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Ask The Doulas Podcast
Real Food for Gestational Diabetes: Podcast Episode #115
March 4, 2021

Real Food for Gestational Diabetes: Podcast Episode #115

Author Lily Nichols talks to Kristin about gestational diabetes during pregnancy and how eating has such a profound impact on our health and energy levels.  You can listen to this complete podcast episode on iTunes or SoundCloud.  Be sure to check out Lily’s book!

Welcome.  You’re listening to Ask the Doulas, a podcast where we talk to experts from all over the country about topics related to pregnancy, birth, postpartum, and early parenting.  Let’s chat!

Kristin:  Hi, Lily!

Lily:  Hello!  How are you?

Kristin:  Great!  How are you?

Lily:  Doing well.

Kristin:  I’m excited to have you join us !

Lily:  Yeah, happy to be here!

Kristin:  So I would love to, first of all, introduce your background to our listeners and then hear what you’ve been up to since we last connected.  So for those of you who aren’t familiar with Lily’s work, Lily Nichols is a registered dietician, a specialist in prenatal nutrition, and best-selling author of the Real Food for Gestational Diabetes book, as well as Real Food for Pregnancy.

Lily:  Yeah.  I think you kind of summed it up really briefly.  As you gather from the title of my books, my focus is very much on how we can use real food and nutrition to optimize pregnancy outcomes.  So, you know, it’s right in the title of the books, right?  So I’m happy to chat more about and any questions you have about my background, of course.

Kristin:  So I’d love to know how you got into this line of work as a dietician, and then what you’re working on now outside of the books you’ve put out in the past.

Lily:  Yeah.  Well, I got into this work in a way a little bit by accident.  I mean, I think things always end up working out the way they’re meant to, but regarding how I got specifically into the prenatal side of things, it was a bit happenstance, that there was an opportunity to work with the California Diabetes in Pregnancy program, which is a state-funded organization that helps put out guidelines on diagnosing and treating gestational diabetes.  And California tends to be a bit progressive, and so their guidelines are also generally pretty progressive, although I’d say mine are a bit more so now.  But in terms of diagnosis, for sure, they are much more progressive than what the rest of the United States follows.  So I’ve worked with them.  I’ve worked with a number of different clinicians, including perinatologists who specialize in gestational diabetes, so a lot of clinical work on top of the public policy work, which then just sort of naturally led into training other professionals on managing and treating gestational diabetes.  And it’s kind of – you know, this work, from seeing it from all different angles and getting pulled into different, you know, research projects, it just kind of snowballed into the focus of my career, and particularly, I’d say my clinical work, where I was able to see, you know, how well do the nutrition guidelines work in real life versus how they proclaim to work on paper was much different than I had anticipated, and that ultimately led me to really investigate, you know, how our nutrition recommendations were set.  Like, what’s the strength of the evidence used to set those guidelines, and how can we do better?  And ultimately, that’s really the reason that my books exist.  If there was no issues with the guidelines, I wouldn’t write books.  I mean, I write them because I take a very critical look at them and personally find that the evidence, particularly the new research from the past 20 years, has very much expanded our understanding of both pregnancy guidelines as a whole but also blood sugar management in pregnancy.  And we can just do so much better and have so much better outcomes if we really put that evidence into practice.

Kristin:  Well, I am so thankful that you put those books out into the world.  My clients appreciate – I refer all of my clients to your books, so it has been very helpful to have you as a resource.  So for those of our audience members who do not understand the difference between gestational diabetes and type 1 and type 2, could you give us a quick rundown of the differences?

Lily:  Sure.  Yeah.  So gestational diabetes is diabetes that either first develops or is first recognized during pregnancy, which is a bit of a nebulous definition because it can also encompass undiagnosed diabetes that was going on preconception or undiagnosed prediabetes that was going on preconception that we’re just identifying because during pregnancy we actually are checking your blood sugar, right?  But I think the classical definition, which I think is being challenged a lot, is that it’s something that just develops during pregnancy.  It is solely a response of the weight gain, placenta changes, changes in how your body responds to and produces insulin, that makes your blood sugar higher than would be expected and more difficult to manage.  I think we’re seeing now in the research that actually quite a large proportion of the cases are actually undiagnosed prediabetes that we’re just identifying the blood sugar issue during pregnancy, which makes sense because there’s been an absolute, exponential rise in gestational diabetes in the past 20 years or so, where now it’s affecting in some populations up to 22% of pregnancies.  Pretty sure I quote an 18%.  That was a bit on the higher end from back then, but I think I quote 18% in my book, and some other sources will say it’s only 5% of pregnancies.  But it has absolutely been on the rise as we’re seeing other forms of diabetes population-wide also on the rise.  As far as how it differs from other types of diabetes, now that I’ve probably confused everybody, when you’re looking at type 2 diabetes, that is a form of diabetes that at least historically developed in adulthood, and it’s essentially your body becomes unresponsive or less responsive to insulin, a hormone that helps you manage your blood sugar, and it can progress to the point where you produce less and less insulin over time and made need supplemental insulin or medication to manage it.  However, it can also often be well-managed or at least co-managed with nutrition and lifestyle.  With type 1 diabetes, that is an autoimmune condition where your pancreas stops producing insulin or produces very, very little, to the point that you will absolutely require supplemental insulin.  So, like, insulin shots to manage your blood sugar, and that is a lifelong condition.  It’s not something that is reversable, whereas with type 2, if you catch it early enough, sometimes it actually can be.  It’s arguable to call it reversable, but it can be, like, managed to the point that your blood sugar is normal.  So is that reversal or what?  I don’t know.  But with type 1, it is something you live with for the rest of your life, and so it’s a much more challenging one to manage because you’re trying to, like, mimic a functional pancreas in your dosages of insulin, and it takes a lot more careful management.  But absolutely can also be well-managed, and there’s many people living with type 1 diabetes to show that that is the case.

Kristin:  And then for gestational diabetes, most of the time but not all, it goes away after delivering baby, correct?

Lily:  Yeah.  So in about 90% of cases, blood sugar will normalize postpartum, at least early postpartum.  However, that can almost be kind of like a honeymoon period because there is a lifetime higher risk of developing type 2 diabetes.  They call it converted to type 2 diabetes, actually.  So in about 30 to 70% of cases, type 2 diabetes will ensue in the coming 5 to 10 years after delivery.  So it is the strongest independent risk factor for developing type 2 diabetes in women that we know of, is having gestational diabetes in pregnancy.  Now, to make – of course, that sounds very doom and gloom.  But I’m always flipping it to the positive, which is that it can absolutely be prevented, as well.  I see gestational diabetes as, like, the warning light coming in on your car.  It’s like pregnancy is a stress test on your system.  Your pancreas is required to produce double or triple, sometimes even more, insulin.  You’re naturally dealing with an insulin-resistant state of pregnancy, and so it’s like, can your body, like, step up to the challenge, right?  And so if your blood sugar is becoming more difficult to manage in pregnancy, it’s actually a sign that probably you want to keep an eye on this for the rest of your life.  It’s like, okay.  There’s a bit of a weak link in my blood sugar management, and I should keep an eye on this.  And if you do keep an eye on it, in many cases, it can be sort of – you can prevent it from actually progressing to type 2 diabetes.  Like, let’s be kind to your pancreas.  Be kind to your blood sugar management system.  Oftentimes, if you can continue with the same diet and lifestyle things that helped you during pregnancy – again, it depends on when you’re actually catching this.  Like, have you been insulin-resistant for, like, 15 years before getting pregnancy, or is it literally something that developed, like, right before or during pregnancy?  Like, depending on when you’re catching it, oftentimes it can be managed and in many cases prevent that conversion to type 2 diabetes.  So I always like to throw that out there because I think people see gestational diabetes as, like, this – just a very, you know, stressful and – it’s a stressful diagnosis, right?  Since I’ve worked one on one with hundreds and hundreds of clients, I mean, you know, even as the clinician, how you approach the topic with your clients can impact how they see the diagnosis.  And it’s like, okay, we want to, yes, take this seriously and talk about how blood sugar management can impact your pregnancy outcomes and your experience of pregnancy, but we also don’t want to scare you to the point that it seems like, oh my gosh, no matter what I do, this is horrible.  And that’s actually not the case.  And a lot of times, I do hear from people that there’s a bit of a silver lining to it.  You know, wow, I had no idea that food impacted me in this way, and when I eat for better blood sugar readings, I also have so much better energy.  And I’m not, like, gaining weight as rapidly, speaking of during pregnancy, as I was before.  And I no longer have that swelling in my ankles that was going on.  Like, you just feel better, and sometimes that’s motivation enough to continue these things long-term.  And you do continue to reap the benefits well beyond post-pregnancy.

Hey.  Alyssa here.  I just wanted to hop on real quick and let everyone know about a really exciting new course that Kristin and I have been working on called Becoming.  It’s all about becoming a mother, and in six weeks online, we will be giving video lessons and live coaching calls weekly with Kristin and I, along with a private Facebook community to offer encouragement and support.  This six-week online class will actually be launching beta, which is our first launch, on March 22, with our live call on March 26.  You can get into this beta program at a really, really super reduced price.  So check us out!  We’d love to have you join us and learn all about pregnancy, birth, and early parenting and especially during this scary time of COVID.  Let us be your expert guides!  We hope to see you there!

Kristin:  So I have a client I’m working with who is about to have her glucola test, and she is very nervous.  And, you know, she’s got a healthy pregnancy, but as you said, it’s stressful.  You know, the potential diagnosis can cause stress, and during COVID, you know, women are facing so much stress as it is.  So what advice do you have for her going into her test?

Lily:  Well, there’s not a whole lot you can really do going into the test.  I give a few notes, which is, pay attention to, like, the type of the test that you’re doing.  So there’s different ways that the glucola is done.  In some countries, and in California, which may as well be its own country, I guess, they do a 75-gram glucose tolerance test that is performed fasting.  So if your doctor says, like, come in fasting, absolutely, come in fasting because that will make or break the accuracy of the test.  There are other ways of doing the test, and this is most of the rest of the United States and rarely in other parts of the world, where they do, like, a two-step method where you come in for a smaller glucola or glucose tolerance test, and then if you don’t pass that screening test or challenge test, they sometimes call it, you’ll come back for a three-hour test with a larger amount of glucose.

Kristin:  And that’s what we’re seeing in Michigan.  Yes.

Lily:  Right.  So that first step, the 50-gram glucose challenge or glucose screening, is generally not performed fasting.  So they don’t check your blood sugar before.  They only check it one hour after you’ve had your drink.  So you don’t need to come in fasting, but I would just caution people to not show up, like, immediately after having a large lunch or immediately after having a smoothie or candy in the car.  I mean, I’ve had people come up with false positives on that test because they came in right after lunch.  And if you come in on a full stomach, you are – already, your blood sugar is at its peak, and now you’re going to add insult to injury, so to speak, by adding 50 grams of sugar on top of that?  Yeah.  Your reading is probably going to come back high.  Part of the reason they do this two-step thing and that they don’t perform it fasting is that they just want to lower as many barriers as possible to actually getting people in to do the test.  However, it can result in false positives and sure, you do the three-hour screening that’s fasted afterwards; however, you have all that stress in the interim of, oh my God, do I or don’t I have it?  Which is why many people have been moving towards just doing this single-step 75-gram test which is fasted.  It’s just a bit more of control over your test.  So I’d throw that out there.  Like, don’t have a bunch of sweets right before you come in, and don’t come in immediately after a meal.  Come in, do your test two hours or so after eating, and if you’re hungry in between, have some sort of a protein snack like some nuts or something or some cheese, just so you’re not already starting your test with elevated blood sugar.  The second thing I would say is, if you err on the low carb side of things, so if you happen to just naturally eat a low-carb diet, you might consider increasing your carbohydrate intake in the week prior to the test for people who consistently eat below about 150 grams of carbohydrates per day.  You can also get a false positive on the test.  And speaking as somebody who falls into that category, that actually happened to me in my first pregnancy.  So I wrote all about it on the blog.  I was one point over, but still.  It’s important for people to know, and I was kind of doing that a bit on purpose.  You know, we’ve known since the 1960s at least that if you restrict carbohydrate intake prior to a glucose test, your pancreas is not adapted to pumping out large boluses of insulin at a time to lower a huge spike in your blood sugar very rapidly.  It’s just become adapted to pumping out just very small, tiny amounts, just sort of pulsing out small amounts of insulin as needed over the day, not huge amounts.  You give those same people a high carb diet for a week prior to a glucose test, and their body adapts, assuming they don’t have diabetes, and you don’t have that issue.  You don’t have the false positives.  So the same is true with general population and pregnancy, as well.  If you eat low carb, your body’s just not adapted to that at this moment.  Now, if you’re somebody who always eats high carb, you should have no issues passing the glucose test.  You know, unless there’s obviously an issue with your blood sugar management.  But for people who are low carb, you know, if your body has the capacity to adapt to it, then you will know if you eat high carb in the week prior to the test.  That should eliminate your concern about a false positive for the most part.  So I always do mention that because the guidance on eating more carbs prior to a glucose tolerance test was eliminated, I believe, in the 90s, and that’s because most people are already eating well over 200 grams or more of carbohydrates per day because that’s what our dietary guidelines tell us to do, and we really didn’t need people eating more bread and more juice and more cereal prior to doing these tests.  But for people who – now that keto and low carb are a little more popular, it has returned to being important to at least mention that.

Kristin:  Yes, that’s very helpful.  So for our listeners and clients who do test positive for gestational diabetes, what tips do you have for nutritional management?

Lily:  So first things first is, you know, everybody’s body responds to food differently.  So there are some rules that would apply to anybody in that the way our body processes carbohydrates versus protein versus fat and how those impact blood sugar.  There’s some constants there, right?  But as far as the absolute details and how much of all of those foods you can consume and expect a certain blood sugar reading, that actually comes down to you testing your own blood sugar and fine-tuning your diet in response to what you’re seeing in your post-meal blood sugar readings.  So the most important thing is that you get a blood sugar meter and start testing to see where you’re at.  Otherwise, we have really – we’re flying blind.  So I can give general guidance, but until you have those blood sugar readings, it can be a bit challenging to know for sure what you should be doing.  Now, of course, generally speaking, it is very helpful to understand that certain foods raise your blood sugar more than others.  So carbohydrates are the foods that break down into individual sugars in your body and then raise your blood sugar or your blood glucose, whereas protein and fat do not necessarily raise your blood sugar.  There are some nit-picky details and exceptions to the rule, but generally, protein and fat just keep your blood sugar stable but they don’t spike it like carbohydrates do.  So the key with understanding this, and I do this is Real Food for Gestational Diabetes, is I just break it down: these foods raise your blood sugar.  These foods don’t.  And so focus on not going overboard on the foods that do spike your blood sugar.  So your carbohydrates are your grains and starches, potatoes, sweet potatoes, fruit.  Milk and yogurt will have a little bit of carbohydrates.  Of course, they’re also balanced with some fat and protein.  And legumes – again, they have carbohydrates.  They also have protein.  They have fiber.  So they’re a bit of a better source.  But we’re usually looking at grains, starches, fruits, anything with sugar, would be your main things that you want to be like, okay, let me just tap the brakes a little bit on those foods, and when I do consume them, consume them in a reasonable quantity in combination with foods that don’t spike my blood sugar.  So your protein-containing foods and fat-containing foods would fall into that category.  And that basic understanding of just splitting up foods into elevates your blood sugar / does not elevate your blood sugar can be really, really helpful for people to just simplify things.  I call it no naked carbs.  So don’t have your carbohydrates solo by themselves because you’ll get a larger spike in your blood sugar than if you combined that carbohydrate-containing food with some fat and protein.  So a perfect example of this is an apple, which is of course a healthy, whole food, right?  However, an apple is primarily carbohydrates.  Sure, it has some fiber, and that helps blunt your blood sugar spike a bit compared to apple juice, for example.  However, if you were that apple, again in its whole form would be ideal, right, versus juice – if you combine it with something that has fat and protein, like, say, some almond butter or peanut butter, you’re going to significantly blunt your blood sugar response to that food, so your blood sugar won’t spike as high, which means your pancreas doesn’t have to pump out as much insulin, either, to match it.  And when you don’t spike as high, it’s kind of like a roller coaster.  You don’t drop as low.  And this is very helpful for managing your hunger and cravings, as well as your blood sugar.  So that would be my main recommendation.  And then you can fine-tune the amount of carbohydrates you can get away with by checking your blood sugar after you eat and seeing where you’re at.  Are you falling within range?  Are you coming in a bit above range?  And that can help you fine-tune things.

Kristin:  And do you recommend that our listeners find a dietician to work with, or can they manage this, again, based on how their levels are on their own?

Lily: I mean, in an ideal world, I think it is helpful to work with a dietician or diabetes educator or any clinician who has a lot of experience with gestational diabetes because there’s just so much nuance to it.  I mean, coming down to even how you check your blood sugar, you know, you can mess that up.  You use a soap that has sugar-containing ingredients.  There’s all sorts of gluco-ingredients in soaps and lotions and things.

Kristin:  I didn’t even think of that.

Lily:  Yeah.  I mean, it happened to me.  You understand a lot when you do things firsthand, so I’ve been a bit of a guinea pig on myself.  I had seen this with clients before, as well, and you do – you know, as a certified diabetes educator, you do learn about all this stuff, as well, but you see it in real life when people are like, but I only had XYZ food, which doesn’t spike me, but my blood sugar came out 20 points higher than it should!  First of all, you have people, if they get an unexpected high reading, wash their hands again, test again to just try to verify if it’s accurate, because meters are not perfect.  But there can be so many things.  You can have a meter that is not super accurate, and sadly, there are some brands of meters that aren’t super accurate because their tolerance for variance is based on type 2 diabetes levels, where with gestational diabetes, you’re expected to keep your blood sugar in a much narrower range.  So if you have a meter that is reading 10% higher, if you’re a 50-year-old man with type 2 diabetes and you only have to keep your blood sugar under 140 or you’re aiming for 180 or something – sometimes the ranges are much more liberal, depending on who you’re working with – that’s no big deal.  But if you have gestational diabetes and you’re trying to keep your blood sugar below, say, 120 after meals, than a 10% variance in the wrong direction is a big problem.  So sometimes it comes down to, is your meter accurate?  Are you test strips expired or not?  Are you cleaning your hands properly before testing?  So I gave you the example of soap, but say you just had an orange, and you have a bit of orange juice left on your finger.  That will read as sugar on a blood sugar test.  So you prick your finger, squeeze out a little drop of blood, test, and it comes out unusually high.  That can be a problem.  So some of this nit-picky little stuff, it can be helpful to have somebody there to guide you so it’s a little less scary.  And especially in those first two weeks after diagnosis, I think that’s when it’s the most raw and the most concerning and the most “I don’t know what I’m doing.”  So if it is possible to get a referral from your provider, you can do that.  I have a free video series on gestational diabetes on my website.  Of course, my book, Real Food for Gestational Diabetes, does walk you through this, and I intentionally wrote that book with as simple language as possible to just kind of cut through all the noise so you can focus on what actually matters and not get distracted by a bunch of extraneous details, so that can certainly be helpful.  But there is always, I think, a time and a place for one on one guidance on this if you can get it.  So I’ll throw that out there.  There are, I know, people who just don’t have necessarily those types of providers or providers who maybe are up to date on some of the nutrition information that I give out, so they might go to a dietician and get really not fantastic dietary advice, like very high carbohydrate diet.  I mean, that’s the reason I had to write my book, because the current guidelines are just so far off from what actually works that, you know, I do have my book available.  I also have a paid online course.  We have a private Facebook group where people can ask questions of me directly and get support from other members.  I try to have as many options from free to, you can get the e-book for 10 bucks to a course to just give you as many options as possible because I want to meet everyone where they’re at.

Kristin:  So what is your advice as far as minerals and supplements with gestational diabetes?

Lily:  Like, which specific minerals?

Kristin:  So just looking at if they’re adding supplements to their diet.  What is good?  What isn’t?  You know, outside of the prenatal vitamin that they’re taking.  Should they be doing anything different once they’ve received the diagnosis?

Lily:  Gotcha.  So as far as supplements, I mean, I do think for most people it makes sense to be on a prenatal vitamin.  I would check, if you’re having a screening for anemia, check to see if you actually need the iron because sometimes too much iron can be a bit inflammatory and create more blood sugar issues.  So check for anemia before you jump for a prenatal that includes iron.  You might want to opt for an iron-free one.   I am just much more of a fan of people getting their iron from food that has all of the complementary co-factors for you to use it.  The type in most prenatals on the market, unfortunately, is just not super well-absorbed and sometimes kind of adds fuel to the inflammatory fire.  As far as additional supplements, we often find magnesium deficiency is more common when there’s blood sugar issues present, so that as a supplement, I think, is very helpful.  Minerals usually are more bulky ingredients for prenatal supplements, so most of them, unless it’s like a multiple capsules per day kind of a formula, just do not have very much minerals at all.  So somewhere between 150 to 300mg of magnesium a day can be really helpful.  Magnesium glycinate is the form that I often recommend.  The glycinate means the magnesium is bound to an amino acid called glycine, which has its own beneficial effects on blood sugar management, and it’s also just very well-absorbed, so you don’t have this GI distress, diarrhea sort of reaction that some people get to magnesium supplements, especially when they’re high-dose.  You can also do a foot soak or a warm bath with Epsom salts in it, and you absorb the magnesium through your skin that way, so that’s always helpful.  Another one would be vitamin D.  A lot of prenatals do not include enough vitamin D.  I just put out a blog post about vitamin D in pregnancy on my blog if people want to read that for more.  But much of the research surrounding that nutrient in pregnancy shows that you need actually up to 10 times more than what the current recommendation for vitamin D is.   So I do recommend, if you do not live in a southern, sunny climate where you get lots of sun exposure without sunscreen on, on a regular basis, which is much of the country that’s not possible, then I do recommend supplemental vitamin D.  And so looking at how much your prenatal has and trying to get around 4,000 IUs per day can be really helpful.  We actually have research studies showing that vitamin D deficiency is more common in gestational diabetes, but also the more severe the vitamin D deficiency, the worse blood sugar readings tend to be, and actually that if you supplement it and correct vitamin D deficiency, the blood sugar readings improve.  Same goes for magnesium, by the way.  And then I’ll add just one more.  I mean, there’s other supplements that could be helpful in pregnancy, but specifically for the blood sugar conversation, another nutrient we’re getting a lot more data on is inositol, which is a B vitamin-like compound.  It’s actually used pretty often in fertility and PCOS, which the majority of PCOS cases have some component of insulin-resistance, and it’s actually a risk factor for the development of gestational diabetes.  So we have all of this positive research on inositol for PCOS and for infertility.  We’re now having studies done on inositol for pregnancy and specifically diabetes in pregnancy, showing pretty positive results.  And so they typically do a dosage of 4 grams, which is also 4000 milligrams per day, of myo-inositol.  So that’s something that you can discuss with your provider.  We have a couple studies now on fasting blood sugar and other markers of insulin resistance.  It’s a very safe supplement, very safe.  There has been absolutely no animal or human studies indicating any sort of toxicity in pregnancy including in the very delicate stages of embryogenesis in really early pregnancy, so that’s really reassuring.  If anything, it’s really been overwhelmingly all positive.  So I do throw that one out there because that’s probably one of the more promising and more well-researched nutrients that can impact blood sugar.  You can go on – I can probably list, like, a dozen more nutrients that also impact blood sugar, and the hope is that most of those would be covered by your food intake and also your prenatal, but you can get kind of nitty-gritty on all this stuff if you really want to.

Kristin:  Sure.  So I’d love to hear – this has been very helpful.  Love to hear any last tips that you have for our listeners, and that could be anything from, again, managing gestational diabetes to stress management to postpartum care.

Lily: Oh, gosh, you give me a lot of good leads to go on with that.

Kristin:  So wherever you’d like to go with that!

Lily:  Well, maybe I’ll give a little nod to stress for a minute, and then I probably have to talk postpartum, as well.  So stress is an underrecognized factor that plays a role in your blood sugar.  So your body has a very real physiological response to stress or perceived stress that often makes your blood sugar go up.  So I think its easy as practitioners for us to just sort of dismiss stress and just focus on the knowns of food and movement and exercise, things like that.  But you absolutely see a really significant response to stress, whether that’s personal work stress or even if it’s immune stress.  If you get a cold, your body is under stress, and your blood sugar is elevated as a response.  You see it firsthand for anyone who has worn a continuous glucose monitor, which is probably not many people listening.  But I know I have, if I have a stressful phone call, and a continuous glucose monitor, you can get real-time readings on your blood sugar, and it graphs out your 24-hour blood sugar readings on a chart.  You can see it.  Like, whoa.  My blood sugar spiked 10 points and remained elevated for 30 minutes as a response to that stressful interpersonal interaction.  So anything you can do to just kind of stay calm and even-keeled is absolutely also helpful for your blood sugar.  I don’t think we can discount that.  And then to just give a quick note on postpartum, I’m just such an advocate for a nourished and slow postpartum, and I think it’s really hard as a first-time mom to, you know, even imagine or put much focus on postpartum because it’s all about the big event of birth.  And I know I fell victim to that, as well, my first time around.  I probably should have read a book on postpartum or something.  But you’re so focused on birth.  How can I create the best birth?  I want it to go like this.  Birth is like, at best, you know, it can be a couple hours.  It can be maybe a couple days depending on the circumstances.  But postpartum is a very long period of time, and I think our culture sees it maybe as a couple weeks, up to six weeks, right?  That’s when you go back to your provider and get a check-up to see that you healed okay.  But it is much more than two weeks or six weeks.  It is kind of a long haul healing process.  And a lot of our western society doesn’t really – we’ve lost touch with our postpartum traditions, where many other places in the world still have those intact, and there is extra attention to care and nutrition and other people coming in to care for the new mother, especially in the first month to six weeks.  It’s often 40 days.  And if you do that, having really been intentional about postpartum my second time around – it’s not that I didn’t have a good postpartum the first time.  I felt like I did pretty well, all things considered.  The second time was just so much more easeful.  Like, just everything about it was so much better because I prepared for postpartum.  I prepared meals in the freezer.  I had my mom come up and stay with us.  I really tried to embody and bring in as many of those practices that these other cultures – I mean, it’s so strange.  You go all across the world, and they’re very similar.  You know, like, how do they all – it’s all like similar types of foods with broths and stews and warming foods and teas.  And it’s the same amount of time.  It’s the same, bringing in other women, especially older women who are mothers or grandmothers themselves to care for you.  It’s like, how is it the same in Mexico as it is in the Middle East as it is in China as it is in Indonesia as it is in Mexico and Brazil and Africa?  How is it the same?  It’s all, like, very, very similar.  I think we have to give some credence to, there’s some wisdom there that we should honor.

Kristin:  There certainly is.  Mothering the mother is definitely something that is ignored in the US, and other cultures embrace it.  That’s why our postpartum doulas do not just work within the first 30 to 40 days.  We work with families through the first year.

Lily:  Oh, that’s fantastic.  Yes.  Yes.  Because often you come out of those first three months a bit in a fog, and you’re expecting it to be easier.  And a lot of things are easier.  Things are less intense, but it’s also still hard.  It’s still a lot.  You know, it continues to be a lot.  I have an 18-month old now, my second, and it continues to be a lot long-term.  It gradually does get easier, but just building in the expectation of having help and having support and having that extra focus on nourishment goes a really long way.  So I think I do a better job in my second book, Real Food for Pregnancy, of really emphasizing the postpartum part.  I snuck in a whole long chapter on it because I started writing that book when I was 10 months out with my first.  Whoa, postpartum is important!  I’m going to put it in a pregnancy book because I know I didn’t seek out – as proactive as I am, I didn’t seek out that information when I was pregnant, and I really should have.  So, here.  I’ll throw it into this book.

Kristin:  I love that chapter!  I’m so glad you included it, so thank you.  So how can our listeners and doula clients find you and your books?  I’d love to – all of the different ways you mentioned, videos and one-on-one courses.  Share all of the ways we can connect with you, please, Lily.

Lily:  Sure.  So you can find me on my main website.  That has my blog.  It links out to my books and where you can find those.  It has a lot of different freebies, so you can download the first chapter of Real Food for Pregnancy for free.  You can check out the free video series on gestational diabetes.  There’s a couple others up there.  So that’s kind of the main hub.  As far as courses – at the moment, I’m not seeing one-on-one clients, but I am still supporting course participants in the Real Food for Gestational Diabetes course.  And that’s fully online, and we also, like I said, have a private Facebook group.  So I do office hours in there every week.  Lots of questions on, especially, fasting blood sugar.  So I go into depth on that.  I have a bunch of bonus presentations included in the course.  I just kind of keep adding on to it.  I’ve been running it since 2015.  There was no course on gestational diabetes out there at the time.  I don’t really know if there’s any others, actually.  I haven’t looked.

Kristin:  I don’t know of any, so – there could be, but…

Lily:  Yeah.  Especially on the client level.  I think there’s some on just teaching practitioners sort of the basics on it, and I do, by the way, have a webinar on that over at the Women’s Health Nutrition Academy.  But as far as supporting clients directly, that’s definitely the place to go.  I have a – just did a big presentation on postpartum recovery after gestational diabetes, so lots on this, concerns about type 2 diabetes and when to get screened and what to do, a bunch of information on that.  I have advanced training on lowering fasting blood sugar with food and lifestyle tips.  There’s a lot of things in there that I just really don’t include anywhere else in my work, so that is really geared directly for clients themselves, although I do have a couple health practitioners that sneak their way into the doors.  As far as – let’s see.  Social media, I am most active these days, although not incredibly active, on Instagram, and my handle is the same as my website.  So it’s @lilynicholsrdn.  And I’m about to launch my own online bookshop.  My books are available on Amazon and many different bookstores.  However, I’m also going to be selling, at least Real Food for Pregnancy, direct from my own site.  So if people want to purchase that, for paperback purchases, we’ll be shipping to the US, and every paperback purchased will come with a free copy of a new e-cookbook that I’m putting out that has 30 recipes following all the principles I outline in my books, but they’re not found in my books.  So 30 new recipes out there.  That will be your – it’s available for purchase separately, but as a thank-you for people who go out of their way to purchase a paperback copy from me directly, I’ll be bundling in that e-cookbook for free, as well.  So that should be launching soon, early March.  So you can check that out.

Kristin:  Fantastic.  Well, thank you for joining us today!  Appreciate your time, Lily!

Lily:  Thank you so much!

Thanks for listening to Ask the Doulas.  If you like this podcast, please subscribe and give us a 5-star review.  Thank you.  Remember, these moments are golden.

 

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Real Food For Gestational Diabetes: An Effective Alternative to the Conventional Nutrition Approach book cover

Real Food for Gestational Diabetes: Podcast Episode #115

Author Lily Nichols talks to Kristin about gestational diabetes during pregnancy and how eating has such a profound impact on our health and energy levels.  You can listen to this complete podcast episode on iTunes or SoundCloud.  Be sure to check out Lily’s book!

Welcome.  You’re listening to Ask the Doulas, a podcast where we talk to experts from all over the country about topics related to pregnancy, birth, postpartum, and early parenting.  Let’s chat!

Kristin:  Hi, Lily!

Lily:  Hello!  How are you?

Kristin:  Great!  How are you?

Lily:  Doing well.

Kristin:  I’m excited to have you join us !

Lily:  Yeah, happy to be here!

Kristin:  So I would love to, first of all, introduce your background to our listeners and then hear what you’ve been up to since we last connected.  So for those of you who aren’t familiar with Lily’s work, Lily Nichols is a registered dietician, a specialist in prenatal nutrition, and best-selling author of the Real Food for Gestational Diabetes book, as well as Real Food for Pregnancy.

Lily:  Yeah.  I think you kind of summed it up really briefly.  As you gather from the title of my books, my focus is very much on how we can use real food and nutrition to optimize pregnancy outcomes.  So, you know, it’s right in the title of the books, right?  So I’m happy to chat more about and any questions you have about my background, of course.

Kristin:  So I’d love to know how you got into this line of work as a dietician, and then what you’re working on now outside of the books you’ve put out in the past.

Lily:  Yeah.  Well, I got into this work in a way a little bit by accident.  I mean, I think things always end up working out the way they’re meant to, but regarding how I got specifically into the prenatal side of things, it was a bit happenstance, that there was an opportunity to work with the California Diabetes in Pregnancy program, which is a state-funded organization that helps put out guidelines on diagnosing and treating gestational diabetes.  And California tends to be a bit progressive, and so their guidelines are also generally pretty progressive, although I’d say mine are a bit more so now.  But in terms of diagnosis, for sure, they are much more progressive than what the rest of the United States follows.  So I’ve worked with them.  I’ve worked with a number of different clinicians, including perinatologists who specialize in gestational diabetes, so a lot of clinical work on top of the public policy work, which then just sort of naturally led into training other professionals on managing and treating gestational diabetes.  And it’s kind of – you know, this work, from seeing it from all different angles and getting pulled into different, you know, research projects, it just kind of snowballed into the focus of my career, and particularly, I’d say my clinical work, where I was able to see, you know, how well do the nutrition guidelines work in real life versus how they proclaim to work on paper was much different than I had anticipated, and that ultimately led me to really investigate, you know, how our nutrition recommendations were set.  Like, what’s the strength of the evidence used to set those guidelines, and how can we do better?  And ultimately, that’s really the reason that my books exist.  If there was no issues with the guidelines, I wouldn’t write books.  I mean, I write them because I take a very critical look at them and personally find that the evidence, particularly the new research from the past 20 years, has very much expanded our understanding of both pregnancy guidelines as a whole but also blood sugar management in pregnancy.  And we can just do so much better and have so much better outcomes if we really put that evidence into practice.

Kristin:  Well, I am so thankful that you put those books out into the world.  My clients appreciate – I refer all of my clients to your books, so it has been very helpful to have you as a resource.  So for those of our audience members who do not understand the difference between gestational diabetes and type 1 and type 2, could you give us a quick rundown of the differences?

Lily:  Sure.  Yeah.  So gestational diabetes is diabetes that either first develops or is first recognized during pregnancy, which is a bit of a nebulous definition because it can also encompass undiagnosed diabetes that was going on preconception or undiagnosed prediabetes that was going on preconception that we’re just identifying because during pregnancy we actually are checking your blood sugar, right?  But I think the classical definition, which I think is being challenged a lot, is that it’s something that just develops during pregnancy.  It is solely a response of the weight gain, placenta changes, changes in how your body responds to and produces insulin, that makes your blood sugar higher than would be expected and more difficult to manage.  I think we’re seeing now in the research that actually quite a large proportion of the cases are actually undiagnosed prediabetes that we’re just identifying the blood sugar issue during pregnancy, which makes sense because there’s been an absolute, exponential rise in gestational diabetes in the past 20 years or so, where now it’s affecting in some populations up to 22% of pregnancies.  Pretty sure I quote an 18%.  That was a bit on the higher end from back then, but I think I quote 18% in my book, and some other sources will say it’s only 5% of pregnancies.  But it has absolutely been on the rise as we’re seeing other forms of diabetes population-wide also on the rise.  As far as how it differs from other types of diabetes, now that I’ve probably confused everybody, when you’re looking at type 2 diabetes, that is a form of diabetes that at least historically developed in adulthood, and it’s essentially your body becomes unresponsive or less responsive to insulin, a hormone that helps you manage your blood sugar, and it can progress to the point where you produce less and less insulin over time and made need supplemental insulin or medication to manage it.  However, it can also often be well-managed or at least co-managed with nutrition and lifestyle.  With type 1 diabetes, that is an autoimmune condition where your pancreas stops producing insulin or produces very, very little, to the point that you will absolutely require supplemental insulin.  So, like, insulin shots to manage your blood sugar, and that is a lifelong condition.  It’s not something that is reversable, whereas with type 2, if you catch it early enough, sometimes it actually can be.  It’s arguable to call it reversable, but it can be, like, managed to the point that your blood sugar is normal.  So is that reversal or what?  I don’t know.  But with type 1, it is something you live with for the rest of your life, and so it’s a much more challenging one to manage because you’re trying to, like, mimic a functional pancreas in your dosages of insulin, and it takes a lot more careful management.  But absolutely can also be well-managed, and there’s many people living with type 1 diabetes to show that that is the case.

Kristin:  And then for gestational diabetes, most of the time but not all, it goes away after delivering baby, correct?

Lily:  Yeah.  So in about 90% of cases, blood sugar will normalize postpartum, at least early postpartum.  However, that can almost be kind of like a honeymoon period because there is a lifetime higher risk of developing type 2 diabetes.  They call it converted to type 2 diabetes, actually.  So in about 30 to 70% of cases, type 2 diabetes will ensue in the coming 5 to 10 years after delivery.  So it is the strongest independent risk factor for developing type 2 diabetes in women that we know of, is having gestational diabetes in pregnancy.  Now, to make – of course, that sounds very doom and gloom.  But I’m always flipping it to the positive, which is that it can absolutely be prevented, as well.  I see gestational diabetes as, like, the warning light coming in on your car.  It’s like pregnancy is a stress test on your system.  Your pancreas is required to produce double or triple, sometimes even more, insulin.  You’re naturally dealing with an insulin-resistant state of pregnancy, and so it’s like, can your body, like, step up to the challenge, right?  And so if your blood sugar is becoming more difficult to manage in pregnancy, it’s actually a sign that probably you want to keep an eye on this for the rest of your life.  It’s like, okay.  There’s a bit of a weak link in my blood sugar management, and I should keep an eye on this.  And if you do keep an eye on it, in many cases, it can be sort of – you can prevent it from actually progressing to type 2 diabetes.  Like, let’s be kind to your pancreas.  Be kind to your blood sugar management system.  Oftentimes, if you can continue with the same diet and lifestyle things that helped you during pregnancy – again, it depends on when you’re actually catching this.  Like, have you been insulin-resistant for, like, 15 years before getting pregnancy, or is it literally something that developed, like, right before or during pregnancy?  Like, depending on when you’re catching it, oftentimes it can be managed and in many cases prevent that conversion to type 2 diabetes.  So I always like to throw that out there because I think people see gestational diabetes as, like, this – just a very, you know, stressful and – it’s a stressful diagnosis, right?  Since I’ve worked one on one with hundreds and hundreds of clients, I mean, you know, even as the clinician, how you approach the topic with your clients can impact how they see the diagnosis.  And it’s like, okay, we want to, yes, take this seriously and talk about how blood sugar management can impact your pregnancy outcomes and your experience of pregnancy, but we also don’t want to scare you to the point that it seems like, oh my gosh, no matter what I do, this is horrible.  And that’s actually not the case.  And a lot of times, I do hear from people that there’s a bit of a silver lining to it.  You know, wow, I had no idea that food impacted me in this way, and when I eat for better blood sugar readings, I also have so much better energy.  And I’m not, like, gaining weight as rapidly, speaking of during pregnancy, as I was before.  And I no longer have that swelling in my ankles that was going on.  Like, you just feel better, and sometimes that’s motivation enough to continue these things long-term.  And you do continue to reap the benefits well beyond post-pregnancy.

Hey.  Alyssa here.  I just wanted to hop on real quick and let everyone know about a really exciting new course that Kristin and I have been working on called Becoming.  It’s all about becoming a mother, and in six weeks online, we will be giving video lessons and live coaching calls weekly with Kristin and I, along with a private Facebook community to offer encouragement and support.  This six-week online class will actually be launching beta, which is our first launch, on March 22, with our live call on March 26.  You can get into this beta program at a really, really super reduced price.  So check us out!  We’d love to have you join us and learn all about pregnancy, birth, and early parenting and especially during this scary time of COVID.  Let us be your expert guides!  We hope to see you there!

Kristin:  So I have a client I’m working with who is about to have her glucola test, and she is very nervous.  And, you know, she’s got a healthy pregnancy, but as you said, it’s stressful.  You know, the potential diagnosis can cause stress, and during COVID, you know, women are facing so much stress as it is.  So what advice do you have for her going into her test?

Lily:  Well, there’s not a whole lot you can really do going into the test.  I give a few notes, which is, pay attention to, like, the type of the test that you’re doing.  So there’s different ways that the glucola is done.  In some countries, and in California, which may as well be its own country, I guess, they do a 75-gram glucose tolerance test that is performed fasting.  So if your doctor says, like, come in fasting, absolutely, come in fasting because that will make or break the accuracy of the test.  There are other ways of doing the test, and this is most of the rest of the United States and rarely in other parts of the world, where they do, like, a two-step method where you come in for a smaller glucola or glucose tolerance test, and then if you don’t pass that screening test or challenge test, they sometimes call it, you’ll come back for a three-hour test with a larger amount of glucose.

Kristin:  And that’s what we’re seeing in Michigan.  Yes.

Lily:  Right.  So that first step, the 50-gram glucose challenge or glucose screening, is generally not performed fasting.  So they don’t check your blood sugar before.  They only check it one hour after you’ve had your drink.  So you don’t need to come in fasting, but I would just caution people to not show up, like, immediately after having a large lunch or immediately after having a smoothie or candy in the car.  I mean, I’ve had people come up with false positives on that test because they came in right after lunch.  And if you come in on a full stomach, you are – already, your blood sugar is at its peak, and now you’re going to add insult to injury, so to speak, by adding 50 grams of sugar on top of that?  Yeah.  Your reading is probably going to come back high.  Part of the reason they do this two-step thing and that they don’t perform it fasting is that they just want to lower as many barriers as possible to actually getting people in to do the test.  However, it can result in false positives and sure, you do the three-hour screening that’s fasted afterwards; however, you have all that stress in the interim of, oh my God, do I or don’t I have it?  Which is why many people have been moving towards just doing this single-step 75-gram test which is fasted.  It’s just a bit more of control over your test.  So I’d throw that out there.  Like, don’t have a bunch of sweets right before you come in, and don’t come in immediately after a meal.  Come in, do your test two hours or so after eating, and if you’re hungry in between, have some sort of a protein snack like some nuts or something or some cheese, just so you’re not already starting your test with elevated blood sugar.  The second thing I would say is, if you err on the low carb side of things, so if you happen to just naturally eat a low-carb diet, you might consider increasing your carbohydrate intake in the week prior to the test for people who consistently eat below about 150 grams of carbohydrates per day.  You can also get a false positive on the test.  And speaking as somebody who falls into that category, that actually happened to me in my first pregnancy.  So I wrote all about it on the blog.  I was one point over, but still.  It’s important for people to know, and I was kind of doing that a bit on purpose.  You know, we’ve known since the 1960s at least that if you restrict carbohydrate intake prior to a glucose test, your pancreas is not adapted to pumping out large boluses of insulin at a time to lower a huge spike in your blood sugar very rapidly.  It’s just become adapted to pumping out just very small, tiny amounts, just sort of pulsing out small amounts of insulin as needed over the day, not huge amounts.  You give those same people a high carb diet for a week prior to a glucose test, and their body adapts, assuming they don’t have diabetes, and you don’t have that issue.  You don’t have the false positives.  So the same is true with general population and pregnancy, as well.  If you eat low carb, your body’s just not adapted to that at this moment.  Now, if you’re somebody who always eats high carb, you should have no issues passing the glucose test.  You know, unless there’s obviously an issue with your blood sugar management.  But for people who are low carb, you know, if your body has the capacity to adapt to it, then you will know if you eat high carb in the week prior to the test.  That should eliminate your concern about a false positive for the most part.  So I always do mention that because the guidance on eating more carbs prior to a glucose tolerance test was eliminated, I believe, in the 90s, and that’s because most people are already eating well over 200 grams or more of carbohydrates per day because that’s what our dietary guidelines tell us to do, and we really didn’t need people eating more bread and more juice and more cereal prior to doing these tests.  But for people who – now that keto and low carb are a little more popular, it has returned to being important to at least mention that.

Kristin:  Yes, that’s very helpful.  So for our listeners and clients who do test positive for gestational diabetes, what tips do you have for nutritional management?

Lily:  So first things first is, you know, everybody’s body responds to food differently.  So there are some rules that would apply to anybody in that the way our body processes carbohydrates versus protein versus fat and how those impact blood sugar.  There’s some constants there, right?  But as far as the absolute details and how much of all of those foods you can consume and expect a certain blood sugar reading, that actually comes down to you testing your own blood sugar and fine-tuning your diet in response to what you’re seeing in your post-meal blood sugar readings.  So the most important thing is that you get a blood sugar meter and start testing to see where you’re at.  Otherwise, we have really – we’re flying blind.  So I can give general guidance, but until you have those blood sugar readings, it can be a bit challenging to know for sure what you should be doing.  Now, of course, generally speaking, it is very helpful to understand that certain foods raise your blood sugar more than others.  So carbohydrates are the foods that break down into individual sugars in your body and then raise your blood sugar or your blood glucose, whereas protein and fat do not necessarily raise your blood sugar.  There are some nit-picky details and exceptions to the rule, but generally, protein and fat just keep your blood sugar stable but they don’t spike it like carbohydrates do.  So the key with understanding this, and I do this is Real Food for Gestational Diabetes, is I just break it down: these foods raise your blood sugar.  These foods don’t.  And so focus on not going overboard on the foods that do spike your blood sugar.  So your carbohydrates are your grains and starches, potatoes, sweet potatoes, fruit.  Milk and yogurt will have a little bit of carbohydrates.  Of course, they’re also balanced with some fat and protein.  And legumes – again, they have carbohydrates.  They also have protein.  They have fiber.  So they’re a bit of a better source.  But we’re usually looking at grains, starches, fruits, anything with sugar, would be your main things that you want to be like, okay, let me just tap the brakes a little bit on those foods, and when I do consume them, consume them in a reasonable quantity in combination with foods that don’t spike my blood sugar.  So your protein-containing foods and fat-containing foods would fall into that category.  And that basic understanding of just splitting up foods into elevates your blood sugar / does not elevate your blood sugar can be really, really helpful for people to just simplify things.  I call it no naked carbs.  So don’t have your carbohydrates solo by themselves because you’ll get a larger spike in your blood sugar than if you combined that carbohydrate-containing food with some fat and protein.  So a perfect example of this is an apple, which is of course a healthy, whole food, right?  However, an apple is primarily carbohydrates.  Sure, it has some fiber, and that helps blunt your blood sugar spike a bit compared to apple juice, for example.  However, if you were that apple, again in its whole form would be ideal, right, versus juice – if you combine it with something that has fat and protein, like, say, some almond butter or peanut butter, you’re going to significantly blunt your blood sugar response to that food, so your blood sugar won’t spike as high, which means your pancreas doesn’t have to pump out as much insulin, either, to match it.  And when you don’t spike as high, it’s kind of like a roller coaster.  You don’t drop as low.  And this is very helpful for managing your hunger and cravings, as well as your blood sugar.  So that would be my main recommendation.  And then you can fine-tune the amount of carbohydrates you can get away with by checking your blood sugar after you eat and seeing where you’re at.  Are you falling within range?  Are you coming in a bit above range?  And that can help you fine-tune things.

Kristin:  And do you recommend that our listeners find a dietician to work with, or can they manage this, again, based on how their levels are on their own?

Lily: I mean, in an ideal world, I think it is helpful to work with a dietician or diabetes educator or any clinician who has a lot of experience with gestational diabetes because there’s just so much nuance to it.  I mean, coming down to even how you check your blood sugar, you know, you can mess that up.  You use a soap that has sugar-containing ingredients.  There’s all sorts of gluco-ingredients in soaps and lotions and things.

Kristin:  I didn’t even think of that.

Lily:  Yeah.  I mean, it happened to me.  You understand a lot when you do things firsthand, so I’ve been a bit of a guinea pig on myself.  I had seen this with clients before, as well, and you do – you know, as a certified diabetes educator, you do learn about all this stuff, as well, but you see it in real life when people are like, but I only had XYZ food, which doesn’t spike me, but my blood sugar came out 20 points higher than it should!  First of all, you have people, if they get an unexpected high reading, wash their hands again, test again to just try to verify if it’s accurate, because meters are not perfect.  But there can be so many things.  You can have a meter that is not super accurate, and sadly, there are some brands of meters that aren’t super accurate because their tolerance for variance is based on type 2 diabetes levels, where with gestational diabetes, you’re expected to keep your blood sugar in a much narrower range.  So if you have a meter that is reading 10% higher, if you’re a 50-year-old man with type 2 diabetes and you only have to keep your blood sugar under 140 or you’re aiming for 180 or something – sometimes the ranges are much more liberal, depending on who you’re working with – that’s no big deal.  But if you have gestational diabetes and you’re trying to keep your blood sugar below, say, 120 after meals, than a 10% variance in the wrong direction is a big problem.  So sometimes it comes down to, is your meter accurate?  Are you test strips expired or not?  Are you cleaning your hands properly before testing?  So I gave you the example of soap, but say you just had an orange, and you have a bit of orange juice left on your finger.  That will read as sugar on a blood sugar test.  So you prick your finger, squeeze out a little drop of blood, test, and it comes out unusually high.  That can be a problem.  So some of this nit-picky little stuff, it can be helpful to have somebody there to guide you so it’s a little less scary.  And especially in those first two weeks after diagnosis, I think that’s when it’s the most raw and the most concerning and the most “I don’t know what I’m doing.”  So if it is possible to get a referral from your provider, you can do that.  I have a free video series on gestational diabetes on my website.  Of course, my book, Real Food for Gestational Diabetes, does walk you through this, and I intentionally wrote that book with as simple language as possible to just kind of cut through all the noise so you can focus on what actually matters and not get distracted by a bunch of extraneous details, so that can certainly be helpful.  But there is always, I think, a time and a place for one on one guidance on this if you can get it.  So I’ll throw that out there.  There are, I know, people who just don’t have necessarily those types of providers or providers who maybe are up to date on some of the nutrition information that I give out, so they might go to a dietician and get really not fantastic dietary advice, like very high carbohydrate diet.  I mean, that’s the reason I had to write my book, because the current guidelines are just so far off from what actually works that, you know, I do have my book available.  I also have a paid online course.  We have a private Facebook group where people can ask questions of me directly and get support from other members.  I try to have as many options from free to, you can get the e-book for 10 bucks to a course to just give you as many options as possible because I want to meet everyone where they’re at.

Kristin:  So what is your advice as far as minerals and supplements with gestational diabetes?

Lily:  Like, which specific minerals?

Kristin:  So just looking at if they’re adding supplements to their diet.  What is good?  What isn’t?  You know, outside of the prenatal vitamin that they’re taking.  Should they be doing anything different once they’ve received the diagnosis?

Lily:  Gotcha.  So as far as supplements, I mean, I do think for most people it makes sense to be on a prenatal vitamin.  I would check, if you’re having a screening for anemia, check to see if you actually need the iron because sometimes too much iron can be a bit inflammatory and create more blood sugar issues.  So check for anemia before you jump for a prenatal that includes iron.  You might want to opt for an iron-free one.   I am just much more of a fan of people getting their iron from food that has all of the complementary co-factors for you to use it.  The type in most prenatals on the market, unfortunately, is just not super well-absorbed and sometimes kind of adds fuel to the inflammatory fire.  As far as additional supplements, we often find magnesium deficiency is more common when there’s blood sugar issues present, so that as a supplement, I think, is very helpful.  Minerals usually are more bulky ingredients for prenatal supplements, so most of them, unless it’s like a multiple capsules per day kind of a formula, just do not have very much minerals at all.  So somewhere between 150 to 300mg of magnesium a day can be really helpful.  Magnesium glycinate is the form that I often recommend.  The glycinate means the magnesium is bound to an amino acid called glycine, which has its own beneficial effects on blood sugar management, and it’s also just very well-absorbed, so you don’t have this GI distress, diarrhea sort of reaction that some people get to magnesium supplements, especially when they’re high-dose.  You can also do a foot soak or a warm bath with Epsom salts in it, and you absorb the magnesium through your skin that way, so that’s always helpful.  Another one would be vitamin D.  A lot of prenatals do not include enough vitamin D.  I just put out a blog post about vitamin D in pregnancy on my blog if people want to read that for more.  But much of the research surrounding that nutrient in pregnancy shows that you need actually up to 10 times more than what the current recommendation for vitamin D is.   So I do recommend, if you do not live in a southern, sunny climate where you get lots of sun exposure without sunscreen on, on a regular basis, which is much of the country that’s not possible, then I do recommend supplemental vitamin D.  And so looking at how much your prenatal has and trying to get around 4,000 IUs per day can be really helpful.  We actually have research studies showing that vitamin D deficiency is more common in gestational diabetes, but also the more severe the vitamin D deficiency, the worse blood sugar readings tend to be, and actually that if you supplement it and correct vitamin D deficiency, the blood sugar readings improve.  Same goes for magnesium, by the way.  And then I’ll add just one more.  I mean, there’s other supplements that could be helpful in pregnancy, but specifically for the blood sugar conversation, another nutrient we’re getting a lot more data on is inositol, which is a B vitamin-like compound.  It’s actually used pretty often in fertility and PCOS, which the majority of PCOS cases have some component of insulin-resistance, and it’s actually a risk factor for the development of gestational diabetes.  So we have all of this positive research on inositol for PCOS and for infertility.  We’re now having studies done on inositol for pregnancy and specifically diabetes in pregnancy, showing pretty positive results.  And so they typically do a dosage of 4 grams, which is also 4000 milligrams per day, of myo-inositol.  So that’s something that you can discuss with your provider.  We have a couple studies now on fasting blood sugar and other markers of insulin resistance.  It’s a very safe supplement, very safe.  There has been absolutely no animal or human studies indicating any sort of toxicity in pregnancy including in the very delicate stages of embryogenesis in really early pregnancy, so that’s really reassuring.  If anything, it’s really been overwhelmingly all positive.  So I do throw that one out there because that’s probably one of the more promising and more well-researched nutrients that can impact blood sugar.  You can go on – I can probably list, like, a dozen more nutrients that also impact blood sugar, and the hope is that most of those would be covered by your food intake and also your prenatal, but you can get kind of nitty-gritty on all this stuff if you really want to.

Kristin:  Sure.  So I’d love to hear – this has been very helpful.  Love to hear any last tips that you have for our listeners, and that could be anything from, again, managing gestational diabetes to stress management to postpartum care.

Lily: Oh, gosh, you give me a lot of good leads to go on with that.

Kristin:  So wherever you’d like to go with that!

Lily:  Well, maybe I’ll give a little nod to stress for a minute, and then I probably have to talk postpartum, as well.  So stress is an underrecognized factor that plays a role in your blood sugar.  So your body has a very real physiological response to stress or perceived stress that often makes your blood sugar go up.  So I think its easy as practitioners for us to just sort of dismiss stress and just focus on the knowns of food and movement and exercise, things like that.  But you absolutely see a really significant response to stress, whether that’s personal work stress or even if it’s immune stress.  If you get a cold, your body is under stress, and your blood sugar is elevated as a response.  You see it firsthand for anyone who has worn a continuous glucose monitor, which is probably not many people listening.  But I know I have, if I have a stressful phone call, and a continuous glucose monitor, you can get real-time readings on your blood sugar, and it graphs out your 24-hour blood sugar readings on a chart.  You can see it.  Like, whoa.  My blood sugar spiked 10 points and remained elevated for 30 minutes as a response to that stressful interpersonal interaction.  So anything you can do to just kind of stay calm and even-keeled is absolutely also helpful for your blood sugar.  I don’t think we can discount that.  And then to just give a quick note on postpartum, I’m just such an advocate for a nourished and slow postpartum, and I think it’s really hard as a first-time mom to, you know, even imagine or put much focus on postpartum because it’s all about the big event of birth.  And I know I fell victim to that, as well, my first time around.  I probably should have read a book on postpartum or something.  But you’re so focused on birth.  How can I create the best birth?  I want it to go like this.  Birth is like, at best, you know, it can be a couple hours.  It can be maybe a couple days depending on the circumstances.  But postpartum is a very long period of time, and I think our culture sees it maybe as a couple weeks, up to six weeks, right?  That’s when you go back to your provider and get a check-up to see that you healed okay.  But it is much more than two weeks or six weeks.  It is kind of a long haul healing process.  And a lot of our western society doesn’t really – we’ve lost touch with our postpartum traditions, where many other places in the world still have those intact, and there is extra attention to care and nutrition and other people coming in to care for the new mother, especially in the first month to six weeks.  It’s often 40 days.  And if you do that, having really been intentional about postpartum my second time around – it’s not that I didn’t have a good postpartum the first time.  I felt like I did pretty well, all things considered.  The second time was just so much more easeful.  Like, just everything about it was so much better because I prepared for postpartum.  I prepared meals in the freezer.  I had my mom come up and stay with us.  I really tried to embody and bring in as many of those practices that these other cultures – I mean, it’s so strange.  You go all across the world, and they’re very similar.  You know, like, how do they all – it’s all like similar types of foods with broths and stews and warming foods and teas.  And it’s the same amount of time.  It’s the same, bringing in other women, especially older women who are mothers or grandmothers themselves to care for you.  It’s like, how is it the same in Mexico as it is in the Middle East as it is in China as it is in Indonesia as it is in Mexico and Brazil and Africa?  How is it the same?  It’s all, like, very, very similar.  I think we have to give some credence to, there’s some wisdom there that we should honor.

Kristin:  There certainly is.  Mothering the mother is definitely something that is ignored in the US, and other cultures embrace it.  That’s why our postpartum doulas do not just work within the first 30 to 40 days.  We work with families through the first year.

Lily:  Oh, that’s fantastic.  Yes.  Yes.  Because often you come out of those first three months a bit in a fog, and you’re expecting it to be easier.  And a lot of things are easier.  Things are less intense, but it’s also still hard.  It’s still a lot.  You know, it continues to be a lot.  I have an 18-month old now, my second, and it continues to be a lot long-term.  It gradually does get easier, but just building in the expectation of having help and having support and having that extra focus on nourishment goes a really long way.  So I think I do a better job in my second book, Real Food for Pregnancy, of really emphasizing the postpartum part.  I snuck in a whole long chapter on it because I started writing that book when I was 10 months out with my first.  Whoa, postpartum is important!  I’m going to put it in a pregnancy book because I know I didn’t seek out – as proactive as I am, I didn’t seek out that information when I was pregnant, and I really should have.  So, here.  I’ll throw it into this book.

Kristin:  I love that chapter!  I’m so glad you included it, so thank you.  So how can our listeners and doula clients find you and your books?  I’d love to – all of the different ways you mentioned, videos and one-on-one courses.  Share all of the ways we can connect with you, please, Lily.

Lily:  Sure.  So you can find me on my main website.  That has my blog.  It links out to my books and where you can find those.  It has a lot of different freebies, so you can download the first chapter of Real Food for Pregnancy for free.  You can check out the free video series on gestational diabetes.  There’s a couple others up there.  So that’s kind of the main hub.  As far as courses – at the moment, I’m not seeing one-on-one clients, but I am still supporting course participants in the Real Food for Gestational Diabetes course.  And that’s fully online, and we also, like I said, have a private Facebook group.  So I do office hours in there every week.  Lots of questions on, especially, fasting blood sugar.  So I go into depth on that.  I have a bunch of bonus presentations included in the course.  I just kind of keep adding on to it.  I’ve been running it since 2015.  There was no course on gestational diabetes out there at the time.  I don’t really know if there’s any others, actually.  I haven’t looked.

Kristin:  I don’t know of any, so – there could be, but…

Lily:  Yeah.  Especially on the client level.  I think there’s some on just teaching practitioners sort of the basics on it, and I do, by the way, have a webinar on that over at the Women’s Health Nutrition Academy.  But as far as supporting clients directly, that’s definitely the place to go.  I have a – just did a big presentation on postpartum recovery after gestational diabetes, so lots on this, concerns about type 2 diabetes and when to get screened and what to do, a bunch of information on that.  I have advanced training on lowering fasting blood sugar with food and lifestyle tips.  There’s a lot of things in there that I just really don’t include anywhere else in my work, so that is really geared directly for clients themselves, although I do have a couple health practitioners that sneak their way into the doors.  As far as – let’s see.  Social media, I am most active these days, although not incredibly active, on Instagram, and my handle is the same as my website.  So it’s @lilynicholsrdn.  And I’m about to launch my own online bookshop.  My books are available on Amazon and many different bookstores.  However, I’m also going to be selling, at least Real Food for Pregnancy, direct from my own site.  So if people want to purchase that, for paperback purchases, we’ll be shipping to the US, and every paperback purchased will come with a free copy of a new e-cookbook that I’m putting out that has 30 recipes following all the principles I outline in my books, but they’re not found in my books.  So 30 new recipes out there.  That will be your – it’s available for purchase separately, but as a thank-you for people who go out of their way to purchase a paperback copy from me directly, I’ll be bundling in that e-cookbook for free, as well.  So that should be launching soon, early March.  So you can check that out.

Kristin:  Fantastic.  Well, thank you for joining us today!  Appreciate your time, Lily!

Lily:  Thank you so much!

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