Gestational Diabetes: Nutrition and Questions

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Gestational Diabetes: Nutrition and Questions
by KMom
Plus-Size-Pregnancy.org

DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider. This particular web section is designed to present more than one view of a controversial subject, pro and con. It should be re-emphasized that nothing herein should be considered medical advice.

Contents

All About GD Food Plans
Some General Guidelines on Food Planning
Glycemic Index Information for the Curious
Caloric Intake: The Debate About Larger Women
Food Numbers to Guide Your Choices
One Sample Plan: About 2100 Calories
Carbohydrate Counting
Food Plan Design Issues
Other Nutritional Issues
Protein Intake
Vegetarians and GD
Vitamin and Mineral Deficiencies in GD
Can I Have Any Sweets?
Are Fast Foods OK?
Can I Use Artificial Sweeteners?
Sweetener Choices
Baking Alternatives and Treats
Are Sweeteners Really Safe? Kmom's Opinion
Sweeteners: A Summary
References
All About GD Food Plans
It is important to emphasize that NO standard gd food plan is currently available. Every registered dietician you see will recommend something slightly different. Women with gd are often given a plan as if it is 'The Ten Commandments' written in stone, and are shocked when they compare their plan with others' and see some of the differences. The similarities generally outweigh the differences, but the differences can be glaring. Remember that when you read this, you are seeing only a few possible versions of gd food plans. Do not take this plan as a medical prescription; discuss your own individual needs with a Registered Dietician (see the section on Treatment and Care Issues for a discussion about dealing with Registered Dieticians). As we larger women well know, one size does not fit all, either in clothes or in food plans!

As far as GD food plans go, they are usually not strongly restrictive or oppressive. Mostly they are just a different pattern of eating, with an emphasis on careful food combinations and timing. It is extremely vital to eat every 3-4 hours to keep blood sugars even, and to eat smaller, more frequent meals instead of larger, more infrequent meals so that your insulin response is not overwhelmed at once. You will not go hungry on this plan, but the adjustment to smaller meals/more often is one that is sometimes difficult. To some, it may feel like they are constantly eating, yet never quite satisfied. Others dislike the regimentation of sometimes having to eat when not hungry or to go hungry at times when they feel like eating. In fact, for some women, the idea of such rigid food scheduling is often the most difficult aspect of the plan. It just takes time to get used to the new routine but it will become easier over time.

It is vitally important to eat proteins with your carbohydrates so that your glycemic response is slowed down and the energy lasts longer; it is also important to limit how many carbohydrates you are eating at one time. Overloading with too many carbs at once is a typical problem that needs to be solved. Most people have too many carbs at one meal without realizing it and overload their systems, instead of spreading out the same intake over several smaller meals and snacks. It's important to realize that people can eat a perfectly healthy food intake, yet still schedule it and combine it in such a way that interferes with good blood sugar control! So although your overall intake over the day is important, what's more important is how you schedule and spread out intake.



Some General Guidelines on Food Planning

Generally speaking, if you compare a lot of plans, some general rules tend to be consistent. Remember that these can vary, and you should consult your own provider for guidelines specific to your situation, but that these are generally recommended by most RDs. Further information can be obtained from brochures from the American Diabetes Association; Kmom highly recommends reading these.

Some foods should generally be avoided. Obviously, sweets of any kind are excluded. Some RDs spell out every little forbidden food in excruciating detail, but we will forego listing all the forbidden foods here and give ourselves credit for some intelligence. If in doubt, read the labels. Any food that has sugar (or a sugar variation, usually ending in -ose) listed as one of the top ingredients is probably not a wise choice. Checking the number of carbs on the label will also give you a lot of information; 1 serving of carbohydrate is equal to approximately 15 grams. In general, you want to avoid concentrations of more than 30-45 grams of carbs at one meal or snack.

It should be noted that non-pregnant diabetics can consume sugar and sweets in limited amounts; for them, a carb is a carb and as long as intake and calories are not excessive and adequate nutritional intake is followed, sugar and sweets can be part of their overall intake. However, for pregnant women with glucose intolerance, sugar should not be part of their intake. Pregnancy hormones cause them to be too sensitive to sweets, plus control during pregnancy has to be much more strict than non-pregnant diabetics must aim for. So sweets during pregnancy should be strictly avoided.

Honey and other substitutes are just as bad for glycemic response as sugar and cannot be substituted. A few books like the What to Expect series promote using foods sweetened with apple juice-concentrate or honey, etc. as a healthful alternative to 'sugar-laden' foods, but this is FALSE from a diabetic standpoint. Foods sweetened with applejuice, honey or molasses, etc. are just as bad for glycemic response as sugar and should not be used with gd.

Other 'forbidden' foods that are less obvious include fruit juices and cold cereals. It doesn't matter whether the fruit juice is sweetened or unsweetened; most people's glycemic response to both kinds of fruit juice is so swift and strong that it's essentially the same as drinking a regular soda-pop. A few dieticians will permit women to use a bit of fruit juice; most will not. Cold cereals, also, are generally not recommended, even if they are not sugar-coated. They are very carb-intensive and provoke a strong response, so they should usually be avoided. Some people can tolerate them, but they cause problems for most and so are generally not permitted. Hot cereals, on the other hand (like regular long-cooking oatmeal), generally do not cause the same quick rise and can be consumed, as long as careful attention is paid to portion-control. Muffins are also generally to be avoided, since they are extremely carb-intensive, considering their flour, fruit, and high sugar content. It's best to steer clear of them most of the time, though a few people may be able to tolerate them with great care.

Foods that you should be very cautious about using include bagels, croissants, white rice, some rolls, baked beans, some peanut butters that use sugar, and some spaghetti sauces that use sugar. These foods are generally very carb-intensive and tend to cause quick spikes in bG in many people. Some people can tolerate some of these foods, others cannot tolerate any. Be very careful if you try them, and be sure to read the labels for carb-content carefully. One bagel may equal as many as 45-50+ grams of carbs, which is the equivalent of more than 3 pieces of bread! That's a whole meal's carbs in one food.

Pasta and brown rice can be used, but remember to monitor carb content and portion size carefully. Overcooking rice and pasta adds to their carb content, so try to undercook them a bit, and use high-fiber (whole-wheat) versions whenever possible. Long-strand pastas tend to be better to use than short pastas, ironically! Look for hidden sugars in certain breads and canned foods, and choose fresh foods over refined or canned foods whenever possible. Remember also that different people respond differently to certain foods than others. Some people can tolerate brown rice or potatoes just fine, while others find their bG spikes drastically after one of these foods. Some people can tolerate pizza, but most people have a sharp bG rise afterwards. The only way to know about YOUR response to these 'trigger foods' is to take careful notes about what you ate if you have a high reading (see the web section on Troubleshooting High Readings) and look for a pattern. Other trigger foods can include bananas, dried fruits like raisins, potatoes (esp. instant mashed potatoes), instant noodle soups, grapes, etc. Become keenly aware of your own personal 'trigger' foods.

Remember that carbohydrates refer to dairy foods, fruits, and starches (and veggies to a much lesser extent). When you eat a meal, you have to count carbohydrates, or add up the total number of carbs in all of your foods combined. The general guideline of consuming 30-45 or so carbohydrates per meal does not mean 45g (3 slices) of bread and then adding milk or a fruit; it means all of your fruit, milk, veggies, and starches must add up to that total instead (say, 2 pieces of bread plus a glass of milk). This is why it is important to read labels and be very aware of the carb content of typical foods! A generalized guide of how many carbs are found in which food types is found below. It is very helpful to know these if you want a bit more flexibility in your food plan.

Food combinations are also an important thing to consider. Some dieticians will tell you never to mix fruit and milk, because they are both fairly simple carbs that cause quick spikes in bG. Others will allow it, as long as the total does not exceed 30-45g and protein is consumed with it. Most dieticians feel it is important to include a protein food whenever you have a carb food, since the protein tends to slow things down and make them more even; your bG spikes less and is available as energy longer (thus preventing a dip later). A few dieticians do not require protein foods with small amounts of carbs, such as at snacks, but do want it there for larger amounts of carbs, like in meals. Ask your dietician about her recommendations.

A protein food at the bedtime snack, however, is generally QUITE important, since you will be going without eating for quite a long time. Milk, starches, and protein are important then, since the combination provides an excellent grouping of short-term and long-term energy sources. This should be able to get you through the night without a huge dip in the middle and a strong spike in the early morning. However, this should be tested through the use of morning urine ketone tests to be sure. A few women need to add a serving of milk at about 3 a.m. in order to keep their bG even throughout the night, especially those first diagnosed with gd who have been experiencing a large amount of ketones. (See the web section on Ketone Testing.) It is very important to keep bG even throughout the day and night! It is not just the highs and lows that you want to avoid, but also the swings between these.



Glycemic Index Information for the Curious

All carbs are NOT equal; some provoke stronger and faster blood sugar rises than others. When referring to an individual's response, these are called 'trigger foods'. A number of years ago, a list of many foods was put together, and a group of test subjects (both diabetic and non-diabetic) were gathered. Their response to each food was tested and then averaged, and a number from 1-100 (or in some cases, higher) was assigned. This is a glycemic index, and its purpose is to show how certain foods cause an average group of people to react. A food that has a very high number attached to it can be expected to be a 'trigger food' for many people, causing their bG to have a sudden fast rise, or to spike out-of-proportion to the amount of food eaten. It should be remembered, though, that individual response varies and some people can tolerate foods that are high on the index; close observation of your own response to each food is important.

There were some surprising lessons learned from glycemic indices; it was discovered that table sugar was not the worst food around for causing sudden steep spikes (although it is up there!). From this, it was found that some (non-pregnant) diabetics can actually have some sugar, on occasion; that they do not have to be forbidden it for the rest of their lives. Since sugar does not offer any nutrition in exchange for its calories, it is not a food that is recommended often, but it can be eaten with care by some diabetics, as long as it is used in place of other carbs instead of in addition to them. The bad news, of course, is that this is not true in pregnancy. In pregnancy, the hormonal influence is just too strong, and women with gd need to avoid sugar and related products completely. But it is comforting to know that if you ever develop type II diabetes, sugar may not have to be stricken from you life forever, just used very cautiously and with full recognition of the nutritional and caloric tradeoffs involved.

A glycemic index can help many people plan their food intake more carefully, though it must be noted that each individual's response will not match the index exactly. It is just a general guide, based on average responses from a group of people. It should also be noted that not all glycemic indices came up with exactly the same results. Slight differences appear between indices, probably because of differences in the groups tested. But general trends can still be detected from these indices, and 'danger foods' highlighted and watched for. For example, a food with a surprisingly high index is cooked carrots. In many diabetics, this seemingly innocent food can cause a strong and quick spike in bG. So even though this food is technically allowed in gd, you may want to give it wide berth or test your own response to it gingerly. Other common 'trigger foods' are white rice, bagels, etc. as discussed above. For a more detailed list of common 'trigger foods', see the website listed below.

Glycemic indices add too much confusion for some people, but others find them immensely helpful. If you desire more information about them or about specific foods, try the website, http://www.anndeweesallen.com/. It also contains links that may be helpful in your search for diabetes information.



Caloric Intake: The Debate about Larger Women

Currently, there is a big debate as to how many calories are appropriate, especially for larger women. Should we consume fewer calories simply because of our pre-pregnancy size? The Recommended Daily Allowance for most pregnant women (average-sized) is about 2400 calories. The tendency in a lot of research is to recommend about a 1/3 reduction in calories for obese gestational diabetics, which usually works out to a recommendation of about 1500-1800 calories per day, depending on pre-pregnancy weight, activity levels, weight gain to that point in the pregnancy, etc. However, in practice, this recommendation does not often seem to be followed as often anymore. Most large gestational diabetics end up with a prescription for about 2000-2300 calories. This is probably a more sensible recommendation (1500 calories seems like a ridiculous level for a pregnant woman, and the safety of this practice has NOT been established so it is currently not recommended by ACOG), but the issue remains to be settled definitively.

Researchers who advocate restricting calories have several concerns. When average-sized women are pregnant, for example, part of their weight gain is to lay down a layer of fat to provide energy during childbirth and breastfeeding. Since larger women already have access to fat storage, they may not need the same number of calories. However, pregnancy should not be used as a time for losing weight. Any woman who is given a restrictive diet with the purpose of reducing weight during pregnancy should find a new provider. Although few providers nowadays insist on this, there are still a few around who do. One woman was told she must lose 40 lbs. during pregnancy, 'or else'. Others have been told that unless they keep their weight gain within 10-15 lbs. (or gain no weight), or unless they stay under 'x' total amount of pounds (i.e. 200), they will have to have a c-section or 'may even die'. This is ludicrous; these are blatant examples of fat-phobic doctors whose care will NEVER be fair or unbiased. Unfortunately, these stories are true. The only proper course of action in these cases is to GET A NEW PROVIDER.

Some providers who are not obviously size-phobic do have what could be legitimate concerns about maternal caloric intake, although it's important to remember that nothing is proven conclusively and the safety of restriction is not established either. There is some concern that a large maternal weight gain can cause more insulin resistance problems and more macrosomia (too-large babies). Some studies seem to support this while others do not; the picture is unclear. So some researchers advocate limiting pregnancy intake in larger women in hopes of keeping down weight gain. However, this ignores the fact that many larger women gain little or nothing in pregnancy, regardless of healthy intake, perhaps because of metabolic changes in pregnancy (Kmom gained 5 lbs. or less in each pregnancy with normal caloric levels; babies are healthy and fine). On the other hand, there is a subgroup of larger women who tend to gain a lot in pregnancy, often those who are closer to average-size, are chronic yo-yo dieters, had a recent large weight loss, or who have complications in pregnancy such as pre-eclampsia. A very large weight gain such as these women tend to experience could indeed potentially cause problems.

The problem is that there is no sure way to predict who will gain too much weight and who will not. Routine limitation of caloric intake in all obese women could cause problems for the many larger women who do not usually gain much weight in pregnancy. Dieticians and doctors who routinely ASSUME that larger women will automatically gain too much weight in pregnancy (and so must be restricted) should be challenged strongly. Perhaps caloric restriction should instead be based more on individual circumstances (history of large weight gain in past pregnancy, strong history of yo-yo diets or recent large weight loss, etc.) rather than a blanket prescription based solely on a woman's size and a provider's assumptions.

Many researchers contend that large women only need to be provided with enough calories to keep them above the level of ketosis (burning fat for fuel, which may create undesirable by-products for babies), but few examine the long-term effects of this near-ketosis on the fetus.Others found a higher rate of needing insulin at caloric intakes close to that of average-sized women, so they recommend lower caloric levels. This might possibly be a justifiable reason for lower levels (though more research is needed to confirm this, plus assure the safety of the approach), but just how low is appropriate (if at all) is not well-established. A number of approaches have been proposed.

Some researchers propose that large women's intake be limited to 12-15 kcal/kg of mother's pre-pregnant weight. For a woman who is 250 lbs., this amounts to between 1400-1700 calories per day---while pregnant! This is a very grave restriction. Other researchers propose that larger women be given 35 kcal/kg of their ideal weight. Assuming that 120 lbs. is the so-called 'ideal' weight for a woman who is about 250 lbs., this would result in a caloric intake of 1800-1900 calories; better but still restrictive. It used to be routine for women of size to be given a blanket caloric allowance of 1800 calories, often with minimal levels of protein and calcium. Some of these women have anecdotally reported higher rates of pre-eclampsia, though it is difficult to distinguish how much of this is due to insufficient nutritional intake and how much is due to the well-established fact that gestational diabetics do have somewhat higher rates of pre-eclampsia.

It's important to note that Dr. Tom Brewer showed in a number of studies that pre-eclampsia can be related to inadequate intakes of protein and other nutrients, though some dispute his research. Other studies have pointed to inadequate protein as a problem in diabetic pregnancies as well. Jovanovic-Peterson and Peterson noted that "Diabetic women may be more vulnerable to protein malnutrition than non-diabetic women during gestation" (Diabetes/Metabolism Reviews, 1996). Confounding the research picture is the fact that while some studies have shown that higher levels of calcium may help prevent some pre-eclampsia, a recent (very large) study found it did not. So drawing conclusions about nutritional concerns is difficult and often based on contradictory studies.

Since it's difficult to know exactly what the most optimal amounts of nutrients are, caution should be used in approaches that advocate strong restrictions of calories because it may be difficult to get in the proper nutrient levels, thus possibly causing complications. Dr. Brewer's studies on pre-eclampsia showed that the old approach to 'preventing' pre-eclampsia through strong caloric restriction, low protein levels and use of diuretics actually made the occurrence and severity of pre-eclampsia worse, not better. It provides a lesson in caution in approaching the use of caloric restriction for gd. Caloric restriction could be helpful, but again it could cause more problems than it solves. More research into its short-term and long-term safety and efficacy is needed before anything like this should be adopted.

Some researchers have already experimented with strong restrictions of caloric intake for large women with gd; one experiment limited large women to as little as 1200 calories---while pregnant! However, this experiment put the women into ketosis (spilling ketones, a substance found in some studies to be harmful to the baby) within a short period of time and was therefore stopped. Other studies have found that restricting intake by about 1/3 (to about 1500-1800 calories) did lower the rates of macrosomia somewhat without causing ketosis. Again, the long-term safety of this approach has not been established yet, but it's an interesting research avenue to pursue. However, it is too soon to recommend this universally for all larger pregnant women. A number of troubling questions remain to be answered about this approach.

The advantage of these restricted-calorie diets is that some of them have helped reduce the levels of insulin needed by some women (or prevented its use for some), and have reduced macrosomia rates somewhat in some women. However, the effects were certainly not universal, and the risks not adequately examined. What is the cost to the baby of such restriction? If the only measurement of 'success' of treatment is in the lack of weight gain by the mother or a smaller size from the baby without any study of the procedure's long-term safety for baby or mother, then the research design is inadequate. Very few studies that examine restricted caloric intake in obese women truly examine the issues adequately and many suffer from significant prejudicial assumptions. The research quality in this area is definitely lacking.

How much less macrosomic are these babies, and is the reduction really significant enough to justify such radical treatment? How effective is the treatment in women of varying degrees of obesity? What is the effect of caloric restriction on the babies of the women who would not have had macrosomic babies at normal caloric levels? Is the treatment also increasing the rate of SGA [small-for-gestational-age] babies, as too-strict levels of prophylactic insulin have been found to do? Does the lower rate of macrosomia translate into decreased operative deliveries and lower rates of shoulder dystocia? [A number of studies have reduced the rates of macrosomia somewhat without decreasing the rates of c-sections or birth trauma, and several others have reduced macrosomia but by such small total amounts that the overall benefit is doubtful. It is unclear at this stage whether macromsomia is really a true burden enough to justify such radical treatment and whether the treatments currently used are really cost-effective.]

Furthermore, is anyone doing long-term follow-up on the babies of women whose caloric intake was severely limited to see what the long-term effects of caloric restriction might be? Most studies stop at birth and measure their success solely on the basis of whether baby birth weight has been decreased (or mother's weight gain decreased). Studies urgently need to follow up on whether these babies had a better birth outcome and whether they have any long-term deficits associated with tampering with genetic size or introducing levels of near-ketosis. Also, has anyone studied whether caloric restriction in the mother inhibits breastfeeding supply and breastfeeding rates in the restricted pregnancies? What caloric recommendations are they making for women who do breastfeed post-partum and on what do they base these recommendations (La Leche does not recommend caloric intake under 1800K for breastfeeding women; if women have been restricted to 1500K during pregnancy while the body prepares for breastfeeding, what effect does this have on mother and baby and breastfeeding rates?) As far as Kmom can tell, the issue of caloric restriction's possible effect on breastfeeding and supply issues has been totally ignored by researchers in this field.

In addition, it is not clear that all infants above 9 lbs. are a problem that MUST be resolved. While it is clear that some babies of diabetic mothers are larger because of maternal hyperglycemia and resulting fetal hyperinsulinemia (and that these cases really do need to be prevented), not all 9 lb. babies are a result of this. Larger women have larger babies, and this is often just as genetic as taller women having longer babies. In diabetes research there is a tendency to treat all babies above the 90th percentile in weight as abnormal and a clinical issue screaming for attention, but the same concern is not present for babies above the 90th percentile in length, suggesting that for some researchers, the extreme concern over reducing fetal birth weight may be a subtle form of sizism. Some babies are going to be born naturally at and above 9 lbs., and unless strong evidence of maternal hyperglycemia and resulting asymmetrical fetal growth is present, the size of these babies may simply be more of a reflection of genetics than of a diabetic problem that needs to be solved. But at present, all babies above 9 lbs. are treated as a 'failure' of inadequately strict treatment instead of possibly a variation on the norm and the result simply of possible genetic heritage. More effort should be made to distinguish between asymmetric and normal-growth macrosomic babies and their implications for birthing issues.

Larger babies can be more difficult to deliver, but often this is a reflection of the doctor's delivery restrictions rather than an inevitable result of the baby's size, and many babies of this size and larger are delivered without problems when the mother is allowed to labor naturally and with efficient positioning. Shoulder dystocia (where the shoulders get stuck) is a legitimate area of concern for babies of diabetic pregnancies because of possible asymetric fetal growth (shoulders/trunk too big), but many babies of well-controlled gd pregnancies are around 9 lbs. without having asymmetric growth. A baby that is around 9 lbs. may be that way naturally and does not necessarily reflect an abnormal growth pattern that will cause problems getting 'stuck' at birth. Besides, shoulder dystocia occurs quite frequently in babies under 9 lbs. as well, and again, the doctor's delivery restrictions are often a contributing factor that goes unrecognized and unblamed. The point is that baby size and birth trauma is a much more complicated issue than gd researchers make it out to be, and while some of it is certainly a problem and preventable, not all of it may be the burning issue that must be treated at any cost.

Higher rates of macromia in gd moms is an important issue and one that does respond somewhat to various therapies, though again, researchers are notoriously lax in establishing their long-term safety and the overall benefits and cost-effectiveness of this approach. However, the all-out push for ALL gd babies to be between 7-8 lbs. may be unfounded and sizist, and does not address the possible harm that might occur if a baby that is genetically meant to be around 9 lbs. is forced through abnormal means to be smaller than nature intended. This is an extremely important point. Frankly, extreme efforts to prevent any baby from being above the 90th percentile smack of putting babies on a diet before they are even born--an abhorrent concept---and is a skewed view of statistics. Being outside of the norm does not make something harmful, it just makes it unusual. It is true that babies of diabetic pregnancies that develop in asymmetric patterns of growth or become abnormally large are an important issue and need to be prevented. But babies that simply represent the upper limits of normality with normal growth patterns do not necessarily represent an occurrence that must be prevented at any cost, no matter what the intervention. This is an issue poorly addressed in the endocrinolgy and obstetrics fields, known for size-phobia, where any baby above 9 lbs. is often seen as a failure of 'control' or insufficiently strong treatment. The whole issue of Large-for-Gestational-Age babies who demonstrate normal growth patterns and whose mothers demonstrated excellent glycemic control during pregnancy should be re-examined and in retrospective, many could be seen simply as a variation of normal rather than a pathological presentation.

The issues of efficacy, importance, and long-term safety must be addressed before use of caloric restriction for obese gestational diabetics can be adopted as a universal recommendation, though research should continue on the issue. The American College of Obstetricians and Gynecologists (ACOG) says that "while maternal weight gain and fetal macrosomia may be decreased, the safety of this approach has not been established, and thus it is not recommended" (ACOG Bulletin #200, 1994). A number of other sources also recommend caution in approaching hypocaloric diets for obese women, including Gunderson in her 1997 article in Diabetes Care ("caloric restriction during pregnancy even in obese women must be viewed with caution, since its effects may pose some risk to the fetus") and Hachey in his 1994 article in American Journal of Clinical Nutrition ("more caution is necessary in using fat- and energy-modified diets to treat women with gestational diabetes mellitus"). The Journal of the American Dietetic Association in its 1995 article on nutritional management in gd notes that "Risk of high levels of blood ketones and risk of sacrificing maternal nutritional status are higher in women who consume hypocaloric diets."

In the meantime, what recommendations should be made to the large mom who has gd? Protocols will depend on the philosophy of the provider, but at this time most providers do not seem to be practicing extreme restriction, though small restrictions do seem to be common. Intake under 1800 calories generally seems to be frowned upon in practice currently; in Kmom's non-medical opinion, it is strongly questionable whether <1800 calories is enough and she has strong concerns whether this is safe for mother or baby. Most larger women with gd are currently being given plans of about 2100-2300 calories by registered dieticians, which seems more satisfactory. Pregnant women of average size are generally told to eat about 2400 calories per day, but since we as larger women may not need extra fat stores, it makes sense to Kmom that a caloric intake of about 2200 calories is sufficient, as long as the mother is not spilling ketones in her urine or losing weight. However, it must be re-emphasized that this is only Kmom's opinion and that she is not a doctor or registered dietician.

In the interests of comparison and discussion, a sample program is listed below. It is about 2100 calories and was given by a real registered dietician in 1997. It is NOT intended to be a medical prescription or advice, just one more source of information about the subject. If a mother has problems controlling her blood sugars on a program such as this below, one option to consider may be to change slightly the amount, distribution, or type of carbohydrate in the plan (for example, to decrease to 40% carbohydrate and substitute a bit more protein and fat to compensate, etc.), but ANY decision must be made in consultation with a health provider and a registered dietician since the issues involved are complex and often involve delicate balances. Exercise therapy, when appropriate, may also help changes in dietary therapies as well.



Food Numbers to Guide Your Choices

*Taken from the American Diabetes Association's "Exchange Lists for Meal Planning".

Starches - 15 grams carbohydrate, 3 grams protein, 0-1 grams fat, 80 calories

Fruits - 15 grams carbohydrate, 0 grams protein, 0 grams fat, 60 calories

Dairy - 12 grams carbohydrate, 8 grams of protein

Skim milk = 0-3 grams fat, 90 calories
Low-fat milk = 5 grams fat, 120 calories
Whole milk = 8 grams fat, 150 calories
Protein - 0 grams carbohydrate, 7 grams protein

Very lean = 0-1 grams fat, 35 calories
Lean = 3 grams fat, 55 calories
Medium-fat = 5 grams fat, 75 calories
High-fat = 8 grams fat, 100 calories
Fats - 0 grams carbohydrate, 0 grams protein, 5 grams fat, 45 calories

Vegetables - 5 grams carbohydrate, 2 grams protein, 0 grams fat, 25 calories

*Note that certain vegetables are actually counted as starches, due to their carb content (corn, peas, etc.). Also, 3 regular vegetables together total 15 g of carbs, or one whole serving, which can throw off your totals. Limit your intake to 1-2 veggies at a time, except for salad veggies like lettuce or spinach.

For examples of each food type and its portion size, see the ADA Exchange List booklet. Serving sizes are extremely important to note, since different diet programs and different food programs use differing standards. For example, in some programs, 1/3 c. of cottage cheese is the standard size, in others 1/2 c. cottage cheese is listed as the serving size. In the ADA booklet, 1/4 c. of cottage cheese is one serving. It is beyond the scope of this faq to list portion sizes; be sure to consult your RD or the ADA booklet for this.



One Sample Plan: About 2100 Calories

120 g protein; about 40-50% of calories from carbs

*Exact calorie totals will vary based on lowfat vs. higher fat dairy and protein choices; this plan assumes the use of lowfat milk (1%) and medium-fat proteins (such as chicken, turkey, cottage cheese, eggs, etc.) on average.



Breakfast

1 protein
1 starch
1 milk
1 fat
Optional: Some people find that adding another protein in the morning helps keep their post-breakfast numbers lower. Discuss it with your Registered Dietician (RD). Adding an extra protein will add about 75-100 calories to your total.

Variations: Some people are able to tolerate a bit more carbohydrate in the morning; some gd plans call for 2 starches in the morning (the extra carb adds about 80 calories). On the other hand, some people cannot tolerate much of anything in the morning, so 1 starch may be better, and even the milk may need to be left out. Consult your RD.

Notes about breakfast: This meal is the most difficult of the day for most gd moms. There is an early-morning surge of hormones that tend to make bG rise more strongly at this time, so being very careful is very important in the morning. A small breakfast is vital. Fruits are definitely to be avoided in the morning, and some women cannot tolerate milk at this time either, so that may need to be omitted. If in doubt, pare your servings down to the minimum, be sure to measure carefully, and consider adding an extra protein. A quick 20-30 minute walk after breakfast is often very helpful too.



Morning Snack

1 protein
1 fruit


Lunch

3 proteins
2 starches
1 milk
1 fat
2 veggies


Afternoon Snack

1 protein
1 starch


Dinner

3 proteins
2 starches
1 fruit
1 fat
2 veggies


Note about Dinner: Some dieticians feel that it is important that one meal a day be an excellent source of iron, which pregnant women need in greater amounts. It is felt that if dietary levels are sufficient, routine iron supplementation may be able to be avoided. This may be more important to the gestational diabetic because besides causing a great deal of constipation and intestinal upset in many women, iron supplements may also impair magnesium absorption in the intestines. Low levels of magnesium may be implicated in impairment of pancreatic insulin production for some women, which could worsen hyperglycemia. So there is a good possibility that avoiding iron supplementation is in a gestational diabetic's best interests, providing her iron levels stay at adequate levels.

Therefore, dinner is designed to promote maximum iron levels through dietary means. It does not contain any dairy, since calcium interferes with the absorption of iron. You should consume a protein or fruit rich in iron at this meal, plus a fruit or vegetable that is high in vitamin C as well, which aids in the absorption of iron. For example, eating a 3 oz. steak (high in iron) plus an orange (high in vitamin C) is a good choice, but adding a milk to this meal would not be a good idea, because the calcium would interfere with the iron absorption. Another idea would be to eat spinach for iron and strawberries for vitamin C. Avoid coffee (even decaf) in this meal as well, since that also impairs the absorption of iron. See the main web section on Nutrition in Pregnancy for further information about iron-rich foods and calcium foods.



Bedtime Snack

1 protein
2 starches
1 milk
Optional: adding 1 extra protein sometimes helps some people keep their fasting bG in better control; consult your RD.

Carbohydrate Counting

Many dieticians now use carbohydrate counting instead of exchanges in food plans. In this, the mom is given a total of carbohydrates that she must not exceed per meal or snack and it is up to her how to 'spend' those carbs (dairy, starches, veggies, fruits, etc.). This requires more label-reading but some people find it easier overall. It is important to know that 1 serving of bread usually is about 15 g of carbs, as is one serving of fruit or milk (check serving sizes carefully).

Most breakfasts in this approach are limited to 15-30 carbs. Women who are especially sensitive and getting high morning readings should avoid milk as one of their morning carbs and should probably limit their intake to 15 carbs. Other women who are less sensitive can tolerate more carbs, sometimes 45 carbs or occasionally even more, and can have milk or even fruit in the morning, but these women are uncommon. Most women need to avoid fruit at breakfast as one of their carb choices. Protein is especially important to have in the morning at breakfast and some women find that adding one extra protein at this time can help keep their morning numbers under control. Discuss it with your provider.

Snacks are usually 15-30 carbs plus a protein. Lunch and Dinner are usually between 45-60 carbs or so, though some women may need 30-45 carbs instead. Remember that veggies have 5 carbs each and must be figured into your total for each meal. The amount of protein and other foods allowed is sometimes specified under this type of plan, and sometimes not. Many gd moms lately have been told to be very strict about their carb counting numbers but that they may eat as much protein etc. as they desire in addition to the carbs (especially if they have had minimal weight gain so far). Each dietician's approach will be slightly different; consult your provider for your specific guidelines.

Many carb-counting plans will resemble the following (remember that this specifies the amount of carbs only; the other foods need to be added in as well, and don't forget that protein should be consumed with most carb intake):

Breakfast - 15-30 carbs (no fruit, sometimes no milk)
Snack - 15-30 carbs
Lunch - 45 carbs
Snack - 15-30 carbs
Dinner - 45-60 carbs
Bedtime Snack - 45 carbs
Obviously, plans will differ depending on individual needs. One concern in using this type of plan is that the mother's intake might be nutritionally unbalanced, since carbs are not specified. All starches and little or no milk or fruit, for example, might make a mother short on calcium or vitamin intake. Consult your dietician for further guidelines for keeping your nutritional needs supplied during pregnancy. Kmom firmly believes that proper nutrient intake is vital in pregnancy for preventing or minimizing problems; be very careful to obtain a varied and well-balanced intake.

Food Plan Design Issues

There are other issues that may affect the efficacy of your food plan. Variations in amount of carbohydrate, distribution of carbohydrate throughout the day, and frequency of eating/meal patterns are all issues that have not received sufficient attention in research. Fine-tuning these issues may decrease the number of women needing insulin therapy, and the importance of individualizing a plan to the needs and particular responses of each mother is often overlooked.

For example, one debate that has occurred is whether it is best to have 6 small meals and snacks throughout the day, or 3 bigger meals plus perhaps a bedtime snack. At least one researcher questioned whether obese women should have daytime snacks, since food stimulates insulin release and hyperinsulinemia is an important factor in fetal macrosomia, even when hyperglycemia is not really significant. Another researcher advocated slightly longer spacing between meals. However, other researchers have found that blood glucose and insulin concentrations were lower in patients who increased meal frequency ('nibbled'). The consensus today seems to be that 3 small meals and 3 small snacks are a better choice in general, but that tinkering to acheive maximal benefits may need to occur on an individual basis. Some women may benefit from slightly longer periods between eating while others will need to strictly adhere to eating every 3 hours or so. Some women simply cannot seem to fit in 6 meals/snacks per day, and a program may need to be redesigned to accomodate 5 meals/snacks instead (Kmom is one of these). If you have problems with the design of your program, be sure to communicate it to your registered dietician, and she can help you design a program that is more suitable to your needs, if possible.

Another issue of controversy is how much carbohydrate a gd mom should have, and how to divide this intake throughout the day. Older programs often had more total carbs (50-60%); newer programs seem to be reducing the amount of carbs to about 45% of intake. A few programs go slightly lower (38-40%). Officially, the American Diabetes Association states that about 15% of women with gd go on to need insulin to help control their bG numbers. However, in many research studies, the number is much higher; sometimes even 50-86%! The inconsistency probably has to do with the lack of a unified standard for when to initiate insulin therapy, research into prophylactic uses for insulin, and with the lack of standardized dietary therapy. Some programs put women on insulin very quickly and without trying to adjust dietary intake at all first, while others work very hard to help borderline women avoid unnecessary insulin if possible. There are therapists who have been able to lower the number of women needing insulin by restricting carbohydrate intake more, distributing it throughout the day differently, using moderately hypocaloric diets, or instituting exercise therapies. Experts in the field have called for more research into fine-tuning nutrition therapy for gd patients, and using nutrition changes along with exercise to aggressively reduce the number of women needing insulin (with its concurrent risks) while still promoting euglycemia during the pregnancy. This is an extremely important area for further research.



Other Nutritional Issues

There are several other nutritional issues of importance to gestational diabetics. First, how much protein is enough? Second, how do vegetarians handle gd? And third, are there vitamin and mineral supplements that can help prevent or minimize gd?

PROTEIN INTAKE

The Recommended Daily Allowance for protein in pregnancy is about 60g. Many older gd programs only included this amount of protein, and as noted previously, some of these mothers anecdotally reported increased rates of pre-eclampsia. Whether that was due to inadequate protein intake or solely to the increased rate of pre-eclampsia found in gestational diabetics is unknown. Dr. Tom Brewer found that low protein intakes did relate to higher rates of pre-eclampsia in his studies, and when he increased protein rates (as well as excellent nutrition overall), the rates of pre-eclampsia dropped significantly. He recommended a protein intake of at least 75-100g. However, it should be noted that his recommendations count the protein in everything you eat, including the small levels of protein in vegetables and fruits and breads, NOT just the amount of protein found in traditional protein foods. So it's really not as excessive an amount of protein as it might first appear.

Javanovic-Peterson and Peterson (Diabetes/Metabolism Reviews, 1996) state that "Diabetic women may be more vulnerable to protein malnutrition than non-diabetic women during gestation" but stop short of any actual recommendations for optimal protein levels. Many gestational diabetics find that increasing protein amounts slightly during 'problem' times of day can help bG readings significantly. However, some RDs caution against too much protein. They are concerned that kidney problems are a significant risk for diabetics down the line and too much protein can overload the kidneys and cause damage. So in anticipation of gestational diabetics getting true diabetes (and remember that a few gd moms will keep it after pregnancy or get it back shortly afterwards), they recommend being cautious in protein intake. On the other hand, however, the gd food program listed above (which was actually prescribed for a gd mom in 1997) has a protein intake of 120g of protein, above even what Brewer recommends. So obviously, not all Registered Dieticians are in total agreement on this issue. It's probably best to avoid excessive amounts of protein, but levels between 75-100 and even to 125g seem to be fairly well accepted. Consult your dietician. (And obviously, if you are carrying multiple fetuses, you will need even more protein. This is extremely important for adequate growth for multiples.)

A few voices object to Brewer's recommended level of protein as excessive, and note that when dairy products are not consumed, less protein is needed. This may be an interesting area to investigate. An example of this viewpoint is found in Diet for a Whole Planet. At this time, however, it seems best to err on the side of more protein rather than less, as long as the intake is not excessive. The risk for pre-eclampsia is higher with gd and inadequate levels of protein and other nutrients may be implicated with problems in pre-eclampsia and diabetes, so it is probably best to be sure to get enough protein, along with an excellent dietary intake of other nutrients.

VEGETARIANS AND GD

What about vegetarians? Can they complete a gd pregnancy without having to eat animal proteins? The answer is yes, of course, though they will have to work harder at getting enough protein. It is easier if they are ovo-lacto vegetarians (eat eggs and milk), since these are excellent sources of protein. However, vegans (who eat no animal proteins, not even milk or eggs) have of course been able to complete successful pregnancies as well. Close consultation with a registered dietician familiar with vegan practices and well-versed in substituting alternate foods will be important.

The main issue will be getting enough protein; many vegetarians use a soy powder to supplement their protein intake during pregnancy. It is known that during breastfeeding, vegans often have troubles with vitamin B12 deficiency; Kmom does not know whether this is a problem during pregnancy as well---it may well be. All that is necessary is a B12 supplement during breastfeeding; consult your Registered Dietician (one familiar with vegetarianism) about whether it is necessary during pregnancy. Ovo-lacto vegetarians probably do not need to worry about supplements as long as they get enough protein and eat a varied diet, but ask your provider.

VITAMIN AND MINERAL DEFICIENCIES IN GD

There is some recent research that indicates that vitamin and mineral deficiencies may play a role in gestational diabetes. It is important to note that this is preliminary research only and no action should be taken at this time. This research needs to be confirmed and if needed, further research undertaken on the effects of adding nutritional supplements. Supplements may not be effective, and as with any other substance, could possibly introduce more risk than benefit. In sufficient amounts, they could even be teratogenic (harmful to the fetus). So although Kmom includes this section for the purpose of familiarizing the layperson with new areas of research, it is important to note that it is too soon to take any action based on this research.

In the article, "Vitamin and Mineral Deficiencies Which May Predispose to Glucose Intolerance of Pregnancy" by Lois Jovanovic-Peterson and Charles M. Peterson (Journal of the American College of Nutrition, 1996), the authors write:

Gestational Diabetes is associated with excessive nutrient losses due to glycosuria. Specific nutrient deficiencies of chromium, magnesium, potassium and pyridoxine may potentiate the tendency towards hyperglycemia in gestational diabetic women because each of these four deficiencies causes impairment of pancreatic insulin production.

They go on to hypothesize that perhaps vitamin and mineral supplementation might be useful to "prevent or ameliorate pregnancy-related glucose intolerance" but note the need for additional research.

Supposed 'chromium deficiency' is a thorny issue. A supplement called chromium picolinate has been promoted in the popular press as helping with weight loss efforts and improving diabetes in some people, claims which have largely been debunked. Most diabetes researchers are divided on the issue. Peterson and Peterson note that "the results of pertinent studies using chromium in [non-pregnant] patients with impaired glucose metabolism are equally divided as to the utility of chromium to improve glucose tolerance." However, they found that chromium supplementation seemed to help gestational diabetics in their trial, though the sample used was quite small (24). It should also be noted, however, that partial funding for the chromium part of the study was provided by Nutrition 21, raising the possibility of a conflict of interest, although probably not serious.

In non-pregnant diabetics, a review of literature seems to point out that chromium supplementation is helpful only to those who were chromium-deficient. In other words, if your chromium levels were low, there does seem to be evidence that this may worsen your blood sugar levels, and that supplementation with chromium could possibly improve your condition. Diabetics whose chromium levels are fine, however, do not seem to benefit much from chromium supplements. Whether this is true in pregnancy is not well-studied; few studies on it exist.

The depletion of chromium during pregnancy has been established by at least 2 studies, but only one study as of the Peterson article has compared chromium levels of women with gd to those of nondiabetic pregnant women (Aharoni et al., 1992). It found lower levels of chromium in the gd women, with a significant decrease over the course of the pregnancy, while the normoglycemic women had no such decrease. The authors theorized that impaired utilization of chromium may play a part in gestational diabetes. This is very interesting indeed, but needs much more research to confirm and explain this phenomenon. The number of studies (and study samples used) are simply too small to draw any concrete conclusions from at this point.

Peterson and Peterson's study supplemented 24 gd moms with chromium picolinate and found significantly improved fasting glucose and insulin levels, and improved peak glucose and insulin responses to a 100g glucose load. However, women with severe glucose intolerance were not able to forego insulin therapy; the authors speculate that perhaps the RDA for chromium in pregnancy is not sufficient for such possibly severe levels of chromium deficiency. They note that further research using larger doses is indicated. An item of concern that they do not address is the safety of chromium supplementation in pregnancy. Kmom inquired about chromium supplementation during her last pregnancy; her OB was not comfortable recommending it due to lack of information about its safety. An information search run by CARE NW (which researches the effects of drugs etc. during pregnancy and/or lactation) also failed to find sufficient information about its safety OR efficacy, so caution needs to be practiced in considering this practice. Until more studies are done about its safety and efficacy, chromium supplementation should probably be avoided.

One other item of possible importance is that zinc and iron decrease chromium absorption. Since iron supplementation in pregnancy is extremely common, this could possibly be a factor in low chromium levels as well. Peterson and Peterson note that "Administration of pharmocological doses of iron impairs chromium absorption because chromium and iron also appear to share a common gastrointestinal transport mechanism. Pregnant women who are supplemented with pharmocological doses of iron for treatment of anemia may therefore have a resultant chromium deficiency."

In contrast, much more research has been done on magnesium deficiencies in diabetes, and a fairly good case for its influence on diabetes can be made. However, research has been stymied by a lack of efficient and sufficiently sensitive tests for magnesium levels, and the efficacy of magnesium supplementation is not well-established. At this time, it is not recommended that most diabetic populations be tested for magnesium deficiency unless they are at especially high risk. However, pregnant diabetic women are one of these high-risk populations, and it is known that babies of hypomagnesemic mothers are at higher risk for certain problems such as hypocalcemia (and other things), although any possible links to malformations and stillbirths has not been firmly established. Since this risk is in the pregnancies of true diabetics who are magnesium-deficient and risk for true diabetic pregnancies may not apply to gd pregnancies, it is not established whether gd moms should be tested or whether their babies are at similar risk. Much more research remains to be done in this area.

Low levels of magnesium are known to possibly predispose to elevation of blood pressure in pregnancy (pre-eclampsia/PIH), and it is often treated with magnesium salts when PIH becomes severe. Much more research has been done on the utility of magnesium supplementation in PIH; magnesium's role in gestational diabetes is less clear. Peterson states in the above article that "Gestational diabetic women are predisposed to magnesium deficiency mediated by glucosuria and impaired intestinal absorption secondary to iron supplmentation." So again, iron supplementation may cause problems in magnesium and chromium absorption, which may in turn tend to cause problems in being able to produce insulin effectively. However, this work needs to be confirmed, and the utility and safety of supplementation established before any recommendations are made.

Magnesium may be important both in keeping the baby healthy and in helping potassium make the pancreas work more effectively. Since magnesium is intricately tied up in the efficient usage of potassium (an important element in insulin production), the two must be considered concurrently too. The theory is that when magnesium is excreted in the urine due to glucosuria from gd, the body also lowers the potassium levels too, in order to keep the two in balance. And since potassium is one key in producing insulin in the pancreas, decreased magnesium resulting in decreased potassium may decrease efficient insulin secretion as well, thus causing or worsening gd---or so the hypothesis goes currently. So magnesium may be doubly important---but more research is needed.

Pyridoxine, also known as vitamin B6, inhibits prolactin secretion, and prolactin has a mildly diabetogenic effect. One study (Spellacy et al., American Journal of Obstetrics and Gynecology, 1977) found a pyridoxine deficiency in gd, though the work is quite old. The proposition of the Petersons is that supplementation with B6 in the second and third trimesters of pregnancy might help counteract the diabetogenic effects of prolactin, which might improve glucose tolerance. Since a rise in prolactin levels performs an important role in early pregnancy, they caution against supplementing too early, but speculate that supplementation later might help. They emphasize that "at present, the role of pyridoxine to improve glucose intolerance in gestational diabetes remains speculative."

Of great concern is the fact that nowhere in their articles do they address whether inhibiting prolactin in later pregnancy could have problematic effects on the pregnancy, including the very important role of prolactin in preparing the body to breastfeed. If they use B6 to prevent the prolactin levels from rising too high, will they also sabotage breastfeeding before it even starts? Will they even examine this issue? Gestational diabetes providers, while paying lip service to breastfeeding, are notorious for de-emphasizing it, interfering with it through unnecessarily obtrusive procedures, and sabotaging it by being uneducated about breastfeeding and supply issues (placing women on the pill without informing them of its risk to supply, etc.). Kmom has very strong reservations about using B6 to inhibit prolactin levels, and is especially disturbed that the possible effect on breastfeeding is not even addressed in the speculation and might not receive any serious attention in the research. Furthermore, prolactin may well play important roles in fetal development in later pregnancy that we are currently unaware of. Inhibiting normal levels of prolactin in order to improve glucose tolerance would involve tradeoffs of risk that may not be justified; one would need to establish that gestational diabetics have an significant excess of prolactin that is causing problems with glucose tolerance and that normalizing these levels improved tolerance while not endangering fetal outcome. As far as Kmom knows, no one has established that gestational diabetics have an excess of prolactin, and tinkering with nature's hormone levels is very tricky and dangerous business. Rectifying vitamin and mineral deficiencies is one thing; lowering hormones that have important pregnancy functions is another. Research in this area needs to tread very cautiously indeed.

Again, supplementation of any of these vitamins and minerals is not established as being safe under the conditions of a gd pregnancy. Too much of a vitamin or mineral (as well as too little) can also be a significant risk, and treatment must be carefully monitored as a result. Much more research is necessary to establish the need for supplementation, the efficacy of supplementation, and the safety of supplementation. Therefore, casual supplementation should be avoided at this time.



Can I Have Any Sweet Treats?

The prospect of going without any sort of 'treat' at all through Halloween, Thanksgiving, the Christmas Holidays, your birthday, or Easter can be very distressing. A very common question for women to raise during gestational diabetes is whether they can 'cheat' at all, or whether there is any way to work in some flexibility.

It's difficult to know what to reply to this, and you'll get different answers depending on whom you consult. Some gestational diabetics are able to have a bit more flexibility and with guidance from a dietician as to wise choices, are able to have a bit of a treat on rare occasions under certain conditions. Others cannot have any flexibility at all and must adhere extremely strictly to their food program. Some dieticians are more open to the idea of flexibility as well, while others would faint at the merest hint of straying. It's hard to know what to do.

In addition, it's important to know that emotionally, denial and anger are a very common part of gd. People diagnosed with 'regular' diabetes often experience the 5 stages of grief as outlined by Kubler-Ross (denial, anger, bargaining, depression, acceptance). This can happen in gd too. Denial in gd can take the form of not following a food plan, 'cheating', delaying or failing to take a bG reading because it may be high, or even stopping insulin treatment. Many women are justifiably angry over their deprivation, and it can throw them back into old poor dieting patterns (including sneaking food). Other women use bargaining to try and get a few food treats, and can easily fall into a cycle of deprivation/overindulgence. It's important to watch for these emotional sandtraps and avoid their lure. They can create havoc with the process of trying to control gd.

The best choice is probably not to have any treats at all but to just abstain for the amount of time left in the pregnancy. Most women are diagnosed as they enter their last trimester; surely 3 months of abstinence is not too much to ask in exchange for your baby's health! Diabetics who are not pregnant can sometimes have sugar, but pregnant diabetics are a different matter. Blood glucose levels have to be so much more strict in pregnancy that there is little leeway at all, and the results involve not just the mother's health but also her baby's. So women who have type 1 or 2 diabetes usually cannot have any treats. Women with gd tend to have less severe glucose intolerance and can sometimes indulge a little, but certainly strict control is also very important in gd as well. There have been cases of women with gd who have played manipulative games with testing (eating well on days of testing and bingeing on other days) that has resulted in the death of their babies, so it's probably better to err on the side of prudence. Certainly, treats using artificial sweeteners can be tried, but it's important to remember that while these are approved for use in pregnancy, the absolute long-term safety of these in pregnancy have not been proven to everyone's satisfaction (see the section on artificial sweeteners). So the best course is probably abstinence.

However, some dieticians will make exceptions depending on the circumstances. Women who are on insulin, who are having trouble controlling their levels at all, or who have any other problems are not good candidates for flexibility in their food plans and should plan on complete abstinence from 'treats'. This is extremely important. Women who have borderline cases of gd, who are able to maintain excellent and extremely stable control through dietary means alone (no insulin), and who do not have any complications may sometimes be able to work something into a holiday dinner, for example. What and how must be carefully considered, however, since all treats are NOT created equal. Some are much more dangerous than others. The key is to count carbs and to time and combine your foods carefully. NOTE: This section should not be taken as permission or advice to 'cheat'. Each person must make dietary decisions for themselves in consultation with a registered dietician or other appropriate health advisor. Their advice should be carefully followed!

If, in consultation with your health advisors, it is decided that you can try some flexibility, you need to choose your 'treat' wisely. For example, take Thanksgiving. A woman might have a choice between pumpkin pie or blueberry pie for dessert. The pumpkin pie is a FAR better choice because it started as a vegetable and is a great source of vitamin A, but mostly because it contains less carbs. The carbs in pumpkin pie mainly