I recently took a phone call from a 31-year-old woman in New Jersey looking for the help of a registered dietitian. She told me she was 17 weeks pregnant with her second child and was “gaining excess weight” which resulted in her midwife referring her to me. Due to my recent relocation from New Jersey to Raleigh, North Carolina, I told her I was not able to see her in person yet was happy to help her over the phone.
Since she stated she preferred to see an in-network provider in New Jersey in order to use her benefits, I contemplated simply giving her the name of another dietitian I knew might be in her plan. However, rather than just sending her on her way I took a few minutes to find out more about her needs to see if I could be of some help.
As we chatted, she shared with me that her first baby weighed 9 lbs 3 oz, adding matter-of-factly that “large babies run in my family.” She also admitted that she was “always hungry” and therefore was eating more than she should. I use the word “admitted” because I detected in her the sentiment “that she knew better but couldn’t help herself.”
Knowing that excess hunger along with excess weight gain can signal insulin resistance, I suggested that she could be at risk for gestational diabetes; her relaxed tone immediately changed to one guarded and slightly defensive. “I did fine on my test with my first pregnancy” she assured me adding, “my midwife and doctor say my blood sugar is normal.”
I quickly reassured her that she and her baby were just fine, and that I was just being cautious to make sure she did not become at risk for gestational diabetes (GDM). Appropriate intervention early in a pregnancy could prevent the very real possibility that gestational prediabetes (a conceptual term introduced in 2010 by Ray, Berger, Lipscombe and Sermer of Mt. Sinai Hospital in Toronto) progresses to gestational diabetes. These obstetrical researchers point out that not only is rapid weight gain an indicator, but also high serum insulin concentrations in the first half of pregnancy, independent of body mass index. In fact, elevated fasting insulin can positively predict GDM in 9 out of 10 cases, making measuring fasting insulin levels in early pregnancy a possible diagnostic tool.
Of course I can’t diagnose gestational diabetes over the phone, but my clinical intuition and knowledge of the progressive nature of all forms of diabetes would not allow me to keep this possibility to myself. I wanted to ask her to test her blood sugar after meals, not just to rely on the fasting or random glucose numbers she was having checked at her appointments. This is another way a pregnant woman can get an early indication of a possible blood sugar control problem.
A third way to get a indication if gestational diabetes could become a problem is to get your HbA1c level checked in early pregnancy. In a study of 500 pregnant women between 24 and 28 weeks gestation, half of those with an HbA1c above 5.3% were confirmed to have GDM through an oral glucose tolerance test (OGTT). An OGTT is still the gold standard, but since HbA1c gives an indication of the past 2-3 months of average blood glucose levels, adding it to your blood tests can provide an early warning or alternatively, help assure you that you are on a good track with your diet and exercise.
But giving this advice would be beyond what I could advise during an introductory phone conversation. The best I could do to help her was to recommend a good book on gestational diabetes and encourage her to read it. I also asked her if she would please let me know how she makes out with the dietitian I referred her to.
I don’t expect that I will hear from her again as she has no obligation to give me an update after such a brief encounter, which I completely understand. And while I would love to help every expectant mother have a healthy pregnancy and give birth to the healthiest child genetically possible, I have learned that my impact is limited to those I can connect with.
So if you are reading this, please consider reaching out to me if you are pregnant and have a concern regarding weight gain, hunger, excessive fatigue, or any pregnancy-related symptom, whether you have been diagnosed with gestational diabetes or not. Even better, make an appointment to meet with me before you get pregnant; I can help you avoid these type of problems and ensure you are eating to optimally nourish your little bundle of joy.
Ray JG, Berger H, Lipscombe LL, Sermer M. Gestational prediabetes: a new term for early prevention? Indian J Med Res; Sept 2010, pp 251-255.
Souyma S t al. HbA1c: A Useful Screening Test for Gestational Diabetes Mellitus. Diabetes Technol Ther. 2015 Dec;17(12):899-904
Note: According to a recent study in the Journal of the American Board of Family Medicine (Arch et al 2016), less than 25% of patients who meet the criteria for prediabetes receive lifestyle recommendations from their primary care physicians. I would guess that this would also be true for pregnant women from their obstetricians. This is an incredible missed opportunity for averting gestational diabetes, and ensuring the overall health of both mother and baby, not to mention for decreasing future health problems.
It is estimated that 1 in 3 Americans has prediabetes, and prediabetes is one of the biggest risk factors for the development of diabetes. Prediabetes represents the most important time to take action and provide counseling on appropriate diet, lifestyle, and exercise changes. Unfortunately, about 1 in 3 diagnosed with prediabetes will go on to develop diabetes within 5 years if not addressed early in the disease process.