Having diabetes is often (and not 100% accurately) attributed to people who eat poorly and are overweight. This stigma often gives pregnant people the false notion that if they are not overweight, or don’t have family history, that they are not at risk for gestational diabetes. While risks for gestational diabetes tend to be higher in those who are overweight or who do have a family history, gestational diabetes can happen to anyone, despite a lack of risk factors.
Understanding insulin and glucose
Remember my article about breastfeeding, in which I discuss hormones and feedback mechanisms? (No? Well, you should go read it here). Insulin, which is a hormone, works with another hormone called glucagon via a negative feedback loop mechanism that is constantly in motion. Insulin is produced in response to high levels of blood glucose in order to help clear your blood of that glucose. On the other hand, glucagon is produced in response to low levels of blood glucose in order to help your liver and muscles release stored glycogen for energy usage. Low levels of blood glucose leads to glucagon production while high levels lead to insulin production.
Your body is a feedback loop machine
Generally speaking, all of this occurs without you even knowing it. You eat some carbohydrates. Your stomach acids break it down. The mush is sent to your small intestines and then into the blood stream where carbs are converted to glucose. Our blood does not like glucose to be swimming around. As such, the mere presence of it signals the pancreas to produce insulin. Insulin has a little discussion with your cells, they come to an agreement and the cells open up and let the glucose in. Once inside, the cell will either convert glucose into energy or send it for storage in muscle and liver cells in the form of glycogen. Several hours after you eat, low levels of blood glucose will trigger your pancreas to produce glucagon. Glucagon tells your liver and muscle cells to take its stored glycogen and turn it back into glucose. You’ll need this to happen if you plan on going to the gym (or drinking that bottle of wine, tomato, tomato…or is it grape, grape?).
What is diabetes?
Diabetes is actually a group of diseases that indicates problems with blood sugar balance. In type 1 diabetes, which is thought to be a rare autoimmune condition, antibodies attack and destroy the cells in the pancreas that make insulin. People who have type 1 diabetes have to have regular insulin injections and blood sugar monitoring for life. The most common type of diabetes, type 2, is thought to generally be a result of poor diet. In type 2 diabetes, your cells ignore insulin’s demands to let glucose in. Ingestion of animal products, dietary oils and GMOs have been linked to insulin resistance. The results of this insulin resistance are high levels of blood glucose. Over time, numerous parts of your body can be damaged from uncontrolled blood glucose levels. This includes neuropathy, poor circulation to the legs and feet, damage to blood vessels, decreased wound healing times, erectile dysfunction, kidney disease and failure, stroke and even heart attack due to plaque buildup. While many of these side effects can be reversed with dietary and lifestyle changes, prolonged uncontrolled blood glucose can have permanent side effects.
Testing for diabetes
When someone has symptoms of diabetes, the easiest and most inexpensive testing is a fasting blood glucose test. This can be done through a finger stick or more accurately, through a venipuncture blood draw. Normal fasting blood glucose levels are anywhere between 70-100mg/dL. If someone has an elevated level, the test will be repeated before diagnosis can occur as one high test can be a false positive. However, if the test is normal and symptoms persist, an oral glucose tolerance test is performed. For this test, a blood draw is done for a baseline and then a sugary glucose drink is ingested. Depending on what specific glucose tolerance test is being performed, blood draws will occur at established time intervals in order to determine the levels of glucose still remaining in the blood.
So what does all of this have to do with gestational diabetes?
I’m glad you asked. Throughout pregnancy, the placenta releases hormones in increasing amounts. For unknown reasons, these hormones have the ability to turn insulin’s great relationship with cells into a choppy one. Most people can overcome this turbulence, but there are a few people who succumb to it. One of the pregnancy hormones that is made, human placental lactogen, has been shown to contribute to insulin resistance even in the healthiest of people.
It is important to understand that gestational diabetes often has little to do with how healthy you eat or how active you are and everything to do with how your hormones are able to interfere with each other. While certain risk factors do exist like being overweight and family history, anyone can develop gestational diabetes. Researchers did set out to prove that not every person needed to be screened. However, the criteria for not screening left such a slim margin (<10%) that care givers around the world have adopted the practice to instead, screen everyone. This is because there are often no warning signs or symptoms of gestational diabetes. The symptoms that do present can often be mistaken for pregnancy symptoms: frequent urination, excessive thirst, fatigue and nausea.
So why are people told to control it with diet and exercise if they already do…that doesn’t make sense!
Even people who eat healthy will have to alter their diet if they get a gestational diabetes diagnosis. You’ll need to spend time with a dietitian as well check your blood sugar levels several times per day in order to determine which foods will spike your blood sugar and which ones will not. While this will be a tedious and difficult task, different foods can and will cause different reactions in different people. It is so important to know what works and does not work specifically for you.
What are the dangers of uncontrolled gestational diabetes?
Just as uncontrolled blood sugar in type 2 diabetes can lead to numerous serious health concerns, so too can uncontrolled gestational diabetes lead to unfortunate occurrences.
High Blood Pressure and Preeclampsia
The risk of both high blood pressure and preeclampsia is much higher with gestational diabetes. Parents are monitored for these conditions much more closely so immediate action can be taken. Actions include limiting sodium intake, being active, and reducing stress levels. Complications of high blood pressure include placental abruption, preterm labor and cesarean section. High blood pressure can affect a baby’s growth inside the womb, resulting in low birth weights.
High blood pressure can also lead to preeclampsia, which is protein in the urine and swollen hands and feet (in addition to the high blood pressure). Preeclampsia can have many dangerous complications to both parent and baby, including pre-term labor, seizures and HELLP syndrome. These conditions can have solemn consequences if not treated appropriately.
Emergency Cesarean Section
High blood sugar does cross the placenta and will trigger the baby’s pancreas to make insulin. This can lead to macrosomia or a large baby. While many people are able to have a vaginal birth with a large baby, some babies can weigh more than 9 pounds, greatly increasing the risk of emergency cesarean section. Additionally, many care providers will recommend inducing labor early if the baby is thought to be large. Labor induction also increases the risk of emergency cesarean section.
Preterm Birth Leading to Respiratory Distress Syndrome
High blood sugar can lead to natural early labor. Furthermore, care providers often recommend inducing early labor when a baby is large in order to decrease the risk of cesarean section (something, as stated above, that can also increase the risk of needing a cesarean section). However, babies that are born too early can experience respiratory distress syndrome due to their lungs not being fully developed. While treatment for fetal lung growth can be given prior to delivery if prenatal care is proactive, natural early delivery may prevent this from being a possibility. This can lead to neonatal intensive care unit stays along with assisted breathing needs.
Hypoglycemia or low blood sugar
Due to the excess blood sugar crossing the placenta, babies often have higher levels of insulin circulating. After birth, the insulin doesn’t simply disappear, while the glucose does. This can lead to dramatically low blood sugar levels, which can provoke seizures in a baby. These can lead (rarely) to brain injury. While scary, glucose solutions can be administered to correct the issue.
Future Gestational and Type 2 diabetes
The risk for having gestational diabetes is increased once you have already experienced it. Additionally, people who do have gestational diabetes, along with the baby, have a higher risk of developing type 2 diabetes later in life, something that can usually be prevented through a healthy lifestyle.
Okay fine, I’m listening, but the drink is so gross!
Yes, we get it, the drink IS gross. Especially for vegans who generally stick to a GMO, food dye and preservative free existence. Most of the drinks have food dyes, sodium benzoate, brominated soybean oil, BHA and sodium hexametaphosphate. The idea of drinking those ingredients can be so off putting that many vegans choose to forgo the test altogether, focusing on the aforementioned yet incorrect, reasons why they are not at risk.
So what should a pregnant person do?
Beyond asking medical manufacturing companies to create a healthier alternative, first and foremost, have a discussion with your medical care team. A Cochrane review in 2017 attempted to discover if alternative methods were safe and effective. Researchers compared results of people who ingested the required amount of glucose through a meal, candy and chocolate versus the traditional drinks. Because this was a look back study rather than controlled randomized trials, researchers were unable to come to any concrete conclusions. This was mainly due to the lack of information on the outcome of the pregnancy, how the birth went and the health of the infant. Unsurprisingly though, they were able to show that reported taste preferences and immediate physical side effects were far in favor of food, candy and chocolate over the drink.
Therefore, if the drink causes you a great amount of concern, then you absolutely should discuss it with your care team. A good team will know and can advise you on how to use an alternate method rather than simply allow you to forgo the test altogether. While this may be a viable option, this should always be done under the guidance of your medical care team so that it is controlled, the test results are reliable and your care team feels that you and your pregnancy are safe.
What about the A1C test?
Recently, the A1C test has popped up in discussions in relation to gestational diabetes testing. While this may change in the future as more studies are being completed, at this time, there are no conclusive studies that support this test as diagnostic in gestational diabetes. In fact, a 2012 study showed that specificity for this test correlating to gestational diabetes was less than 70%. A1C testing can be done early on in pregnancy in order to determine if a person may have been diabetic or even pre-diabetic prior to becoming pregnant. However, the result of this test has no proven correlations to a gestational diabetes diagnosis nor can it predict the risk level a person may have.
The bottom line
Despite the fact that only 7% of pregnant people will develop gestational diabetes, the possible outcomes of not controlling it are far too dire to ignore. Lack of family history and physical fitness levels should not be factors that make the decision of not having this testing done. Studies show that most people who have gestational diabetes are able to control it, have a healthy pregnancy and go on to deliver healthy babies!