Gestational Diabetes

I frequently receive emails asking me about Gestational Diabetes (GD), which is the term used for diabetes that is diagnosed only after a woman, previously considered normal, displays abnormal glucose tolerance test results during pregnancy.

Because obstetricians do a very good job of diagnosing and treating GD, I have not discussed it on my web site. If you are pregnant and have GD your doctors are almost certain to give you insulin to normalize your blood sugars. The blood sugar targets given pregnant women are much lower than those given the average person with Type 2 diabetes--low enough to ensure health. Follow them and you should avoid the problems associated with GD that were suffered by those of us whose GD was not well treated in the past.

Some women have found the chat boards at Diabetic Mommy helpful for finding support.

The real problems with GD only start after you give birth to your baby and bid goodbye to your obstetrician. Why? Because the average family doctor still appears to believe that GD is nothing more than one of the many complications of pregnancy and that if your blood sugar returned to "normal" after delivery, you need do nothing else.

The problem here is that the family doctor is all too likely to define "normal" as meaning "having an A1c under 7%" or, if he's a bit better educated 6.5%. Perhaps he won't even run an A1c test but will merely send you for a fasting glucose test. If the result comes back under 125 mg/dl, he may tell you you "aren't diabetic" and that will be that.

Unfortunately, if you have experienced a diabetic pregnancy, "that" is far from that. Because no matter how "normal" your doctor may tell you you are, you would not have developed GD unless your ability to secrete insulin was so borderline, before you started your pregnancy, that the stress of adding your baby's metabolic demands to that of your own organs exhausted it.

Relieving this stress by giving birth to your baby may return you to your previous state--but even if it does, the fact that you had GD should make you realize that your blood sugar control is only marginal, and this means that any other stressor might well push you back into full fledged diabetes.

What are those stressors? There are many.

1. Environmental pollutants that increase insulin resistance or damage the beta cells. These can include exposure to pesticides and industrial chemicals. Atrazine--a commonly used herbicide has been linked to increased insulin resistance. Arsenic, which is given off by power plants, has also been linked to diabetes. So have PCBs.

2. The use of FDA approved medications known to raise blood sugar or increase insulin resistance. These include cortisone treatment--either injections or prednisone pills, most SSRI antidepressants and the atypical antipsychotic drugs.

If you wonder if a drug you are taking can stress your blood sugar control, download the official FDA "Prescribing Information" by googling the name of the drug and the words "Prescribing Information" and look in the "Side Effects" section of the Prescribing information for the word "hyperglycemia." Drugs known to cause weight gain also may cause the same kind of stress to your marginal insulin production capacity.

You can find links to the studies that discuss environmental and pharmaceutical causes of insulin resistance and diabetes HERE

3. Gaining more weight. Though weight gain is often the result, rather than the cause of insulin resistance, if your weight gain results from overconsumption of fructose and eating a high carbohydrate diet, even a low fat one, some of your new weight is likely to be intracellular liver fat, which has only recently been recognized as a significant cause of increased insulin resistance. Carbohydrates not dietary fat turn out to be what raises the triglycerides that get deposited in the liver.

4. Autoimmune attack on the beta cells of the pancreas. A small but significant proportion of those who develop GD suffer from LADA a slow developing form of autoimmune diabetes. These people may experience a slight improvement in their blood sugars after they give birth, but over time their ability to secrete insulin will decline because there is currently no way to halt this kind of autoimmune attack.

What Can You Do?

The best approach to take if you have experienced a diabetic pregnancy is this. Once every month or two, test your blood sugar at home after meals. If you can't afford the expensive prescription strips, use the cheaper strips and meter sold at Wal-Mart under the "Relion" brand.

If you see values over 140 mg/dl one hour after eating, test more frequently. Blood sugars routinely going over 140 mg/dl are capable of damaging your beta cells leading to full fledged diabetes. Even with out diabetes blood sugars in the "pre-diabetic" range have been shown to be capable of giving you the early diabetic complications.

If you see blood sugars over 140 mg/dl an hour or more after you eat, cut back on carbohydrates using the advice you will find here:

How To Get Your Blood Sugar Under Control

Cutting back on carbohydrates is usually all most people need to regain normal blood sugars, even those who have been given diagnoses of Type 2 diabetes.

When Diet Might Not Work

If you were thin when you became pregnant and still developed Gestational Diabetes--or if you developed GD very quickly after becoming pregnant no matter what your weight, your situation may be more complex. Pregnancy often gives the first sign that a person may have one of the rarer forms of diabetes often called "Type 1.5." If you think this might be the case, read these pages:

LADA - Slow Onset Type 1 Diabetes With Some Type 2 Features

MODY - It's Not Type 1 or Type 2 But Something Else

Before you attempt to diagnose yourself, please be aware that MODY is much, much rarer than LADA. But the incidence of LADA appears to be increasing swiftly as part of the whole society-wide explosion of autoimmune disease and if you have any other autoimmune disease in the family, or have relatives diagnosed with Type 1 diabetes the chance you might have a rare form of "Type 1.5" goes way up.

It is also worth noting that while most overweight people who get GD are most likely to move on to an ultimate diagnosis of "Type 2" diabetes, overweight people also can develop autoimmune diabetes. Unfortunately, doctors often assume any overweight person must have Type 2 diabetes and do not run the tests that could diagnose LADA. No matter what you weigh, if your "Type 2 diabetes" continues to deteriorate, does not respond to oral drugs or to cutting carbohydrates, it may not be Type 2 diabetes at all.

Since LADA requires a very different kind of treatment than regular Type 2, this is significant. Oral drugs will not correct LADA and over time a person with LADA who is not given insulin can end up in the emergency room in a dangerous state called "Diabetic ketoacidosis" that happens when the pancreas stops making insulin.

So if you have had a diabetic pregnancy, and afterwards your blood sugars continue to rise, even if you cut way back on carbohydrates--especially if you have a family or personal history of other autoimmune-related disorders, such as authoimmune Thyroid disease or rheumatoid arthritis--insist that your doctor test you for the antibodies associated with Type 1 diabetes to see if you actually have LADA.

If your family doctor isn't familiar with LADA--and many are not--insist on seeing an endocrinologist, ideally one associated with a large hospital that has a medical school.

Most women who were diagnosed with GD in mid pregnancy probably do have the genetic makeup that over time leads to the development of Type 2 Diabetes. If this is your situation, and you see abnormal blood sugars after eating, you will respond strongly to cutting back on your carbohydrate intake.

And because you got warning of borderline high blood sugars early, you can rejoice because you have been given a golden opportunity to prevent your diabetes from progressing because GD gave you the warning which let you catch oncoming Type 2 diabetes very early, before it has been given a chance to ravage your organs.

Aggressive control with diet and modest exercise, aided, perhaps by metformin, if your doctor will prescribe it to you, should keep your blood sugars in the normal range for decades.

You also will want to feed your children diets that are not high in carbohydrates because chances are if you don't handle them well, neither will they. Teaching them that each meal does not have to start with bread, continue on with potatoes, and end with dessert can go a long way to helping them stay metabolically normal no matter what genes they have inherited.

 

Myth Busters: Gestational Diabetes is Indeed Real Diabetes

If you have had Gestational Diabetes you may be confused about whether this means you have "real diabetes." If your family doctor is like most you may have been told not to worry about it. Many doctors treat GD if it were nothing more than a complication of pregnancy which goes away when the pregnancy is over.

So while today's obstetricians are aggressive about helping their patients control their blood sugars through the pregnancy, as soon as the baby is delivered, they hand women with GD back to their primary care doctors whose attitude towards blood sugar control is far more relaxed, giving the woman with GD the message that their diabetes is "over."

Post-pregnancy screening, if it occurs at all may be nothing more than administering a single A1c test or, perhaps, a fasting glucose test. If these come back "Normal"--i.e. under 7% for the A1c and under 125 mg/dl (7.0 mmol/L) for the fasting glucose--the doctor will consider the case closed.

Unfortunately, it isn't closed, and the fact that you developed GD should be treated as a big red flashing warning. A new study published in the Journal of Clinical Endocrinology and Metabolism looked at the genetic make up of a group of women who had had Gestational Diabetes and compared it with a group of women who did not. They concluded "The prevalence in a prior GDM [gestational diabetes mellitus] group of several previously proven type 2 diabetes risk alleles equals the findings from association studies on type 2 diabetes. This supports the hypothesis that GDM and type 2 diabetes are two of the same entity." [emphasis mine]

This study found that the group of women who had experienced GD had a frequency of 11 different genes linked to diabetes that was very similar to that found in groups of people who have been diagnosed with Type 2 diabetes.

Common type 2 diabetes risk gene variants associate with gestational diabetes.
Jeannet Lauenborg et al. Journal of Clinical Endocrinology & Metabolism, doi:10.1210/jc.2008-1336

The only reason that your PCP doesn't think you have diabetes, is that he is using much laxer standards to diagnose than your gynecologist did.

We know that women tend to develop diabetes in a pattern where the post-meal control deteriorates many years before fasting control goes away. This is probably one reason why obstetricians screen for GD with the glucose tolerance test, NOT the fasting glucose test. But most PCPs still screen women for diabetes using only the fasting glucose test. Those who don't often rely on A1c test, a test which even the ultra-conservative ADA says should not be used for diagnosing diabetes.

Your blood sugars may be going into the diabetic range after meals but if your fasting blood sugar is only in the "impaired" range, your A1c may be somewhere between 5.9% and 6.3%. That is a value too many PCPs consider to be normal, though, in fact, it is linked by a lot of research with a much higher risk of heart disease. And even worse, blood sugars that go high after each meal make you more insulin resistant and more insulin resistance causes even higher blood sugars. They also may poison the rest of your remaining beta cells, via what is known as "glucose toxicity."

If you are a woman in the early stages of diabetes, the only test that can accurately tell you if you are diabetic is one that looks at your blood sugars after you eat a high carb meal or drink a glucose solution. The Glucose Tolerance Test is a good test. Or you can test yourself at home using the meal test described on this page: Am I Diabetic.

If you see a result over 200 mg/dl (11.1 mmol/L) after a meal two or three times make sure you have washed your hands before testing so you aren't getting sugar from your fingers on the test strip. If the reading is real, you should assume you have diabetes and get back to controlling your blood sugar the way you did when you were pregnant. The ADA's published criteria for diagnosing diabetes include two random glucose tests over 200 mg/dl (11.1 mmol/L) though many family doctors are ignorant of this fact.

Obstetricians train their patients to shoot for much lower blood sugars than do PCPs and most endocrinologists. This is because they have learned that normal blood sugars results in normal pregnancies. Unfortunately, family doctors have not gotten the message that diabetic complications can be prevented by maintaining normal blood sugars no matter what the diagnosis, so they are much less aggressive in helping people get their blood sugar back to the normal range.

Another major issue that many doctors ignore is the question of when, during your pregnancy, you developed gestational diabetes. Typically this happens towards the end of the pregnancy as women get larger and more insulin resistant.

But some of us, like, say, me, became diabetic much earlier in our pregnancy, and when this happens it may point to something different from insulin resistance being at fault. Early GD may be caused by insulin deficiency.

If you have a condition that causes beta cell dysfunction, as opposed to insulin resistance, pregnancy may unmask it. These conditions occur in in young, thin people who doctors don't think of as being at risk for diabetes, so doctors often don't notice these forms of diabetes until they have had years to ravage your body and finally cause serious symptoms. Despite my having had two diabetic pregnancies where I became diabetic very early in the pregnancy, it was more than a decade until my doctors finally thought of giving me a diabetes test that wasn't a fasting plasma glucose test.

Two forms of non-Type 2 diabetes which can cause Gestational Diabetes that arises early in the pregnancy are LADA, which is a slow-onset form of autoimmune diabetes which seems to becoming much more common over the past decade, and MODY, which is the term used to refer to a group of unrelated genetic forms of diabetes which have in common only that they are passed in dominant genes and that they limit the body's ability to control blood sugar.

You can read about LADA here: http://www.phlaunt.com/diabetes/18382053.php and about MODY here: http://www.phlaunt.com.diabetes/14047009.php.

MODY is much rarer than LADA, so if you have had GD when you were thin especially if it came on early in the pregnancy, and if you also have a family history of other autoimmune diseases, that would be the first diagnoses to have checked out.

In any case, the important thing is not what caused your gestational diabetes, so much as making sure that after you have your baby and your blood sugar seems to improve you do what it takes to keep it under control.

With that in mind, here is what I suggest you do. It is what I wish I had done after my GD pregnancies:

1. Every three months test your blood sugar after eating a high carb meal to see how your blood sugar is doing. If you see blood sugars that are over 140 mg/dl two hours after eating, test more often and work on getting your blood sugar down.

You should also put some effort into finding a doctor who will work with you to prevent your pre-diabetes from turning back into full-fledged diabetes.

There are a lot more things you can do at this "pre-diabetic" stage than there are once you've let high blood sugars kill off your beta cells. If your doctor does not take pre-diabetes seriously, find a younger, better trained doctor who will.

2. Go Easy on the Carbs!. Cut down as much as possible on the carbohydrates you eat. Don't drink high carbohydrate fruit juices, spritzers, or sodas, or eat side portions of starchy foods that will raise your blood sugar. You don't have to be obsessional about it, but before you eat something with carbs in it, stop and think: Is this carb really necessary? Some are. But most are not worth the spike they will cause in your blood sugar.

3. Start walking more and sitting less. If you are insulin resistant, exercise may help lower your insulin resistance. Walking is a lot less likely to cause injuries that put you out of commission for long periods of time than are trendier but more injury-provoking athletic pursuits. I learned this the VERY hard way, as I was too aggressive with exercise in my younger years and ended up with serious non-reparable orthopedic problems that now limit my ability to exercise. More walking and less weights and hours on the stair climber and rowing machine would have been smarter!