Can low carb or keto help with gestational diabetes in pregnancy?

Pregnant Woman Having Blood Glucose Checked

When Natalie Thompson Cooper was diagnosed with gestational diabetes in her first pregnancy, at age 28, she was very concerned. The condition, which affects at least one in seven pregnancies to as many as one in five, causes blood sugars to rise abnormally high, called hyperglycemia.1

Natalie knew hyperglycemia bathed her body tissues and her unborn daughter in glucose, putting both her and her fetus at risk for a wide range of potential complications, including miscarriage, birth defects, macrosomia (very large size), high blood pressure, pre-eclampsia, seizures, birth trauma, and higher rates of C-section and even stillbirth.2

Moreover, gestational diabetes (GD) — also called ‘carbohydrate intolerance of pregnancy’ — greatly increases the risk that the mother and her offspring will both face future health problems, such as much higher rates of eventual type 2 diabetes, metabolic conditions, and cardiovascular disease.3

GD is one of the most common and significant complications of pregnancy. Prenatal guidelines the world over recommend the routine screening of all pregnant women and then, if positive, strict management, starting with dietary therapy, then if that does not work, insulin injections.4

However, to this day, what constitutes the best “dietary therapy” is hotly debated, with some researchers proposing a diet high in complex carbohydrates (60% carbs) and others lower carbohydrates (40% carbs).5

However, the recommended “lower carb” GD diet is still far higher than the under 20 g per day of the strict low-carb high-fat or ketogenic diet. In fact, many guidelines for GD recommend women, on an ostensibly “lower-carb” diet, eat a minimum 175 g of carbohydrate daily, a level at which many women see their blood sugar rise out of control.

“Honestly, 175 g of carbohydrate is stupid! Women should be going as low as it takes to keep their blood sugar regularly under 90 mg/dl (5 mmol/L),” says Dr. Lois Jovanovic, one of the world’s leading experts in diabetes in pregnancy. Jovanovic is recently retired as the director and chief scientific officer at the Sansum Diabetes Research Center in Santa Barbara California. “Women ask me, ‘Do I have to eat carbohydrates?’ and I say, ‘No you do not!” If you do eat carbohydrates [with GD], you will have to have insulin. It is that simple.”

Natalie Cooper Thompson is a case in point.

Natalie, an elementary school teacher in Buford, Georgia, was told after the diagnosis of GD in her first pregnancy to eat carbohydrates at every meal and at three snacks a day, getting a daily carbohydrate requirement of at least 175 g — enough so that no ketones would be found in her urine.

She ate what they advised — bananas, whole grain toast, fruit, rice, steel cut oats — and was checking her blood sugar with a home monitor seven times a day. The results were always too high. Soon she was on four insulin injections a day, but still the GD was uncontrolled. She developed preeclampsia (high blood pressure and protein in her urine). Her daughter was born by C-section at 37 weeks, weighing 8 lbs (4 kg). “The diet did not help me AT ALL!”

Finding the ketogenic diet

Six years later — after failed fertility treatments for her PCOS, a miscarriage, and a successful adoption — Natalie discovered ketogenic eating. She lost 40 lbs (18 kg) in three months, which brought her weight down to 210 lbs (95 kg), helping her infertility and her PCOS symptoms. Much to her surprise, after six years of infertility, she was suddenly pregnant.

Natalie Thompson Cooper 24 weeks in all three pregnancies

Thompson Cooper during three different pregnancies

In the second pregnancy she developed GD, again, at 18 weeks. Her doctors and dietitian gave her exactly the same advice — carbs at every meal and at three snacks a day to a minimum daily requirement of 175 g. This time Natalie just smiled and nodded but kept her carbs below 50 g and monitored her blood sugar regularly with a home meter. She eventually needed insulin, but just one injection at bedtime. “It wasn’t perfect, but I was much more successful at keeping my blood sugars in check. There was no way I could eat the amount of carbs they recommended. If I did, my blood sugars would be way too high.”

Now, age 36, she is happily pregnant again — 24 weeks6 — with her third pregnancy. She has continued keto eating these past two years, which led to resolved infertility, a total weight loss of 95 lbs (43 kg) and a healthy pre-pregnancy weight of 155 lbs (70 kg). In June, at 18 weeks, she had a glucose tolerance test again to screen for GD. She drank a sickly sweet drink with 50 g of sugar, and had her blood glucose checked one hour later. This time she passed with flying colours: her blood sugar was 85 mg/dl (4.7 mmol/l). “That is about as perfect as you can get!”

Will she still develop GD later in this pregnancy? She doesn’t know, but she will do her utmost not to up her carb consumption and will monitor her blood sugars regularly. She has set the goal of under 50 g of carbs a day, and hopes to get to 25 g if possible. “I cannot believe that 175 g of carbs is still being recommended for GD! It is insane.”7

Is the current advice based on solid science?

Nichols book Real FoodDr. Jovanovic and U.S. dietitian Lily Nichols both agree. Jovanovic has been consulting in the last few years around the US, telling endocrinologists and ob/gyn doctors that women can safely cut carbs to the level that keeps their blood glucose tightly controlled (see below) even if that means no carbs at all. She says to doctors looking after women with GD: “Repeat after me: pregnant women do not need to eat carbohydrates!”

Nichols gives the same advice. She is the author of the 2015 book Real Food for Gestational Diabetes, offers online gestational diabetes course and blogs at PilatesNutritionist.com.

Nichols has specialized in gestational diabetes for most of her career, particularly with a California GD program called “Sweet Success”, which also recommended the minimum 175 g of carbs daily for GD. “It was always really disappointing to see how many of my prenatal clients would end up, as we say, ‘failing diet therapy’ and would have to go on insulin. It didn’t make sense to me why somebody with gestational diabetes, which translates as carbohydrate intolerance, would need such a high level of carbs,” said Nichols.

That experience set Nichols off digging into the historical research literature to find out why 175 g a day had become the arbitrary measure for lower-carb GD dietary management. “It turns out that this number is a best guess and not based in solid science. There is no evidence that eating fewer than 175 g of carbohydrates is harmful. The only reason medical professionals continually push a higher-carb diet is due to unfounded fears around ketosis.”

lily-nicholsAs detailed in an earlier post: Is low carb safe in pregnancy? good scientific studies around low-carb ketogenic eating in pregnancy are sorely lacking. However, ketones in the urine of pregnant women with GD “freak doctors out,” says Nichols, because they fear the life-threatening conditions of diabetic ketoacidosis in pregnancy or starvation ketosis. “These are not the same as nutritional ketosis at all,” says Nichols whose book has an entire chapter on the misconceptions surrounding ketosis in pregnancy. Dr. Jovanovic agrees: “Put the ketone stix away. Ketones in urine do not mean anything.”8

Both women, as well as reproductive expert Dr. Michael Fox, note that nutritional ketosis in pregnancy is a natural state, which is normal and safe, and likely beneficial to general fetal growth as well as fetal nerve and brain growth.

Dr. Fox notes that in obstetrics training, doctors are taught that, most commonly, ketones in the urine would represent starvation ketosis. This is often seen in hyperemesis patients (severe nausea and vomiting) and in patients who are not eating enough calories during pregnancy.

As long as pregnant women are eating frequently (at least every 3 hours) and consuming plenty of calories (about 2500 calories or more per day), ketones in the urine or blood is not an abnormal state and it is expected with a ketogenic approach.

While pregnant women might get push-back from doctors not yet familiar with nutritional ketosis, Dr. Fox suggests one way to educate the medical team would be to say “I am following a ketogenic nutritional approach and ketones are expected in the urine. Unless you believe that I am sick, I will continue my diet.” Then recommend that the physician visit Diet Doctor.

In short, all three experts say, pregnant women with GD can reduce their carbohydrates and not fear ketones in their urine as long as their blood sugars remain in normal ranges and they are eating enough calories from nutrient dense foods for themselves and their babies. (Note: High blood sugar combined with very high blood ketones is ketoacidosis and a medical emergency. Diabetic ketoacidosis cannot be diagnosed with urine ketones; it is only found in blood ketones and generally found among women with type 1 diabetes.)

In extensive interviews for this post, these experts offered four practical tips for managing the risk of GD for all pregnant women, especially those at higher risk of GD, such as women with polycystic ovarian syndrome (PCOS), pre-diabetes, obesity, and previous GD in pregnancy.

Tip #1 Have early blood sugar tests to assess your risk

Women who go into pregnancy with pre-existing insulin resistance, or undiagnosed pre-diabetes, are much more likely to develop GD. “A lot of women unknowingly have blood sugar issues, even before pregnancy. And the physiology of pregnancy naturally increases insulin resistance in all women. By the 10th week of pregnancy, insulin levels are up to 3 times higher than they were pre-pregnancy.”

An HbA1c test — which measures the average blood sugar levels in the previous three months — taken prior to pregnancy or early in the first trimester can help identify women at risk in advance. Values greater than 5.7% indicate prediabetes and many doctors treat this the same as gestational diabetes. The higher the number, the higher your average blood sugar. A level of 5.9% or higher accurately predicates gestational diabetes 98.4% of the time.9

A fasting blood glucose prior to pregnancy or early in the first trimester can also help flag potential problems, if values are higher than 5.6 mmol/l (100 mg/dl), which is suggestive of prediabetes. Both women note that, depending on your result, you may need to make blood sugar control a bigger priority. “Tackling it up front can prevent blood sugar issues in the pregnancy and future complications,” Nichols said. Jovanovic agrees: “Waiting until 24 to 28 weeks to diagnosis GD means the fetus may have many weeks earlier in the pregnancy exposed to high blood sugars. You want to be on top of it early.” Note: HbA1C tests later in the pregnancy are less reliable because of rapid blood cell turnover and low iron stores.10

Tip #2 Self monitor with a home glucose monitor

Women at higher risk of GD, or with a confirmed GD diagnosis, or who are interested in knowing about how their pregnancy and their diet is impacting their blood sugar, should consider getting a home glucose monitor and checking their blood sugar regularly. Times of the day to test are: a fasting blood glucose first thing in the morning and one to two hours after every meal or snack.

Even just two weeks of testing can quickly show how the foods you are consuming are impacting your readings, enabling you to adjust your diet accordingly. Called eating to the meter, home monitoring “is the proactive way to go.” says Nichols and Jovanovic. “It can be a bother, but the meter doesn’t lie. If your blood sugar is high, you need to do something about it” says Nichols.

Both note that if you have a couple of weeks showing normal blood sugar, you can keep eating the way you are eating. Just be aware that if your readings looked great in early pregnancy, you need to check again for a few weeks in the 24-28 week window since insulin resistance goes up in later pregnancy. Some people like Natalie Thompson Cooper have chosen to self-monitor their blood sugar regularly through their entire pregnancy.

Many types of home glucose monitors are available from your local pharmacy. Follow the instructions that come for your particular meter. In general, wash your hands with soap and water and dry well before testing. Do not use alcohol wipes as this may alter the result. Also so not touch any food before testing, as this can also raise the readings.

While optimal results are not yet know, as blood sugar levels are on a continuum, the general consensus is that you are aiming for the following results:

  • Fasting blood glucose in the upper range limit of 90-99 mg/dl (5.0 to 5.5 mmol/l); under 90 mg/dl is optimum.
  • 1 hour post meal (postprandial) blood glucose less than 140 mg/dl (7.8 mmol/l); under 100 mg/dl is optimum.
  • 2 hour post meal blood glucose less than 120 mg/dl (6.7 mmol/l); back down to 90 mg/dl is optimum.
  • Avoid maintaining blood glucose levels too low (below 4.5 mg/dl) as there is an increase likelihood of small for gestational age infants; you may not be giving your baby enough nutrition.

Keep track of your daily blood glucose readings, the food you ate, and the exercise you did, either in a notebook or through one of the online trackers. The free SugarStats tracker is very easy to use.

Tip #3 Understand the options for screening and diagnosis

Screening for GD typically happens in the first trimester for those at high risk (women with previous GD or PCOS) and at 24-28 weeks for all other pregnant women. The first test is typically the glucose challenge test: chugging a syrupy sweet drink with 50 mg of sugar and having blood glucose tested one hour later.

Nichols blogged about her own experience with the test during her pregnancy in 2015 and how she failed it by 1 point, reading 141 mg/dl (7.9 mmol/l) rather than the cut off of 140 mg/dl (7.8 mmol/l). Her failure was likely because she was eating a low-carbohydrate diet prior to the test. Her home glucose monitoring revealed perfectly normal blood sugar levels and ruled out a gestational diabetes diagnosis.

False positives in the glucose challenge test are common, particularly among women who eat a low-glycemic, low-carb or ketogenic diet, because their bodies are not accustomed to handling that amount of sugar at one time. Many women find drinking the sugary liquid very difficult, causing nausea, vomiting, dizziness, and headache. Studies have found eating 50 g of sugar in 28 jelly beans or 10 sticks of a very popular (in North America) strawberry-flavoured licorice candy, called “Twizzlers” may be easier to tolerate, with fewer side effects, but still provide the same results.11

435px-Twizzlers-Pile

Twizzlers

Women who fail the glucose challenge screening typically must then have the three-hour Oral Glucose Tolerance Test (OGTT) to confirm GD diagnosis. That entails drinking twice the amount of sugar (100 g) and having blood tested hourly over the next three hours.12

Nichols notes in her blog about failing the test that the two-step screening method for gestational diabetes is outdated because a fairly high percentage of healthy women “fail” the first test while some women with excessive insulin production “pass” it and are never formally diagnosed.

“That’s why the International Association of Diabetes and Pregnancy Study Group (IADPSG), the World Health Organization (WHO), and nearly all countries aside from the United States recommend the more reliable and specific 2-hour, 75 g glucose tolerance test, which is done fasting and includes more rigid cut-offs for diagnosis,” she says. However, the 75 g fasted test is not yet the standard test in all countries, and it may lead more women to be diagnosed with GD (likely because it catches women with “mild” gestational diabetes).13

Nichols and Jovanovic note that women can forego the tests if they instead choose to track their blood sugar at home. If you show your doctor the results of your readings, you can usually convince them to forego other tests. “You can always decline the tests. You have that right. But you should be tracking your own sugars,” says Nichols. Jovanovic advises: “Just show them your home blood sugars. That is all that matters.”

Some women eating low-carb/ high-fat or ketogenic diets decide to refuse the standard GD tests altogether. Katie Bravie of Hobart Tasmania did just that. Now 32 weeks pregnant, Bravie, 26, lost 23 kg (52 lbs) over the previous two years by following the ketogenic diet. She is loathe to add any sugar, even in a test, back into her body. Her midwife demanded she take the screening test and told her there were no other options.

“I went to my family doctor for backup, who knew my journey with my weight loss and keto. She said drinking that amount of sugar would make me sick after two years of no sugar and it would result in a false positive.”

Instead the doctor did an HbA1c test as well as a test called a fructosamine blood test, which is another way to test for evidence of high blood sugar. Her results were fine. She is staying the course on her keto eating during pregnancy. “I love having a keto pregnancy,” says Katie, who says her midwife continues to be “freaked out” by the presence of ketones in her urine. “But I just secretly laugh it off. I know I am fine.”14

Tip #4 Eat a nutrient-dense “real-food” diet

The cover of Nichols book features two fried eggs with sliced avocado and cherry tomatoes — a low-carb high-fat meal. “It is the perfect breakfast, or any meal, for gestational diabetes,” she says. Her advice: eat nutrient-dense foods over empty calories.

“Some low-carb people are just living off fat bombs and bulletproof coffee. You need to have good, common sense with variety in your diet.” Have protein like meat, fish and eggs, snacks like nuts and seeds, lots of vegetables with healthy fat like olive oil or butter. Try to eat liver once or twice a week, to help ensure a good natural intake of vitamins, minerals and antioxidants in your diet.

Avoid all processed foods, added sugar, refined carbs, as well as high-glycemic fruit and fruit juices. If your blood sugar is still high, cut out all fruit except berries for now. “You do not need to add in bread and cereals to have a healthy pregnancy,” says Nichols. Pay attention to how you feel, and monitor your blood sugars. “Some pregnant women may feel better eating slightly more carbs, but I think the majority of women with GD, and all pregnant women in general, do better with at least one-half to one-quarter the carbohydrates recommended in conventional nutrition guidelines (which is upwards of 65% of calories from carbohydrates).

Are gestational diabetes programs around the globe now registering that message and advising lower carb? Alas, not yet.

Sarah H. 37, of Southern England, was diagnosed with GD a month ago, early in her third trimester, which is now in its 38th week. She was referred to a dietary program for women with GD. “The NHS dietitian told me to eat bread with every meal and snack on biscuits and low-fat ice cream!” She was also advised to avoid all saturated fat and to feel free to include in her diet fruit juice, dried fruit, bananas, crisps and sponge cake.

“What do you think would happen if I followed their advice?” said Sarah incredulously, emailing the advice she received to Andreas and the Diet Doctor Team. She believes she has been likely insulin resistant and prediabetic for years.

She found the low-carb high-fat diet, and Diet Doctor, five years ago. During this pregnancy, her third, she has been eating a more liberal low-carb diet, consuming more fruit than normal.

But now with the GD diagnosis, she is sticking to a lower-carb diet and monitoring her blood sugars regularly by a home meter, and doing well. “Home monitoring is brilliant. I love doing it. I can see the impact of the foods I eat immediately,” says the math teacher. “I know if I followed the NHS dietary advice my blood sugar would get much, much worse.”


Anne Mullens

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Stories

  1. The New England Journal of Medicine: Hyperglycemia and Adverse Pregnancy Outcomes

  2. As of Sunday July 23 2017

  3. Canadian Diabetes Care Group: Proper Management of Gestational Diabetes Improves Health for Baby – and Mom

  4. The American Diabetes Association: An Early Pregnancy HbA1c ≥5.9% (41 mmol/mol) Is Optimal for Detecting Diabetes and Identifies Women at Increased Risk of Adverse Pregnancy Outcomes

  5. Journal of General Internal Medicine: Pitfalls in Hemoglobin A1c Measurement: When Results may be Misleading

  6. American Journal of Obstetrics & Gynecology: Single Abnormal Value on 3-Hour Oral Glucose Tolerance Test During Pregnancy Is Associated with Adverse Maternal and Neonatal Outcomes: A Systematic Review and Metaanalysis

  7. American Journal of Obstetrics & Gynecology: The Impact of Adoption of the International Association of Diabetes in Pregnancy Study Group Criteria for the Screening and Diagnosis of Gestational Diabetes

  8. World Journal of Diabetes: Indicators of Glycemic Control in Patients with Gestational Diabetes Mellitus and Pregnant Women with Diabetes Mellitus