5 Takeaways from Working in Gestational Diabetes

In this episode, I share five key insights from my experience supporting clients with gestational diabetes. We’ll cover both the clinical and emotional aspects of care — from navigating nutrition strategies to building trust during a challenging time. Whether you're new to GDM or looking to strengthen your practice, you'll come away with practical, evidence-informed takeaways.

https://guidelines.diabetes.ca/cpg/chapter36 

Transcript

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Hi, and welcome to the Femme Health Nutrition Podcast. I'm Nilou Deilami, registered dietician and founder of the Women's Health Nutrition Learning Hub, a platform where dieticians and nutrition professionals can learn, connect, and collaborate on all things related to female health and nutrition. If you haven't already, you can check out the website at w hn learning hub.com. The link is also in the episode description. This podcast is intended as an educational podcast for dieticians, healthcare professionals, and anyone interested in female health and nutrition. The content covered in this podcast is not intended as medical advice. If you have any questions or concerns about your health, please consult with your healthcare team or dietician. And before we jump into the content for today, I just wanted to share that I will be changing this from a weekly podcast to a biweekly podcast. I was a little bit over ambitious, I think when I, decided to do this weekly, and I think that. I wanna put together episodes that provide more value and to do that, if I have a little bit more time, I'll be able to create better quality content for all of the listeners. So if you'd like to know when new episodes are available, I do recommend subscribing. I'll also be announcing them in the newsletter as well every time they are launched. Okay, so let's jump into the content. So this episode is a little bit different than the previous episodes in that I will be talking a little bit about my personal learnings from working in a gestational diabetes clinic over the past couple years. It is a little bit less research heavy and more about what I've learned firsthand working in a gestational diabetes program. I've been working there for a couple years now, on a casual basis actually, but I've learned so much. I had previously worked in adult diabetes and I'd worked in prenatal nutrition, but this was just such an interesting blend of both of those worlds. Honestly, it's such an interesting field and I feel like it's something that we're not really exposed to in other areas of practice because it is so specific and niche. So the way it works here in Vancouver is if somebody is diagnosed with gestational diabetes, they do get referred to a pretty intensive program. I mean, it depends. The level of follow-up does depend on the program, but it's pretty intensive. Uh, patients are monitored closely and they're followed for their entire pregnancies. And then they're kind of discharged into the community. Now, gestational diabetes is. Often treated in a silo there isn't much conversation about GDMI feel like in preconception or general prenatal care. Or postpartum even. Which I honestly think is a missed opportunity. So even if you're not working in gestational diabetes, if you're a dietician who works in prenatal care or diabetes or just want to better support people during pregnancy, you may find the information in this episode helpful. So I'll start with a quick refresher on what gestational diabetes is and how it's diagnosed here in Canada, and what treatment typically looks like. So gestational diabetes or GDM is a glucose intolerance that first develops during pregnancy. It's most commonly diagnosed in the second or third trimester, so somewhere between 24 and 28 weeks. And it can affect anywhere between 3% to 20% of pregnancies in Canada, depending on the population that you're looking at. Now why gestational diabetes develops is because of the increasing insulin resistance in the second and third trimesters that are driven by what we call contra insulin effects of placental hormones. So hormones that the placental releases, including human placental, lactogen. Cortisol and estrogen can interfere with insulin function and reduce glucose uptake by maternal cells. Uncontrolled GDM does pose serious risks for both the mother and the child, and these include preeclampsia, preterm birth. macrosomia, which means a larger baby making delivery more difficult, and the C-section more likely neonatal hypoglycemia. And it also increases the mother's long-term risk for type two diabetes. Now, as per the guidelines by Diabetes Canada, we typically use a two step approach, for diagnosing gestational diabetes. So the first is to screen with a. Glucose tolerance test of 50 grams of glucose between 24 and 28 weeks. And if the one hour value is above 7.8, then we proceed to a second oral glucose tolerance test. The second test is with 75 grams of oral glucose, and it can be diagnosed based on the levels of the fasting, one hour or two hour glucose. and gestational diabetes is diagnosed if any one of the following thresholds are met. So if fasting is 5.3 or above, if one hour after is 10.6 or above. Two hours after is nine or above, and the unit for these would be millimoles per liter. I should have mentioned that. So you can find the exact reference ranges. in the description of the episode, I've added the Diabetes Canada gestational diabetes guidelines. Now there are some clinics that are just moving towards more of a one step test, especially for a higher risk group. So it really depends on the clinic and how they're, they're going about the test. But essentially there's a glucose tolerance test. And depending on the results, somebody may or may not be diagnosed with gestational diabetes. Now in diabetes and pregnancy clinics, I just want to mention that, it's not only gestational diabetes patients that are seen, we also see patients who have type one or type two diabetes. That's kind of out of scope for this episode. I'll be mostly looking at gestational diabetes. So who is at risk? people who have a family history of type two diabetes. Those with higher BMI or insulin resistance. Some populations are at a higher risk. So for example, those from African Arab Asian, Hispanic, indigenous, or South Asian descent may be at higher risk older maternal age, so age of 35 and older. Those who have PCOS may be at higher risk, and also those who have already had gestational diabetes or large for gestational age infant in the past. Now when somebody is diagnosed with gestational diabetes, their blood sugars are primarily managed through. Either medical nutrition therapy, so a lot of it is focused on quality of carbohydrates, quantity of carbohydrates, and ensuring that there's protein, fiber, and all those things that we all know as dieticians as part of the meal to keep those blood sugar stable. Physical activity. So we typically recommend walking after meals as the safest form of activity. Glucose monitoring to some extent, whether it's through finger prick or continuous glucose monitoring would be part of the plan. And if needed, a pharmacological therapy might also be needed. So, for example, for some people it might be metformin. Um, often it's insulin. And really in these kind of programs, you do need a team. So you typically have a dietician, a nurse, and a physician on the team to help support that patient throughout their journey. Okay, so now that we've set the stage, let's get into the heart of the episode. The five key things I've learned from working directly with people who have gestational diabetes. The first is that, gestational diabetes diagnosis can really trigger a sense of shame as professionals. Of course, we know that gestational diabetes is complex. It can really affect anyone. but I didn't fully anticipate how much shame some people would feel until I started working in this program. A lot of people carry intense guilt about their diagnosis. Even when you explain the physiology, like for example, how insulin resistance may increase during pregnancy because of placental hormones, the self claim tends to still show up. So people might ask, is this my fault? It's probably because I didn't eat well enough. They're afraid that it's gonna hurt their baby. And this is where I found that counseling skills really matter and how it really helps to kind of normalize the diagnosis. Referring it to as maybe common or manageable and not as a personal failure, it does to some extent help relieve a little bit of that emotional burden. It's also really nice to have that regular follow up with clients, which thankfully, in these sorts of clinics, we do have the opportunity to do. The next thing is fear and anxiety around food, and this is a big one, I see a lot of fear around food and after a diagnosis, people often become hypervigilant. So I've heard things like Will this harm my baby if I eat it? Am I allowed to eat fruit at all? Should I stop eating carbs completely? Sometimes I have people who've read information online and they come in eating very few carbohydrates where there isn't actually much research that that can actually help JDM and it could potentially be problematic. And I do have a blog post about that on the website in case you want to read it. But generally there's a lot of fear, especially around carbohydrates. And I think the way sometimes we talk about gestational diabetes, like if you have it, you might have increased risk of C-section and neonatal hypoglycemia. And when we're explaining all of these things, it can lead to a lot of fear and anxiety. So I think, again, normalizing the diagnosis, talking about how it is manageable, can really help. And really digging in and deconstructing those fears. Sometimes we don't have a lot of time, but it does help to talk about the why behind our recommendations. And of course we as dieticians we try to do this, but sometimes in a fast paced environment it can be challenging. So just telling people, about the reasons behind our recommendations. Talking a little bit about the physiology of blood sugar fluctuations, and also. Normalizing the need that maybe they do need pharmacotherapy or insulin, and that's not a failure. Bringing those conversations in early on can be really helpful. The next thing I've learned is health literacy levels. Are really important in this population. Again, we're working with people who are going through a very stressful time. They are vulnerable, so even with people who have higher health literacy levels, this can still be very overwhelming and. With the health literacy piece, there is the diet aspect where people may not have that knowledge of how carbohydrates impact blood sugars, how protein affects blood sugars and all of that. But there's also, I. Lack of understanding of what insulin is. So I actually see a lot of people who are very resistant to trying insulin because they have, this idea that it could potentially harm the baby. So again, it comes back to how are we providing that education? Are we explaining the, why? Are we using plain language? Are we really listening to see what they have understood before we kind of start to counsel? And just being aware that with working with different people from different populations, they will have health literacy differences. The next thing I've noticed is that cultural influences matter a lot. This is something that I've, um, increasingly aware of and cultural food practices and rituals around pregnancy are so deeply meaningful to people, and to be honest, they are often overlooked in standard gestational diabetes care. I remember I once had a client told me that they're avoiding knot because somebody in their family believed it might harm the baby. I had another one who was told to eat several dates every day to prepare for labor, which was a family tradition. I've had people ask me if they need to give up chapati or in Jira or rice or foods that are staples in their daily diets, and you look at the handouts that we're providing to patients in these centers And even though we're trying to make them more culturally relevant, they're still largely based on Western dietary patterns. It doesn't really reflect the reality of so many families, especially where I work, where it's largely an immigrant population that we work with. So what I've learned is really the importance of cultural humility. I was once working with this incredible indigenous advisor and they said that you can never truly be competent in somebody else's culture, but we can practice cultural humility. Instead of cultural competence and as dieticians living in places that are very diverse, like in Canada where I am, it would be very challenging to be competent in all cultures. But a cultural humility approach can help you stay curious and open to learning. And I see that patients are really deeply appreciative of this. So some of the questions we might ask are, you know, what do you normally eat? Can you show me pictures or tell me how this specific food is made? Are there any cultural foods that are important to you during this pregnancy? Let's figure out how to incorporate them in a way that doesn't spike your blood sugar. And also, what has your family or community told you about eating for pregnancy? Because this is what I'm seeing. We see people's family members, mothers, aunts, siblings, are giving advice on nutrition. So we focus on how can we build blood sugar friendly strategies within those traditions, and when we take the time to do that, clients can really feel seen and they can connect with you and be more open with you as well. The final learning that I've had is that the postnatal support gap is real. And here's the thing, we spend weeks, sometimes months supporting people during their pregnancy, but once the baby is born, the support kind of disappears. And considering how much. Gestational diabetes increases risk of type two diabetes. I find that really surprising. So yes, we do follow up testing and we talk about that. And most programs, OBGYNs talk about this with patients, family physicians, and we do get another glucose tolerance test around six weeks postpartum. But a single test doesn't change much in terms of behaviors. And we kind of need a little bit more time in the postpartum period with patients. We need to have that time and space to talk about some of those long-term strategies that can help prevent diabetes down the line given the new reality with a new child and a new family structure. And I don't think this should necessarily be done while they're in a diabetes and pregnancy program because there's just so much one person can absorb and. The focus in those programs is really to have that healthy pregnancy, but afterwards, there really needs to be more support. I think for private practice Dieticians, this would be a really interesting, niche to work in postpartum care for people who have had gestational diabetes. So those are five things I've learned from working in a gestational diabetes program. I know this was a little bit different in format to my previous episodes where I've gone through, more research and I'll be doing more of those as well. But I thought maybe I could kind of share some of those practical insights. That I have experienced, and that probably other professionals are experiencing in this space as well. Thank you so much for tuning in. If this episode resonated with you, please feel free to subscribe or share with a colleague. Just as a reminder, this podcast will be going from a weekly to a biweekly frequency, so the next episode will be coming in two weeks, along with my newsletter, where I will also announce it. If you haven't checked out the newsletter yet and you're not a subscriber, you can still subscribe at w hn learning hub.com. You can also see several blog posts about gestational diabetes on the website. Thank you again for joining me for this episode. As always, please feel free to share any feedback and I hope you have a lovely day.