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Friday
Oct142011

Glass Shards of Diabetes

When I heard Dr. Oz talk about what diabetes does to the body (synopsis below), it finally sank in what was happening (diabetes-wise) to my body as I ate and ate and ate some more, giving me my ponderous belly (“Buddha belly”) and I could visualize the internal damage I was surely causing myself when I ignored the disease that has killed several members of my family.

Gestational and regular Diabetes Mellitus (GDM/DM) have been an on-going discussion on my Navelgazing Midwife Facebook Page for the last few days. The conversation began with the vaginal, pain-med-free birth of this 13 pound, 11 ounce baby boy in England. When there are babies this huge in the news, I typically comment about undiagnosed GDM and then the rebuttals ensue. “I had an 11 pound baby and I didn’t have GDM!” or “Not everyone with a big baby has GDM.” And I end up explaining diabetes, over and over again, so I thought it was darn tootin’ time to explain myself here, offering a place to refer to because the discussion will continue coming up as our privileged cultures get fatter and fatter, and more and more women will be diagnosed with GDM/DM and our families, with DM, too.

Also, when this topic comes up, I get comments like this one:

“I have a huge family history of Type II DM, and I've had two 9+ babies. I'm a healthy weight, active, and eat a decent diet... but I feel like I'm just a ticking time bomb for DM!”

The last thing I want to do is scare the bejeezus out of anyone! What I do want to do is 1. Make my Self grasp the gravity of my own situation and 2. Encourage women (people) at risk to pay attention, not freak out.

So, as I said, Dr. Oz explained why diabetes is so devastating in a way, for the first time, that made so much sense. He had an animation that (in its most simplistic form) showed how a carbohydrate changes into a glucose molecule after we eat it and how the glucose (sugars) flow through our bodies, literally feeding our brains and muscles so they are able to function. He also showed how the pancreas sends out insulin receptors, scattering them throughout the body so they can metabolize the glucose for the brain and muscles to absorb, explaining they act almost like vacuums, the glucose zooming towards the insulin. However, when we eat more carbs/sugars than our bodies need, the pancreas can’t keep up with sending out enough insulin receptors and the glucose then zips around the body, causing damage and the extra calories make fat, especially fat around the middle of the body. This inability to keep up is the Insulin Resistance (IR) we’re hearing more and more about. The newest term is Impaired Glucose Tolerance (IGT), a description often called Prediabetes. Other forms of IR are Polycystic Ovary Syndrome (PCOS) and Metabolic Syndrome (MS). All of these are often used interchangeably, but do have nuances of differences that are better explained by the experts, not in this basic piece.

What is a part of this piece is that when I say “GDM,” I am lumping in all the different IR, PCOS, MS, etc. issues because they all go hand in hand, merely located on different parts of the same spectrum of pancreatic metabolic pregnancy disorders.

I know this part is boring as crap, but bear with me, the good stuff’s coming.

So, when we left the glucose, it was floating around looking for some insulin to metabolize it. Dr. Oz brilliantly describes the glucose (crystals) as glass shards that course through the body, slicing things as it wanders hither and yon. In our arteries, the shards make cuts and the artery then “bleeds”, forming a clot and then a scar when it heals. Over and over again, the shards cut, “bleed,” then scar, building up on each other. Sometimes the shard slices off a section of the scar tissue, making an even bigger spot that eventually scars and the part sliced off “floats” downstream, mashing up against another group of scars. Eventually, over time, the scar tissue... and other cholesterol thingies... have built up so much, it completely closes off the artery; arteriosclerosis, one of the major risks of diabetes.

This shard analogy explains a lot of the damage diabetes causes, from slicing the kidneys into eventual failure to causing eye damage, blinding the diabetic. However, I cannot, for the life of me, find why GDM causes stillbirths. As a midwife and as someone who discusses this topic so often, it frustrates me terribly not to know the exact biochemical/physical mechanisms between diabetes and babies being born still. All over everywhere, we can find that stillbirth is a potential complication of GDM, but I’ve scoured .org and medical journals looking for the specific piece of information I’m looking for. If someone out there can help, I would very much appreciate it –and I know others would, too.

This brings me to a point, actually, that we hear such and such is a risk of <fill in the blank> (stillbirth from diabetes, as an example), yet it isn’t explained why. I believe if we knew why complications happened, women would be more compliant; I know I would be.

Audit on Stillbirths in Women with Pregestational Type 1 Diabetes, found in Diabetes Care, written in 2003, is one of very few articles/studies I found that explains what happens to the fetus in utero and why he or she eventually dies:

Early as well as late suboptimal glycemic control may predispose to fetal distress, due to fetal hyperinsulinemia, acidosis, and hyperlacticemia, as maternal hyperglycemia and elevated HbA1c are risk factors for fetal asphyxia, possibly leading to intrauterine death.

And while this speaks about Type 1 diabetes, it does, absolutely, have a great deal to say about Type 2 during pregnancy; mainly, the better the glycemic control, the safer the baby.

(As an aside, I learned a new term: “neglectors.” In the same study, explaining the stillbirths goes this way:

The lack of fetal surveillance together with the lacking improvement in glycemic control during pregnancy, the high rate of smokers, and the low social status indicate that this group has limited compliance, corresponding to the term “neglectors” introduced by Mølsted-Pedersen and Pedersen in 1967.

I suspect today’s term is closer to “non-compliant.”)

Onward.

Large-for-Gestational-Age vs. Macrosomic

During these endless Net conversations (which I thoroughly enjoy, by the way), big-babies-as-a-genetic-factor butts up against the big-baby-because-of-undiagnosed-GDM. What is the difference and who gets to say which is which (or who is who)?

In the olden days, a large for gestational age (LGA) baby was different than a macrosomic baby, but in the literature now, I see the terms being used interchangeably; odd. This makes the distinction between the genetically large and macrosomic babies nearly impossible. But, I did find these two definitions, what I have been familiar with for many years.

Large for Gestational Age:

“Gestational age is a measure of the growth and development of the fetus in the uterus and the infant after birth. LGA refers to a fetus or infant who is larger than expected for the age and gender or with a birth weight above the 90th percentile. The measurement is based on the estimated gestational age of the fetus or infant, compared with what is considered normal height, weight, head size, and developmental level for a fetus or infant of the same age and gender.”

Macrosomic:

“One of the most important factors about macrosomia is the differential rate of growth of the fetal head, chest, and trunk as gestation proceeds, both in the babies of diabetic and of nondiabetic mothers. Until 36-38 weeks, the fetal head generally remains larger than the trunk. Between 36 and 40 weeks, however, the relative growth of the abdomen, chest, and shoulders begins to exceed that of the fetal head. This is especially the case in babies of diabetic mothers where glucose substrate levels are higher in both the mother and fetus. Thus both in prolonged gestation and in babies of diabetic mothers the size of a baby's trunk is likely to increase, increasing its chances of shoulder dystocia.”

I do agree there can be ten pound babies of six feet tall moms and that is likely enough to not be a macrosomic baby, but ten pound babies of  5’4” 200+ pound moms are a different story.

The basic point of this whole post is to say that just because a woman tests negative for GDM does not mean there aren’t other insulin-related issues at play… issues that can make for abnormally-sized babies and include the complications that come along with such babes. For those with IGT/Prediabetes, most will develop Type 2 Diabetes within ten years. I’ve also read there are ten to fifteen years before the Type 2 Diabetes diagnosis where pre-diabetes is taking a toll; one that, too often, includes pregnancy.

I met a woman just today whose first baby weighed eleven pounds and she’s post-dates with her second. When I mentioned glucose issues, she defensively told me she didn’t have GDM, but how can someone not be convinced there is some glucose/insulin issue at play? What are doctors and midwives not saying that lead moms to believe nothing is wrong? Do these women have to finally develop diabetes in order to retrospectively acknowledge their child’s size was, indeed, a giant wake-up call about their future health? That is exactly what I had to do after bragging about not being diabetic with a 10 pound 6 ounce baby; I might not have tested positive, but I positively had something glucose-related going on.

Why are there so few of us talking about this in the midwifery/natural birth community? I believe this is something we all need to work with. Don’t we want our mamas and babies to stay safe? Sweeping this issue under the rug is going to do nothing but cause more stillbirths, more shoulder dystocias and more diabetes for everyone. Let me tell you, first hand… diabetes SUCKS.

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Reader Comments (41)

My guess is damage to the placenta--did you look there? I did find several studies, but only this one applies so far
http://care.diabetesjournals.org/content/21/10/1753.full.pdf

October 14, 2011 | Unregistered CommenterJennifer Tow

This is a great explanation , thanks. Personally my wake up call was when my mother was diagnosed with type 2 and she gave me some books to read. Suddenly I realized the damage that I was doing to my body by binging on sugar and how our diet is actively contributing to this epidemic. Hopefully I am young enough to change my outcome. The signs are there- the nine pound baby, the fat around the middle etc.

October 14, 2011 | Unregistered CommenterSarah T.

Would you recommend that all pregnant women follow the GDM diet? Are there certain women who should follow it even if they don't test positive?

October 14, 2011 | Unregistered CommenterJamie

I'm not sure I would trust Dr. Oz to give unbiased, evidence-based information.
http://scientopia.org/blogs/whitecoatunderground/2011/02/24/dr-oz-youre-not-helping-diabetics/

http://www.sciencebasedmedicine.org/index.php/dr-oz-once-the-learner-now-the-master-of-woo/

http://scienceblogs.com/pharyngula/2011/09/dr_oz_crosses_the_line.php

October 15, 2011 | Unregistered CommenterQoB

This is so, so important. I was diagnosed with GDM (no surprise, as I have pcos and am/was quite overweight.) i had daily insulin injections from 30 weeks on. My son was born at 38w0d (induced) at 8 lbs 3 oz. Not huge or macrocosmic, but perhaps getting there. I did have IV fluids, though, so that may have added a few ounces. Regardless, I remember being so thankful that he wasn't bigger.

It was a heck of a wake up call. I was killing myself and my baby when I picked up a fork. I immediately started eating very few carbs - I went from eating tons of fast food, donuts, cookies, etc to having a plain chicken breast for dinner with some cottage cheese as a side.

I don't think people realize that huge babies aren't always healthy and can have correspondingly huge problems. Maybe not now, but down the road.

Since delivery, my sugars have looked okay, but it's not enough. I've lost 36 pounds and need to lose 60 more. (I also feel better than I have in a l o n g time!!!) One day at a time, right??

October 15, 2011 | Unregistered CommenterM. L.

Another brilliant post. There is so much psychology surrounding diabetes which I think plays a large part. In my own practice I most commonly see 2 types of diabetic women.

There is the woman who never tests & says 'i'm not going to let diabetes control me' - she throws frequent hypos & also often wakes up with BM's in the 18's - 20's. She feels generally dreadful & has probably had as a stillbirth/macrosomic baby/baby with heart defects. She is obese & her life is controlled by her diabetes.

Then there is the woman who tests throughout the day & says 'I will not be controlled or defined by diabetes.' She controls her sugars, has the occasional hypo & has a healthy baby.

What is the issue with women & compliance or whatever you want to call it?

October 15, 2011 | Unregistered CommenterLiz

My 6th and last baby was born at 10lbs 7oz. I fully admit now that I had Gestational diabetes. It's a long drawn out story, but I have had 5 home births, and none of my midwives have ever tested me for GD. Most of them figured that my urine would be off if I had it so we didn't bother.....I just naturally was prone to having big babies.

My last baby fit your description to a T. He was barel chested he had a 13in head and a 15in chest. It took two midwives to help manuver him out. He seemed fine after birth but several hours later he started breathing rapidly and wasn't nursing well at all. We took him into the ER and were admitted for 3 days while they did a septic workup on him. Looking back now, I am positive that he was suffering breathing difficulties because of my uncontrolled GD. Eventually he was discharged with a diagnosis of TTN.....but I alone know the truth.

I spoke with my midwife after the birth and asked her if she thought I was too much of a risk now for a HB, but she told me she would attend me at home again. That has caused me to reflect deeply on the safety of homebirth. I know that I would not feel safe delivering at home again, and it really causes me concern that the one person who is supposed to be assessing that risk(my midwife) doesn't see that I would not be a good candidate for HB again. (6+ pregnancies, large birthweight babies, and a history of PPH, and GD) it's all irrelevant now though because my husband and I decided we are done.

Anyway, thank you Barb for being the voice of reason in the crowd. I have had to do a lot of deprograming of myself to get to these conclusions. It has been wonderful to hear you say the things that are echoing quietly in the back of my mind.

October 15, 2011 | Unregistered CommenterC

Proud of my CNM. She didn't mess around with me. I only had a baby who was 8 lbs 5.9 oz, but that was not the norm for me. Mine are anywhere from 6 lbs 11 oz to 7 lbs 13 oz. This last baby was almost a full pound bigger out of nowhere. I was 39 and weighed 240 lbs at her birth at my short 5ft5in. I also fail those initial glucose tests and have to take the 3 hour, which I pass. Last time I had LOW sugar. It was an odd curve, I started out with a normal number in the 1st hour, but instead of raising like I see is normal it lowered and lowered until it was 42 in the last draw. This made my doctor declare she was sorry she had me retest (because my initial test was borderline). But the midwife wisely said, "those numbers show something is wrong with your insulin production somewhere...eat the diabetic diet and exercise this time." I appreciate her caution. Before, I would have doubted her and questioned her and been angry with her. Now though I heed her warning. I wish I were more careful with my eating, I'm trying. It' s almost like I'm a teenager...tell me to watch my sugars and it makes me want them MORE! But walking, I am doing well with. I hope I can just be careful enough to help my baby and to help the future me not get diabetes...

October 15, 2011 | Unregistered CommenterDawn

Yes! I think the diabetic diet is great for Everywoman, not just women diagnosed with GDM or who has a history of LGA/macrosomic babies. It's great for me, too, and I'm not even pregnant.

Since Meghann (my daughter) had her super-sized (9lbs 10oz) first baby, I've been forced to look at this issue very closely... again. Including my own issues with compliance. When I got home from San Antonio, my doctor was very unhappy with my BGs and wanted to start me on insulin. I immediately stopped eating the massive amounts of Starbursts and my glucoses went down to the normal range; insulin averted for the moment.

I have been eating *strict* diabetic diet for 2 weeks now and I have not had ONE CRAVING for Starbursts (or any other contraband). I am eating every 2 hours, something small, counting Exchanges, and am losing belly girth at a rate that surprises even me. I weigh on Mondays and, yes, I have started and stopped this dozens of times, but I can't keep failing. I have a grandbaby to watch grow up! So, for me, weight is ancillary; my BGs are the real gauge. My daily average BG since 2 weeks ago is 101. I am REALLY proud of myself.

And, for crying in a bucket. How can I preach compliance and not be myself. Hypocrite is not a cloak I enjoy wearing.

Re: Dr. Oz. I did not quote him as an expert in anything but a great description of something I didn't understand previously. I'm aware he might not be the Scientist of the Year, but that wasn't why I used his video.

October 15, 2011 | Registered CommenterNavelgazing Midwife

Barb, did Meghann have any glucose issues? Did y'all expect such a big baby?

October 15, 2011 | Unregistered CommenterM. L.

Not diagnosed, but I asked that a HgbA1c be drawn when labor labs were drawn; don't know what it was yet (postpartum appt. is next week). I'm encouraging Meghann to be tested for Type 2 when she goes next week. Not sure if she will yet or not.

I saw the baby growing and knew something was going on from that first u/s at 23 weeks and the baby looked like a 30+ weeker. She measured LGA for weeks at the end. When she was at the end of labor, and then being wheeled into the OR, there were guesses about the baby's size. Not even the OB was close at 8+ pounds. I said Gabriella was at least 9 1/2 pounds and was right... she was 9lbs 10oz.

Meghann was 10lbs. 6oz. and I tested negative for GDM then... oh, so arrogantly bragging about it for many years. I'm sad I set my daughter up for her macrosomic baby 27 years later. Very sad.

October 15, 2011 | Registered CommenterNavelgazing Midwife

Barb- I'm confused about something though. Baby Gabby appears to just be a big baby right? She gained lots of weight after birth as well and is quite chubbily-wubbily. Is it possible she's just a bigger person, but not necessarily in an unhealthy way?
How do we determine the difference between 9+ pounds = insulin issues vs. 9+ pounds = genetically bigger?
Also, do you have a link to a good GD diet overview? I'm sorta familiar with the diet, but could use better parameters.
Thanks

October 15, 2011 | Unregistered CommenterJamie

:( I'm so sorry. (((hugs))) Honestly, I wondered if Meghann had PCOS when I saw some of the pics you posted on the NgM Facebook page. This is not in any way criticism - I just noticed some small things similar to what I have with it.

We know so much more now about glucose and the importance of identifying women with pre-diabetes than we did even ten years ago or so. It's quite amazing. What bothers me to no end is the dismissal of GD that I've observed in the natural birth community. Henci Goer has a piece on it that blows my mind - it's flat-out dangerous misinformation.

In addition, common perceptions about nutrition are often so wrong as to be frightening. All the low fat stuff out there makes blood sugar issues worse!!! When I started the diet for GD, I did enjoy all the full-fat salad dressings (which help increase nutrient absorption too!) It's SO HARD to get away from the standard American diet .... But there's no choice anymore for those of us facing insulin issues.

October 15, 2011 | Unregistered CommenterM. L.

Thank you so much for addressing this so well! I've been a nurse for many years and yet have stayed overweight much of my adult life...KNOWING all the while what was going on. It's pointless to ignore the problems caused by diet, weight, and insulin resistance. They just have to be addressed! My kiddos were 8 lb 6 oz, 10 lb 1 oz, and 9 lb 10 oz at birth. All of us were very healthy at and after birth, and I always tested negative for GDM. Interestingly enough, for my first I was 180 at conception, and with both my second and third I was 200 at conception (I'm 5'4" tall). With my third I made a conscious effort to eat much better than I did with my second. Point here is, I could guarantee you, beyond the shadow of a doubt, that insulin resistance played a roll in my kid's birthweights.

As an aside, I cut sugar from my diet completely, in every form (including natural sugars like honey and agave nectar). I haven't missed it, honestly. I still eat fruit in moderation. The other day I had a small mango-banana-strawberry-carrot juice smoothie from Jamba Juice for the first time in nearly a month. HOLY COW. Talk about sugar demons! My body felt terrible, and it sent me on an all-out junk food craving fit! Thankfully I abstained, but it was amazing to me how large amounts of even NATURAL sugar affected my body so strongly. I would have never noticed that intense reaction had I not spent the last month working on resolving my insulin resistance.

I'm looking forward to my next pregnancy. I hope to weigh significantly less, eat an excellent diet, and stay fit up to the end of my pregnancy. We'll see how that goes. :)

October 15, 2011 | Unregistered CommenterJessica D.

Gabby, absolutely, was macrosomic. In fact, I had Meghann, in her dazed state, *feel* the fat she had on her, the brown fat in particular on the base of the back of her neck... and the fat on her arms and trunk... to remember what macrosomic felt like. It's *very* different from a typical LGA baby.

I recently told Meghann how incredibly worried I was as I saw the baby grow and grow during the pregnancy, how I couldn't get the picture of a deadly shoulder dystocia out of my mind. I'm totally able to walk into births with a clean mind... and did... but you could almost hear my audible sigh of relief when Meghann chose to have a cesarean instead of stressing the baby out more with an unproductive labor. As it was, even the c/s was challenging because the torso was so large; the midwife had to do some serious fundal pressure to birth that torso. When she told me that (the CNM), I wept with relief that my vision had not come to fruition.

I'll find the diet info I've been using and post it here, but know that ALL the info isn't even on one site, which is rather stupid, in my opinion. You'd think the ADA would have a great page explaining everything, but the info is so incredibly basic, it frustrated me no end to figure out what I really needed to do to keep myself safe and eating right.

October 15, 2011 | Registered CommenterNavelgazing Midwife

That must have been terrifying - I can't imagine the fear!

October 15, 2011 | Unregistered CommenterM. L.

I do agree there can be ten pound babies of six feet tall moms and that is likely enough to not be a macrosomic baby, but ten pound babies of 5’4” 200+ pound moms are a different story.

Asking in a completely sincere way, as this has interested me for some time and I have never gotten good data on it-- what evidence is there to strongly suggest that adult height of either parent has any significant bearing on the size of a child at birth (assuming term)? Also, related (not as much to your post, but generally)-- what evidence is there to suggest that the size of a baby at term predicts that baby's future adult height or "build?" How strong are those correlations?

I am, of course, not an idiot-- I understand why it would be conventional wisdom (whether or not "true") to believe that these things have strong correlations, even if there is no scientific evidence to back it up. But I am wondering if there is any (studies, etc.), and if so, what it is.

October 15, 2011 | Unregistered CommenterDreamy

Another great entry, I love your blog!

I tested negative during my third pregnancy; my son was a term baby at 9lbs 7oz with a 15 inch head (had the nickname ET for a while) which was quite a task to push out my 5'3" body-things have never been the same since, if you know what I mean... At 195 pounds, I was the heaviest I've ever been before he was born. He was hypoglycemic and I had to fight like hell to keep them from shoving the bottle of glucose water in his mouth. He also ended up under bili lights on top of it. But what a nursling he was! Despite all that he fed like a champ, was off the growth charts, nursed til he was almost three and grew into a huge kid until he started school which was when his weight and height seemed to normalize. He's now 22, 6'2.5" and on the thin side, though I've seen the tendency for him to gain weight at times.

My question is, has anyone had the experience of getting full blown Type II DM after GD? This is something I've been worried about as I have Type II in my family. My grandma's last baby was almost 10 pounds and she ended up being diagnosed with DM later in life but this was after my aunt was born.

October 15, 2011 | Unregistered CommenterPam

Pam: 5-12% (depending on who you read) of GDM moms will STAY Type 2 DM after the pregnancy. The standard of care (which I actually didn't know) is to test ALL post-GDM moms at 6-12 weeks postpartum with either the 75g load, one hour OR the 100g, 3 hour GTT (again, depending on who you read). *Also*, on top of those women, another 50% of women will develop Type 2 Diabetes within 5-10 years after having their first GDM baby.

So, yes, you are absolutely at risk. You are at risk: because you have a family member with Type 2 DM and because you had a baby over 9 pounds... and it sounds like you *did* have GDM, even if it was undiagnosed (sounds like you are saying that, right?), so you have several risk factors going.

Therefore, it behooves us (myself included) to EAT like we have Type 2, even if we've not been diagnosed with Type 2 (which I have, however) and exercise like we have DM so we can 1) either keep it at bay or 2) if we DO need meds (as even the most meticulous diabetic possibly can), they will be fewer than we might otherwise have needed.

October 16, 2011 | Registered CommenterNavelgazing Midwife

It is such a difficult issue. I had diagnosed GDM (well-controlled with diet) with my 3rd baby and she was 9 lbs. 10oz. With my fourth, I was "clear,' but he was 10 lbs. 6 oz. -- and a mild shoulder dystocia. I also weighed at least 250, but I was following a diabetic diet, despite the lack of "official" diagnosis. (The CNM handled things very well with the dystocia, BTW, and it resolved within a couple of minutes.) He was definitely the most barrel-chested of my children, but he didn't get the macrosomic label. Since then, like Jamie, I have given up all forms of sugar (except for whole fruit). And flour. And wheat. I lost 90 pounds. Now, with my 5th pregnancy at age 44, I'm am the "smallest" I have ever been while pregnant, but I'm still "measuring big." I went straight to the 3-hour glucose test, and I came up completely clear. But I've got the family history and personal history that worries me. I'm a little nervous about another dystocia. NGM, I'm sorry for your struggles with diabetes. To be honest, it was the trouble I saw with overweight women who were just a bit older than me (through my work with the Chicago-area-based nonprofit we have both been involved with) in addition to the dystocia that got me to completely give up the sugar. It concerns me that what the ADA recommends is pretty liberal -- it's as though they don't think people will comply, so why even try. I really believe that diabetics *need* to give up processed carbs -- to save their lives. The surprising part is that I no longer have any cravings for sugar, which I could never have imagined.

October 16, 2011 | Unregistered CommenterKathleen

This is a very interesting discussion as I now find myself pregnant with my 4th. I am 6 feet tall and 280lbs. My first two kiddos were c-sections (breech and FTP/malpositioned baby). They were 8lbs 3 oz (36 weeks) and 9lbs 15oz (term). My third, a vba2c, was 12lbs even. Looking back, I had something going on, even though I passed the 3hour gtt. I crossed into type II about 1 year after her birth. I have big babies, genetics playing a factor. But 12 lbs was WOW. She had fat across the bridge of her nose even! I don't want that again, which is why I am being crazy careful with my numbers. But I am still scared. Even though this baby was unplanned, he/she is still very much wanted and I want a healthy baby (and a healthy mama too). I have my first ob appointment tuesday and wondering what the hell I have gotten myself into. ;-)

October 16, 2011 | Unregistered CommenterVicki

Okay. So I don't want to get jumped on as someone who dismisses GD, insulin resistance, and all the attendant risks. I believe they are real.

However ...

I had a co-worker who was diagnosed with borderline GD and followed the diet very strictly. She was thin and in great shape when she started her pregnancy and had very reasonable weight gain (30 pounds by the end). She was constantly being told, based on U/S, that her baby was HUGE, and she might not be able to have a vaginal birth. Starting at around 28 weeks, she was told he was measuring four to six weeks ahead in size and that his head was in the 95th percentile. She had horrible headaches from low blood sugar the entire time she was on the GD diet.

She was induced three days past her due date for suspected big baby and postdates concerns related to GD. She had a 7 lb. baby with a normal head circumference.

I understand that the baby's birth weight could indicate that her GD diet was successful. However, it's hard for me to look at how miserable she was (again - it wasn't that she couldn't eat what she wanted - it was debilitating headaches from low blood sugar), the anxiety she suffered by constantly being told she would never be able to birth her baby, the fact that she was just barely over the line on the 3-hour test, and think that she was well served by that test or that diet (or those ultrasounds).

Obviously, there is no way to know what would have happened if she had done something else. Maybe she would have had a 10 lb. still baby. I certainly didn't interject myself and tell her not to follow her doctor's advice.

But ... I guess my question is ... what about women like her?

October 17, 2011 | Unregistered Commenterchingona

1. If she did have GDM, her BGs were not managed very well. Hypos are very dangerous, too.
2. Interesting her sonos were so off, but they ARE +/- 2 pounds at term. It'd be interesting to know if she had the same sonographer each time, which would account for the continuous off-ness.
3. I'd love to know how big her placenta was and *where* it was to see if that was part of her measuring big.
4. I'd love to know if she was on meds, too, which could totally account for the hypos.
5. There are FARRRRRRRRRRRRRRRRRR more UN-diagnosed GDM than there are erroneous diagnosed GDM and there, by the odds, *have* to be erroneously diagnosed women.
6. I'm sorry she had to be induced; that had to have been incredibly frustrating/angering to her when the baby came out.
7. It's true. Even professionals make mistakes.
8. If I was going to err, it would be on the side of caution... and the Diabetic Diet really, really should NOT be the cause of so many hypos. The diet includes eating every 2 hours and if you test low, you eat more. I can't help but feel her counseling is where things may have gone wrong. Hard to say without her chart, though.

October 17, 2011 | Registered CommenterNavelgazing Midwife

Where can find info about the diabetic diet? Both of my babies were macrocosmic, and I have signs of insulin resistance, but haven't tested positive for diabetes. I'd like to change my diet and exercise for my health.

October 17, 2011 | Unregistered CommenterRebecca

I don't know what her counseling was like, but I usually saw her eating at her desk throughout the day, so I know she was snacking. She took regular blood sugars and showed them to her doctor at weekly appointments. They were the ones who suggested her headaches were from her sugars, but she was never told to make any adjustments to her diet. I don't think she was on medication, but I'm not sure. She did come out of the whole thing rather bitter toward her doctors. She put a lot of trust in them and did everything they told her to do to keep her baby safe.

I know you've mentioned doing a days worth of sugars rather than the 1 and 3 hour tests. Would those be better at catching false positives as well as people with IR issues that slip through the 1- and 3-hour tests?

I understand why this matters so much, but you seem really intent on sweeping everyone up in the same net.

October 17, 2011 | Unregistered Commenterchingona

I have a lot to say about diabetes. I have type 1 (developed it as an adult after the birth of my first daughter) and have educated myself on the disease.

Basically, it's the High to Low bloodsugar that can cause a stillborn baby.

My story: when I was 28 weeks pregnant with my daughter, 8 years ago, I took the GTT. I almost told my doctor that inwanted to skip it since I was 25 and healthy weight. Nothing close to over weight. No family history of diabetes. Well, the day after the test the doctors office called and sent me to a specialist. My one hour test came back at 385. I did not understand what that meant at the time.

I was told I had to follow a strict diet and take insulin injections 4 times a day. I was also told to test my blood sugar 7 times a day. I was shocked. I delivered a 5 pound 12 oz baby at 38.5 weeks.


2 weeks PP I was given another GTT and told everything was fine. This was done at the same perinatologist office. I was nursing around the clock and followed the same diet for 2 years.

When my daughter turned 2 I became very ill. I dropped 10 pounds in a month and became crazy thirsty. My husband urged me to test my bloodsugar and it was 400! I drove myself to the ER where they tried to tell me that I had type 2 just because I had "gestational diabetes". Insert shock on my end. I was 120 pounds. They asked me if I wanted insulin! They treated me very poorly.

The following day I saw another bad general practioner who also tried to tell me I had type 2 and put me on a horrible insulin concoction. I was miserable. Finally, I called the Diabetes and Glandular Clinic here in San Antonio, and saw an endocrinologist. He did some different tests and it came back that I have type 1 diabetes and was no longer making insulin.

I have now been on an insulin pump and never had an a1c about 7.1. I stay around 6.2. I have had 2 more girls and I am 18 weeks pregnant with another baby. My control is so tight that during delivery I need no insulin.

I have such a wonderful OB who trusts me because I have proven that I take my health seriously. I get few lectures about an occasional high reading. ;) I know more about diabetes than most of the general population.

Anything blood sugar over 120 sends the extra glucose to the baby. The baby had a properly working pancreas and uses the extra insulin to get big. Too big. Also, the placenta causes diabetics to take more and more insulin because it causes insulin resistance in the mother.

I hope this makes sense. ;)

October 17, 2011 | Unregistered CommenterAnnie

I think part of the problem is that the "diabetic" diet is so hard to follow. Research has now proven that saturated fat DOES NOT cause heart disease, yet everyone- even diabetics- are told not to eat it. Diabetes DOES cause heart disease, because it's linked to- tada- glucose issues, not cholesterol, as previously thought. However, this is such dogma that diabetics are now told not to eat fat OR sugar- and who can live like that?

I have been following a WAPF diet (loosely) for the past year, and have seen great results. I eat butter, whole milk, cheese, and plenty of grass-fed protein and seafood and veggies. Minimal fruit and almost no grains. I definitely think that everyone should eat like this and if they did, diabetes would not nearly be the problem that it is today. I'm 19 weeks pregnant, also, and am curious what the size of this baby will be.

Also, the test for GDM is so flawed that really there are a lot of false positives, and a lot of women make it through who really do have insulin resistance issues. I think women should be screened based on family history and body type, along with other factors such as diet and lifestyle.

October 17, 2011 | Unregistered Commentersara r.

I just want to thank you again for bringing this issue to the attention of moms like me. It's how I found your blog at the beginning of my fourth pregnancy (2nd with GD) and helped me stay on track to an 8 lb baby (vs the 10 pounder I had with uncontrolled insulin resistance.)

Keep up the good work!

October 17, 2011 | Unregistered CommenterMeredith

good article, barb, although I'm not sure what *exact* pathophys you are looking for in diabetes-->stillbirth? you've lined them all up here. diabetes predisposes the baby to many risk factors in a variety of different ways, all kind of boiling down to 'bad' nutrient transfer to the baby - i.e., uteroplacental transfusion - and hormonal cascades resulting from maternal hyperglycemia and insulin production. So it's not one in particular thing with GDM that increases the stillbirth rate but all of the stuff that GDM can do to a baby can put too much strain on the fetus, who ultimately is inadequately nourished by the placenta, and any of the resulting scenarios in and of themselves increase the rate of stillbirth. Make sense?

The GDM testing *is* flawed as mentioned above. Pregnant women to have higher blood sugars than non-pregnant women once the placenta kicks in with all of it's insulin-blocking hormones. And it's true that some mom's bodies (and some babies' placentas) can be more predisposed to these things and other. But I also think that big babies usually do have some blood sugar "issues", even if it's a routine divulgence in sweets and ice cream and a particularly sensitive mom/baby.

I think we should do more random blood glucose levels, and glucose levels after a carb or sweet treat that the mom might normally have to help her guide food choices. The need to cut out or severely limit milk, ice cream and juice/sweet beverages is probably the biggest factor in mamas that are making all of the other 'right' choices in their diet, IMHO.

October 18, 2011 | Unregistered CommenterL&D RN

oh yes - and also as mentioned by @Annie - and this is basically falls into the hormonal cascade from abnormal insulin production - the hypoglycemic dips that happen can reak havoc on a fetus. hypoglycemia = starving brain. you know, not good for a fetus :)

October 18, 2011 | Unregistered CommenterL&D RN

Barb, some years ago I spent a lot of time in the medical library trying to find the origin of the GDM-stillbirth link. Not to mention a host of other complications frequently listed...thrombocytopenia etc. Those lists went back to O'Sullivan's original article and were quoted and requoted in subsequent studies. My readings led to the conclusion that GDM increases risk of SD thus increases risk of permanent neurologic injury mainly Erb's palsies. That is why we screen, to avoid SD and the risk of Erb's. Now it has been 15 years since that search, but I am not aware of research showing GDM-stillbirth link. I could be wrong. If you find it let us know.

October 18, 2011 | Unregistered CommenterMadonna Lactans

NGM, have you watched the movie "Fat Head"? Usually available on Hulu and Netflix. Gives great explanations of the effects of sugars/carbs on the body. You might be interested.

October 19, 2011 | Unregistered CommenterDenise

I'll look for it, Denise... thanks!

October 19, 2011 | Registered CommenterNavelgazing Midwife

ETA, it starts out a bit hokey, but stick with it....

October 19, 2011 | Unregistered CommenterDenise

What are your thoughts on routine testing for Gestational Diabetes? With my first pregnancy I got the test at 28 weeks and it came up normal, not even borderline. After a couple of weeks I started feeling like my blood sugar wasn't 'right', and within a week gained some weight suddenly. I bought a glucose monitor, and adjusted my eating to maintain normal blood sugar, and was fine from that point. For my second I skipped the 28 week test and went directly to monitoring, and except for a day here and there I was able to manage very well, and avoided the spikes.

I just feel like instead of relying on a single test routinely done, women could be better served with more education, and encouraged to monitor for awhile. I was never diagnosed with GD but if I had just stopped at the one test and never thought more about it my baby and body would have suffered.

October 20, 2011 | Unregistered CommenterJkruger

Thanks for the information. I follow along on FB when discussing this issue as well, since my 6mth. old was born 11lb. 14oz. I've never really thought much about it, other than the total shock when we weighed him. My levels were always well within normal, I am almost six feet tall, pre-pregnancy weight of 130, no family history of diabetes, etc. His head was not abnormally large, but his chest seemed fairly wide...although, to be fair, he's quite long also. He was also my easiest baby to give birth to. He took FOREVER to come out all the way (in water, breathing with the occasional push), but he's the only one who didn't result in a tear.
Anyway, I appreciate being able to delve deeper into these issues and analyze myself/my babies as well as having the information for future mamas.

October 22, 2011 | Unregistered CommenterSummer

I find this all very interesting and if I have more babies (or get back into direct birth work) will have to study further. I have very, very difficult pregnancies due to nausea and as result struggle to gain weight. I am 5'4" and generally begin my pregnancies at around 105lbs. Over there years I've been more or less healthy at that weight. My first a couple of pregnancies I ate very much the SAD and by my last pregnancy 4 yrs ago was eating a modified Weston Price type with no gluten and almost no refined sugars. My first and third pregnancies I did the standard 1 hr GTT with no issues. Pregnancies 4-6 were with a homebirth midwife who relied on urine testing which also showed no issues. Second pregnancy ended in a stillbirth due to hydrops prior to the GTT.

My first two living babies were 7'13 and 7'11 respectively - both induced a couple of days after their due date for no other reason than my and the HCP impatience. My first pregnancy with my midwife she really worked with me on getting my weight up (because I started under weight) but with the nausea and my evolving diet learning I didn't pull it off and gave birth 2 wks early to an 8lb baby with a GA of almost 37 wks and a rather unhealthy looking placenta. The next pregnancy I ate better, gained more weight (about 38lbs) and gave birth 10 days past my due date to an 9'14 with a GA of 40 wks (barely child was covered in vernix). The last pregnancy struggled again with weight gain (31 lbs iirc) and gave birth 3 days after my due date to an 8'4 baby with a GA of 39 wks. I am quite sure of the dates of each of my last 4 pregnancies.

So.... I don't know what to make of myself. It seems that I need a bit longer to cook babies to get them to 40 wks GA. I didn't have much trouble birthing the almost 10 lber - he took about 20 minutes of pushing which is long for me as usually they come out in less than 5, and I felt a lot more exhausted after his birth, but nothing that I can complain about. He also needed a bit more support to maneuver his shoulder but did not get stuck. Also he does have some muscle tone issues now which one could argue might be related to some struggle during the birth process but we were not aware of it at the time (midwife arrived as I began pushing - I tend to commit to being in labor late).

So... It is difficult given all of that to believe I have GDM issues and I generally follow a diet fairly close to a GDM diet anyway - but I'm open and frankly curious about a little Monday morning quarterbacking on the topic.

November 13, 2011 | Unregistered Commenterjessica

Random comment, not necessarily about your case, Jessica.

Not all women with GDM are fat. Not all women with insulin issues have GDM. Women with insulin issues may have passed their GTT with flying colors.

I would LOVE to see the HgbA1c become a standard test in the prenatal panel and during delivery. I think it might help us have more information than we have now about this issue.

November 13, 2011 | Registered CommenterNavelgazing Midwife

If we do have another baby I may just do that :). I am not opposed to non-invasive testing (and for me blood tests are relatively non-invasive) as long as I maintain autonomy over my care choices. As always than you for the information and thought provoking discussion.

November 13, 2011 | Unregistered Commenterjessica

I hate to drag up an old discussion, but I am pregnant with my third and I'm now sitting here paralyzed in fear. I'm tiny. 5'2 (at most), and pre-kids I was 110lbs on a bad week. I shot up to a smidgen over 150lbs with my first, but I had HIGH stress levels, so I might have eaten to compensate. The doctor assured me that he felt normal. When I gave birth 48 hrs later, we were all shocked with his size. He was incredibly muscular (very little fat), he was long, and he weighed in at 9lbs 2.5oz. I had a hard time getting him out so forceps were used, but he had no damage. I however had 3rd degree tearing. I also had an epidural though, I think I blame it and my lack of control over the delivery than his size though. I was shocked with his size. I was the heaviest in my family weighing in at 8lbs 8oz and I was almost 2 weeks overdue. So this 9 pounder was a bit of a shock. I never had any highs or lows through the pregnancy. Just back pain. I was back in my size 0s by 3 months PP without really changing my diet or exercise routine.

My second pregnancy I started out heavier (I was coming down off an antidepressant). I was about 136lbs at conception and shot up to 197lbs at birth. I had terrible edema that came and went. But, the majority of my weight was gained during the last 3 months that corresponded with my Pelvic Girdle Pain/SPD that rendered me essentially immobile. So, eating + no exercise or movement = weight gain. I also got very very very little sleep with the amount of pain I remained in at night. My son was born 1 week early weighing in at 9lbs 5oz and was 24.5" long. He too was long and lanky with very little fat. He just looked like an older baby. Again, epidural, again assisted birth with a vacuum, but he had no damage. He did however score a 6 or a 7 on his APGAR so they took him to the nursery to be sure, and he was fine. He did have a blood sugar problem (I can't remember if it was low or high) but I was in SOOO much pain even before the epidural wore off (thanks SPD), I'm not even sure I was totally with it to nurse him properly. They cleared his blood sugar within the first 24hrs (after I got a few meals and developed a nursing rythym with my son and a little sleep.. after 72hrs + of being awake). They were fine with sending us home at the 24 hr mark because I was an experienced mom and I knew what to watch for.

Now, here I sit. I've been battling my weight since I had him. I have gotten more lax, or lazy, and I have become kind of sheltered. I don't want to take the kids to the park. It's always too hot or too cold.. or there is something that stops me from wanting to get out and walk or any of the things I used to enjoy doing. At the beginning of last year I was exercising and I finally got under the 140lb mark. Some personal and family stress ALL year led to that going out the window quickly. I shot back up to 150lbs and that's where I've stayed until this pregnancy. I'm 15 weeks now and I'm 155lbs. I LOVE sugar. Cookies, sweet tea, chocolate, everything. I always have. I think I'm kind of addicted to it all. But now I'm sitting here scared. I always thought I just had big babies. My dad was just diagnosed with TypeII diabetes and his brother died from it a few years ago. My dad has been overweight for years and years. It came as no surprise. But, now what about me?? I feel like I suddenly have a bullseye on my forehead. I'm scared. I'm scared that I could be harming myself, my baby, and most of all, how I can possibly eat bland food? I like spices and sauces and flavour. I also dislike a lot of things depending on texture. Diets fail with me quite quickly because of my love of food.

Thank you for this information. I will try to do what I can to change. I just kind of want to cry because I seemingly HAVE to.. not just want to:(

January 9, 2012 | Unregistered CommenterCrystal

Thank you for this. I was recently diagnosed with GDM and I too was defensive because I missed passing by a very few points, am a very normal, small weight, have gained slightly less than my target for this stage, eat very healthy, and have had ALL normal fasting and postprandials since being diagnosed. But now I understand that it is the monitoring that is important, not the diagnosis, so that my baby and I can remain healthy. Thank you!

August 1, 2012 | Unregistered CommenterYvette

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