The incidence of diabetes is increasing at an alarming rate in the United States. Nearly 21 million adults and children currently have the disease, another 54 million have pre-diabetes and about half of Americans are currently at risk for type 2 diabetes. Projections by the Centers for Disease Control and Prevention forecast that the prevalence of type 2 diabetes could double by the year 2050.
The growing epidemic of obesity is believed to be a major contributor to the increase of type 2 diabetes. Of particular concern is the increasing prevalence of obesity in women of child-bearing age which is associated with gestational diabetes or diabetes diagnosed during pregnancy. Gestational diabetes affects between 2 and 14 percent of all pregnancies, making it one of the most common problems of pregnancy. Although gestational diabetes usually disappears after childbirth, it is likely to develop again during subsequent pregnancies. In addition, women with gestational diabetes are at a higher risk of developing type 2 diabetes later in their lives. Studies have shown that 40 to 60 percent of women with gestational diabetes develop diabetes within 20 years of their pregnancy.
Gestational diabetes and diabetes most commonly affect women who are overweight, over 25, have a family history of diabetes or belong to an ethnic group with a high prevalence of diabetes—Hispanic-American/ Latino, African-American, Asian, East-Indian and Native American. The American Diabetes Association recommends that all pregnant women be screened for gestational diabetes between 24 to 48 weeks gestation. However, women who are at high risk for developing gestational diabetes may need to be screened earlier in pregnancy. The standard screening test is measurement of plasma glucose one hour after a 50-gram glucose intake. Women with an abnormal value are then given a 100-gram glucose intake during a three-hour oral glucose tolerance test. The diagnosis of gestational diabetes is made if there are two abnormal values.
Gestational diabetes usually develops during the second or third trimester of pregnancy, when the placenta begins producing large amounts of hormones that cause insulin resistance. If the pancreas is unable to produce enough insulin to meet the increased need, glucose builds up in the bloodstream (hyperglycemia) and gestational diabetes develops.
Although having gestational diabetes does not increase the risk of the baby being born with diabetes, babies born to mothers who had gestational diabetes are more likely to become overweight or obese and are more likely to develop type 2 diabetes when they get older. The most frequent complication of gestational diabetes is a large baby. A large baby can lead to complications during labor and delivery. For example, a cesarean delivery may be necessary to avoid injury to the baby’s shoulder or arm. Other potential problems for the baby include hypoglycemia (low blood glucose), jaundice and prematurity.
Gestational diabetes is treated by improving diet and exercise or with insulin. As with type 1 or type 2 diabetes, the goal is to keep the blood glucose levels as close to normal as possible to ensure that both mother and baby are healthy. For most women, following a meal plan and eating a well-balanced diet is enough to keep blood glucose levels within a normal range. The American Diabetes Association recommends that all women with a diagnosis of diabetes or gestational diabetes receive nutrition counseling by a registered dietitian when possible. The appropriate diet consists of an individualized meal plan (medical nutrition therapy) that takes into consideration a woman’s energy and nutrient needs, eating habits, food preferences, appetite and expected weight gain. A weight gain of 25 to 35 pounds is considered appropriate for pregnant women who were at an average weight before pregnancy and for those women who have gestational diabetes. A diet should not promote weight loss during pregnancy.
A typical meal plan consists of three meals and two to four snacks each day with a consistent amount of carbohydrates along with meals and snacks. Other nutrition recommendations include eating more whole grains, increasing fiber intake, limiting foods high in sugar and fat, eating a small breakfast and not skipping meals. In addition to eating a healthy diet, exercise can be helpful in keeping blood glucose levels within a normal range. Walking for 20 to 30 minutes after a meal may help lower blood glucose levels. These recommendations also apply to all individuals with diabetes.
Self-monitoring blood glucose levels can help evaluate the effects of diet and exercise. Usually, testing should occur four times per day—in the morning before breakfast and two hours after each meal. Changes to meal plans or added physical activity may be necessary to achieve blood glucose targets. However, if the meal plan and/or increased activity cannot keep blood glucose levels in target, daily insulin injections may be recommended. This information also applies to all individuals who have diabetes whether they are pregnant or not.
After delivery, blood glucose levels should return to normal. However, a glucose tolerance test is recommended six to eight weeks after delivery to check for type 2 diabetes or impaired glucose tolerance. Even if future pregnancies are not planned, women should be screened for diabetes once a year. Although women who have had gestational diabetes are at an increased risk of developing type 2 diabetes, chances of developing diabetes can be reduced significantly by achieving a reasonable body weight, eating healthy foods and staying physically active. According to the American Diabetes Association, losing weight through a healthy diet and exercise are the keys to preventing diabetes.
Pregnancy is a very special time for a woman even when gestational diabetes becomes a part of it. Pregnancy can provide an excellent opportunity to develop lifestyle behaviors that will reduce the potential risk of type 2 diabetes. Having a healthy baby is a very special reward for making these lifestyle changes.
Because obesity is so closely associated with diabetes, we must control the weight problem in the United States, especially in children and younger adults. Diabetes is a devastating disease that has far-reaching implications not only for the pregnant population but also for our society as a whole. tpw