#155 | Gestational Diabetes Prevention and Management with Author Lily Nichols, RDN, CDE

So who decided that just because your body can bring a 50 to 100 gram load of glucose down to a normal range quicker that that's better than somebody who's maintaining healthier blood sugar levels with overall lower insulin levels on a day to day basis. So you can have somebody with a very mild manageable case of gestational diabetes who ends up being recommended all sorts of interventions and has their birth plans destroyed and gets risked out of care for no reason. And that's a different clinical scenario than somebody whose blood sugar is consistently spiking to the 160s 180s or two hundreds after meals and isn't being appropriately managed. Those are entirely different clinical scenarios.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Thanks for having me to the show. My name is Lily Nichols. I'm a registered dietician, nutritionist and a certified diabetes educator who specializes in prenatal nutrition and gestational diabetes. I think most people know me for my work for my two books, real food for pregnancy and real food for gestational diabetes. And today we'll be talking about gestational diabetes.

So I think one of the most common things that occur common fears that women have in pregnancy is that they're going to become gestational diabetic. And they're going to have all these potential complications later in pregnancy and an induced birth. Can you start to talk to us a little bit about some of the ways that women can help prevent developing gestational diabetes, diabetes, and maybe even some of the myths and misconceptions around it?

Sure thing. So you know, that's the million dollar question, can you prevent gestational diabetes. And if we had a crystal ball and had all the answers, everybody would be doing that. And we would have much lower rates of this pregnancy complication. Unfortunately, there's so many potential risk factors, some are in your control, but some are not within your control that can predispose you to gestational diabetes, that I'm of the opinion that it's just a matter of stacking the deck in your favor, but you never know how the trajectory of your pregnancy is going to go. So some of the risk factors that are within your control, are entering pregnancy at healthy weight. And I guess that's one of those things where I don't know if that's in your control, if you're thinking about it ahead of time, or if you're already pregnant. But that is one of the potential risk factors. Levels of certain nutrients can actually help with blood sugar and insulin regulation. This includes vitamin D, magnesium, chromium, a number of B vitamins. So I'd say one of the biggest ones would be getting your vitamin D levels at a healthy place. Whether you're planning for conception or already pregnant, the quality of your diet also can play a role as well.

Are those nutritional levels something that women can go and have their blood? I mean, I know they can get those levels checked. But that's not routine care in obstetrics, or even midwifery care. Do you recommend that women go and have blood tests to check their magnesium levels, their vitamin D levels, their chromium levels, their B vitamins,

i It is rare to have all of those things checked unless you're working with like an integrative functional medicine practitioner. And so some of those things, you're probably looking at, you know, a full comprehensive micronutrient panel. But in terms of what can easily easily be ordered from a conventional practitioner, I do recommend screening for vitamin D levels as early in pregnancy as you can. The other ones, again, a bit debatable, like red blood cell magnesium could be helpful to have but it's very, very rarely checked. So I'd say vitamin D would be the easiest one and that's the one with arguably for pregnancy specifically and gestational diabetes. Specifically we have the most data on to back it up as a as an evidence based thing to check.

In my experience. Most people who get their magnesium RBC levels check their lows, so would you recommend that women just go ahead and start on site magnesium supplementation preconception early. I mean, it's a good idea. Since most people are deficient in magnesium, sadly, our soils are pretty depleted. So a lot of our foods are lower in magnesium than they previously were. So it's not a bad idea, it's a pretty safe one to take. I wouldn't say recommend it to you know, absolutely everybody across the board, you have to take it. But if you have the means to afford additional supplementation, having like a magnesium glycinate, even in like a low dose of 200 milligrams per day, is really helpful for overall glycemic control.

And really, where do you like to see vitamin D levels? There's so much controversy around that, you know, yeah, national doctors tend to recommend much lower levels than what I guess functional medicine doctors recommend.

Absolutely. Yeah, I mean, I have like a 90 minute training just on vitamin D and pregnancy, specifically over at the Women's Health Nutrition Academy. So speaking from what the research tells us, you know, the conventional guidelines suggest, you know, just having your vitamin D over 30 to 32 nanograms per mil, a lot of functional practitioners recommend levels that are much higher, sometimes like 50, or 60 nanograms per mil or even more. The data specifically on pregnancy suggests that you need levels of at least 40 nanograms per mil, if more is better, has yet to be defined in the literature. But I really do try to aim for about 40. They've actually found I know, we're not talking about this pregnancy complication in particular, but they found that women who maintain their vitamin D levels greater than 40 have a significantly lower risk of preterm birth by like 60 to 70%. It's It's astounding. So if we really want to support optimal vitamin D levels, we should be aiming for that that level.

Okay, so this at this point, what we know is, many women are getting gestational diabetes, they're told they have gestational diabetes. And I think sometimes the target moves a little bit, right, like how they define gestational diabetes I've seen changed a little bit over the years as well. Do you think this generation is getting gestational diabetes more than the previous generations did? Do we know anything about that?

So from the data as we have it, yes, it's becoming more common. Whether or not this is a true reflection of increased rates of gestational diabetes, or increased screening or more stringent screening guidelines. All of those are factors. But we also know as a as a population as a whole, even outside of pregnancy, diabetes and prediabetes rates have been dramatically on the rise. And gestational diabetes is essentially the same pathophysiology, just with pregnancy thrown in the mix. And a lot of times, if we are screening early in pregnancy, which I'm an advocate for via first trimester hemoglobin emergency, you see that a lot of women are entering pregnancy already pre diabetic, and we just treat it as gestational diabetes, but they were technically pre diabetic, and we're undiagnosed and we're simply catching it. In pregnancy, that all falls under the umbrella of gestational diabetes. By the way, it's not just high blood sugar that develops during pregnancy, it's high blood sugar that is first diagnosed, first acknowledged in pregnancy, whether or not that was pre existing, you really don't know unless you're screening super early in pregnancy, or doing some follow up testing postpartum to see if those blood sugar issues persist. So I'd say it's both were diagnosing more because in some countries, the screening guidelines are stricter, or universal screening is recommended, where sometimes it was reserved to so called high risk groups before but also the prevalence is as a whole increasing alongside the increasing rates of other blood sugar issues as a population.

Can you just talk very briefly about the pathophysiology of gestational diabetes and the role of the placenta and how that sort of changes they are how that sort of contributes to the gestational diabetes.

So let's back up to just normal pregnancy physiology uncomplicated, not involving any sort of diagnoseable gestational diabetes, because pregnancy as a whole is an insulin resistant state. So insulin is a hormone your body releases to help manage your blood sugar levels. During pregnancy, your body releases more insulin, sometimes two to three fold more insulin by the end of pregnancy, to account for an increase in insulin resistant resistance, where your body is not as responsive to the insulin levels that are in your system. So to overcome this, if all is going as planned, your body simply produces more insulin, and this is all by design. It helps to shunt nutrients to baby instead of those nutrients being utilized by maternal metabolize. was admits to support fetal growth if this adaptation doesn't go precisely as planned. And by the way, the placenta and placental hormones are a factor in this insulin resistance state that you start experiencing naturally. In mid to late pregnancy, if this adaptation doesn't go as planned, your your body maybe is not producing quite as much insulin as it needs or you're coming into pregnancy with pre existing insulin resistance, or something is going on that has massively increased your insulin resistance beyond what would be physiologically expected, then we get the state of blood sugar that's higher than expected that falls into the gestational diabetes category. But if all these adaptations happen, as expected, no gestational diabetes, your blood sugar levels Absolutely, actually average about 20% Lower during pregnancy. So your body is really designed to overcompensate for that insulin resistance with greater insulin production. It just that doesn't always happen that way.

That's one of the reasons that we need to eat so frequently in pregnancy to maintain a healthy blood sugar because it is very easy to get low blood sugar in pregnancy, is that correct?

Oh, potentially, it depends on the stage in pregnancy. In early pregnancy, hyperglycemia is pretty common because you already have slightly increased insulin production, but very low insulin resistance. Oftentimes, insulin resistance is actually lower in early pregnancy than it is outside of pregnancy. So for example, in women with type one diabetes, who have to take insulin shots like exogenous insulin, sometimes they have to reduce their dosage and early pregnancy because they're not as insulin resistant as they normally would be. So you're prone to hyperglycemia. In early pregnancy, low blood sugar. later on you're the adaptation is that your body can more easily switch fuel sources later in pregnancy, so you can more easily switch to burning fat as fuel versus carbohydrates as fuel. So if you have, you know, a healthy metabolism, you're less likely to go hypoglycemic in later pregnancy. The challenge though, is that your your stomach is so compressed by baby growing, that sometimes you're just not able to eat as large of a quantity of foods at meals, which naturally will lead you to eat more frequently, but your body has a lot of stopgaps in place to try to prevent low blood sugar.

If a woman is diagnosed with gestational diabetes, can she ever manage it with diet to the point that she can reverse the diagnosis in pregnancy?

Whether you can reverse the diagnosis becomes a matter of debate. However, whether it can be managed, where your levels don't spike into the gestational diabetic range? Absolutely, I see that all the time. And I will see that, especially more frequently for people who are following my approach for nutritional management for it. I will also add that there is a chance of a false positive diagnosis for gestational diabetes for So for whatever reason, depending on the screening method you used, you could have tested positive even though you're not and you have no known blood sugar issues. So there have been chance there have been cases. In my clinical experience where we've had clients that we've realized it's a false positive because all their numbers are not just like slightly within range, I mean, perfectly in range even when eating higher carbohydrate loads. Those cases are sometimes a misdiagnosis.

And interestingly, you you won't get rescreened once you get a positive gestational diabetes diagnosis. It's not like they're gonna say in four weeks, I'm sure we'll rescreen you and see if it's still positive. It's kind of like you're labeled now. And it's an unfortunate situation and with providers, I think a lot of providers jumped to worst case scenario with gestational diabetes. So if you, you know, don't pass the test so to speak, you're automatically treated as high risk. I'd find that practitioners who have been in the field for longer and have more experience are more willing to be like, Okay, maybe that was a false diagnosis or you're so well controlled, we're not going to force additional tests and screenings and a birth interventions on you just because because really the the relative risk of any sort of adverse outcome on with gestational diabetes is dependent upon your blood sugar control over the long term. So if your blood sugar's well within range for you know, since your diagnosis, you're really at no higher risk of any sort of adverse outcomes than somebody who didn't get diagnosed. Remember that such as false negatives. You can have clients who are spiking blood sugar, pretty high, but they happen to pass the screening test.

I think that's a really important point for people to understand that it is not the diagnosis of gestational diabetes, that is a problem. It's everything that happens after. And if you are managing your blood sugar health in a healthy way, and you're not having those spikes, there is no risk to you, your baby, your placenta, your body, everything is normal, just because you have that diagnosis doesn't mean that you're gonna have bad outcomes and birth.

Absolutely.

So if a woman goes to a, let's say, a traditional provider in pregnancy, and she is diagnosed with gestational diabetes, what did they usually tell her to do about it, and then let's start to talk about what you recommend instead.

I mean, in an ideal world, they would be giving you some nutrition or dietary advice. Even conventionally, the first intervention is diet and lifestyle. So typically some type of movement or exercise and a dietary plan. And then if those are not enough to manage blood sugar levels, then they might consider medication. I will say some conventional practitioners, a their dietary advice is not very well suited to the diagnosis, and we can talk about that. But also, some are really quick to push medication, instead of giving time for the client to try diet and lifestyle. So speaking of what the conventional diet is, I mean, I didn't write a book on gestational diabetes, because I didn't feel there was information out there on it. There's plenty of information out on gestational diabetes, you know, I worked at the California diabetes and pregnancy program on those guidelines. And they're better than some of the guidelines. But still, it's often a mismatch for the diagnosis. So gestational diabetes is elevated blood sugar during pregnancy. However, it can also be defined as carbohydrate intolerance during pregnancy, meaning your body is not able to tolerate as large of a quantity of carbohydrates and still maintain normal blood sugar levels as somebody else. And so the dietary guidelines for gestational diabetes are actually pretty high in carbohydrates. And it's often too much for their body to handle without having high blood sugar after each meal. So if you think of like a typical glucose tolerance test, which can be anywhere from 50, to 75 to 100 grams of glucose in one sitting, well, the carbohydrates that you eat, most of those carbohydrates are converted into glucose in your body. And a typical meal plan for gestational diabetes has meals that have anywhere from 45 to 75 grams of carbohydrates per meal. So if the majority of those are converted to glucose, why are we expecting that somebody who failed a 50 gram glucose tolerance test is going to be able to handle a meal plan that has 60 grams of carbs per meal? It doesn't take a rocket scientist to say that that doesn't make sense.

Can I jump in quickly with a question about carbohydrates? Yep. So bread is carbohydrates. Yep. And bread is comprised of carbohydrates, and so is a salad. So let's talk about the distinction between getting carbohydrates from produce versus I don't know if we want to say refined, processed. Can you just talk a little bit about that? Well, there's a couple of factors as comparing bread and salad. So plant foods are for the most part, mostly carbohydrates, with the exception of like, the really high fat items like nuts, for example. And nuts and seeds have some carbs, but they're mostly protein and fat. The difference really isn't in carbohydrate density. So yes, a salad has some carbs, but you may get a gram or two of carbs and your whole bowl of lettuce versus a grain is much more concentrated in carbohydrates. So a typical slice of bread will have about 15 grams of carbs.

Okay? So if you have three grams of salad and three grams of bread, is there still a difference? Nonetheless, if you had the carbohydrates from the bread versus the same amount of carbohydrates from bread versus the same amount of carbohydrates from salad, yes, it would still be different because of the amount of fiber relative to the carbohydrate load and also the processing. So a salad is unprocessed like it's it's the carbohydrates are locked into the individual cells in those greens. And you're also getting probably a two to one ratio of like, fiber to carbs. Whereas with bread, you're maybe getting I mean Max like three to five grams of fiber. burger that's like a super high fiber bread would be maybe three to five grams of fiber, per, you know 15 grams of carbohydrates per slice. So that ratio of fiber to carbohydrates is different. Furthermore, if the grains have been processed and flour before it was made into bread that affects the glycemic index, was it sourdough fermentation or regular fermentation that makes a difference? There are so many potential variables, but typically vegetables, especially green vegetables, do not spike your blood sugar as much as grain or fruit or starch based carbohydrates.

And can you talk about the importance of fiber in this conversation?

Yeah, so you know, fiber takes up room in our in our intestines and slows down how quickly the carbohydrates that we're eating are absorbed into our bloodstream. So they generally lower the glycemic index or lower how quickly your blood sugar spikes or how high it spikes after meals. So the general advice to have you know, unprocessed or unrefined carbohydrates is really a matter of a the these foods are more nutrient dense, they haven't been processed to remove micronutrients, but B, it takes longer for our bodies to actually access and digest the carbohydrates in those foods. So it's really vital, not only to think about, you know, quantity of carbohydrates that are consumed, but the quality of carbohydrates as well.

Okay, so if you want to continue Lilly explaining what you recommend, and what you see having a better effect on women's glycemic indexes, or their insulin production, insulin production during pregnancy, what are you finding?

Well, I have found that the conventional carbohydrate recommendations are often too high to really help with adequate blood sugar management and pregnancy. So instead of you know, 45 to 75 grams of carbohydrates per meal, it might be more like 15 to 30. Maybe in somebody who's really active 45 grams of carbohydrates, an emphasis on unprocessed carbohydrates is big. And also making sure you're pairing those carbohydrate choices with other foods that don't raise your blood sugars. So things that are high in protein, fat, and fiber, help dampen that blood sugar response. So that's, that's the biggest thing that we can do to reduce the glycemic index of the meals. And lastly, I'm a huge proponent of clients eating to the meter, which means you play around a little bit, you know, in the first couple of weeks after you're diagnosed with different types of foods, different quantities of foods and see how your individual blood sugar response is, because it really is very, very individualized. Some people tolerate potatoes quite well as a carbohydrate source. Other people, it seems despite them no matter what Same goes for rice, or bread or fruit. So it's really dependent on the client. And so I like to individualize it to the client, put the onus in their hands, empower them with the information to respond to what they're seeing on the meter, and customize it to what works for them.

What kind of monitoring Are you usually recommending that women do for their blood glucose? When when you're talking about the meter? Can you explain that?

Yeah, so typically, when you're diagnosed, you'll be given a blood sugar monitor, also called a glucometer. Where you prick your finger and test your blood sugar, typically, it's four times a day, first thing in the morning and an hour or two after each meal. That's that's the standard recommendation, I'd say newer approach that some people are using if they have access is to use a continuous glucose monitor, which gives you information on exactly what's happening with your blood sugar, like over 200 time points per day, you essentially attach a little sensor to your arm and you can scan it and see where your blood sugar at is at at any time point. But that's not as widely available. It really depends on the clinician you're working with whether they're willing or not to prescribe it. Sometimes even which country you're in because some countries you can get them over the counter and other ones you have to get a prescription.

I think that technology is amazing and wouldn't how much would our health as a society change? If we were all monitoring our blood sugar around the clock for a period of time we would learn so much about the foods that we eat, and how they impact our body. It could just be so transformative for our health.

Absolutely. Even as somebody without diabetes, I've I've worn a CGM before I've written about it in a post called CGM experiment and it's really eye opening. I think it would change people's health for the better.

So why is that not the recommendation for pregnant women when a woman gets diagnosed with gestational diabetes are you Even just maybe as a screening tool for whether or not they actually have this, we could help them so much more. And we could reduce so much of the frightening experience that women go through when they get this diagnosis and all the unnecessary interventions that they are subjected to. I agree. I mean, I'm looking at it this way, checking their blood sugar at some point. And some people do choose to screen via home monitoring. Instead of taking a glue Cola, I talk about the different screening methods and alternatives and which ones make sense and don't make sense in Chapter Nine is real food for pregnancy for people who want to like consider different options. But that really is for the person who's like committed enough and empowered to check their blood sugar for a couple of weeks. Even without a CGM, just with finger sticks at home, it really does make a difference, because you can see like, wow, my symptoms after eating that pasta feeling are like really sleepy and tired. And that corresponded with my blood sugar spiking, and hey, this other meal that I had, I felt really good. And hey, look, my blood sugar didn't spike. And you can start to make more empowered choices about the foods you're eating and the combinations you're eating versus just feeling like you have no control over your energy levels and well being and blood sugar levels and everything else.

So that was my next question, I'd really like to hear your opinion on the screening tool that is most commonly used, which is to do the one hour glucose test around 28 weeks or 25 to 28 weeks of pregnancy. And how actually effective that is at picking up true gestational diabetes.

It's a long topic, we could do a whole hour talk just on the different screening options. As a whole, it is from the conventional perspective, and the research perspective, the most studied and therefore what they believe the most validated way to check for gestational diabetes. It is however, not perfect, especially the one used in the United States, which is the two step method of 50 grams screener followed by a three hour 100 gram test. There's an organization called the International Association of diabetes and pregnancy or something like that I D PSG, and they advocate for a different version of the good Cola, which is a single test 75 grams of glucose performed fasting. And that catches more cases of gestational diabetes and it doesn't delay treatment. Because if you are getting screened, you know right before your third trimester, you say so called fail the 50 gram screener, then they they schedule you for the next one, what if your appointment is delayed two weeks, okay, then you wait a week for the results to come back, then you wait another week or two to get referred to a specialist, you've now wasted a month to five weeks of time with elevated blood sugar that didn't get treatment. And that's a problem. Because the greater amount of time that we can spend in healthy blood sugar levels, the less risk there is to both mom and baby for any adverse outcomes. So if anything, we should be moving to that version of screening, which most other countries do the US lags behind on that. The gluco though, is not perfect, because there are both cases of false positives and false negatives. And in the case of just to give you an example of a false positive situation, we've known since at least the 1960s. For people who eat a lower carbohydrate diet, they're more prone to fail. A glucose tolerance test. Your body is not currently adapted to that type of diet. We see it in animal studies too, by the way, you put horses, pregnant horses, on alfalfa and hay, and you put pregnant horses on grains, which group fails the glucose tolerance test, the horses eating their healthier diet, their diet and their species appropriate diet of grasses, because they're not adapted to the high carbohydrate load. We're the ones eating more grains, their pancreas has adapted with increased production and they will so called pass the screener test which one is healthier is really the question that is the question. So who decided that just because your body can bring a 50 to 100 gram load of glucose down to a normal range quicker that that's better than somebody who's maintaining healthier blood sugar levels with overall lower insulin levels on a day to day basis. This has always been up for debate.

This has always been our personal frustration. The the way testing is done in the United States and the nasty orange glue cola drink that Yep, That's not how we eat. That's not typical of what we do, we're typically eating a balance, not everybody, but you're typically eating a balanced meal with carbs with carbs, protein, fat and fiber. And as a midwife and my homebirth practice, that is how we screen women, we gave them a three different options of meals to choose from that included a high amount of carbohydrates, but was also included some fiber and fat. And let's see how your body is responding to the way you're typically eating, as opposed to this, you know, straight sugar load.

Yeah, I do recommend, you know, a two week screening period for people who are going to skip the glue cola. And by the way, I mean, I can like, put myself in that group. And my second pregnancy, I skipped the bucola and I were CGM. One time each trimester to see where I was at, on top of fingerpicking. I kind of treat myself as a science experiment, because in my first pregnancy, I did drink the 50 Gram bucola In the name of science, and I failed by point and then tested my blood sugar for two weeks, I wasn't about to drink 100 grams of glucose in one sitting. But I tested my blood sugar for two weeks. And all my numbers were perfectly within range, even when eating high carbohydrate meals. So to perfectly illustrate the point of I'm an example of somebody who eats healthier, relatively low carb, and therefore I am prone to so called failing the screening test. Now I have to add in a nod to the general population, the US as a whole 58% of our calories are coming from ultra processed foods, which is mostly sugary foods. So for people who are not eating very healthy, and are not super on top of you know, they don't want to check their blood sugar for two weeks or other things, I think there is a there is a place for the Bukola. If you're drinking smoothies, or juice on the regular, if you're having cereal for breakfast and rice and pasta on the regular, your body should be able to handle a glucose tolerance test with no problem. But if you're eating lower carb, your insulin production is adapted to that diet. So you could still do the test, you'll want to carb load ahead of time I certainly didn't, and didn't want to. Or you could do something like test your blood sugar for a couple of weeks, including some high carb meals as you are and see where you're at. But at the end of the day, I think we have to get out of this binary thinking of like gestational diabetes or not gestational diabetes, because it's really a matter of blood sugar is on a spectrum. And severity of risks we know from the data is associated with how high the blood sugar levels are actually getting. So you can have somebody with a very mild manageable case of gestational diabetes, who ends up being recommended all sorts of interventions and has their birth plans destroyed and gets risked out of care for no reason. And that's a different clinical scenario, then somebody whose blood sugar is consistently spiking to the 160s 180s or two hundreds after meals and isn't being appropriately managed. Those are entirely different clinical scenarios.

What I'd really like to talk about too, is you know, when I, when I have a client who is diagnosed with gestational diabetes, her management of it aside, my concern is always that her provider is now going to pressure her relentlessly into an earlier induction out of fears around having a so called Big Baby. And I say so called because we know that it's about head positioning, it's about fetal positioning, Trisha wants shared some data that showed when Shoulder Dystocia occurs, I believe it was a 48% to 52% split as to whether the baby was even large. Anyway, I mean, what are really the risks of gestational diabetes? Can we talk about that? Because I feel like that's never a part of this conversation. And I, I just think we need to clear that up a little bit. Yeah, what are the risks of it when it's mild or whether it's severe?

I think they jumped to worst case scenarios. So in worst case scenarios, uncontrolled blood sugar, can impair fetal lung development can of course, you know, change the anthropometrics of the babies so they accumulate more, more fat, they're bigger babies. It can change their ability to like adapt postnatally so if your body is regularly having high blood sugar levels, maternal insulin does not cross the placenta. So the baby's pancreas takes up the slack, and they start over producing insulin. So babies born to mothers who have poorly controlled blood sugar have larger pancreas as they produce more insulin, and they're born essentially insulin resistant. So the risk of hypoglycemia can be quite high in those infants because they're adapted to a high sugar load. So they're born. The cord is cut the sugar supply is cut but their insulin production remains high. It won't stabilize, it won't stabilize, they go hypoglycemic, we're technically physiologically in pregnancy. Your body adapts to go into ketosis more regularly. In later pregnancy, you go into fat burning mode, and the baby uses ketones as energy. And during the first few days of life, they're living largely off of their fat stores their deepest in ketosis in the first few days of life. But these babies who are sugar adapted from this super high sugar load, they never got used to using fat and ketones as energy, they go hypoglycemic, their insulin is too high. And of course, that's an immediate medical emergency. But long term, these children have anywhere from a six to 19 fold higher risk of diabetes and obesity by the time they're 13. So these, this is all the scenario of uncontrolled blood sugar and pregnancy, when your blood sugar levels stayed within range, most of the time, you can have a few highs here and there, everybody does, then you see much lower risks of any of those things. It's really almost indifferent to, you know, a pregnancy, not so called complicated by gestational diabetes. So it's really a matter of where your blood sugar levels are at. Not so much whether you have a positive diagnosis of gestational diabetes or not, if that makes sense.

So Lily, if a woman does get a diagnosis of gestational diabetes, what's the first thing that she should do? What we know that you have two books that talk all about this? Can you share a little bit of the highlights from your books about us some key things that women can do to start trying to manage the situation and avoid complications, the complications that you just mentioned?

Yeah, absolutely. So, you know, the first few weeks after diagnosis, I think, for everybody are the most scary, because you've heard all of these scary risk factors, and you don't want to be high risk. And you don't want to have all of these complications or birth interventions. So it's totally normal to feel anxiety about it. So the first thing is to better understand what this diagnosis means and where where your blood sugar levels are at how your body is responding to food. So checking your blood sugar is the first step really. And if your provider is not providing you with a glucometer, then you can buy one of those over the counter. As far as learning how food affects your blood sugar, and really understanding and conceptualizing what this diagnosis means I'd recommend checking out real food for gestational diabetes, that book is intended to walk you through from oh my gosh, I've been diagnosed, what do I do to here's what it is, here's how you manage it. Here's how you customize and personalize meal plan to work for you. So unlike the traditional guidelines, I give you sample meal plans with three different levels of carbohydrates. So I'm not telling you you have to eat this one, one cheat meal plan that you might get from like a nutrition class you go to but here's, you know, many days of meal plans with different levels of carbohydrates and how to choose which one is going to work for you and to adapt to that. That book really is intended for you've just been diagnosed with gestational diabetes. If you are still in the case of I want to prevent it, I want to understand the screening options, then I'd recommend checking out my other book real food for pregnancy, I do have a section on steps you can take to prevent gestational diabetes. There's also a section on different lab test options for diagnosis. So the pros and cons of a glucose tolerance test and the different types of glucose tolerance tests using hemoglobin ABMC. In the first trimester, for example, whether test meals juice, Jelly Bean are good alternatives or testing your blood sugar for a couple of weeks. that walks you through a little more on like the preventative and testing options for it. So you're well prepared for those different options. And then I have many, many other resources on gestational diabetes out there I have a free video series on my website and I also have a comprehensive online course with you can access you know q&a with me during office hours and whatnot for people who want to take it even further beyond those resources.

If you could give women one tip on how to best eat to keep their glucose levels healthy. Yeah, that'd be start with breakfast.

Fix your breakfast. And what I mean by that is not make yourself breakfast. I mean yes, make yourself breakfast and eat breakfast. I think that's a good idea for most people, but fix the issues with breakfast for giving you optimal blood sugar levels and then oftentimes your blood sugar control falls into line more easily for the rest of the day. Fewer cravings Bureau blood sugar spikes. And so what that really looks like because prioritizing having more protein and fat at breakfast. And some people still can have some carbohydrates but not having that be the center of the meal because once you get on this blood sugar roller coaster of a spike, it's usually followed by a crash, which physiologically makes you hungry and crave more carbohydrates to bring your blood sugar up to the normal range, but we usually overeat because we're so hungry and then up spiking and crashing and spiking and crashing all day long. So work on breakfast first, whether or not you're pregnant whether or not you have gestational diabetes, this applies to everybody. It makes a very significant difference in your well being and your blood sugar levels

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