Understanding Gestational Diabetes. How to Prevent, Detect, and Support it. Holistically.

We have teamed up with the incredible Jacquie Pypers from Better than Bread to get her Nutritionist and Clinical perspective on Understanding Gestational Diabetes. 

As you hit your third trimester, depending on your care provider's recommendations you might be prompted to conduct the Oral Glucose Tolerance Test (OGTT) between 24-28 weeks gestation to test for gestational diabetes mellitus (GDM). 

You might have more questions about ‘the why’ for these types of procedures. We hear you. Seems intense…consuming 75g of glucose on an empty stomach (?)

Personally (Bree) felt very unaligned about this test based on the ingredients in the test itself and that I would absolutely never consume. I was also concerned that I may get a false positive based on this and I would be ‘categorised’ into a high risk area unnecessarily. Noting that I was expecting twins in my most recent pregnancy, I was worried this would put me into an even SMALLER box as I was birthing in the hospital system and I had heard SO many stories of false positives!

On balance I was aware of the importance of understanding GDM, if I had it and if it was impacting my pregnancy as it is a serious diagnosis that does need managing.So why was I (Bree) so on the fence about this? Well, I don’t usually drink 75g of glucose on an empty stomach – that’s the equivalent  of eating 4 Bananas, 14 dates, 2 cans of Coke or 5 tablespoons of honey (however you can visualise this intake best). 

Standard procedure is testing with Glucola. Discovering an alternative to Glucola is a logical choice for many women, considering not only its unpleasant taste and potential for adverse side effects but also the presence of concerning ingredients in its composition. However some of us, including myself, in the past had taken the advise prescribed as gospel and just went along with it.

The list of Glucola ingredients includes Water, Dextrose (D-glucose derived from corn), Citric Acid, Natural and Artificial Flavors, Modified Food Starch, Glycerol Ester of Wood Rosin, Brominated Soybean Oil (BVO), FD&C Yellow #6, Sodium Hexametaphosphate, and Sodium Benzoate. Notably, this lineup contains genetically modified organisms (GMOs) from corn, preservatives (sodium benzoate), artificial flavours, artificial colours, and BVO (prohibited in Europe and Japan). Certainly not something I (Bree) would choose usually to put into my body.

We will discuss various testing options, including alternatives to the standard Oral Glucose Tolerance Test. 

Jacquie: As a clinical nutritionist with a keen interest in hormones, fertility and pregnancy, GDM and the OGTT is a common conversation that comes up in my clinic. 

As the risks to the mother and child of unmanaged GDM are very serious, the conversations around the OGTT are important to have. While I am not anti OGTT, I am pro-education and informed choice and unfortunately I think there is a large missing chunk of information being told to pregnant women in the conventional health sector. 

It is paramount for women to understand firstly, what GDM is, who is at risk of developing GDM, how to prevent it (the right way), and what other options are out there to diagnose other than the OGTT. 

Here is some terminology to understand first:

What is GDM: 

• GDM is a type of diabetes that affects pregnant women, and is characterised by elevated blood glucose levels. This condition arises due to insulin resistance, where the body struggles to cope with increased insulin demands during pregnancy. GDM is one of the most common health complications during pregnancy, projecting to increase to 42% of pregnancies by 2030. 

Understanding glucose and Insulin:

• Glucose is the body's main fuel source.
• Insulin helps move glucose from the blood to cells for energy, think of it like a lock and key mechanism. Insulin is like a key that helps glucose (sugar) from the food you eat, get into your cells to be used as energy.
• Insulin resistance occurs when the body has trouble using insulin effectively. It is like the lock on the door is not working properly and insulin has a hard time letting glucose into the cells. As a result, glucose ends up floating around in the blood, leading to high blood glucose levels. This can lead to serious health complications over time if it is not managed correctly as high blood sugar levels create lots of inflammation and oxidative stress 

Jacquie: Oxidate stress explained: imagine your body as a city. In this city you have criminals called “free radicals” and police called “antioxidants”. These free radicals come in and cause damage to cells and DNA. Normally the police or “antioxidants” will come in and protect your cells against this damage. In cases where there is a lot of oxidative stress like that in GDM, there is an imbalance between the free radicals and antioxidants leading to damage and health complications. 

Jacquie explains the Physiological adaptions to insulin during pregnancy:

• Our bodies are extremely smart, especially during pregnancy. During pregnancy the body adapts to ensure there is enough  glucose for the babies growth and development. In order for this to happen, the placenta produces hormones that have a direct affect on your insulin levels, essentially blocking some of it’s action and usually begins between 20-24 weeks of pregnancy.  

• As a result, the mother becomes slightly insulin resistant (the key doesn’t go into the lock as easy) so more glucose stays in the blood and gets passed onto the baby. 
• Normally, the pancreas will produce enough insulin to overcome insulin resistance, but when this does not occur, blood glucose elevated above normal and GDM results. 

(GDM) who is at risk and how can you prevent it:  

• Gestational diabetes mellitus (GDM) is increasing, primarily attributed to shifts in the Australian demographic—such as delaying childbirth, rising rates of type 2 diabetes mellitus (T2DM), women with larger body sizes, and a more sedentary lifestyle.
• Had GDM in a previous pregnancy. 
• Has a family history of type 2 diabetes or GDM (mother or sister)
• Is of older age (above 35 but especially above 40)
• Is above the healthy weight range (obesity or overweight) 
• Has a history of elevated blood sugars 
• Polycystic ovarian syndrome (PCOS)
• Previous high birthweight 
• Physical inactivity 
• Twin pregnancies
• Those on certain medications including steroids 
• Low fibre and high glycemic index diets 
• Certain ethnicities: African, South Asian, Polynesian, Middle Eastern, Chinese, South east Asian, Hispacin and South American

Jacquie: A proactive and preventative approach is paramount to minimising the occurrence of GDM. It is important to remember that even those with no risk factors can still develop GDM but also that while GDM is frequently attributed to pregnancy hormones, most women, including those at higher risk, can prevent its onset with proper guidance and optimal choices both before and during pregnancy.

Early screening with routine fasting blood glucose, insulin and haemoglobin A1c  can show early signs of glucose dysregulation prior to and during pregnancy while diet and lifestyle factors play a huge role in prevention. 

Risks of Untreated Gestational Diabetes:

The risks of untreated/unmanaged GDM include:

• Excessive birth weight 
• Early (preterm) birth. 
• Breathing difficulties. ...
• Low blood sugar (hypoglycemia). 
• Obesity and type 2 diabetes later in life. 
• Stillbirth.

Not only that, GDM increases the risk of long-term complications, including obesity, impaired glucose metabolism and cardiovascular disease, in both the mother and baby.

Diet and Lifestyle Prevention

Jacquie: In clinical practice I often encounter concerning dietary recommendations given to women with glucose concerns. These recommendations frequently include foods that are high in sugar and carbohydrates, low in protein, healthy fats and vegetables, which is the exact opposite of  what these women need to do and for some, also a driving factor that got them into their situation in the first place. 

Balanced Nutrition:

From a dietary perspective, the best approach to prevention and management of GDM is to eat a low GI diet that includes quality protein (eggs, meat, fish, full-fat yoghurt, tofu, nuts and seeds), good fats (grass fed butter, extra virgin olive oil, avocado, oily fish), complex carbohydrates (vegetables, beans, chickpeas, lentils, quinoa, whole oats). Refined and processed carbohydrates (bread, pasta, rice) have no place in the case of GDM and are simply unnecessary. 

Studies have shown that by using a low-G1 diet for women with GDM, effectively halved the number needing to use insulin, with no compromise of obstetric or fetal outcomes.

•   Eliminate refined sugars/carbohydrates. If you do need to sweeten food, use Stevia, which is a natural sweetener that does not raise blood sugar levels.
•  Opt for low glycemic index (GI) carbohydrates, evenly distributed throughout the day. Foods that would usually be considered healthy such as tropical fruits and dried fruits, maple syrup, coconut sugar, goji berries should be avoided.
•  Maintain a balance of macronutrients (protein, fat, and carbohydrates) in meals and snacks.
•  Increase fibre  intake to slow down carbohydrate digestion.
  

Micronutrients:

•  Ensure sufficient intake of vitamin D through supplements if deficient, as it correlates with gestational diabetes risk.
• Include magnesium-rich foods like Leafy Greens, nuts and seeds, (soaked/soured) wholegrains, legumes, fish, dairy and dark chocolate.

Movement

Regarding movement, it's evident that the greater your body movement, the more favourable the impact on blood sugar levels. When muscles are engaged in exercise, they utilise glucose for energy, leading to a reduction in blood sugar. Additionally, exercise can enhance insulin sensitivity, curb excessive weight gain, and alleviate anxiety and stress. Aim for at least 140 minutes per week of moderate exercise. In Pregnancy, this can be walking or stretching, it dosn't need to be vigorous, listen to what your body needs.

Manage Sleep and Stress:   

• Prioritise sufficient sleep.
• Magnesium Bath or spray to optimise magnesium levels.
• Implement stress management techniques and seek support.

It's important to note that gestational diabetes can still develop in women who diligently follow preventive measures. It's crucial to understand that it's not your fault; your body undergoes numerous metabolic and hormonal changes. Rest assured, there are various ways you can support and help you manage the condition alongside a Nutritionist or Naturopath who specialises in GDP Management.

Diagnosing Gestational Diabetes: Exploring Testing Options

The Oral Glucose Tolerance Test (OGTT) is the standard diagnostic method, but alternative options exist if it's unsuitable for some individuals or it doesn't align with you:

Fasting Plasma Glucose (FPG) Test:   

• Measures glucose levels after an overnight fast, providing a less time-consuming alternative to the OGTT.
• Downside: May not assess the body's ability to manage post-carbohydrate glucose levels. 

Haemoglobin A1c (HbA1c):

• Measures average blood glucose over the past 2-3 months.
• Downside: Limited use for diagnosis during early pregnancy; more research is needed. 

Home Blood Glucose Monitoring:  

Opting for a glucometer at home to monitor blood sugar levels is a choice some women prefer. This involves tracking blood glucose levels for a few weeks, measuring levels pre-meal, 1 hour after a meal, and 2 hours after a meal—an essential practice when dealing with gestational diabetes but also a great idea for everyone (not even pregnant women) to learn how you respond to different foods/beverages.

• No Need for Glucola Consumption
• Provides valuable insights into how dietary choices influence the body.
• Non-Fasting Tests Reflect Normal Glucose Response: Non-fasting tests may offer a more accurate representation of the body's typical response to glucose.
• Drawbacks: Frequent Testing Required: Testing must be conducted multiple times a day over a span of a few weeks. Susceptible to User Error: Prone to user error in execution.

• Drawbacks: Potential for False Negatives: There's a risk of obtaining a false negative result if a woman alters her diet or tests at the wrong time, making both home testing and the Glucola test susceptible to false negatives.

Fructosamine:

• Measures the previous 2-3 week blood sugar trend with ideal levels being between 200-270umol/L.

Jacquie: When it comes to diagnosing gestational diabetes mellitus (GDM), the OGTT is often considered the "gold standard." However, the idea of consuming 75 grams of sugar (equivalent to almost 2 cans of coke) may not seem ideal. Additionally, this diagnostic method is applied uniformly to all pregnant women without considering factors such as diet, lifestyle, and risk factors.

There are several concerns with this approach. My biggest concern is that, according to the Royal Australian College of General Practitioners (RACGP), OGTT results can be influenced by factors like carbohydrate intake, fasting duration, time of day of the test, and activity level during the test. The RACGP recommends consuming 150 grams of carbohydrates in the 3 days preceding the OGTT, equivalent to about ten 40-gram slices of bread per day. However, many women do not typically consume such a high-carbohydrate diet, potentially leading to false positive GDM diagnoses. While some people may consume 75 grams of carbohydrates in a meal, the body does not respond with the same glucose (sugar) spike if that meal also contains fats and protein compared to 75grams of pure glucose.

I advise consulting your doctor before making any decisions specific to your individual situation. But what is my view and what would I do if I was pregnant? This would all depend on my risk factors. Being someone with little to no risk factors for GDM and also someone that routinely tests my fasting insluin, glucose and HbA1c levels with no cause for concern. I would opt for HbA1c, fasting glucose and fasting insulin as my screening tool during pregnancy and if results were considered to be high I would move to an OGTT.. If I was high risk then I would ensure I did everything I could pre, during and post pregnancy to minimise any potential health risks. 

Remember, you have the final say in what you do with YOUR body. If you do have a high fasting glucose, insulin or HbA1c level, you can ask for a retest once you have changed your diet/lifestyle. If you are diagnosed with GDM many cases can be managed via diet and lifestyle. 

Work with Jacquie via booking on her website: https://betterthanbread.com.au/
We love her no BS approach to nutrition and her incredible understanding of gut health and all things Hormones.

Jacquie will be recording a Podcast with us very soon to dive even deeper into supporting a Holistic Pregnancy, make sure you are following @nurturedbeginningsonline via instagram so you know when it is released!

We hope this gives you some insight into how you can advocate for yourself and support your Pregnancy with evidence based information to consider. Ensure discussions with your primary healthcare provider and a gestational diabetes-specialised dietitian or nutritionist who specialises in gestational diabetes are had to ensure your wellbeing.

Photo by Zoe Morley Photography