The Management of Women With Gestational Diabetes
In this podcast, Jennifer Smith RD, LD, CDCES, discusses the management of women with gestational diabetes, including the psychological impact of gestational diabetes in women, technology recommendations for pregnant women with the disease, and more.
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TRANSCRIPTION:
Jessica Bard: Hello, everyone, and welcome to another installment of Podcast360, your go-to resource for medical education and clinical updates. I'm your moderator, Jessica Bard, with Consultant360, a multidisciplinary medical information network. More than 8 in 100 pregnant women develop gestational diabetes in the United States, according to the CDC. Registered dietitian and diabetes care and education specialist, Jennifer Smith, is here to speak with us today about the management of women with gestational diabetes, the psychological impact of the disease, technology recommendations, and more.
Jennifer, thank you for joining us on the episode today. Please tell us a little bit more about yourself.
Jennifer Smith: Of course. Again, my name is Jennifer Smith. I'm a registered dietitian and certified diabetes care and education specialist. I work with Integrated Diabetes Services with a very popular, well-known gentleman, Gary Scheiner, and I work with all ages of people who have diabetes. We're worldwide, so we provide education to people with type 1, type 2 diabetes in the realm of helping them to navigate, and we've got a wonderful crew of clinicians that I have the pleasure to work with.
I work with a lot of athletes and women with diabetes because there are certainly avenues to move down in terms of which piece of individualization needs to be done. I've had type 1 diabetes myself for more than 35 years and have certainly seen a lot of the movement in the past 5 or 10 years and the changes and the benefits of what we now have as new technologies. So, I'm glad to be here. Thank you.
JB: We're happy to have you. Thanks again for joining us. We are talking about the management of women with gestational diabetes today. To get started here, when does gestational diabetes occur?
JS: Yeah. Usually, when we're looking at gestational diabetes and diagnostic standards, all women who have a pregnancy are going to have a glucose tolerance test, essentially. If they don't have diabetes preconception already, then sometime during that 24-to-28-week period in pregnancy, you're going to have a glucose tolerance test, essentially, in order to be able to evaluate the glucose levels when your body is tested with a glucose load or glucose being a sugar load. Right? It could be done via IV, or it could be done with just what's called an oral glucose tolerance test which is where a woman would drink a very lovely tasting glucose sort of solution and then evaluate what blood sugar levels look like in the hours following that glucose intake. And they have to be within a target range in order to not be diagnosed with gestational diabetes.
JB: And what is the importance of a healthy diet and lifestyle in the management of pregnant women with gestational diabetes?
JS: It's as important as anybody, honestly. But in terms of glucose management, which is really what we're looking for. Right? We're looking at lifestyle changes or just continuing lifestyle adjustments that may have been sort of started prior to conception, but maybe nobody had any navigation or education on how to do things better. Exercise or activity of any kind and nutrition or food, they're very big pieces in the management of glucose in anybody who has diabetes.
And in pregnancy, because our glucose target range is much tighter– 63 to 140 is really what we're aiming for as that target range–and that includes the post-mealtime period. So, you know, if you have gestational diabetes, we are really looking at either the 1-hour or the 2-hour post-meal blood sugar levels. And at that 1-hour mark, the aim is for 140 or less. At the 2-hour mark post-meal, we're looking at under 120. And then coming into the next meal, in the range usually somewhere fitting a little below or maybe a little bit above a 100, essentially.
Fasting ranges, meaning the first time we wake up in the morning, we’re really looking for glucose levels again under 95 for fasting. And so, because of the tightening of that, education really needs to be, focused for women on what does activity do to blood sugar or blood glucose. And what does the type of food and the content and the portion of food at certain times through the day, what does that do to blood sugar as well? If it were in my ability to do anything for women with gestational diabetes, I would 100% put on a continuous glucose monitor for every woman who has diabetes in pregnancy because it really is a very good visual on those trends. Rather than doing what's most common are finger sticks or blood glucose monitor testing in the fasting time and especially in the aftermath of meals to meet those tight targets.
But if you want more information and you want to be able to put together an activity and the food that you're eating and put those pieces in a way that you can make some good adjustments, then a continuous glucose monitor is 100% the way to go. You know, many times in the diet realm, we're really looking at controlling to meet nutrition needs in pregnancy, which are higher. right? Not higher by a lot, and mostly calorie intake needs to go up slightly in the second and the third trimester, so it doesn't necessarily mean eating for two. You're not.
I mean, you are, but you're not. Right? Your body is changing a lot. You've got a developing baby. But it really equates to maybe 200 to 300 extra calories, which is not a heck of a lot of extra calories.
Right? And so, from an education standpoint, when a woman is diagnosed with gestational diabetes, it is really, really important for them to get good quality education about what this means. Because they may not have any idea. Most people don't have a reference point at all.
And it goes into changes that they're already making, now there's another change that needs to be put in. And these might be women who already have a family that they're taking care of at home, so they're being asked to make some pretty considerable changes for themselves. And what does that look like in respect to their family life or their lifestyle?
JB: We talked about healthy diet and lifestyle. We mentioned education and the use of a CGM. Do you have anything else that you'd like to share about how a patient with gestational diabetes really should be managed?
JS: Absolutely. A diagnosis is typical without, again, diabetes preconception. Gestational diabetes is diagnosed in somebody who has no idea that this is coming. Right? And so, in terms of management, referral to a knowledgeable dietician, especially– someone who has experience working with gestational diabetes or a dietician, registered dietician who also has the credentials of being a certified diabetes care and education specialist. Then they should be managed closely with, potentially a high-risk doctor team, not just an OB team, but more of an MFM or a high-risk team, which allows them to really have that in-depth quality care, especially if their glucose levels are not able to be managed just with lifestyle changes of diet and activity.
Right? If there's medication that's going to be added, first and foremost, it's going to be insulin. And that really requires a quality practitioner who understands how to help the person learn about it and navigate it well to keep those tight targets. So, it may even involve an endocrinologist or like I said, an MFM, a maternal-fetal medicine doctor who has extensive experience with high risk, including diabetes, either preconception or in this case, gestational diabetes, can really help them manage. And they may require more visits, more ultrasounds, and more evaluations. There's certainly going to be a lot more testing, and that really requires a practitioner to be able to understand the data that's being asked in recording from the woman with gestational diabetes.
If they're asked to do finger sticks to get blood glucose values, if they're asked to change their nutrition habits, if they're asked to use a continuous monitor, then who is looking at that data? Right? Who is going to help them pick it apart and make sense of what probably looks like gibberish to them? So, a quality health care team, again, not just necessarily primary care, but a really well-educated OB or a high-risk maternal-fetal medicine doctor. And depending on medication use, might even move them into using endocrinology as a service as well.
JB: I can imagine, and it would be understandable if there were psychological effects of this disease on women. What can the psychological impact of gestational diabetes be in women?
JS: Yeah. I mean, I think that's sort of multilayered. Right? I think with an initial diagnosis like that, there's always the thought “What did I do? I thought I was healthy. I thought I was doing everything I was supposed to be doing. What did I do wrong?”
So, from a psychological standpoint, you have this guilt of “I must have done something.” And then along with that guilt is the concern now of “what have I been doing to my developing baby?”
“I and out about this in almost the end of 2nd trimester, and all along glucose levels… maybe they were already going up, and now we discover it at this point.”
So, I think there could be a mentality that women may be considering “What have I done so far?”
Then the other psychological components are considering the big lifestyle changes that women might be asked to make. Maybe they're just somebody who's so busy and has the type of job that exercise has never been something that regularly fits in. So now they're being asked to walk 30 minutes every single day or take a walk after meals to control that post-meal blood sugar rise. That's hard. That's a major impact. And many women also have families that they're helping to take care of beyond this pregnancy.
That also has an impact on the family structure and getting the family involved in understanding why a woman might now be really paying attention to things or might be using an app to look up or log foods or look at blood sugar levels or keep records, and that takes away, in some ways, from what their normal day-to-day involved. It's in addition to that. And then the worry from a psychological standpoint, “Long-term, what does this mean?”
Many times at diagnosis, a lot of women are told a diagnosis with gestational diabetes may long-term mean that you're predisposed to type 2 diabetes, especially if the lifestyle changes that you're learning now are not continued in the postpartum period.
And so not only now are many women worried, but then there is a lingering thought that after the baby is delivered when gestational diabetes typically goes away, is there the potential that something is going to hit later? And when? So there's a lot to think about. And, again, that's the place where a very good clinical team is important for a woman to be able to share and be able to talk to somebody who can give quality feedback and help assure them that with good management, all these concerns can be well controlled.
JB: Now one thing that I've heard you say a few times is that it's important for clinicians to match the right technology to their patients. Let's talk about technology and how women can use technology to manage their gestational diabetes. Is there anything that you might recommend?
JS: Sure. Thankfully today, even if a woman is given a blood glucose meter to do a fingerstick to get their blood glucose information, thankfully today, a good majority of the monitors on the market have an app that they work with. And so as soon as the glucose value is given, it connects with the app via Bluetooth, and it essentially allows all that data to be stored in one place, which then with a good clinical team can easily be moved into their clinical database via some type of electronic medical record or many of the glucose monitors connect with online databases. Things like Glooko and Tidepool and some of the other systems, allow that data to be synced. And then if the clinician has an account, their clients or their patients can essentially seamlessly have all that data transmitted. They can evaluate it and even give electronic medical record responses back to questions. It moves into something like telehealth and the importance of the ability to connect in between in-office visits. That often, especially in gestational diabetes, means a lot more and a lot tighter management of health because there are checkpoints between those actual office visits.
Other technology, even if a woman with gestational diabetes has to start using insulin as a management tool. And that's what I would really suggest when a clinician is discussing that they need to add insulin, from a psychological standpoint a lot of women think “Well, I guess I failed. I must not be doing something well enough. I have to use insulin now.”
And that's not the case. Many times, the hormones in pregnancy shift so significantly that the use of insulin, you should think about it and teach about it as if it's a tool that we're going to use. Just like this blood glucose meter is a tool for information, insulin is a tool to help us keep our blood sugar where we want it.
We have really nice insulin injection devices that are also technology-driven, thankfully, and they help to bring together the information that the dose was given, what time it was given, and apps that connect with these insulin pen delivery devices to allow the person to even be able to see when their last dose was given, to be able to share the reports with their clinical team and to be able to show “I'm doing the job that you asked me to do, and these things are not working out, so let's make some adjustments.”
And then as I said earlier, continuous glucose monitors are a piece of technology that I think every single person with diabetes, whether it's gestational diabetes, type 1, or type 2, should have access to a continuous glucose monitor. From a point of time to point of time, every 1 to 5 minutes, a new CGM value is generated and put out. And that pattern of information gives a more fluid look at where glucose is heading and where it has been. If a woman is started on insulin, it also is a really nice way to have comfort that what you've taken is working the way that it's supposed to. Anytime we include medication, especially blood sugar-lowering medication like insulin, we also need to have a discussion about hypoglycemia or low blood sugar.
With continuous glucose monitors, with the alerts and the alarms and the things that we can have values set for high and low blood sugar that makes a piece in that psychological management of this. There's a little bit of a feeling of less frustration because you can see what's happening with a continuous monitor and all this data put together. I'm thankful for all the technology that we have, especially in the past 5 years. It has really it has really bloomed considerably.
JB: That's great. Is there anything else that you'd like to add to this episode today?
JS: I think in terms of gestational diabetes, again, there's not much ahead-of-time talk, like preconception talk, that can really be done about it because it's something that no woman is really expecting to happen in preconception. With those who already have diabetes, obviously, the talk about management should start well before pregnancy happens. But gestational, that’s a period of life that just happens when it happens.
JB: Sure. That makes sense. Well, thank you so much for joining us on the podcast today.
JS: Of course. Thank you so much.
JB: For more diabetes technology content, visit consultant360.com.