Planned Pregnancy with Diabetes

Dr. Mitalee Barman

Consultant Diabetologist 

• Women with diabetes face the risk of developing obstetric complications and diabetic complications as well as congenital defects in their babies.  They have to monitor blood glucose levels more frequently throughout their term and they often need more frequent interventions and visits to the doctor. 
• Women with diabetes also face the risk of having big babies. This happens when the blood sugar level of the mother is high and   the foetus gets too much sugar through the placenta. The baby's pancreas senses the high sugar levels and produces more insulin to use up all the extra sugar. That extra sugar is converted to fat and as a result the baby may become too large to be delivered normally and a Caesarean delivery becomes necessary.
• Sometimes babies of women with diabetes develop   dangerously low blood glucose levels as soon as they are born. This is because the uncontrolled levels of blood sugar of the mother during pregnancy and especially 24 hours before delivery makes the pancreas increase secretion of insulin in the baby to cope with the extra sugars. After delivery, when the source of sugar is suddenly taken away, the blood sugar levels drop.

Good blood sugar control means keeping blood glucose levels within the ideal range (70 to 100 mg/dL before meals, less than 120 mg/dL two hours after eating, and 100-140 mg/dL before the bedtime snack) by balancing meals, exercise, and diabetes medications.

So, a planned pregnancy is essential for women with diabetes as good sugar control before conception is vital as many women do not realize they are pregnant until they are well into two to four weeks of pregnancy. 

For healthy off- spring and a complication -free pregnancy 

1. Avoid pregnancy till HbA1c  is in good control (< 6.5 %)  because high blood sugar levels early in the pregnancy (before 13 weeks) can cause birth defects as the first 8 weeks of pregnancy are very important for  the baby’s physical development. There is also an increased risk of miscarriage and diabetes-related complications. 
2. Eat a well - balanced diet
3. Exercise and be active
4. Keep blood glucose at optimum levels
5. Get eyes and kidneys checked, 
6. Stop smoking and avoid alcohol.
7. Let your doctor know about your medications as some of them such as statin, ACE inhibitor or similar blood pressure medications should not be taken by pregnant women.

(Ref: Diabetes Balance)

Making Lifestyle Changes for Better Health…

Changing old lifestyle habits related to one’s diet and physical activity is not an easy task and it gets harder if there are lots of changes to be made.

The best way to achieve one’s goal of reducing weight and preventing Type 2 diabetes is by making the change one step at a time.

Get Started

1. Find out how focussed you are by asking yourself if you are willing to change your habits.

2. Find out what lifestyle changes you need to make. The changes must be important enough to motivate you. Break them up into smaller steps.

3. Choose a few areas for improvement that are easy to do, you want to do the most, and that will make the biggest impact.

4. Make your goals SMART

Specific - Your goal must be clear and well defined. Vague or generalized goals are not helpful.

Measurable - Include precise amounts, dates, and so on in your goals so you can measure your degree of success.

Attainable - Make sure that it's possible to achieve the goals you set.

Relevant - Goals should be relevant to your requirement. This will help you to develop the focus you need.

Time Bound - Your goals must have a deadline.

For example

1. Setting diet related goals : 

How long?… For the next month

How often?... four days each week

Realistic and Specific?… I will eat two pieces of fruit a day — one at breakfast and one as an afternoon snack. 

2. Setting activity  related goals: 

How long?... For the next month

How often?... four days each week 

Realistic and specific?... I will take a 15  a minute- walk after lunch 

5. Pin up your goals where you will see them often and practice them.

6. At the end of the specified period see if you were successful.

If you weren't successful, try again. Revise your goals or choose easier ones.

Were you successful? CONGRATULATIONS! Now choose some new goals to work on.

A Healthy Habit: Read Food Labels

Shelves in the supermarket are stocked with a variety of ready to eat, instant or processed foods and in today’s fast paced life there are choices that we make because we just don’t have the time or the energy to start from scratch. For instance most people buy packaged wheat flour and choosing a good brand is a dilemma, as there are so many available, each one professing to offer the best! Most processed foods and instant foods come with nutrition fact labels. Learning how to interpret food labels can help educate people with or without diabetes about how to make better food choices for better health.

Food labels provide a lot of information.  Understanding the information   that food labels provide allows people to compare foods, make better choices, and understand serving sizes in relation to carbohydrate content.

The Serving Size

The first place to start when you look at the Nutrition Facts label is the serving size and the number of servings in the package. Serving sizes are standardized to make it easier to compare similar foods; they are provided in familiar units, such as cups or pieces, followed by the metric amount, e.g., the number of grams.

Calories 

Calories provide a measure of how much energy you get from a serving of this food. The calorie section of the label can help you manage your weight .

Total carbohydrate tells us how many grams of carbs there are in a serving. It includes sugar, complex carbohydrate and fibre. Do not concentrate only on sugar content as you may miss out on foods that are naturally high in sugar but also have other necessary nutrients.

The value under sugar shows the amount of natural or added sugar.

Avoid unhealthy ingredients such as hydrogenated or partially hydrogenated oil and refined sugar. Look for foods with less fat, sugar and salt.

However, there are some facts one must be aware of in order to choose wisely.
Sometimes sugar, salt and fats come under different names

 Did you know?

   ‘Sugar free’ does not mean ‘Carbohydrate free’

   ‘No added sugar’ does not mean ‘no carbohydrate’

READ FOOD LABELS CAREFULLY.

Managing Type 2 Diabetes mellitus

Managing Type 2 diabetes is not a fixed process. It keeps changing. At first, oral medication may be enough. Later insulin may be needed to control blood sugar levels. 

For some people with diabetes, a healthy diet and plenty of physical activity is enough to control blood glucose; for others, oral medications and injections work well. The medication that people with diabetes use to manage glucose levels depends on what they eat, their level of physical activity and their weight.

Medications to treat Type 2 diabetes help the body to produce more of its own insulin; produce a feeling of fullness after meals; and slow down the movement of food through the stomach.

Losing weight and being more active can help avoid or delay the use of insulin ―a hormone that helps to control blood glucose levels  by allowing the  body to absorb glucose from the blood. As Type 2 diabetes progresses, the person with diabetes may need to take more tablets and insulin injections. 

There are different types of insulin:  

• Short- acting human insulin
• Intermediate acting human insulin
• Premixed insulin
• Analog insulins

The number of insulin injections a day depends on personal needs. For some people with diabetes, injecting just once a day is sufficient to manage blood glucose levels but as diabetes progresses, there is a chance that this will increase.  

It is important to test blood glucose regularly when using insulin. 

Tips on choice of injection sites:  

• It is important to rotate your site to get the best benefit from the insulin. 
• Do not use the same spot on a particular site to inject insulin. Injecting the same spot can cause small hard lumps that can affect the way insulin is absorbed thus affecting blood glucose control.
• The best places to inject are the abdomen, buttocks and outer thigh as they have a layer of fat below the skin and not too many nerves. 
• Massaging the site before or after injection may speed up absorption of insulin and so, is not recommended. 
• Exercise can also increase the rate at which insulin is absorbed in the body. So, don’t inject the part you are going to exercise. If you do, wait at least 45 minutes before starting. 
• Use a new spot within a chosen site each time. Move around within the chosen site keeping at least one finger distance from the last injection.
• Move in the same direction. 

Best injection  sites

The abdomen is the best site for injecting morning and noon doses of insulin and injecting into the upper thigh at night decreases the risk of having hypos during the night.

A few points to keep in mind when using insulin:

• It can lower blood glucose levels so make sure you know what to do in case of a hypo.
• Be careful when you drive
• Control portion sizes as insulin can add on weight
• Consult your dietitian for a good diet plan and learn how to count carbs.

Vitamin D- the Sunshine Vitamin

Most of the Vitamin D we need is made when the skin is exposed to the sun’s ultraviolet B rays.

Vitamin D is required for strong teeth and bones, muscle health and general health. It helps the body to absorb calcium and phosphate from food.

Deficiency of vitamin D can result in softening and weakening of bones - rickets in children and osteomalacia  in adults, and  can also make bones  porous and brittle - osteoporosis in adults. A lack of it is also related to other health conditions such as heart disease, cancers, allergies, and Type 2 diabetes.

We get most of the vitamin by going out in the sun but some foods such as oily fish ( sardines and mackerel ), egg yolk, meat and some fortified foods also provide some quantities.

At risk of Vitamin D deficiency:

• People with darker skin, as it takes the skin  a longer time to synthesize the vitamin
• Babies and children from the age of 6 months to 5 years. 
• Pregnant or breast- feeding women especially teens and young women
• Older people who are over 65 years
• People in situations such as illness who are unable to come out of their homes or live in climates without much sunlight
• Vegetarians and those who have insufficient intake of milk products 

Vitamin D made in the body from food or from sunshine is safe but supplements can cause bone and kidney problems especially in children and older people.

Help your body make Vitamin D

Exposing hands and face to the sun is the main source of Vitamin D. BUT…

• 10 – 15 minutes is enough depending on skin colour.  Darker skins need longer exposure.
• The best time of the day is between 11 a.m. and 3 p.m. as the sun is the strongest at that time but that is also the time when you are most likely to burn. 
• It takes less time for the body to make Vitamin D than it takes to burn your skin, so expose yourself to sunshine only for short periods of time.

A Mediterranean diet could reduce the risk for Type 2 diabetes.

The Mediterranean Diet is a way of eating based on the traditional foods and drinks of the countries surrounding the Mediterranean Sea including Italy, France, Greece and Spain.

It includes unprocessed plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts, plenty of olive oil and a glass of wine with a meal and is often regarded as one of the healthiest of diets.

Bread is an important part of the diet throughout the Mediterranean region, and is eaten plain or dipped in olive oil — not with butter or margarine, which contain saturated fats or trans-fats.

Although fat consumption is high, the prevalence of hypertension, cardiovascular disease, obesity, cancer and diabetes has always been significantly lower in Mediterranean countries.

Nuts are another part of a healthy Mediterranean diet. Nuts are high in fat, but most of the fat is healthy. Because nuts are high in calories, they should not be eaten in large amounts — generally no more than a handful of plain nuts a day.

The Mediterranean diet is healthy because 

• butter is replaced with healthy fats, such as olive oil. 25% to 35% of calorie intake consists of fat. Saturated fat makes up no more than 8% of calorie intake.
• foods are flavoured with herbs and spices  instead of salt.
• red meat is recommended only a few times a month.
• fish and poultry  are included at least twice a week.
• a little red wine is included along with the meal (optional).

Meals are prepared and eaten together with family and friends. 
Physical activity is considered important .

Foods you can choose from

Vegetables:  Tomatoes, broccoli, kale, spinach, onions, cauliflower, carrots, Brussels sprouts, cucumbers, etc. 

Fruits:   Apples, bananas, oranges, pears, strawberries, grapes, dates, figs, melons, peaches, etc.

Nuts and Seeds:   Almonds, walnuts, Macadamia nuts, hazelnuts, cashews, sunflower seeds, pumpkin seeds and more.

Legumes:   Beans, peas, lentils, pulses, peanuts, chickpeas, etc.

 

Tubers:   Potatoes, sweet potatoes, turnips, yams…

Whole Grains:   Whole oats, brown rice, rye, barley, corn, buckwheat, whole wheat, whole grain bread and pasta.

Fish and Seafood:   Salmon, sardines, trout, tuna, mackerel, shrimp, oysters, clams, crab, mussels, etc.

Poultry:   Chicken, duck, turkey and more.

Eggs: Chicken, quail and duck eggs.

Dairy:   Cheese, yogurt, Greek yogurt. 

Herbs and Spices:  Garlic, basil, mint, rosemary, sage, nutmeg, cinnamon, pepper, etc.

Healthy Fats:   Extra virgin olive oil, olives, avocados and avocado oil

Evidence of health benefits …

Eating more legumes such as peas, chick peas, lentils, alfafa and beans helps improve glycaemic control in people with Type 2 diabetes, as well as lowers the risk of developing coronary heart disease. – (Scientists from the University of Toronto)

Certain dietary patterns that include vegetables, nuts,  and monounsaturated fatty acids keep the heart healthy. – ( Researchers at McMaster University)

The traditional Mediterranean diet can help protect people from Type 2 diabetes. – (A study published by the BMJ7)

The combination of foods in the Mediterranean diet lowers the risk of heart attack and cardiovascular-related death much more than a strictly low-fat diet does. – ( A study published in the American Journal of Medicine)

Researchers have suggested that the diet could also help to slow the aging process.

A Mediterranean diet enhanced with additional portions of antioxidant-rich extra virgin olive oil or mixed nuts could protect cognitive functioning in older adults-  (Researchers in Spain)

Researchers suggest that keeping to the diet can cut the risk of endometrial cancer in women by more than half.

Role of Diet and Nutrition in the Prevention of Chronic Diseases

Ms Thameena, 

Dietitian,MVH  

         
Hunger and malnutrition , rapid changes in the diets and lifestyles, "nutritional transition",  where traditional foods such as cereals and potatoes are increasingly being replaced by diets that are richer in added sugars and animal fats,  increased caloric content of  food ,increased fat content, excessive consumption of  meat, dairy products, and eggs, individual risk factors such as  unhealthy diets,  low levels of exercise,  and  genetic factors   are all responsible for the high levels of chronic diseases .

The risk of developing chronic disease can be reduced at any age, therefore people of all ages can benefit by eating healthy food, maintaining optimum weight, and exercising.

A well balanced diet consisting of different food groups as well as increased physical activity can prevent chronic diseases.

‘Safe range’ guideline to healthy eating

• Total fat intake should be 15 to 30% of total dietary energy intake.
• Free sugars found in soft drinks and many processed foods should be less than 10% of total energy intake.

• Consume at least 400g of fruits and vegetables per day. Along with wholegrain cereals this can provide sufficient fibre.
• The WHO also makes recommendations about body weight – in terms of Body Mass Index (BMI) – and physical activity. 
• Body Mass Index (BMI) is a simple index of weight-for-height that is commonly used to classify underweight, overweight and obesity in adults. 

• For good cardiovascular health, at least 30 minutes of moderate physical activity such as brisk walking every day is recommended for people of all ages.

• Certain types of foods and eating habits such as snacking, binge-eating, and eating out can contribute to excessive weight gain and obesity. 
•  Regular physical exercise
•  High dietary fibre intake
•  Healthy food and activity choices at home, school and workplace

 …provide protection from obesity

Some factors that may increase the risk:

• Sedentary lifestyles, particularly sedentary occupations and recreational activities such as watching television

• Large portion sizes

• High intake of drinks containing added sugars  

Prevent obesity by encouraging healthy habits early in life. Maintain a healthy Body Mass Index and control waist size. Do moderate to high level of regular physical activity such as  walking for one hour per day, and limit consumption of foods and drinks that contain high amounts of fats and sugars.

The number of cases of diabetes is currently estimated to be around 150 million worldwide, but that number is expected to double by 2025.

  
Inactive lifestyles and excessive weight gain increase the risk of type 2 diabetes, especially when excess fat is stored in the abdomen.

Efforts to prevent excessive weight gain and cardiovascular disease can also reduce the risk of developing diabetes. Measures include maintaining a healthy weight, engaging in at least one hour of moderate physical activity every day, consuming sufficient fibre from fruits, vegetables and wholegrain cereals, and limiting consumption of saturated fats.

  

Cardiovascular Disease 

 


Certain dietary fats, especially those that are commonly found in dairy products, meat and hydrogenated oils increase the risk of cardiovascular disease. Other dietary fats, such as those found in soybean and sunflower oils, can lower the risk of cardiovascular disease. Fish oil which is found in fatty fish is also beneficial.

A high intake of salt can increase blood pressure and the risk of stroke and coronary heart disease, whereas eating a diet high in fibre and wholegrain cereals can reduce the risk of coronary heart disease. 

 A high intake of fruits, vegetables, and fish can contribute to good cardiovascular health and reduce the risk of developing certain cardiovascular diseases. Alcohol consumption should be limited. 

Prevent cardiovascular disease 

• Limit intake of dairy products, meat and cooking fats such as clarified butter or ghee. 
• Eat 400 to 500g of fruits and vegetables every day 
• Have fish once or twice a week. 
• Restrict salt intake to less than 5 g per day and 
• Exercise for at least 30 minutes a day 

Dental disease

Diet is an important factor that can cause dental disease. Caries develop due to the presence of sugars from the diet and bacteria. The tooth surface can also be attacked by acids from some foods and drinks. 

Sugar consumption is the most important factor for dental caries. Studies have found a strong link between the amount and frequency of sugar consumption and the development of caries. 

Eating certain foods, such as cheese, may stimulate secretion of saliva which can protect against the development of dental caries. Breastfed babies tend to have less dental caries in early childhood than babies fed on formula milk. ..

To reduce the risk of dental diseases:

• Cut down on the amount and frequency of consumption of sugar,
• Ensure adequate exposure to fluoride, and 
• Avoid certain nutrient deficiencies.  

Osteoporosis

Osteoporosis is a disease affecting millions of people around the world that leads to brittle bones that break easily. The risk of osteoporosis increases with age and can lead to illness, disability, and even premature death.

Calcium and vitamin D deficiencies increase the risk of osteoporosis in older people. A healthy diet, increased sunlight exposure, increased physical activity, eating more fruit and vegetables, and consuming less alcohol and salt can reduce the risk.

In short, a lifestyle combining physical activity with healthy food is the best way to reduce the risk of developing chronic diseases.