly, so rather than decreasing over time, the numbers actually increased. In the second pregnancy, my insulin response and glucose utilization was sufficient, so my body cleared the glucose from my blood as expected.
What is gestational diabetes? What causes it?
Within the diagnostic criteria, a value higher than the cutoff indicates insulin resistance. Insulin is a hormone produced by specialized cells in the pancreas, called β-cells. Insulin acts like a key, opening up “doors” on cells, allowing glucose to enter. However, during pregnancy, the hormones produced by the placenta interfere with the body’s ability to produce and/or use insulin. This results in insulin resistance, also known as glucose intolerance. Without a proper insulin response, glucose isn’t processed properly and therefore builds up in the bloodstream. This state is called hyperglycemia.
There are two main causes of hyperglycemia in GDM.
Acquired insulin resistance during late pregnancy. This form is likely caused by pregnancy-induced factors, like placental growth hormone or increased immune molecules called cytokines. These factors cause aberrations in insulin signaling reduce insulin-mediated glucose uptake in skeletal muscle. Skeletal muscle uses a lot of glucose and therefore effectively decreases blood glucose levels. This form of insulin resistance abates soon after pregnancy and insulin signaling returns to normal within 1 year postpartum [2].
Chronic insulin resistance. This form is present before and after pregnancy and is exacerbated by the above-mentioned pregnancy-induced factors. Chronic insulin resistance is caused by pancreatic β-cell dysfunction as well as aberrations in insulin signaling, resulting in reduced insulin production and reduced glucose uptake. Most women diagnosed with gestational diabetes have a combination of acquired and chronic insulin resistance. However, the existing insulin resistance is undiagnosed until the prenatal glucose tolerance test [2].
Genetics can influence the amount of insulin produced. It is estimated that less than 5% of GDM cases are caused by autoimmune disorders that affect pancreatic β-cell function [2]. Being overweight or obese or gaining excess weight during pregnancy are major risk factors for developing GDM.
What is the incidence and recurrence rate of gestational diabetes?
Previous reports report the incidence of GDM in the U.S. to be as high as 14%, [3, 4]; however, a more recent study reported an incidence of 9.2% in the U.S. [5]. These results are confounded by several factors, primarily the population studied—GDM tends to be higher in Hispanics, Asian/Pacific Islander, Native Americans, African Americans and etc [5, 6], as well as the test and cutoffs used to diagnose, which varies widely. Additionally, risk factors include being overweight or obese, smoking, poor diet, or having children later in life. All reports indicate that the incidence of GDM is rising.
A separate study evaluated the recurrence rates of GDM in women with multiple pregnancies. They used medical records gathered from Kaiser Permanente Southern California, from 1991-2008 of 65,132 women who had 2 pregnancies and 13,096 of which had 3 pregnancies [6]. Their findings are summarized below.
These data indicate that the risk of GDM increases with each pregnancy.
These results show that the incidence of GDM in the second pregnancy is almost 10-fold higher if the previous pregnancy was complicated by GDM. So my risk of developing GDM in this pregnancy was 13.2-fold higher than someone who didn't previously have GDM.
This chart shows that the outcome of previous pregnancies influences the risk of GDM in the 3rd pregnancy. In my case, since I had GDM and now don’t, my risk during a third pregnancy would be 6.3-fold higher than a woman who didn’t previously have GDM. If the previous 2 pregnancies were complicated In 3rd pregnancy, the risk in the 3rd pregnancy is drastically higher—25.9-fold.
Overall, these results show that although prior GDM does increase risk, GDM in subsequent pregnancies is not a definite. Measures such as improving overall health by exercising and not smoking, losing excess weight, and making conscientious dietary choices like choosing whole, nutrient-dense foods and limiting highly-processed, high glycemic foods can reduce the risk of GDM. Hopefully additional studies will evaluate the effectiveness of alternative approaches, like probiotics, inositols and natural supplements to improve insulin sensitivity and glucose tolerance as a means to prevent GDM.
Have you had GDM with any of your pregnancies? I'd love to hear your experience!
References
International Association of, D., et al., International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care, 2010. 33(3): p. 676-82.
Metzger, B.E., et al., Summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care, 2007. 30 Suppl 2: p. S251-60.
Hunt, K.J. and K.L. Schuller, The increasing prevalence of diabetes in pregnancy. Obstet Gynecol Clin North Am, 2007. 34(2): p. 173-99, vii.
Chen, Y., et al., Cost of gestational diabetes mellitus in the United States in 2007. Popul Health Manag, 2009. 12(3): p. 165-74.
DeSisto, C.L., S.Y. Kim, and A.J. Sharma, Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010. Prev Chronic Dis, 2014. 11: p. E104.
Getahun, D., M.J. Fassett, and S.J. Jacobsen, Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet Gynecol, 2010. 203(5): p. 467 e1-6.
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