Contact Information Cathy Butler (Nurse) Phone 905-632-3737 ext 5510 Fax 905-681-4884 Stephanie Brindle (Dietitian) Phone 905-632-3737 ext 5777 Fax 905-681-4884 Dr. Jeff Lang Phone 905-634-0800 Fax 905-634-0825 Dr. Barry Hunter Phone 905-639-7732 Fax 905-639-9612

Joseph Brant Memorial Hospital 1230 North Shore Blvd Burlington, ON www.jbmh.com

11/05

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Gestational Diabetes and Healthy Babies

Questions to Ask/Notes

Table of Contents Page # Introduction Gestational Diabetes (risk factors) Fetal Risks Screening for Gestational Diabetes Treatment Plan Health-Care Team Blood Glucose Testing Ketone Testing Diet Carbohydrate Counting Making Healthy Choices Sample Meal Plan Exercise Weight Gain Insulin After Delivery/ Next Pregnancy Conclusion Glossary Questions/ Notes

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3 4-5 6 7 8 8-9 10 11 12 13 14-15 16 17 18 18 19 20 21-22 23

Prepared By: Gestational Diabetes Team Stephanie Brindle RD CDE Cathy Butler RN CDE Dr. J. Barry Hunter M.D F.R C.S (C) Dr. Jefferey D. Lang M.D F.R C.P (C)

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Introduction Macrosomia – the medical term for a newborn baby who weighs more than 4200 gms (8 lbs, 13 oz).

Oxytocin – the hormone that causes the womb to contract.

Pancreas – the gland that produces insulin.

Paediatrician – a physician who specializes in caring for children.

Placenta – the barrier between mother and baby that allows sugar and nutrients from the mother to be passed freely into the baby’s blood stream but does not allow insulin to pass.

Ultrasound – a sound wave picture of the baby.

Uterus – womb

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Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy, appearing in up to five per cent of all pregnancies. It usually develops in the middle of the pregnancy, between the 24th and 28th weeks, when hormones interfere with the mother’s ability to use insulin. While gestational diabetes will last for the rest of the pregnancy, your baby will not be born with diabetes. There is a 98 per cent chance that the diabetes will disappear after you have your baby. Your gestational diabetes care plan will require you to take extra care of yourself. You will need to follow a special meal plan, exercise, monitor your blood sugar levels and visit your health-care team regularly. You may also need to take insulin. At first, gestational diabetes may be a little unnerving for you. The information in this brochure, combined with the work and support of your health-care team, will help you reach the ultimate goal of your pregnancy – a healthy baby.

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Gestational Diabetes Gestational diabetes is the result of your body not using glucose (blood sugar) properly. Glucose is a form of energy used in the body. Although the body can make glucose, a large amount comes from the food you eat. Insulin is a hormone produced by the body to help your cells use glucose. If your body cannot produce enough insulin to meet your needs, glucose cannot be used by the cells and it accumulates in the blood. This is what happens when you have gestational diabetes. A blood test can detect these higher than normal blood sugar levels. Gestational diabetes develops because the placenta (see page 22) produces hormones during pregnancy. These hormones can interfere with your body’s ability to use insulin. As the placenta grows, it produces more and more hormones which make it harder for you to regulate your insulin levels. Usually, a mother’s body will adjust to produce more insulin but sometimes it just can’t make enough to keep blood sugars within the normal range. The result is gestational diabetes.

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Glossary Carbohydrate – the main source of food energy in the diet; it is broken down by the body into sugar. Carbohydrates can be found in fruits, some vegetables, milk products, grains and starches.

Gestational Diabetes – diabetes that occurs during pregnancy and goes away after pregnancy. Gestational diabetes is diagnosed from a standard glucose tolerance test.

Glucose – a simple sugar; main source of energy used by the body for fuel.

Hypoglycemia – blood glucose levels below normal that can result in sweating, irritability, shakiness, a fast pulse or unconsciousness if not corrected.

Insulin – the hormone made by the pancreas necessary to help the body use and/or store sugar.

Ketones – produced during the process of fat breakdown in the body. If the body is not getting enough sugar, due to lack of food or insulin, it will break down fat in order to produce energy. 21

Conclusion

Risk Factors for Gestational Diabetes

Gestational diabetes can be a challenge. It means that you have to take extra special care of yourself during your

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Previous diagnosis of GDM

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Previous delivery of a baby weighing more than 4200 gms (8lbs, 13oz)

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Member of a high-risk population (e.g. Aboriginal, Hispanic, South Asian, Asian or African descent).

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Age greater than 35 years

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Obesity

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Family history of diabetes

pregnancy. You need to follow a healthy diet plan, exercise regularly and monitor your blood sugar and urine ketones. You may need to take insulin. With the use of this plan and the help of your healthcare team, you can reach the ultimate goal of your pregnancy – to have a healthy baby!

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Fetal Risks If you have poorly–controlled gestational diabetes, your baby has an increased risk of weighing 9 pounds or more. The medical term for this is macrosomia. Macrosomia occurs when some of the extra sugar from your blood crosses the placenta and is taken up by your baby. Your baby then has to produce more insulin to help use the sugar, causing your baby to grow bigger and store more fat. This can make a vaginal birth more difficult. Uncontrolled gestational diabetes can also put your baby at increased risk for breathing problems, low blood sugar levels after delivery, and jaundice (yellowing of the skin and eyes). Your baby may also be at increased risk of being overweight and developing diabetes later in life.

After Delivery

In 98 per cent of women with gestational diabetes, the condition disappears when their baby is born. To reduce your risk of developing diabetes later on, it is still important to maintain your healthy lifestyle through a healthy diet, regular exercise and reaching a healthy body weight. Arrange to have your doctor take a glucose tolerance test between six weeks and six months after you deliver or about one month after you stop breastfeeding. You also need to have your doctor monitor your blood glucose status on a yearly basis.

You can greatly reduce or eliminate these risks by controlling your blood sugars and keeping them in the target range.

Gestational diabetes may return with your next pregnancy. Once you find out you are pregnant, make an appointment with your doctor. Your doctor who will refer you to the gestational diabetes clinic if your OGTT (Oral Glucose Tolerance Test) is high.

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Weight Gain The recommended weight gain during pregnancy is based on your pre-pregnancy weight. It is recommended that most women gain 22 to 28 pounds during their pregnancy. A member of your health-care team will tell the ideal amount of weight you need to gain for your pregnancy. If you are overweight, you may not need to gain as much. During the first three months of your pregnancy, you only need to gain two to four pounds. Over the remaining six months, your weight gain should be slow and gradual at about one pound per week. If you are not gaining weight, you may not be eating enough. You should check your urine for ketones every morning.

Insulin If your blood sugars remain high and you are following a healthy diet and exercise routine, you may need to include insulin in your gestational diabetes care plan. The insulin will help keep your blood sugar levels within their target range. 18

Screening for Gestational Diabetes Women are usually tested for gestational diabetes between their 24th and 28th weeks of pregnancy. If you have several risk factors, your doctor may also test for gestational diabetes during your first three months of pregnancy. This test involves having a blood sample taken one hour after you take a sugar drink. If the results show that your blood sugar is higher than normal, you will be given a second test called a glucose tolerance test. One blood sample will be taken before you take the sugar drink and another one at 1 hour and 2 hours following the drink. If two of the three blood sugar readings are still higher than normal, your doctor may diagnose you with gestational diabetes.

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Treatment Plan Once you have been diagnosed with gestational diabetes, it is important to develop a routine (with the help of your health-care team) that will help control your blood sugar levels.

Your Health-Care Team Your health-care team involves a number of health-care professionals as well as your family, friends and the most important member – you!

Obstetrician: a medical doctor who specializes in the care of women during pregnancy and delivery.

Doctor of Internal Medicine: a doctor who specializes in medical conditions, e.g. diabetes.

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Exercise

Exercise and being active are part of your gestational diabetes care plan. Moderate exercise, that does not leave you too tired, helps your body lower blood sugar levels. When muscles are working, they use extra energy and they draw on blood glucose as a source of this additional energy. Even after you stop exercising, your muscles continue to lower blood sugar levels. The muscles use the circulating glucose in the blood stream to fill their glucose stores. Participate in low impact activities such as walking, swimming, or riding a stationary bike. Always remember to check with your doctor before you start an exercise program.

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Sample Meal Plan Breakfast Egg, ham, cottage cheese, cheese or peanut butter Whole grain cereal or bread Low fat milk or yogurt (plain or diet) Fresh fruit Lunch Sandwich with lean meat, fish or low fat cheese on whole grain bread or bagel Soup or raw vegetables or salad Milk Fresh fruit Daytime Snack Ideas Low fat milk and cookies or Vegetables and low fat dip or Low fat yogurt – plain or diet or Small muffin Dinner Lean meat, fish, chicken or legumes Bread, potato, rice or pasta Cooked or raw vegetables or salad Milk Fresh fruit Evening Snack Ideas Whole grain crackers with low fat cheese or Toast and peanut butter or Pita bread with hummus

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Diabetes Nurse Educator: a health-care professional who assists you in monitoring your blood sugar by teaching you how to use a glucometer. If insulin is needed she will show you how to give an injection as well as teach you signs and symptoms of high and low blood sugar and their treatment.

Dietitian: a specialist in nutrition and foods who teaches you how to change your diet to keep your blood sugar within the target range and eat the nutrients needed to provide for a healthy baby.

Friends and Family: a support network that encourage you to take extra special care of yourself during this very important time in your life and your baby’s life.

You: the most important member of your health-care team! You are the one who knows your body and your lifestyle best, making you an essential contributor to a healthy pregnancy and baby. We encourage you to be involved and ask questions!

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Blood Glucose Testing Your blood sugar is affected by many factors such as your diet, activity level, amount of insulin you produce and even stress. Keeping track of your blood sugars will help you and your health-care team determine how and why your blood sugar may change over time so that you can better control it. In order to keep your blood sugar in the desired range, you need to check it using your glucometer. The nurse educator will teach you how to test and record your blood glucose levels. Test your blood sugar four times a day: • • • •

Before breakfast—this is called a FBS (fasting blood sugar). 1 hour after starting breakfast. 1 hour after starting lunch. 1 hour after starting dinner.

Please remember: • The target range for FBS is 5.3 or less. • The target range for blood sugar taken 1 hour after starting a meal is 7.8 or less. 10

6. Most protein foods (meat, fish, poultry, eggs and peanut butter) do not contain carbohydrates. Include a protein food at each meal and evening snack. It will slow down how fast your blood sugar rises. 7. Fats such as butter, margarine, oils, mayonnaise, salad dressings and gravy are concentrated sources of calories. However, they do not contain sugar and they help slow the rise of blood glucose following a meal. Eat fats in moderation, especially if you need to control your weight. 8. You may use artificial sweeteners such as Splenda, Aspartame, Nutrasweet and Equal. Limit your use of products that contain these sweeteners to two to four servings a day. 9. Snacks are a very important part of your meal plan. Small frequent meals will create smaller rises in blood glucose and will help to keep blood glucose levels more stable throughout the day. Try not to let more than four hours pass between your meals and snacks. Make sure you eat a bedtime snack so that you don’t go without food for more than 10 hours from your last meal until breakfast. 10. Drink 8 to 10 glasses of water and sugarfree drinks daily. Avoid alcohol and limit caffeine. Remember: even unsweetened fruit juices contain natural sugar. Try to avoid them. 15

Ketone Testing

Making Healthy Choices 1. Eat three meals and two or more snacks at the same time every day based on Canada’s Food Guide to Healthy Eating. Try not to go more than four hours during the day without food. 2. Avoid concentrated sources of sugar in your diet such as jam, maple syrup, corn syrup, white sugar, brown sugar, honey, cakes, pies, chocolate, candy, regular soft drinks, tonic water and fruit juices. Your body absorbs them quickly and they cause the blood sugar to rise quickly. 3. Choose high fibre grains and starches. These foods will be absorbed slower and will slow down how fast your blood sugar rises. Examples are whole grain breads and cereals, brown rice, whole wheat pasta and legumes. 4. Vegetables and fruits have fibre and nutrients but they also contain natural sugar. The fibre helps to slow down the absorption of sugar in the blood. This is why it is better to eat a small piece of fresh fruit rather than have fruit juice. Choose dark green and dark orange vegetables and fruit more often. 5. Milk and yogurt are rich in calcium, vitamin A and vitamin D. They also contain natural sugars. Choose low fat milk and milk products more often.

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Your body uses sugar as its number one choice for energy. If your cells are not getting enough sugar, because you aren’t eating enough or you don’t have enough insulin, your body will break down fat in order to produce energy. During the process of breaking down fat, ketones are made.

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Call the dietitian if your ketones are greater than trace.

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Test your urine for ketones daily when you first get up in the morning.

Ketones may appear if you: •

Eat too few calories;

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Leave too much time in-between meals and snacks.

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Diet The foods you choose during your pregnancy are a very important part of your gestational diabetes treatment plan. You need to include foods from each of the four food groups from Canada’s Food Guide to Healthy Eating at every meal. The type and quantity of food you eat is important.

Carbohydrate Counting

“Carb” counting is a flexible way to plan your meals and maintain a consistent intake of carbohydrates from day to day. Carbohydrates are found in many foods including cereals, breads, pasta, rice, fruits, some vegetables, milk and yogurt, sweets and desserts. Most of the carbohydrates you eat are broken down into glucose which raises your blood glucose levels.

Balancing the food groups in each meal will help regulate how fast your blood glucose increases after you eat. This will help you reach good blood sugar control as well as develop healthy eating habits! Your dietitian will work with you to create a meal plan and eating pattern to best suit your needs.

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Over half of your calories should come from carbohydrates. Making healthy choices will help to manage your blood glucose levels.

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