Treatment of Gestational Diabetes

 

Diet

Different roads can lead to the same destination, and so there is not one size fits all correct diet for gestational diabetes. Some doctors prefer a diet based on calorie counting and differentiate lean, overweight and obese women. I do not like calorie counting, carbohydrates should be counted, too, and that makes a lot of counting. As such, I will introduce a diet which has delivered results, and a majority of women who follow this diet do not need insulin treatment.

Our diet is made up of three key groups of nutrients: carbohydrates, protein and fat.

•  Carbohydrates, as part of our typical diet, are the main source of energy, and provide about 50% (often more) of total energy intake. The problem is that they increase blood glucose levels (glyaemia) and require insulin for its metabolism. And for a diabetic, that is a problem. That is why intake of carbohydrates needs to be reduced.
• Protein also moderately increases blood glucose, but significantly less than carbohydrates. The protein reuquirements during pregnancy are increased (for healthy growth of the foetus), and that is why there will be no restrictions on your protein intake.
•  Fats do not increase glycaemia, on the other hand, they slow down the metabolism of carbohydrates, and have a positive impact on the overall glycaemic index of a meal. It is important, however, to pick quality sources of fat.

We differentiate two groups of carbohydrates – simple and complex.

• Simple carbohydrates (or sugars), in most cases represented by glucose, have a sweet taste, absorb rapidly, increase glycaemia greatly and require a lot of insulin for its metabolism. They occur naturally in fruit and milk, but the problem are added sugars which form part of processed food products.
• Complex carbohdyrates include starch and fiber. Starch is made up of glucose units and begin to break down already in the mouth as a result of saliva effects. Starch absorption is slowed down by fat as well as fiber. For a diabetic, the safest sources of carbohydrates are foods, which contain lot of fiber but little sugards and starch. The top pick is vegetables that is not sweet. Intake of all other foods containing carbohydrates require monitoring, and it is necessary to exclude some foods/food products altogether (sweets, sweet drinks).

 

Accordingly, changing carbohydrate intake represents the cornerstone of this diet.

The diet requires the following: 

1.     Do not use sweeteners, that is exclude simple sugars such as white and brown sugar (beet and cane), honey, glucose, syrups (maple and others), grain sweets etc. In the intestine, simple sugars are absorbed very quickly and may significantly increase glycaemia in diabetes – they have so called high Glycaemic Index (GI). All foods, which contain simple sugars, also have to be reduced, ideally avoided altogether. What contains simple sugars? Besides sweets, biscuits, sweet bakery, sweet meals and sweetened beverages (lemonades, juices), the following items are also inappropriate due to high simple sugar content: muesli and breakfast cereals, muesli/energy bars, canned and candied fruit, preserved fruit, marmelades (including „dia“), jam, ketchup, sweetened tomato sauce, vegetables pickled in sweet-sour juice. Be also aware of dressings and various flavoured sauces, instant products. Beer (including non-alcoholic) also significantly increases glycaemia. Sugar is also an ingredient in low quality processed meats (salamis, saussages, pates), flavoured dairy products (fruit yoghurt) and brown (coloured) bread (eg. Brown Kaiser roll).

Read labels – the nutritional content of a product highlights total carbohydrates per 100 grams of product. Under this item, there is “of which sugars”, which includes simple carbohydrates (occurring naturally and added). If the product contains more than 5 grams per 100 grams, the food is not suitable for you. 

2.     Glycaemia is also significantly increased by starches, complex carbohydrates which are converted to glucose during digestion. They are contained mainly in bread and other side dishes (potatoes, rice, pasta, dumplings etc.) and it is important to reduce their intake. All products made of white flour (white bread, white pasta) and white rice contain only starches without fiber and increase glycaemia as quickly as sugar (they have a similar, sometimes even higher, glycaemic index as sugar). From a nutritional perspective they are not valuable and it is important to reduce their intake to minimum levels. The method of preparation also affects glycaemia, eg. baked or fried potatoes have a high glycaemic index. Glycaemia is also significantly increased by products from potatoes, flour, rice or corn: crisps, flakes, popcorn, bars, crackers, thin slices, puffed bread (“polystyrene”). Foods high in fiber have a more favourable impact on glycaemia, as they slow down digestion of starch a reduce the glycaemic index – legumes and whole grains (quality whole grain bread, brown rice, buckwheat, millet, quinoa etc.).

 

3.     The intake of protein and fat is not restricted. It is, however, important to pick quality sources: meat (not processed meat products), fish (particularly fatty fish), eggs, cheese, unsweetened dairy products. Quality butter, lard, cold-pressed oils, seeds, nuts and avocado are also suitable sources of fat. Avoid ultra-processed oils (margarines, refined oils, hydrogenated and partially hydrogenated fats).

 

4.     Ideal plate contains a moderate portion of proteins (meat, fish, dairy product or eggs), enough vegetables (salads or cooked) and a moderate side dish (ideally in a wholegrain form), size of which needs to be individually tailored based on glycaemia. Traditional side dish is not strictly necessary, vegetables can be sufficient. However, vegetable should be accompanied with quality fat (extra virgin olive oil, butter etc.) Fat provides satiety, is a source of fat-soluble vitamins, essential fatty acids and it also lowers the glycaemic index of the meal. In terms of soups, bone/meat broths and vegetable soups, without flour, are suitable. Sauces should not be sweetened, and ideally not thickened with flour.

5.     Food very low in carbohydrates which you can eat without restriction:

–        Some types of non-sweet vegetables: leaf salads, spinach, cucumber, courgette, iceberg lettuce, sauerkraut, green beans, kale, fennel, PATIZON, asparagus, rhubarb, French onion, spring onion, chives, garlic, herbs, mushrooms. Include other sweeter types of vegetables into your carbohydrate intake. Only quality oils and vinegars or lemon juices should be added to vegetable salads, or a pinch of salt (sweet and sour sauces/dressings containing sugar are inappropriate)

–        Meat (chicken, red), liver, fish, eggs, most types of cheese

6.     Fruit also contains simple sugars, suitable portion is one mid-sized piece of fruit, max 1-2x times per day. Fruit can be consumed as part of snacks, not combined with main meals, fruit should not be consumed to fill up in between meals. Fruits with higher glycaemic index, such as banana, mango, pine apple, kaki, grape fruit, melon, are less suitable. Fruits with added sugars (canned fruit, candised fruit, marmelades) and juices are inappropriate. A galss with 100% juice is made of several pieces of fruit, which is a lot of sugars. On top of that, freshly squeezed juice contains all the sugars, but minimum fiber. There is a substantial difference between the glycaemic index of whole fruit and juice.

7.     Buy only full fat dairy products without added ingredients (yogurt, cottage cheese, kefir), you can then add fruit, nuts, seeds yourself. By doing this, you can avoid low fat dairy products – they contain more carbohydrates (thickened with starch) and have limited nutrition value. Some pregnant women with diabetes see increased glycaemia after consuming milk and dairy for breakfast, than would be expected based on carbohydrate content and when compared to the same dairy product later in the day. In these cases, it is important to drop milk and dairy products from breakfast. It is also important to check glucometer to find out if these foods still “pass” (do not trigger hyperglycaemia), and in case of higher blood glucose, to eliminate milk and dairy from breakfast – it is possible to include them later in the day. It is also important to include milk in carbohydrate counting (200 ml contain 10g of lactose), you can add dark cacao (not Granko or other products with added sugars). Cream is ok, but only unsweetened. Butter does ont contain carbohydrate and you can eat it for breakfast.

 

8.     Quality wholegrain and sourdough bread is better than white bread. Practically all wholegrain bread on sale contains added caramel or malt and substantially increases glycaemia. If unsure, buy a regular bread such as Sumava or rye bread. To those of you who observe that small piece of quality bread increases glycaemia too much, we can recommend a home-made low carbohydrate “bread” made off almond or coconut flour, or so called “Evening bread” (supplied by Penam bakery, in the Czech Republic, which only contains 3.6 grams of carbohydrates per 100 grams. However, it is not suitable if gluten intolerant – it contains more gluten than regular bread.

 

9.     Eliminate most processed meats (salami, poor quality ham, hot dogs, saussages, pates). Other than unsuitable macronutrient composition and a list of harmful substances, they also contain carbohydrates, including simple sugars. Quality ham (cut from bone), quality bacon are suitable.

 

10.  Dietary intake of carbohydrates should not exceed 200 grams per day, but even less can be sufficient in the context of adequate intake of quality protein, fat and vegetables. Meal frequency is individual (typically 3 larger up to 6 smaller meals per day). It is not advisable to snack on carbohydrate-containing foods in between meals, sweet vegetable, cheese, a piece of meat are ok. It is useful to establish a regular routine and avoid going hungry, because that tends to result in overeating at the next meal. “Second” dinner is important for some women (small snack roughly an hour before bedtime), which can improve fasting glucose in the morning. However, it is individual, other women see better fasting glucose without this “second” dinner.

 

11.  Avoid food (food products?) which contain artificial sweeteners,  so called “light” foods and “dia” products. They do not increase glycaemia and are recommended to other diabetics, but not during pregnancy, because these are chemical susbtances for which we have little information about their effect on foetus and can be potentially risky. Be careful abour all food products labelled as “no sugar” or “without sugar” or “without added sugar” – sugar is often replaced by artificial sweetener. Using fructose (fruit sugar) is inappropriate. Small amounts of fructose, which naturally occur in fruit, is not harmful, however in larger doses impairs liver metabolism a worsens diabetes. Natural sweeteners (stevia, erythritol, xylitol) can be used sparingly, in small doses.

 

12.   Drinks – we recommend water, unsweetened tea (watch out for fruit teas with fruit pieces) and unsweetened coffee or “melta” (Caro). You can squeeze up to 1 citrus fruit into 1,5 liter water. Fruit juices, juices and beer are not suitable due to their high content of simple sugars.

How to keep track of carbohydrates in diet:

The carbohydrate content of foods can be determined from a Carbohydrate Table, which you can print out and keep for future reference.

You can find a detailed list of foods and their content on the Internet. You might argue that whilst I criticise calorie counting, I want you to count carbohydrate intake just a few lines later. I admit that at the beginning, it will be necessary to weigh foods containing carbohydrates on kitchen scale, but that only applies for the first week or two. Once you master estimating carbohydrate content in meals so that you do not exceed your recommended intake at each meal, you can store the scales away again. From then on you will know how big a slice of bread you can cut, how many potatoes put on the plate, how many spoons rice or pasta. Be honest and whenever you are in doubt, use the scales.

If you are fine with eg. meat with green leafy salad for lunch, there is not even a need to count carbohydrates. Carbohydrates in vegetable rarely exceed the recommended limit. If you combine a traditional side dish (eg. potatoes) with vegetables, it is necessary to count carbohydrates even in sweet vegetables, and adjust the portion size of potatoes.

How to calculate carbohydrate content in food/side dish?

Values in Column A (and on nutrition labels) outline, how many grams of carbohydrates are in 100 grams of the food.
For example, I want to find out, how many grams of carbohydrates are contained in 130 grams of rice. Calculation: value for rice in Column A / 100 * weigth of rice (28/100 * 130 = 36). Result: 130 grams of boiled rice contains 36 g of carbohydrate. For carbohydrate content of grains and legumes when dry and unboiled, use the information on the food label.

How to calculate an appropriate portion size of a food/side dish?

Values in Column B outline the weight of a food, which contains 10 grams of carbohydrates.
For example, I want to find out the porion size of a side dish which offers 30 g of carbohydrates. Calculation: 3 * value in Column B. Result: 30 g carbohydrates is contained in 150 grams of potatoes (3*50), 60g of bread (3*20), 108 g of boiled white rice (3*36), 120 g of cooked pasta (3*40), 159g of boiled bulgur (3*53) etc.

 

Snacks

What to do, when the temptation is stronger than all the good intentions in the world? Then go for recipes of the “last resort”. It involves enjoying food as part of meals or snacks where you control carbohydrate content. Remember that in between meals you should never snack on anything containing carbohydrates.

• If diabetes is well controlled, you could eat a little bit of quality dark chocolate (70% or more content of cocoa). Be sensible, don’t overdo it and do not snack right after the main meal.
• You could bake an apple tart – classic dough and apples, remove sugar, breadcrumbs and also raisins, but you could add nuts and cinnamon – one piece to go with afternoon coffee should be ok (not an entire loaf!).
• Fruit bowl with cream: fresh fruit (not canned), weighted amount (up to 30 g of carbohydrate), regular cream, freshly whipped and without added sugars (not the spray cream, which is not really a cream – typically partially hydrogenated oil with sugar).
• Dark cacao: only true cacao, without added sugar
• Home-made ice-cream: made of fatty cottage cheese or cream, mix with fruit and let freeze (no added sugar).
• “Diet” pancake: dough without sugar (flour, try the French way with buckwheat, egg, milk), roll some fresh fruit into the pancake, finish the design with cream without sugar. Yummy.

Does not sound that bad, does it? At the beginning, you can feel a little bit of discomfort, sometimes even hunger, but that is usually temporary, until the organism adapts to a “new order”. After that most women say they started to feel better.

 

Frequently Asked Questions:

How can I tell if diet is sufficient and insulin is not required?
To ensure that you adhere to the diet correctly, you need to check your fasting glycaemia and also after meals. This includes regular checks (as agreed with your diabetologist) as well as occasional checks after meal where you are unsure about its effects on glycaemia (for example, dairy products for breakfast, fruit etc) – more here.

How about weight gain during pregnancy with gestational diabetes?
If you have already gained 8-10 kilograms before starting the diet, you will typically not gain any more after delivery, and that is ok. At the beginning of the diet (the first week or two), your weight might drop by 1-2 kg, which is not a risk. A greater weight loss, however, is not advisable and would not benefit the foetus.

How strictly do I need to adhere to the diet? Is it necessary to count carbohydrates? Is it not sufficient to restrict sugary foods?
Gestational Diabetes has its natural course. As the weeks go by, the level of gestational hormones keeps, which make diabetes worse, keeps rising. In some women, the course is mild from beginning to end, and it is typically sufficient to avoid sugary foods. It is impossible to estimate the course of diabetes up front. Dietary errors which are insignificant at the beginning may not be as the weeks go by. Unless the woman keeps regularly checking her glycaemia, she may be completely unaware of hyperglycaemia. By sticking to the diet, you are also preventing a deterioration in the course of diabetes and the need to start medication and insulin later in pregnancy.

Practical tips how to eat:
Dietary tips for each meal (breakfast, snack etc.) are reviewed in Meal plans.

Exercise

There are still many unfounded opinions about alleged risks of physical activity during pregnancy, among general public, and – sadly – also among doctors. The reality is that, in contrast, physical inactivity, or “couch potatoes”, is exactly what is not going to do any good during pregnancy. Hard physical activity during a high-risk pregnancy, especially lifting heavy items, it certainly not advisable, that is common sense. However, it has been shown that regular and increased physical activity during a physiological pregnancy do not increase risk of miscarriage or pre-term delivery. In contrast, women physically active up to a year before pregnancy and during pregnancy are at significantly lower risk of gestational diabetes, and also pre-eclampsia. In one study, women who exercised intensively had lower risk of pre-term delivery. There are only very few complications during pregnancy where a woman is advised to restrict physical activity.

For all other women – do not fear physical activity, it burns blood glucose and lowers glycaemia, and that is exactly what we need during gestational diabetes. The body benefits especially in the morning – as we explained already, this is whe insulin restistance peaks, and when it is particularly difficult to maintain normoglycaemia. Possible the worst idea is to go to sleep after breakfast. That alone could cause hyperglycaemia even without a dietary error.

How to exercise? I will not be sending you to dig in potato fields, which is unlikely to be the ideal type of activity for a pregnant woman. Common sense will also tell you that running is also not the best exercise as of later stages of pregnancy, just like the majority of contact sports (eg. ball games) – not because of the physical activity itself, but due to risk of injury. Walking, swimming and individualized exercise are ideal, particularly with specific focus on pregnant women. These days, there are plenty of offers for pregnant women wishing to exercise, one just needs to pick. Exercising once a week is better than nothing, but you probably guessed that it may not be enough for health.
Ideally, you need to exercise every day. If it is difficult for you to handle exercise because of time constraints, you can at least aim for more physical activity during routine daily tasks – for example, if you can get there by foot, do not drive or go by tram. That applies particularly in the morning. If you are at home, go for a walk after breakfast, if you work, try to walk at least some distance. Please do take all this advice with a pinch of salt. I definitely do not tell women late in their pregnancy to stroll on main traffic roads in the morning to get to work! Enjoy walking where the conditions are right. Some of you may argue that “running around with kids” is sufficient, or that you “run enough at work”. Sure, it is, but stress should not be involved. Stress increases adrenalin levels, and that raises glycaemia. So, “stressed running” around anything does not count as physical activity. In that case, pick something more relaxing and calming (eg. pregnancy yoga), when you put your kids to sleep or get back from work.

Remember, if you engage in sensible levels of physical activity after birth, you will lower your risk of developing diabetes (and other health problems) not only during your next pregnancy, but also later in life.

Insulin

Dear moms with gestations diabetes, do not fear insulin. Many women before you survived, and you will, too. I can assure you that after a few initial doses of insulin you will think to yourself: “Not as bad as I expected. Actually, it is perfectly fine.” If classic gestational diabetes is involved, you will get rid of insulin right after the delivery.
To dispel initial concers, here are some basic bits of information to get started:
Insulin is a substance natural for the human body. You are not injecting yourself with any foreing, “chemical” substance. You are injecting something your body is missing. Your baby is not harmed in any way, insulin does not even cross placenta (the molecule is too large). Normal glycaemia is what matters most for your baby, not necessarily the method of getting there.

Diet and physical activity are sometimes just enough. As explained at the beginning, a small minority of those with gestational diabetes, will see hyperglycaemia (fasting glucose above 5,1 mmol/l or more, one hour after meal 7,8 mmol/l or more) repeatedly.

The next step in the treatment in these cases is insulin. You can argue that you can still tighten up your diet. But if you do not do dietary errors and follow everything described above, then there is little to tighten up. It would mean even stricter carbohydrate restriction, in other words, eating an unbalanced diet (with lots of protein and fat) or starving. That is not a good solution. For all participants (ie. yourself and your child), the only correct solution is insulin.

Insulin is injected under the skin with the use of insulin pen, inserted with an insulin cartridge. Using the pen is very simple, the injection as well. You always carry the pen in your bag, in a practical wallet. In a vast majority of women, we start insulin treatment in an outpatient clinic, but in women who also suffer from other additional complications of pregnancy, we choose to start insulin therapy whilst admitted to hospital.

What about hypoglycaemia?

Yes, insulin therapy is associated with a risk of sudden drop in blood glucose, so called hypoglycaemia. It can present as hunger, nausea, lightheadedness, shaking, sweating, black spots in front of one’s eyes, heart palpitations – every person perceives different symptoms, but in repeated hypoglycaemias, the set of symptoms tends to be similar. IT is said that whoever experiences hypoglycaemia, they will recognize it next time immediately. Unless you promptly eat something, a severe hypoglycaemia can result in unconsciousness. This, however, tends to occurs mostly in patients who have longstanding diabetes. We do not see this In women who “only” have gestational diabaetes.

When does hypoglycaemia occure and how to prevent it?

The golden safety rule says: if I inject insulin before meals, the meal MUST contain carbohydrate. If such meal only contains eg. a slice of meat with vegetable salad, and excludes a side-dish, there is a risk of hypoglycaemia. This type of meal contains only negligible amount of carbohydrates. I emphasize that eliminating carbohydrate altogether is not appropriate even for women on “diet only” – but for women on insulin, this even more important – due to the risk of hypoglycaemia. The risk of hypoglycaemia is higher in more strenuous exercise and for several hours after that. Sometimes it is important to prevent this by lowering insulin dose or adding an extra snack, but the approach is individual and you can sort it out with your doctor.

Types of insulin

Insulin used in the treatment of gestational diabetes comes in two types: shortacting (“short insulin”) and longacting (“long insulin”).

• Shortacting insulin, also “day” insulin, is injected during the day before main meals. The best injection site is the skin of lower abdomen, which offers the fastest absorption rate. It’s main effect is to “cover” dietary carbohydrate – the dose is set so that glycaemia afer meals (as measured one hour after the meal is finished) is normal, ideally between 6.0 – 7.3 (max 5.0 – 7.8). Actrapid, Insuman rapid and Humulin R insulins are applied some 30 minutes before meal, Novorapid and Humalog insulins 10-15 min before meal.
• Longacting insulin, or “depot”, “basal” or “night” insulin, is injected once a day, iedeally around 10pm (independent of second dinner). The best injection siet is skin on the thigh, which offers slow absorption. The objective is to cover basal need for insulin (independent of food intake). It is necessary in cases where fasting glucose is elevated. The dose is titrated by the doctor so that fasting glycaemia is 4.0 – 5.0. Due to an additive substances which slows down absorption, the ampule of insulin is a little bit opaque – it has a „milky“ colour. This is not a defect, but a norm. This insulin, however (in contrast with shortacting insulin) needs to be mixed (not shaken) before injection, which is done by slowly rotating the pen 180 degree there and back. A perfect mix requires some 10 rotations. Mixing of this insulin is very imprortant – otherwise the dose does not match reality!

General rules for injecting insulin:

• do not use the same injection site
• rotate more sites
• disinfection of the injection site is not an error, but also not needed
• set the correct units of insulin to be injected (according to instruction of your doctor) before injection
• stick the needle under the skin, press the applicator and count to five before you pull the needle out again (so that the insulin has enough time to absorb and does not spill)
• after you pull the needle out of the skin, a small droplet of insulin usually pops up (not a defect)
• you do not need to change the needle in the pen after every injection (if you inject several times per day, it is ok to change the needle every 1-2 day)

How to store insulin

• the pen with insulin cartridge you are using should be stored in room temperature up to 25 degrees of Celcius
• a pen with insulin should never be exposed to higher temperatures (near radiators, in the car etc), if it happens by mistake, change the insulin cartridge
• backup cartridges with insulin should be stored in the fridge (but should never freeze)

Treatment after birth

Finally some good news – there is essentially no treatment after birth required. The classic gestational diabetes ends with delivery – specifically, by disconnecting the placenta. The hormones released by the placenta, which cause diabetes, rapidly decrease, and with that diabetes disappears.
A diabetic diet will be prescribed at the six week ward, which is ok (the hormones decrease gradually). In women who required insulin therapy, the insulin is typically deprescribed the day after delivery (if the dose was relatively low, insulin will be deprescribed right after delivery).

 Do not forget the following three important things:

• After the first six week, no later than six months after giving birth, remind your general practitioner, who will send you for a repeat OGTT to confirm gestational diabetes which disappeared after delivery. Caution – outside pregnancy, different criteria apply, it is sufficient to check fasting glucose and at 120 min in an OGTT test. Fasting glucose should be below 5.6 mmol/l and below 7.8 mmol/l at 120 min. More on “What to do after delivery?”1. After the first six week, no later than six months after giving birth, remind your general practitioner, who will send you for a repeat OGTT to confirm gestational diabetes which disappeared after delivery. Caution – outside pregnancy, different criteria apply, it is sufficient to check fasting glucose and at 120min in an OGTT test. Fasting glucose should be below 5.6 mmol/l and below 7.8 mmol/l at 120 min. More on “What to do after delivery?”
• In the next pregnancy, diabetes will likely return, but you can reduce the risk by engaging in sport regularly and eating a healthy diet.  There is no need to automatically go on a diet at the beginning of the next pregnancy, nor to undertake any additional extra investigations not recommended to all pregnant women. It is important, however, to undergo tests in time and correctly – see more on “How is it diagnosed?”
• Gestational diabetes is a warning for you that in the future, you are at risk of Type 2 Diabetes, the risk of which can be significantly lowered by adopting a healthy lifestyle. Eat healthy, exercise and do not gain weight.