GESTATIONAL DIABETES WITH LILY NICHOLS, RD {S5E6}

 Tasha (00:01:04): Hello and welcome to another episode of Raising Healthy Mothers. Today. I am so honoured to welcome Lily Nichols onto the show. Lily is a registered dietician and nutritionist over in the US, and she's also a certified diabetes educator. She's best known for her incredibly well-researched and definitely much referred-to books by me - Real Food for Pregnancy and Real Food for Gestational Diabetes. Welcome to the show, Lily. 

Lily: Hi, thanks for having me. 

Tasha: So I'm particularly interested to talk about gestational diabetes with you and that's why I invited you onto the show because I think it's one of those areas that in the UK, for sure where there is a lot of confusion, a lot of panic around the diagnosis and how to manage it. So I'm hoping that we can dive into your thoughts on gestational diabetes and what it means for the pregnant mum and how to manage it from a real food perspective. 

Lily: For sure. 

Tasha (00:02:08): So let's start with the basics. What is gestational diabetes? 

Lily: So gestational diabetes can be defined in a couple of different ways. One way is elevated blood sugar that first develops during pregnancy. Another one is elevated blood sugar that's first recognized during pregnancy, which can actually mean two different things. One means this is something that developed as a consequence of all of the changes that your body undergoes during pregnancy. And the other one implies that maybe there were some preexisting risk factors or preexisting blood sugar issues that were unknown prior to pregnancy. Because we don't do that great of a job of screening on a regular basis, the general population for blood sugar issues. But during pregnancy we do screen for those things. So maybe it was something going on before pregnancy, but we didn't catch it. And then finally, another way to define it is carbohydrate intolerance of pregnancy. 

So taking it beyond that, we just have elevated blood sugar. Carbohydrate intolerance implies that your body is unable to tolerate large amounts of carbohydrates at a single sitting without experiencing elevated blood sugar as a consequence. So it's a bit of a nebulous thing, but essentially it's high blood sugar in pregnancy. We don't really know, you know, was it happening beforehand? Is it only happening during pregnancy? And that's part of the reason that we often screen postpartum to see if there's blood sugar issues that are, that are ongoing after pregnancy. 

Tasha: Well, it's really fascinating that you kind of have that three sort of different definitions and you can't actually ever know, from the sounds of it, which one it is if you are diagnosed with gestational diabetes. 

Lily: Yeah. It's kind of hard to figure out. So I mean sometimes there are; like I worked with the California diabetes and pregnancy program which is more widely known as Sweet Success and they have some different diagnostic criteria. And one of them is to screen in the first part of pregnancy with a test called a hemoglobin A1C, which checks average blood sugar over approximately the last three months. So that would catch something that was going on previously. So if your A1C is in the prediabetic range, which is 5.7% or greater, they would treat it as if it's gestational diabetes. But technically this woman has prediabetes, we're just managing it during pregnancy. So we're calling it gestational diabetes, if that makes sense. And sometimes if the blood sugar readings are really high, say an A1C of 6.4 or greater, which is in the type two diabetes range, then we actually could diagnose in pregnancy that it was type two diabetes. 

But really since blood sugar is always in flux, it's kind of hard to know for sure until pregnancy has passed and your body is sort of recalibrated to a non-pregnant state. And to just continually check. But we do know gestational diabetes is, in women, the number one independent risk factor for developing type two diabetes. That's the earliest warning sign and the most reliable predictor actually; doesn't mean it's fate or destiny that'll happen. There's still a lot of things that you can do to reduce that risk, but it is a pretty reliable indicator that your body has some challenges managing your blood sugar and your insulin levels and you know, to be a little more proactive about it. I sort of give the analogy that it's like the warning light coming on in your car. It's like, okay, the system isn't working 100% as it should. Is your car gonna break down right now? Like, no, but down the road in five years or so this could be an issue so let's keep an eye on it. 

Tasha (00:06:16): And that's a really interesting analogy. And I find that is true of a lot of things actually that this kind of warning light comes on for lots of conditions that I think ‘we need to look at this now because 5 or 10 years or even 20 years later, this might actually show up as a bit of an issue. And I guess that's the kind of role we have as, as nutritionists or dieticians to intervene at an earlier stage that might get picked up during pregnancy or soon after that might not have done otherwise, because as you said, we don't do a good job of these diagnostic screening.  

So are we more disposed to become more insulin resistant during pregnancy? Is that a thing? 

Lily: Yeah, that's absolutely a thing. So in normal pregnancy, uncomplicated without any blood sugar issues, your insulin sensitivity decreases over the course of pregnancy, which in other words means your insulin resistance goes up and insulin resistance is something that happens when your body becomes less responsive to that particular hormone. That's a hormone that helps your body manage your blood sugar levels – insulin lowers your blood sugar levels. So as pregnancy progresses, your body becomes more insulin resistant, which means your body has to produce more insulin to overcome that insulin resistance, to result in the same, you know, maintenance of low blood sugar levels. So that's a normal pregnancy phenomenon if all systems are working as properly as they should, as they're designed. I should say the pancreas adapts and it'll produce about two to three times more insulin in later pregnancy than it does when you're not pregnant. 

And in fact, your body maintains lower blood sugar levels during pregnancy than outside of pregnancy. So if all systems are go and there's no preexisting insulin resistance that your body already has to contend with, you actually end up with maintenance of lower blood sugar levels than you were if you weren't pregnant. So it's a physiological design. And sometimes things don't go well with that design. So, you know, in the case of gestational diabetes, if there was preexisting insulin resistance, or if there's other factors that are greatly increasing your insulin resistance, like maybe you've gained significantly more weight than is recommended during pregnancy. Maybe you're eating a really high carbohydrate diet or lots of sugars, which spikes your blood sugar more and necessitates your body to produce even more insulin. It can get to the point where it can't keep up with the insulin production. 

If there's any deficit, I guess, in the pancreas where it has trouble producing more insulin, you might have fairly normal levels of insulin resistance, but your pancreas is kind of sluggish at producing insulin. That can show up as 'gestational diabetes' really, because all it means is your blood sugar is higher than we would expect, but there can be different physiological reasons behind it. And then of course, you know, placental hormones can interfere with insulin signaling. And so it's just one thing on top of the other is happening. Insulin resistance is going up. You have these placental hormones that are triggering even more insulin resistance. You have increased weight, which again, that's a normal part of pregnancy. You are going to gain weight during pregnancy. But that further increases your insulin resistance. So if there's things in the system that aren't working 100% as anticipated, high blood sugar can be the result. 

 Tasha: And so common for it to not be working a hundred percent. I mean, you know, because of our lifestyles, the environment we live in, we are not living optimal optimum lives. 

Lily: Yeah. Arguably we're not really living, you know, the way our ancestors did, even if you're not going all the way back to you know, caveman times, if you just go back 50 or 100 years, how many of our families were doing jobs that, required a lot of physical labour, they were growing or raising their own food. We certainly didn't have all the processing of our food, you know, sugar consumption and poor quality fats consumption has gone way up and displaced our more traditional intake, which actually included a fair amount of animal fat. And you know, we had vegetables, we had a root cellar with our veggies. It wasn't like we weren't opening a bag of dehydrated, mashed potatoes. You were making mashed potatoes from whole potatoes and from butter that you clabbered from the cream that you milked from your cow, you know, it's just a totally different environment. We weren't on screens, 24/7. We had a lot more exercise. We had a lot more natural sun exposure and all of those things that turns out do play a role in how well your body can manage your blood sugar levels. 

Tasha (00:11:30): Yeah. Unsurprisingly, really when you lay it out like that, I definitely recognize that. I talk to my grandmother quite a lot about the difference between being pregnant now and being pregnant, when she was pregnant and it is yeah, completely different world. 

I'm really fascinated about the fact that we are kind of insulin resistance, it’s potentially a kind of physiological norm and it's totally expected what our body will do. Do you, I mean, do we know why that adaptation happens? 

Lily: So part of it is different stages of pregnancy affect our body in different ways. So in the first part of pregnancy, just on sort of a general level across all mammals, actually it's considered an anabolic stage. It's a stage where your body is trying to build up. Nutrient reserves and fat reserves to later be transferred to the baby in later pregnancy. And some of these adaptations we have to remember really are more better suited to a time period when we didn't have 24/7 food available, we might face famine or food scarcity. Maybe we were in a hunter–gatherer environment. Your body had sort of stop gaps to make sure that no matter what happened, even if you went without food for a period of time that the baby would still be nourished. So your body sort of preferentially builds up nutrient reserves in early pregnancies. 

You're actually more insulin sensitive, blood sugar levels are lower. Your body accrues more fat during this stage, which surprises people because your baby isn't growing that much at that stage. I mean, obviously lots of things are developing, but in terms of the putting on of mass, like weight, the baby's very, very small in early pregnancy, it starts growing much more rapidly towards the end. So your body is the one that's preparing for sort of transferring those nutrients to baby later on in pregnancy preparing for postpartum to have sufficient fat stores to fuel breastfeeding and whatnot. As you get to the halfway point or so in pregnancy – and it depends woman to woman really when this shift happens – but over time, your body kind of switches to a catabolic state where it's more preferentially trying to send rather than just micronutrients, vitamins and minerals. I mean that continues to be transferred, but towards the end, you're really transferring more energy, more calories, more glucose, more protein, more ketones, more fatty acids. So your body starts pulling from your maternal stores as well that it had built up earlier in pregnancy. And part of that is if your body is more insulin resistant, that means that it's not trying to take up all that sugar and energy for itself. It's instead diverting that across the placenta to the baby. And again, those mechanisms, it seems are, are more well suited to our earlier existence decades or centuries ago when we didn't have such an abundance of calories available to us. And have so many processed foods available to us that tend to be, you know, blood sugar spiking foods. 

Tasha: Yeah. That's really fascinating that we have that switch from anabolic to catabolic throughout pregnancy. I that's really incredible. 

Lily: It's true across all mammals really. They've done a lot of research on like farm animals on this topic and it's like the sheep and the cows and the goats, like they all have this shift that you can, you can measure via various metabolic markers. 

Tasha (00:15:23): Amazing. I mean, what I find really fascinating is a lot of women crave carbohydrates, especially in the first trimester, but often throughout the whole of pregnancy. I mean it's really common and I'm really interested as to why you think that is. 

Lily: Well, so early pregnancy, like I said, your body is more insulin sensitive, so it has an easier time managing your blood sugar. You're also pretty prone to hypoglycemia. And then on top of that, there's so many metabolic things going on, your body is building a placenta – the placenta doesn't really take over for the supplying nutrients to the baby until around the second trimester. It's not, it's just not developed enough yet to be supplying baby with fuel. That baby's actually growing from what they call the endometrial glands, which is really interesting. Essentially, you know, your endometrium is like the lining of your uterus, right? That's what you shed every month with a monthly menstrual cycle. So essentially what would've been lost during your period, that's actually the fuel source for the early embryo and later the placenta develops and implants and slowly takes over the nutrient supply.  

So I believe the carbohydrate cravings to have more to do with managing your symptoms in that early stage of pregnancy. So like food aversions, nausea – super common – your thyroid is also undergoing huge changes. By mid second trimester it is pumping out 50% more thyroid hormones. It's really upregulating your metabolism. So this means you want energy and if you're also nauseous and have food aversions, and the only thing that sounds good is carbs. By default, I think you're just going to be eating more carbs in the first part of pregnancy. 

And I don't think that's a problem necessarily. I think you just need to follow your body's lead, do the best that you can. And within reason choose the best quality carbs that you can tolerate. And whenever possible, try to match them with some protein and fat so you're not just on a really wild blood sugar roller coaster, which tends to actually worsen the nausea. It's kind of this annoying conundrum where it's like, ‘I know I need to have some protein, so I'm not starving and nauseous again, but like, I really don't wanna eat any protein’. So, you know, you make amends and do whatever proteins your body can tolerate for the time. Maybe that's scrambled eggs with cheese and salsa, or maybe that's a grilled cheese sandwich or Greek yoghurt. I'm mentioning a lot of dairy because a lot of women find that easier to tolerate in that stage, you know, nuts and seeds, those sorts of things, if you're finding you're meat-averse.  

As you get to later in pregnancy... So first of all, I think like, I don't wanna say people can develop bad habits, but if you're not really conscious about how you feel after you eat – carbs are, you know, they're delicious, they give us a nice dopamine surge – it's really easy to get in sort of a cycle of just eating carbs. So if you get on that train via, you know, a need for survival in the first trimester and you don't break that cycle once the nausea and food diversions have subsided you will just kind of continue on that cycle. And it's a physiological mechanism too. It's not a willpower thing. You know, you eat carbs, you get a blood sugar spike, your body produces insulin, you get a blood sugar crash, then you're hungry. 

Your body gets kind of an emergency signal that like, ‘oh my gosh, your blood sugar is low or it's dropping really fast. We better eat something to raise our blood sugar back up’. And so you are on this cycle again and again and again. And if you're not conscious about reincorporating normal food back into your life, when the nausea and aversions have subsided, it's really easy to just be on this carb cycle again and again. So I really try to encourage people to be aware like, ‘okay, are my symptoms like enough that I could now tolerate having a little chicken or having egg, or incorporating a little more protein?’ As you incorporate more protein, it tends to stabilize your blood sugar a lot better. You don't get quite the spike and you don't get quite the drop. 

So your body doesn't get that emergency of 'you need to eat carbs to raise your blood sugar'. You can actually go longer between meals before being hungry again. And your blood sugar is just not on as much of a roller coaster, but that does require some, you know, checking in with yourself and, trying to kind of offset those first trimester nausea–aversion eating habits, which again, I don't wanna demonize that. I think you gotta do what you gotta do, but eventually as that stage lessens – and it might take a while sometimes it's into the midway mark of pregnancy, women are still feeling some nausea and aversions into 20 weeks. It's usually less. But try, just try to get that protein in that's probably arguably the most important macronutrient and source of micronutrients for you to really focus on. And it does have carryover benefits for your blood sugar. 

Tasha: Yeah, totally. And I’m really totally on board with that, but I also really recognize in myself during pregnancy to have that kind of, as you said, almost hangover where I had that. I definitely had meat aversion in first trimester and had a preference towards carbs. But also I find in third trimester because I get really bad heartburn and sometimes nausea and even vomiting from that. I can easily fall back into this, especially at breakfast time when it's just so difficult to think of anything other than toast, cereal. 

Lily (00:21:40): Yeah. That's a time where I might think about well, think about your heartburn triggers in and of itself. So avoid the things that are triggering for you personally. But that can be a time when smaller meals, smaller, more frequent, just kind of grazing throughout the day makes more sense for a lot of women in the later stages. And then again, thinking on the protein terms, because there's actually research showing that a high carb and a blood sugar spiking kind of a meal can actually trigger the heartburn. Because it relaxes the lower esophageal sphincter so your food can more easily come up. So it's a fine balance, right? Because the carbs are quicker to digest and they taste good. They're easy on the stomach. 

If they come back up, it's not as blah. But at the same time you still wanna have that balance –you don't have to omit carbs, but can you fit in maybe some protein that's less gross in the chance that it burps up or comes back up like a Greek yogurt or cottage cheese with berries? Just trying to match the carbs with a little protein can sometimes offset that, but you know, it's a fine balance and every pregnancy is different. Every woman is different and you just gotta do what you gotta do to manage the symptoms day to day, week to week. 

Tasha (00:23:10): Yeah. No, that's really great advice though. And I totally agree that I notice if I have had a carb heavy meal and not had very much protein it can definitely be worse for sure. 

So just coming back to gestational diabetes then, so what are the risks? We talked about the fact that it increases the risks of type two diabetes for mum, but what are the risks to baby, if mum is diagnosed with gestational diabetes? 

Lily: So first of all, I would say that a diagnosis of gestational diabetes doesn't mean that there will necessarily be any problems with baby. It's all about where your blood sugar is at on average, over time, over the course of the pregnancy – that is really the bigger risk factor for problems. So when blood sugar is not well controlled and I always wanna clarify that because I feel the advice that you're given is really often very doom and gloom. You know, it's like, ‘oh, you have gestational diabetes. It has all these risks’. And you're given this very fear mongering lecture, that's disempowering, and almost like to scare you into compliance. Which I think is just the absolute opposite of helpful.  

So nonetheless, it is important to understand that there can be risks. If the diagnosis isn't taken seriously and a woman doesn't make many shifts to her eating habits, so her blood sugar is just high a lot, I'd consider that uncontrolled gestational diabetes. There can be a number of risk factors ranging from issues with baby's growth and birth ranging all the way to issues with their metabolic health later in childhood or into adulthood, which I think is the bigger issue than this concept that ‘oh, if your blood sugar's high, your baby might grow larger than normal’ – a lot of people don't really see that as a problem. What's the problem with having a bigger baby? It's not really the size of the baby that's the issue. It's the metabolic exposure that they had in utero that led to the size is simply a consequence of that because there's also very healthy babies who are slightly bigger and it's no big deal. 

So the metabolic issues are that exposure to high blood sugar during pregnancy affects the baby's pancreas, their insulin production and their insulin resistance. So they can actually become insulin resistant in the womb. Once they're at a certain point of pregnancy where their body, the baby's body, starts producing insulin. If they're exposed to high blood sugar via mum, and really their blood sugar levels are like a mirror image of what the mum has and mum's insulin does not cross the placenta. That means the baby's pancreas has to pick up the slack to produce enough insulin, to maintain low blood sugar. Higher blood sugar in baby is dangerous. I mean, our physiology knows this. And so it produces lots of insulin that results in more deposition of fatty tissue in the baby. So they're large, not because they're like exuberantly healthy, it's because they've been exposed to a whole lot of excess fuel and their body has, you know, stored it away to try to keep their organs safe from the damage of high blood sugar that can lead to issues at birth. 

There could be challenges with lung development as a result of high blood sugar. Of course, if the baby is really disproportionately large, especially in the shoulders, which can happen, sometimes there's a higher risk of injury during childbirth or necessity for surgical intervention or whatnot.  

But there can also be an issue with low blood sugar at birth. So you have to think about what's happening. A lot of people are like ‘that doesn't make sense. Wouldn't their blood sugar be high at birth?’ Well, their body is adapted to having an IV essentially, via the umbilical cord, of sugar. So once the baby is born and the cord is cut their sugar supply stops immediately, but their insulin production is matched for that high blood sugar. So they go hypoglycemic because they're producing a lot of insulin. So that can be a medical emergency in itself.  

All that stuff seems like it only matters around birth. My bigger concern is that these metabolic exposures, well, yes, it can make the birth and early days of life, more challenging or risky. Long term they have a higher risk of type two diabetes and obesity later in life, which can be anywhere from a six to 19 fold increased risk. Again, this is exposure to uncontrolled blood sugar and pregnancy. This doesn't happen with mild, well-managed cases. I always have to counter it because it's serious and it sounds scary, but it also doesn't have to be. So when we see these rising rates of childhood obesity and type two diabetes, we all wanna point finger at poor quality food, too much sugar, not enough exercise. And those things do all count, you know, in childhood. But also if your physiology was literally programmed in the womb to be insulin resistance and have trouble with blood sugar management it's like you are more prone to have a poor outcome when you tack on all of those issues that modern children are facing, which is an abundance of poor quality food that's often really high in sugar and sitting behind screens and not moving very much. So if we can sort of stack the deck in the baby's favour with better blood sugar management in pregnancy, they're not already starting out life from day one predisposed to diabetes. I mean, we used to call it adult-onset diabetes. That's what type two diabetes was. And they had to kind of nix that from the definition because we're now diagnosing two year olds with diabetes and that's just crazy, that really shouldn't be happening. But you know, you look at the stats, in the US about half of the adult population has some form of diabetes or prediabetes, most of which is undiagnosed. So again, we're often catching it during pregnancy and it can actually be a really positive opportunity to learn how does your body respond blood sugar-wise to different foods? And how does that make you feel? You can start making these sort of mindful eating connections, the blood sugar connections, and you can carry those things through the rest of your life to hopefully not develop type two diabetes later on and carry those same nutritional principles forward when your kids start eating food and hopefully, you know, keep them healthy long term. So it can be a positive thing. And I always try to point that out because I think a lot of people get stuck on the scary part. 

Tasha (00:30:38): Yeah. And I think it is really encouraging as well when you say that the sort of risks that you talked about, the major risks, both at birth and long term are really when it's really poorly managed, very disaster sort of levels. Whereas actually a lot of the time it can be managed when it's caught early enough which I'm hoping that we can get onto, but before we do that I'd love to talk a little bit about testing. So you mentioned at the start about the HbA1C in early pregnancy. I don't think that's something that's done here routinely here. In the UK you get the oral glucose tolerance test if you have a risk factor. So again, it's not a routine test, it's if you're over a certain BMI or if you have family history of diabetes or anything like that. So it's not a standard test. 

Lily: Oh, interesting. So they don't do universal screening for it. 

Tasha: No, they don't. So I'm really fascinated because HbA1C is one that we use a lot to understand, in a non-pregnant state in clinic, to understand what is going on with your blood sugars, right. As you said, it's a good mark of what's been going on for the last three months. But it's stated in the UK to not be reliable during pregnancy, and that's why they don't use it. So I'm really fascinated to know a bit more of your insight into testing. 

Lily: Oh, well, there's some nuance to that. And I will say most places in the US are also not screening with A1C in the first trimester. There are some places in California and especially the west coast who follow the Sweet Success guidelines who are more likely to do screening in the early part of pregnancy. Now there's been a lot of debate about the use of A1C in pregnancy, and you're correct that it's not reliable in pregnancy in the later stages. And that's because your A1C is essentially measuring how much of your hemoglobin is glycated, that's why it's hemoglobin A1C or glycated hemoglobin is another way to say it. So how much of your hemoglobin is sugar-coated. In pregnancy, your red blood cells, which carry hemoglobin turn quicker. So it doesn't stick around in your system quite as long, and then your blood is more dilute. 

So the sugar molecules don't have as much time, not as much interaction because it's so watered down, your blood's so watered down to glycate as much of the hemoglobin. So it can show up artificially low in later pregnancy. So it's really only a reliable marker from a diagnostic standpoint, in the first trimester. And that's really to give us an indication of what was happening with your blood sugar pre-pregnancy. Now it's not perfect. However, as you get into the greater than 5.7% range, especially in the greater than 5.9% range, the chances that a high A1C will predict a woman later failing the oral glucose tolerance test, that's a 98.4% chance. If her A1C is over, is 5.9 or greater, there's a 98.4% chance she'll also fail a glucose tolerance test later in pregnancy, meaning it's highly predictive of you having blood sugar issues later in pregnancy. 

And technically those blood sugar issues came with you into pregnancy. That's why your A1C is, is high. So they use it as a screening marker. So in California, at least, anyone following the Sweet Success guidelines, if your A1C was 5.7% or greater, in other words, in the prediabetic range, we just treat it as if it was gestational diabetes. You didn't have to do a glucose tolerance test. We would just monitor your blood sugar for the remainder of pregnancy. And I worked in a setting with a perinatologist and that's what we did. We screened everyone universally with A1C. It is inexpensive. It doesn't have to be done fasting. Just add it to the first trimester blood work for the first visit, see where you're at. If it came out in the high range we'd treat it as if it was gestational diabetes, they got a blood sugar meter. We monitored over the course of pregnancy. Then you have two-thirds of the pregnancy to intervene and do something preventing issues, because there's a lot of complications in pregnancy that can result from high blood sugar, like preeclampsia, cholestasis, and so many different things. Whereas if you only wait until the 24 to 28 week mark with the glucose tolerance test, you really only have one trimester of pregnancy to do anything. So for those who had a normal A1C, we wouldn't bother testing them again until that 24 to 28 week mark. And then we'd use a glucose tolerance test at that point. So that's the short and long story about the A1C. 

Tasha: Yeah, it's fascinating. And it makes sense as well to do that in that early stage. So was that within the first eight weeks or so? 

Lily: We'd do it within the first 13 weeks. So the first trimester technically of course, as you get further along, you're catching less and less of the preconception time. So if you do it earlier in the first trimester, that would be the most accurate. But it still provides at least some level of insight no matter when the first trimester labs are drawn into what's going on with your blood sugar, you could also just do a point of care fasting blood sugar check and see what's going on. In California for women that were high risk, if you weren't going to screen with an A1C, you could do a glucose tolerance test earlier in pregnancy. They sometimes do that. Some people also just opt to do home blood sugar monitoring, because none of the testing methods are perfect. And I actually outline this in chapter 9 of Real Food for Pregnancy in the lab test for pregnancy, all the different options and the pros and cons of each one. Like the glucose tolerance test can have a false positive or a false negative. It's a single point in time on a single day. It can differ by the time of day. It can differ by what your typical diet has been in the last day or week or more prior to taking the test. It doesn't give you a really full, comprehensive view of what's happening with your blood sugar, but it is the simplest and, from a research perspective, the most validated way to screen for gestational diabetes, even if it's not perfect. For the really motivated client doing two weeks of blood sugar monitoring at home might give you actually more information. They can also start to see how different foods affect their blood sugar differently. They can get a picture of their fasting, blood sugar for 14 days instead of a one-day check. You know, like what if you had really bad sleep the night before, your toddler woke you up five times. You know, yeah, your fasting blood sugar will come out higher that day for better, for worse. Right? So, you know, there's different options and pros and cons to really all of them. 

Tasha: Yeah, I mean, I'm a big fan of the at-home monitoring because of that awareness, the direct correlation between what you're eating and what's happening with, your blood sugars, really soon after, and then as you said, stress and sleep and exercise as well and how that affects your blood sugars. So yeah, I do. I'm a big fan of that too. But it's interesting about the oral glucose tolerance test and it's noninvasive because it doesn't take any blood out of you, but it's a lot of sugar. 

Lily: Yeah, yeah. It's a lot of sugar. There's a lot of reasons people don't like it, you know, if you eat sort of moderately low carb like I do, you can get a false positive. I actually have a blog post for my first pregnancy on my blog. If you wanna read it, ‘I failed the Glucola’ is what it's called. You can use the search bar to find that so you can get a false positive on it. You can get a false negative on it sometimes. So there's a lot of different additives and things in many of them, not all, that a lot of women don't wanna be exposed to. So there's that, then there's also the argument, you know, is it really physiologically normal for your body to be able to process 50 to 100 grams of sugar in one sitting? 

And I give the example in my book, they've done studies on animals, so they've done studies on pregnant horses and some of the horses they fed their usual diet, which was hay and alfalfa and the other horses, they gave a grain ration. So one was eating a normal diet, low carb, really what horses are designed to eat. The other horses were given grains and guess which group failed the glucose tolerance test. So the horses that were eating the grains, their bodies became adapted to a high carb diet. They produced a lot of insulin in large boluses because their body required that and they passed the glucose tolerance test. Whereas the horse is eating their normal, species-appropriate diet, they failed the glucose tolerance test because their body is not adapted at that moment in time to produce large boluses of insulin in response to a glucose load. 

So I do make the case in the book. You know, if you are in the category of somebody who's pretty metabolically healthy, doesn't eat a ton of carbs. Doesn't regularly eat a lot of sugar, juice, smoothies, super high carb foods like oatmeal, rice, those sorts of things. You know, you are at risk for getting a false positive on a glucose tolerance test and you might be a person who would be more interested in doing an alternative screening method, like checking your blood sugar for two weeks. The challenge is different medical practitioners sometimes don't think that's valid or don't wanna accept it. They really just want you to do the test, which you can also carb-load for a week ahead of time, get your body, if it's able to adapt, it'll adapt. And you should pass the glucose tolerance test just fine.  

When I did it, I did not carb-load. I was kind of doing it for science, so I was like, ‘let's see what happens, I've heard, this is a thing’. And I don't know if it's a thing. I mean, I only failed by a point, but still it was like, ‘wow, Okay’, and then I followed that up with a couple weeks of blood sugar monitoring and everything was A-okay. And even high carb meals in the context of a mixed meal. My body had no problem with that, none of the readings were high. So you can also sort of do a combined thing, but you know, anytime you're doing something, that's not the way the system does it, you become maybe what they'd call a problem patient. I can't say I was the easiest for people to work with. But you also gotta learn to advocate for yourself and that'll come in handy with your birth choices. 

Tasha: Totally, totally. 

Lily: And all of the decisions that you'll be thrown into later on. 

Tasha (00:42:48): Exactly. I'll find that blog post that you mentioned and linked it in the show notes. Because I think that will be really fascinating for people to follow up on.  

But also mentioning that horse study and the species-specific diet leads us nicely onto how can we manage gestational diabetes with potentially a more species-appropriate diet for ourselves. So what would you say are your top recommendations, specifically with a gestational diabetes diagnosis, let's go with, it's a mild one rather than that sort of really poorly managed one. What is your general recommendation there? 

Lily: Well, from a species-appropriate standpoint, I'll throw out a little interesting statistic, which was a study that looked at over 220 modern hunter–gatherer populations and their average carbohydrate intake was 16 to 22% of calories. Compare that to the US dietary guidelines, I'm sure the UK is pretty similar. They recommend 45 to 65% of your calories from carbohydrates. So first of all, I think we need to eat a species appropriate amount of carbohydrates. They don't need to be eliminated, but arguably it's gonna be less than the guidelines. And you have to think about it really from a logical standpoint and any of these glucose tolerance test options give you anywhere from 50 to 100 grams of glucose, the recommended minimum amount of carbohydrates per day, that you’re given. So you get a gestational diabetes diagnosis. 

You're given a diet that has no less than 175 grams of carbohydrates per day. So you split that up into meals and really you're looking at no less than 50 grams or so of carbohydrates at a meal. If you failed a glucose tolerance test that has a similar amount of carbohydrates, why are we then 'treating' with a diet that has that many carbohydrate, why are we expecting your blood sugar to come out in the normal range? If it clearly did not do it that well when you did the standardized tests in the office. So that's just a little food for thought.  

Secondly, I'll add that in practice when you give those diets – and I was a good little dietician who followed the rules for a long time – it doesn't work. So at least half of my clients would have no change, no positive change in their blood sugar or their blood sugar would sometimes get worse with the dietary advice. 

So it was very clear that we shouldn't be giving so many carbohydrates to somebody who's already carbohydrate intolerant during pregnancy. So first of all, you need to bring your carbohydrate load down to a level where your body can have normal blood sugars after that meal. And that amount is gonna be different person to person. So it's gonna take some testing, but it's arguably gonna be less than what the guidelines tell you to eat. The other thing is you need to be having enough of your other macronutrients, your protein and fat, to help mitigate blood sugar spikes from those carbs. So I use the term, no naked carbs. Don't have a piece of bread by itself, make sure we're having the bread with something that has protein and fat in it and hopefully a high-quality bread that has fibre in there, which further helps to mitigate your blood sugar spike. So instead of having bread by itself, you match your bread with an egg or two in the morning, and you can play around with this, with your blood sugar meter and see what happens when you only have toast by itself. What happens when you have toast with eggs, it's a vastly different blood sugar response. So make sure you're pairing your carbs appropriately – no naked carbs. Honestly it can be just those two things are really enough for you to get started.  

I do think there's arguably like a role for talking about a number of different micronutrients, your vitamins and minerals, that help with your insulin signalling and insulin production. So the less processed foods you're eating, they're not only better for your blood sugar because they don't have as many refined carbohydrates. But they also have all these other vitamins and minerals that helps your body really function better in its blood sugar management system. So there's definitely a role for that. And that's why my books have the title ‘Real Food’ added in there because there is a role for a lot of these micronutrients for not only the whole pregnancy health and foetal development, but just from blood sugar management as well.  

And then, you know, the final thing is, everyone is gonna have a different response to different foods. There really isn't a one size fits all. So the general things I've already talked about pretty much hold true, but you'll have some women who have a better blood sugar response to potatoes than they do bread. And the next woman it's gonna be the opposite. Some women do great with certain types of fruit, other women, their blood sugar response to an apple is just horrendous, but they do great with berries or great with another type of food. 

So you really have to what I call ‘eat to the meter’, pay attention to what your blood sugar readings are from your blood glucose meter and honor that like, ‘okay, wow, that meal of, I don't know, fill in the blanks like pasta did really did my blood sugar, no favoors. Maybe I can try doing a pasta made with legumes or lentils. Like they have all these bean and lentil pastas now. Maybe I can try swapping out some of the pasta for some broccoli or green beans or something. Maybe there wasn't any protein with the meal and I need to add like a bolognese sauce that has like ground beef in it and some Parmesan cheese on top. So I'm getting that extra fat and protein in there to help like mitigate that spike’. Those are, that's the part of it. That's really a one-on-one learning thing, you with your meter, maybe with your healthcare provider or nutritionist, if they're, able to help you with that. But it's very much figure-outable. And doesn't need to be nearly as scary or as complicated as I think it is generally presented. 

Tasha: And I think it's really fascinating as well, to be reminded that we are so individual and have different responses to different carbohydrates and even different fruit, as you mentioned with the apple versus the berry thing. And doing that n=1 experiment is actually an opportunity to get really intimate with how well your body works with certain food. And it is fascinating. But as you said, you do have to be quite motivated and quite interested really. 

Lily: A continuous glucose monitor is a little blood sugar meter that stays on your arm for approximately two weeks. And you can scan it at any time. You don't have to prick your finger. You know, the thing goes in once and stays there for a while. You can scan it with your phone or a reader and see exactly what's happening with your blood sugar. I mean, it's taking a reading 200 something times per day. So you can see exactly when you're spiking, how high you're spiking, how quickly you're dropping. And that is fascinating. 

Tasha: Potentially obsessive, I imagine. 

Lily: Yeah. I mean, so I've done it, several times and I've written about it on my blog, if you wanna read about it look up CGM experiment and you'll see. So there's certain carbs that my body really doesn't do well with and others that it's fine with. So that's always interesting to learn those things. And I think for some people it can lead to over obsession. So I think you have to use it carefully with a specific goal in mind. And unless you have type one diabetes or something, I don't think it needs to be something you're wearing continuously at all times, but just from a two-week window of wearing it, you will learn a lot about what spikes your blood sugar, how high it spikes, how different combinations of food affects it, how quality of sleep affects it, how stress affects it. It's more significant than you think. 

These are all things that you just learn so much more from CGM than you would from a single point finger prick. So if that is available to you, that's super, super helpful. It gives you so much insight. But yeah, there can be downsides because I think some people will wear it and pathologize any tiny little blood sugar spike is a problem. So you might opt to really overly restrict, where physiologically it's normal to have variations in your blood sugar. You wanna avoid a hundred-point spike or whatever. But it's okay to have some variations. It's okay to occasionally test your blood sugar insulin system in your body with a higher carb meal. It's not the end of the world. It's really, the issues are frequent super high spikes or sustained high blood sugar over long periods of time. So you do wanna be careful that you don't start inadvertently starving yourself or going keto when you don't really need to go keto. So, you know, you have to take it with a grain of salt. 

Tasha (00:52:45): Yeah, exactly. And be sensible. Fab, that was really useful. And I think, going back to the managing aspect of it, just taking those two points that you said actually does just simplify it for other people and, as you said, not make it too scary a prospect, at least at the beginning.  

Right now I wanted to ask you, and this is related to gestational diabetes, but pregnancy generally, eating in pregnancy, around the safety of eating liver in pregnancy. Because I know it's something that you talk about in your book. And I know it's something we could probably talk about a lot, but I'm really fascinated because it is something that, you know, pregnant women are not recommended to eat, in the UK at least. And I imagine it's the same in the US. But what is the story behind that? 

Lily: So the issues really against liver are usually twofold. One is related to its vitamin A content. It is very high in vitamin A we'll talk about that in a second. And the other one is sometimes there's specific advice against consuming prepackaged liver pate, and that is a food safety concern over a risk of it being contaminated with listeria. I have a whole section in chapter 3 of Real Food for Pregnancy breaking down the research on liver. If we're just gonna take it from like the vitamin A standpoint, the research that suggests you need to limit your vitamin A intake comes exclusively from studies that supplemented with high doses of synthetic supplemental vitamin A, not food sourced vitamin A, and there is a difference in how your body metabolizes different types of vitamin A. 

There has never been a study showing that liver is a teratogen or that the vitamin A specifically in liver is a teratogen. Teratogen is something that causes birth defects by the way. So I think we need to take it a little bit with a grain of salt on that side of things. That said, I don't recommend extremely high doses of liver that like give you tons and tons of vitamin A. My argument is for liver being included in the diet, maybe weekly or even just a few times a month as almost like a multivitamin supplement in a way. Liver really is the most nutrient dense food on the planet, arguably. And a lot of the nutrients that contains are difficult to get in the same concentrations in foods elsewhere. And just to talk about the vitamin A for a minute, in the US 80% of childbearing age women are not meeting the RDA for vitamin A. The RDA – recommended daily allowance, how much of a nutrient you should have in any given day – is already set at a very conservative, low level. So if 80% are not getting sufficient vitamin A, why are we now telling women to completely exclude a food source of it? It would make a lot more sense if you even wanna draw a parallel on synthetic and naturally occurring vitamin A, which I don't think you can fully make, but if you wanna go there, it would make a lot more sense to give like a limit, like a weekly or monthly limit rather than full exclusion, because full exclusion pretty much guarantees you're gonna be deficient in vitamin A.  

So they did a study in the Netherlands where 70% of women who did not consume liver failed to meet the RDA for vitamin A where it was very rare among women who consumed it regularly. There was another study out of South Africa in the sheep farming area where the people who produce the animals tend to consume more of the organ meats, because those aren't as valuable at market. So they consumed liver, I think it was an average of 2.3 times per month, and there's no vitamin A deficiency there. There's also no evidence of birth defects there. 

And there's another study I found recently that showed over the past 30 years – so we get all concerned about vitamin A and birth defects – but over the past 30 years, they've identified 20 cases of birth defects attributed to vitamin A intake and not a single one of those was attributed to the consumption of liver. Meaning it was synthetic supplemental vitamin A. So the risks are very, very small to begin with, likely don't even apply to liver. And you're also going to be excluding a really nutrient dense food and likely subjecting yourself to some nutrient deficiencies. We're all concerned about excess, but a lot of these same birth defects can be caused by insufficient vitamin A intake. That was actually most of the research prior to the 1990s was on vitamin A deficiency and its risk for birth defects. You know, you expose experimental animals to vitamin A deficiency and they often can't even carry a pregnancy to term or it results in a stillbirth or really, really severe birth defects. And so it's a Goldilocks nutrient, you know, we can't be so fearful that we don't consume any it's something that it makes sense to have in your diet a little bit, a few ounces a week is plenty for liver, really fills in a lot of nutritional gaps, totally safe, not excessively high levels of vitamin A and you're you're better nourished. 

Tasha: I know and I totally agree. And it's so frustrating that it's such a stark recommendation of no consumption whatsoever, whereas other things, in the UK at least, oily fish is recommended to be kept to two portions a week. And to avoid the bigger fish, which is relatively sensible advice for the contamination with mercury and it just seems a bit limiting to not have that similar kind of idea behind liver consumption. 

Lily: As well. Yeah, they really should have given an amount if you're gonna make the recommendation, at least make an amount. Even if you wanna stick within the like 10,000IUs per day limit, break that down into amount of liver per week and give them guidance on that. But they don't do that.  

Tasha: I have to say actually getting people to eat liver in the first place is often quite a challenge so it’s not a common food. 

Lily: It is a self-limiting food too. Like it has a intensity of flavour. It's an acquired taste. First of all, if you didn't grow up eating it, then it's weird to eat liver. I didn't grow up eating it. So it's something I learned to eat. But it's a self-limiting food. If I'm having straight up liver, usually I make it into like a pate and hide it in ground meat dishes, so it's really small amounts spread over the course of a meal or a dish that we eat over several days. But if I'm actually gonna fry up chicken liver and eat it, I'm hard pressed to get three ounces down the hatch, you know, you're pretty done with the flavour of liver after an ounce or two, you know? So it isn't a food that I see people overdoing. 

Tasha: No, you're not gonna gorge on it. 

Lily: Very, very rarely, I think maybe in the case now that people are talking about liver and lots of people are taking liver supplements, desiccated liver. I have had some people where they're taking all these different desiccated organ meats and on top of their prenatal vitamin that has vitamin A and I'm like, ‘okay, whoa, wait, maybe you don't need to have like 10 capsules of desiccated liver every single day’. You know, that's arguably not really ancestrally, you know, that's not normal either. So I mean, now I have to give the caveat, but in a general population, it's very rare that liver is over-consumed. 

Tasha: Yeah, yeah, no. Great. And it's great to have that overview of why the guidance is to avoid it and actually why that potentially is quite a flawed guidance. That's really useful.  

Well I think we can sort of wrap things up there. We have talked a lot longer than potentially we expected to, but this has just been absolutely fascinating and really, really helpful, I think certainly to myself and hopefully to my listeners as well on gestational of diabetes. Thank you so much. I'll definitely put some links to those blog posts that you mentioned. I'd love to link to the Sweet Success as well. I think that might be quite an interesting thing for listeners. 

Lily: Yeah. I'll pull up those for you. 

Tasha: Yeah, that'd be great. And also obviously links to your books as well. And hopefully this will be a really useful one. Thank you so much for coming on the show. 

Lily: Thank you.