#85 | Understanding Gestational Diabetes with Dietitian Leslee Flannery

They're eliminating every carb. They're afraid to eat fruit, they're afraid to eat whole grain bread, they're afraid to eat so many things and they're just confused. They're lost, they don't know what to do. So it's just a relearning of how to incorporate carbs. That won't take your blood sugar.

It's all hormones. And it's, it's not like just keep coming back to just how it's not physiologic the way we're doing this.

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Around one in 12 women are diagnosed with gestational diabetes, which can leave them feeling confused, ashamed and overwhelmed with questions like Have I done something to cause this? What can I eat now? And does this mean I'll have to be induced. In this episode, we speak with Leslie Flannery, a dietitian from Ohio who loves supporting and educating and empowering women with gestational diabetes. Because diet isn't the only cause. And it doesn't mean you have to cut out all the foods you enjoy. We'll discuss options for avoiding the glucometer and fear screening. Why Some Women in a healthy BMI range can test positive and the most misunderstood point of all, how exactly it can potentially present a risk for your birth.

Thank you so much for joining us today. We are really excited to hear from you all about gestational diabetes. So let's just jump right in. And have you explain a little bit about how you got into this work and, and teach us what you know. Yeah, thank you so much for having me. I love the prenatal space. I always like talking to other people about it other women especially. So I have been a dietician now almost eight years, and just about seven and three quarters of those years, I've worked with pregnant women. I started my career in community nutrition at a women infant and children's WIC office. And I really love the work there because I feel like it's such an underserved population. And I was working with pregnant postpartum women. And I just thought though, like in that particular space, they couldn't really delve deeper with them. So I moved into a maternal fetal medicine office where I was able to work and just focus solely on gestational diabetes, and absolutely loved it. And I thought, wow, there's such a need here for these women, they need support. And then he started to really realize in the doctor's office, I couldn't quite support them the way that I wanted to. So then I have now branched off and I'm doing a private practice where I can really get in there and support them the way that I feel they need supported.

So what have you seen in the gestational diabetes world? What kind of trend Have you seen recently?

Yeah, so I will tell you, I would even say as much as like 98% of the women that I see by the time they get to me, so they've had their diagnosis, right? They failed the one hour they failed the three hour. That's typically what happens by the time they get to me, they're eliminating every card. They're afraid to eat fruit, they're afraid to eat whole grain bread, they're afraid to eat so many things, and they're just confused. They're lost. They don't know what to do. So it's just a relearning of how to incorporate carbs. That won't spike your blood sugar.

Do you want to give us a little background quick on just gestational diabetes, what it is how it develops? Yeah, so gestational diabetes, I always say it's its own beast. It's not 100% like type two diabetes. It's not just like type one diabetes, it's strictly blood sugar issues in pregnancy. So in pregnancy, just naturally, every woman's blood sugar gets a little bit higher, there's more of an insulin resistance in pregnancy, and some women can overcompensate for it and end up being fine and not really have to deal with the blood sugar issue of gestational diabetes. But then there's some women for different reasons that we could get into, that just can't overcompensate for the extra load of pregnancy. So I just like to break it down with my clients like in that very basic explanation, because I think a lot of times there's a stigma around gestational diabetes, that they've done something wrong, that they're unhealthy, that they were eating too many sweets. And, you know, diet plays a huge role in controlling blood sugars. But there are many women that I've talked to who don't have a perfect diet and don't end up with gestational diabetes. It's really hormonal driven. The hormones that come off of that placenta are strong. And they kind of slow your insulin down from doing what what it's supposed to do, which is lower your blood sugar.

Leslee, I have a question for you. It's not diabetes type one. It's not diabetes, type two, is it diabetes? Once someone is diagnosed with it in pregnancy? Does it otherwise exactly mirror diabetes?

I would say the difference is it mirrors more closely type two diabetes, but I don't think you could completely follow guidance given to a type two diabetic because you have that placenta. So that placenta makes things different, right? Because the placenta, the hormones that come off of it, they surge overnight. So that's why fasting blood sugar in particular is usually a really big struggle for the women that I talked to. So yeah, to answer your question, it is it's more similar to type two, because type one is autoimmune, it's completely different. But it's basically just that load from pregnancy that's causing it. So I treat it slightly different than I would treat someone if I'm just talking to a type two diabetic.

Let's talk a little bit about how we screen for gestational diabetes and how accurate it is. And you know, a lot of the women who are part of our community are concerned about the way the test the glucose to drink and just decline the test. Because they don't believe in it. So can you speak to us about that?

Yeah, I think honestly, it speaks to a greater issue, which is a lot of pregnancy. information that we use, or a lot of things that we go off of, at least I know in the nutrition world are outdated. I feel like I am not a huge fan of the gu cola. I personally think it's disgusting. But I also think that most women I'm talking to are not on a regular basis every day multiple times a day drinking 50 grams of sugar at one time. And then for that three hour, I believe it's 100 grams of sugar. And it's like, is that really an accurate representation of how our body handles things? I don't think so. I think that would be a shock to anyone system. And so many women, including myself. So in my first pregnancy, I failed the one hour and had to take that three hour. And it was a nightmare. I mean, you just feel terrible. I a lady just recently told me that she passed out and she had to be taken to the ER, I hear it makes you know people so sick that can't continue on with it. And you know, it spikes your blood sugar really high, and then it tends to drop it really low. So I just wish that that would change. And I hope it will in the future. I know some OBS are allowing women to just track their blood sugar's for about two weeks. And I love that because that's telling us a more accurate picture of like, How are your numbers after you eat a meal that you would normally eat?

I just want to give out a little bit more to the conversation around the glue, cola drink and the way we eat and help to make sure that everybody understands that when we eat food, we have protein, fat and fiber, along with the carbohydrates that we consume. And when you consume straight carbohydrates, whether you're pregnant or not, you get that massive rise in blood sugar. But that is not like as you said, That's not normally what we do. So we're using this screening test that is outside of you know, we're sort of throwing our body out of whack when we do that. And how do we how can we expect our body to respond normally when we're not used to? That's not physiologic, it's not normal.

Right? And those drinks are liquid sugar too. So let's just talk about liquid gets digested much quicker than a piece of whole grain bread would, and there are chemicals and food dye and a whole lot of other things that health conscious women would never ever put in their body under normal, even non pregnant circumstances. So the irony hits them often like I can't believe my quote, health care provider is having me drink something I would never drink. So can you talk a little bit about the three hour test? because not a lot of people are acquainted with that. And you mentioned a woman passed out from it. So I'm sure they're curious what you meant by that. What did they have to do for the three hour?

Yeah, and it's not that's not everyone's experience or not to like put fear into you. But I have never heard of anyone passing out from it. But I've heard of a lot of women just resenting it and feeling terrible isn't just a greater quantity of the drink it is it's 100 grams of sugar and what they do you have to fast for that one, so you haven't eaten since whatever time you stopped eating the night before you're coming into this and fasting they give you 100 grams of sugar and just for anyone who might not know that's more than like a mountain dew, which is pretty high up there. It's a lot and then they are still not allowed to eat during that three hour timeframe where they're pulling your blood and check Your blood every hour on the hour. So it's a lot. I mean, you know, I just, for me, personally, I have low blood sugar. And if I don't eat in a certain amount of time, I start to feel bad. So then you put all of this sugar in someone's system. On top of that, of course, they're gonna feel terrible.

And then you draw their blood three times, which is a stressful event, which raises cortisol, which further messes with your blood sugar, it's a recipe for a disaster, plus, you're pregnant, and you are, you know, your your blood pressure can be low in pregnancy, you can get hypotensive if you're laying down, and now you're sticking a needle in your vein, and you've completely thrown your blood sugar out of whack. It's all connected. It's all hormones. And it's, it's not I just keep coming back to just how it's not physiologic the way we're doing this. yet. We have the capability and the technology to monitor blood sugar, even without, you know, fingerprints, right through just the sensors in the skin. They have this technology yet, we're still using this incredibly old fashioned method that is very uncomfortable for pregnant women. So I'm glad we talked. I'm glad we touched on that. But so what does a woman do? If she gets this diagnosis? How do you help these mothers?

Yeah, I think first and foremost, I like to clear up the confusion, like we just said that it's nothing that you've done, because women come to me honestly, in tears, like just so upset. It's a very emotional thing. It's vulnerable. As women, we put a lot on ourselves, we're carrying the baby, and a lot depends on us. So to know that something is wrong, then we feel we internalize that we feel all the blame, and then it doesn't it's a perfect storm, it doesn't help if you have a health care provider that saying like, Oh, well, maybe your weight and like throwing around what it could have been. And not just being honest, like it's hormonal II driven. Sure, there are things that we can do to help fix it. But what I do with my clients is I just start to teach them the basics of carb portion size, how we pair them timing of meals and snacks throughout the day matters. Consistency is huge. And so yeah, I just I really work with them within what they're doing in their life and what they like and don't like to eat. I'm not a huge fan of really strict meal plans, because they don't think they work. But I would rather work within the things that you like, and we figure out a good way of balance for you. That will work.

So before we continue, I just had a couple of questions, I first want to ask, what's your opinion on the food alternative, because when I had my home birth, my home birth midwives were supportive of me having a meal that was comprised of 50 grams of carbs as an alternative to the drink. And that made me feel a lot more, a lot more at peace with with taking the test. So that that's my first question. What do you What's your opinion on that?

Yeah, I think that's definitely a place to start for sure. I mean, again, I don't know what the right answer is. But I like that better. I like a general just tracking to see how it goes over two weeks time. I like a food test. Like maybe like you're saying like maybe it's like a banana and a juice or something that gives you a high carb just to see how your body reacts to that. Yeah, I definitely like that. I just think there needs to be changes.

Yes. So in home birth, it's typical that you offer a what's called a two hour postprandial test, which means you eat a very specific meal, but you have to measure it's a it's more than the 50 grand Glu cola drink, it's more like 100 grand carbohydrate load, and then you measure the blood sugar two hours postprandial or two hours posts eating and that is a representation of truly what's going on in your body each time you eat much more so than taking 50 grams of sugar on an empty stomach and measuring your blood sugar An hour later. The problem with doing it that way is that most it requires a little bit of nutritional counseling and ensuring that your client or patient understands exactly how to do the test and that they're going to follow the instructions properly.

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So what's wrong with gestational diabetes? What's the risk?

So the biggest risks that I would take the most common risks would be macro sowmya, where your baby is born larger than gestational age and hypoglycemia in the baby so the baby could be born with lower blood sugar. You know, there are more serious risks. I feel like at least in my experience of working with women, the more serious things like stillbirth breathing issues, things like that are in women who were uncontrolled diabetic already coming into pregnancy versus just true gestational diabetes. And I almost hate to like, talk too much about the risk because it freaks women out. But you can be very well controlled. And we'll keep an eye on baby's growth and size. And just letting moms know that we can control it and keep it well managed.

So to me, what concerns me is when a client has gestational diabetes, I now think, oh, boy, at the end of pregnancy, they are really going to pressure her into induction. Do you have any comments on that? or? Yeah,

and I I was just telling several different clients that this week genetics also plays a role in the size of your baby. Yes. So yeah, and I agree, a lot of my clients are very concerned with induction and being forced into induction. I think that's something that also kind of irritates me about the medical field sometimes. And I just think that we have to do better for women.

Another point, I think that's important to make two points. Actually. The first one is that getting a diagnosis of gestational diabetes does not mean that you're going to have a macrosomic baby, right? It it's all about how it's managed. Getting a diagnosis of gestational diabetes means that you are having some issues with your blood sugar and your insulin sensitivity, how you manage that is what impacts the birth outcome. So if you have gestational diabetes, that's extremely well managed and your blood sugar's are studied, and your insulin is working well for you, then there really is no increased risk in the pregnancy. If you have gestational diabetes and has managed really, really poorly or you're not paying any attention to it, then you know, that's where potential problems arise. The other point I want to make is about macrosomia. Macrosomia is not just about having a big baby, it's about the way the baby grows, it's about the development of x, excessive fat in the shoulders, which puts you at risk of shoulder dystocia. So it's big babies aren't the problem. If I'm understanding you correctly, and what I understand is it's not that macrosomia is about more fatty tissue around the shoulders is that gestational diabetes can lead to more fatty tissue around, that's where the fat tends to deposit. So let's say you have a normal, like a normal sort of a not large for gestational age, baby, you have a normal for gestational size baby, but you have this extra fat deposit on the shoulders, or that's the problem with gestational diabetes. And the shoulder dystocia risk because a large for gestational age baby is just a bigger baby in the woman's pelvis and all the things that go into play with that moment, her genetics and all that allow that baby to move through. But if you have a small for gestational age baby or a normal for gestational age, baby plus these extra big shoulders, that's where you get the risk of maybe getting stuck at the shoulder. It's not always teased apart in the, in the medical literature or in conversation, the difference between the two. So I just think it's important to talk about that.

Yeah, and like you were saying that a lot of women can be managed well, I think that should be a conversation that physicians are having, like, just keeping it open and honest that yes, if we get to a point where we're noticing the shoulders are measuring bigger then you talk about the risk, but I think a lot at least my clients are coming to me scared to death because one lady is in tears because she's like, my doctor is talking to me about stillbirth and I'm crying and they're wondering if I'm okay. And I'm like, you know you're in a pandemic, doing this by yourself hearing that that's very jarring. So instead of going at it that angle, I wish physicians would go at it like what you're saying, right at least help women understand that distinction.

So avoiding the diagnosis in the first place is probably the best option. And then once we get it managing it like Leslie saying now if it's managed, Leslie manner, we'll get into that. Does the induction recommendation have anything to do with how they are testing later in pregnancy? Or do they not test anymore and they you know, that pressure to be induced is there regardless?

I think it depends. I wish there was more continuity of care across the country because I talked to women from all over this country and Some have very liberal physicians who are willing to like look at them as an individual case, which I love. And then some are like you're saying, maybe a little bit more old school, they, they know that induction is something that happens. And so they'll just push it. I did have a client though we worked really hard, got her blood sugar's under control, she wanted a home birth, that's why she came to me because if, if she had to go on insulin, then she'd be transferred to her doctor, and she couldn't do the midwife home home birth. And she did, she got it. So under control that she only had to check her fasting, and they allowed her to do a home birth, and to me is like, that just made me so very happy.

I think the standard care is basically that if you get gestational diabetes diagnosis, you're getting you know, more frequent ultrasounds in the end of pregnancy, and they're doing these estimated fetal weights based on those ultrasounds and then the induction is determined based on whether or not you, you know, your your estimated fetal weight, whatever that is. But again, that goes back to the same discussion we were just having about whether you know, it's a true issue with microsomia, or it's just a big baby, and it's normal. So can you give our listeners a few pointers on some pointers maybe on how to if they're thinking about getting pregnant? Is there anything they can do before pregnancy to help prevent the development of gestational diabetes? We already know that sometimes there isn't anything you can do that it's just your physiology or genetics. But how can women help themselves? Try to avoid getting this diagnosis? Yeah. I think like I was kind of touching on before, the most common thing I see from women that I work with, it really isn't. It isn't their pre pregnancy weight, it's more about their meal patterns. So women who are going really long periods of time without eating or eating inconsistently, or like you said, they're not getting a good balance of carb fat protein. Balance isn't glamorous, but it works. So I think if you can kind of get that figured out really early on even pre conceptually, that will very much help reduce your risk of having blood sugar issues later, I like to put a guess my two cents in with the weight gain and pregnancy because there's a bigger thing here at play with the women I work work with. And I think that's just diet culture, in general tends to teach women, their body has to look a certain way. And let's just be honest, women from the time that they're very small, hear about weight and see images and body sizes. And we all play into that. And so when you become pregnant, that doesn't go away. And when a doctor is telling you that now maybe you have to restrict your food. It's a mind game. And so I honestly don't talk about really weight gain unless clients are concerned about it. Because I'm like, let's control your blood sugar's that is more important to me, then if your weight goes up three pounds, or if it stays steady, I had a client who hurt she lost four pounds in a month. And I'm like, that's okay, because you've just changed to some healthier options. So, weight gain, and pregnancy is not linear. Sometimes it dips, sometimes it goes up, it won't be like your best friend.

And that's okay. Yes, and some women gain, you know, significantly more than the recommended amount for their BMI at the time they get pregnant, and they are absolutely fine and others can gain just within the normal range and still develop gestational diabetes. So the point is about not how much weight you're gaining, but what is causing the weight gain, how you're getting there, what you're consuming, and how you're consuming. It is so important. It's just such a way that people just don't understand like you can have the strawberry jam, but like, have it with some protein, have it with some eggs, have it with some fat, have it with butter, don't have it plain don't. People just don't grasp that you don't have to deny yourself these things. It's just you have to eat them in the right way.

Yes, if we're only focused on weight, we missed so many other important things. It's just one indicator of health. It's not everything.

So Leslee, based on all your experience, what is it that you wish women most could know if when they get a diagnosis of gestational diabetes? What's the one thing you just need them to understand?

But I think the food and the balance and learning how to eat your foods is beyond important. I mean, I'm a dietitian. That's why I got into this. But more so I find that there is a need for support for community to know that you are not alone doing this. Six to 9% of pregnancies end up with gestational diabetes and getting a diagnosis of gestational diabetes you can most certainly have the birth that you desire.

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