Diabetes During Pregnancy - Management of Diabetes in Pregnancy

Pregnancy (Diabetes during Pregnancy) is a wondrous and exciting time. Itís a time of change, both physically and emotionally. With the proper attention and prenatal medical care, most women with diabetes can enjoy their pregnancies and welcome a healthy baby into their lives.

Why Tight Blood Sugar Control Is Critically Important for women with Diabetes During Pregnancy

Blood sugar control is important from the first week of pregnancy all the way until delivery. Organogenesis takes place in the first trimester. Uncontrolled blood sugar during the early weeks of pregnancy increases the risk of miscarriage, and birth defects. (Women donít develop gestational diabetes until later in pregnancy, which means they don’t share these early pregnancy risks.)

Later in the pregnancy, uncontrolled blood sugar levels can cause fetal macrosomia, which may lead to shoulder dystocia, fractures, and the need for Cesarean section deliveries. Very high blood sugar levels can increase the risk of stillbirth.

Maternal hyperglycemia can stimulate fetal hyperinsulinemia, and lead to neonatal hypoglycemia when the glucose supply (umbilical cord) is cut.

Because of all these increased risks, home deliveries are not typically recommended for women with any form of diabetes. As many as two thirds of all women with diabetes have unplanned pregnancies and most women don’t realize that they’re pregnant until six or more weeks into the pregnancy. That’s why it’s critically important for women who have diabetes to use contraception and achieve tight blood sugar control prior to conception. Many health-care providers suggest at least three to six months of stable blood sugar control prior to attempting to conceive. Hemoglobin A1c should be within 1 percentage point above the lab normal, which means striving for a HbA1c of less than 7 percent.

Women using oral agents should be switched to insulin prior to becoming pregnant. Oral agents are contraindicated in pregnancy. It’s also important to make sure that any other prescription drugs or over-the-counter medications that are being used are safe for pregnancy.

Typical Blood Sugar Targets During Pregnancy

Fasting blood sugar:

95 mg/dl if meter reads whole blood.
105 mg/dl if meter is plasma calibrated.

Blood sugar level measured 1 hour after the meal:

140 mg/dl if meter reads whole blood.
155 mg/dl if meter is plasma calibrated.
(Your doctor may have different blood sugar targets for you. Follow your doctor’s advice.)

Dietary Management

Calorie requirements increase by 300 calories per day during months 4-9. Most women end up needing a total of about 2,000-2,200 calories per day. Weight should be monitored and calories adjusted to ensure appropriate weight gain.

A minimum of 1,700-1,800 calories per day is recommended during pregnancy. Eating too few calories or too few carbohydrates can cause the production of ketones. Ketones can pass through the placenta and may have a negative impact on the fetus.

Diabetes during pregnancy is one situation when a slightly lower carbohydrate intake may be prudent. I usually recommend that 40-50 percent of the calories come from carbohydrate. I have women start with the lower end and move up as tolerated. (Women using insulin often tolerate 45-50 percent, as insulin can be adjusted to cover.) Excessive carbohydrate intake may make it difficult to maintain the strict blood sugar control required during pregnancy. Itís equally important to ensure adequate carbohydrate intake. If too little carbohydrate is eaten, then important nutrients from the carbohydrate food groups may be lacking. Grains, milk, and fruits are each important components of a healthful diet.

Calorie Level	Grams of carbohydrate needed to provide 40-50 % of total calories
1,700	170-213
1,800	180-225
1,900	190-238
2,000	200-250
2,100	210-263
2,200	220-275
2,300	230-288
2,400	240-300
2,500	250-313
2,600	260-325

Once carbohydrate goals are determined, itís important to distribute the carbohydrate intake throughout the day. Eating too much at one time can cause the blood glucose to go dangerously high. It works best to split the carbohydrate budget between three meals and two to four snacks–for example, 45-60 grams of carbohydrate for each main meal and 15-30 grams of carbohydrate for each snack. (Note: some women do best to limit breakfast to 30 grams of carbohydrate secondary to hormonally mediated glucose intolerance that commonly occurs in the morning.)

Dietary Strategies for Controlling the Blood Sugar

Distribute carbohydrate between three meals and two to four snacks. Distributing the carbohydrate throughout the day allows the body to process it one batch at a time.
Milk and fruit are both healthful choices. However, they tend to digest rather quickly, which means that the glucose derived from those foods enters the bloodstream rapidly. To prevent spiking post-meal blood sugar levels, itís recommended to eat those foods one portion at a time.
Avoid fruit juices, regular soft drinks and sugary beverages.
Avoid added sugars. That includes natural sugars, honey, and syrups. Every bite should count toward good nutrition.
Breakfast matters: Because of hormones, blood sugar levels can be especially difficult to control at breakfast time. For women with elevated post-breakfast blood glucose values, it helps to avoid milk, fruit, and refined breakfast cereals at the breakfast meal (since those foods digest so quickly). Milk and fruit should still be included, but at meals or snacks other than breakfast. A breakfast that consists of starch plus protein may be better tolerated. Another option is to limit breakfast to 30 grams of carbohydrate and distribute the remaining carbohydrate between the other meals and snacks. But donít skip breakfast.

Blood glucose monitoring is crucial. If the above dietary guidelines are being followed, and blood glucose cannot be maintained within target levels, then insulin should be added or adjusted until control is achieved.

At least half of all Americans are overweight or obese. Excess weight poses many health risks. Obesity increases the chance of developing numerous diseases, including:

Type 2 diabetes
Hypertension
Lipid Abnormalities
Coronary heart disease
Peripheral vascular disease
Stroke
Gallbladder disease
Osteoarthritis
Sleep apnea and respiratory problems
Certain cancers, including endometrial, breast, prostate, and colon

Input versus Output

If the calories you eat are roughly equal to the calories you burn, then theoretically, you will stay about the same weight. When caloric intake exceeds the body’s requirements, excess calories are stored as fat.

One pound of body fat stores roughly 3,500 calories! Ouch! To get rid of one pound of body fat requires using 3,500 calories out of storage. That wonít happen in a day. Weight takes time to put on and takes time to take off. A caloric deficit of 500 calories per day can mean losing one pound per week. To achieve this, it’s best to combine caloric restriction with an increase in energy expenditure through regular exercise.

Small dietary changes can make a difference over time. Giving up 150 calories per day saves you 54,750 calories per year! (150 calories is the amount of calories in either 1-ounce of regular potato chips, or 12 ounces of regular soda.) When cutting back on calories, be sure to eat a varied and well-balanced diet. You still need the recommended amount of vitamins and minerals. The food pyramid is one tool to assist you in following a balanced diet.

A suggested rate of weight loss is 1-2 pounds per week. Health benefits can be realized with even modest amounts of weight loss. Health experts recommend an initial weight loss goal of 5-10 percent of current weight. I usually advise women who are working on weight loss to eat at least 1,200 calories per day, and men who are limiting their diets to eat at least 1,400 calories per day.

Eating for non-hunger reasons

Sometimes people eat in response to situations or events other than hunger. Situational eating and emotional eating at times is normal, but if not kept in check can contribute to weight and health problems. Individual counseling, classes, workshops, and support groups may be valuable in breaking patterns that lead to overeating.

Behavior Change Tips

Identify what triggers ìnon-hungerî eating.
Create a strategy for making a change.
Predict challenges and devise a plan to overcome them.
Act on your plan.
Get support, if needed.
Evaluate your progress.
Don’t get discouraged, and donít give up!
Refine your plan, or make changes to your plan as needed.

100 Tips for Successful Weight Management

Set realistic goals.
Take it one day at a time.
Keep a food record.
Don’t use food as a reward.
Don’t eat on the run.
Take small bites and savor each bite before swallowing.
Don’t eat in the middle of the night (unless, of course, you’re experiencing hypoglycemia).
Make an appointment with a registered dietitian.
See a counselor about behavior change.
Make crafts instead of baked goods.
Ask your family and friends to be supportive of your weight loss efforts.
Use smaller plates, cups, bowls, and glasses.
Serve food from the stove and not from serving bowls at the table.
Set your fork down in-between bites.
Eat slowly.
If hungry, have a small, lowfat snack an hour before the meal to curb your appetite.
Drink a glass of water before each meal.
Drink a glass of water before each snack.
Limit sweets and desserts.
Don’t skip meals; it sets you up for overeating later.
Choose calorie-free beverages.
Don’t eat for emotional reasons such as anger, depression, or stress
Don’t shop for food when you’re hungry.
Don’t shop for food when you’re tired.
Don’t overeat at holidays or celebrations.
Be patient with yourself.
Choose smaller portions of high-calorie foods and larger portions of low-calorie foods.
Keep meat portions the size of the palm of your hand, up to twice a day.
Keep fat portions the size of your thumb for each meal.
Packaged snack foods should have less than 3 grams of fat per serving.
Use a measuring cup to measure reasonable portions.
Think positive thoughts.
Take a field trip to the grocery store to look for lower-fat, more healthful options.
Use lowfat cooking methods.
Choose lean meats.
Choose nonfat and lowfat dairy products.
Read food labels to compare calorie content and fat grams.
Limit fast food restaurant dining.
Eat vegetables at every meal.
Choose higher fiber foods.
Donít buy tempting foods.
Limit alcohol intake.
Let your friends and family know what your food needs are.
Include regular exercise in your life.
Take the skin off the chicken and turkey.
Don’t eat fried foods.
Start your meal with a broth-based vegetable soup (choose low sodium, if appropriate).
Bring a healthful snack along when traveling or away from home.
When at work, don’t eat at your desk.
Skip the butter, margarine, and mayo (or use nonfat/lowfat varieties).
Use diet soft drinks.
Share dessert when dining out.
Join a support group.
When served large portions, put half of your restaurant meal in a to-go bag before you eat.
Donít eat standing in front of the refrigerator.
Donít eat in front of the television.
Donít eat standing up.
Chew a piece of gum while preparing meals.
Brush and floss your teeth right after dinner.
Love and accept yourself.
Strive for five: eat at least five portions per day from the fruits and vegetable groups.
Reward yourself for making progress (but don’t use food as the reward).
Visualize yourself losing weight.
Don’t eat a larger portion just because itís a reduced-fat version.
Bring a healthful dish to parties so that you know there will be an appropriate choice available.
Drink at least 8-10 cups of fluid each day.
Weigh yourself first thing in the morning, but no more than once a week.
Snack on raw vegetables and fat-free dip.
Make a plan in advance for how you’ll handle a tempting situation.
Make a list of reasons why you want to lose weight and review it often.
Avoid fad diets.
Look for the words lowfat, nonfat, or fat-free on the package.
Divide your food evenly throughout the day; don’t eat heavy evening meals.
Donít go to sleep right after a meal.
Finish your meal with a walk instead of dessert.
Call a buddy when things get tough.
If you do eat a food that isn’t a good choice, limit the portion size.
If you feel like you’ve fallen off the wagon, get back on.
Don’t give up.
Pick up new hobbies.
Keep healthful snacks handy.
Plan your menus in advance.
Buy a lowfat cookbook.
Shop from a list; don’t impulse buy.
Package and freeze leftovers for future use.
Donít strive to be a member of the clean plate club.
Wait at least 15 minutes after you finish your meal to decide if you’ll have seconds.
Start your meal with a salad; use lowfat dressing.
Fill at least half of your dinner plate with vegetables.
Have fresh fruit for dessert.
Don’t skip breakfast.
Eat only when you’re truly hungry.
Stop eating when you’re satisfied.
Don’t arrive at a restaurant or party too hungry; have a small snack first.
Schedule main meals 4-6 hours apart.
Schedule snacks at least 2 hours after a main meal.
Use a small teaspoon to sample while you cook.
Politely refuse, rather than feel obligated to eat something you shouldn’t.
Ask the waiter which menu selections are low in fat.
If it’s a high-fat but favorite item, include it in small portions and infrequently.