Gestational Diabetes: Future Risk of Diabetes

by KMom

Copyright 1998-2001 KMom@Vireday.Com. All rights reserved.


DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider. This web section on gd is designed to present more than one view of a controversial subject, pro and con. It should be re-emphasized that nothing herein should be considered medical advice.

 

CONTENTS

 

Chances of Developing Type II Diabetes (NIDDM)

General Information

The facts and figures that are quoted about your chances of developing type II diabetes (NIDDM) vary tremendously from source to source. The most-often quoted statistics usually state (with minor variations) that about 50-60% of women who have had gd will develop type II diabetes within 10-20 years. Women who needed insulin in their gd treatment, developed gd early in the pregnancy, or who had a difficult time maintaining consistent control probably have an even higher rate, and should monitor their blood glucose quite often post-partum. (One website about gd quoted a 50% risk of diabetes within 5 years if insulin was needed during pregnancy, though no research citation for this statistic was given.)

Is getting type II diabetes a foregone conclusion after gd? No, but it is likely. GD is probably often part of the continuum of ongoing developing insulin resistance that will lead, in many cases, to the eventual development of type II diabetes. However, a very small percentage of gd mothers actually develop type I diabetes (IDDM) instead, showing that their 'gd' was probably a case of previously undiscovered IDDM. It should be noted though that this is quite unusual, and that most cases of gd are related to the syndrome of insulin resistance that characterizes type II diabetes/syndrome "X".

However, gd does not always lead to 'frank' diabetes (the full-blown disease), and some women do avoid getting it. If 50% of women get it within 10-20 years, that also means that 50% do not. Certainly some of those women may indeed get NIDDM subsequently after that time, but long-term monitoring is just getting started since gestational diabetes as a modern diagnosis is fairly recent. Other studies have shown lower rates of getting NIDDM, while still others have shown rates that are even higher, particularly in certain risk groups. More time is needed to study the problem before a more conclusive result can be determined, but it's best to treat gd as an 'early warning system' for a possible problem later, and act accordingly. Better safe than sorry!

Having had gd shows that you have the gene for developing diabetes and that you probably have significant insulin resistance (difficulty utilizing your insulin well). It also may show that your pancreatic beta-cells have had problems producing enough insulin to overcome insulin resistance and/or you have decreased or inefficient insulin receptors. As noted above, many researchers now see gd as simply part of the continuum of the progression of insulin resistance/diabetes in most women. Your task now is to improve your insulin sensitivity and take the burden off of those beta-cells, and to keep your blood lipids, blood pressure, and blood glucose all in line. Since many people who are insulin-resistant tend to have poor cholesterol/blood lipids, high blood pressure, and high blood sugar (so-called 'Syndrome X'), ALL of these factors need to be monitored carefully in women who have had gd, just in case. Yearly testing of all of these levels is VERY important.

Remember, the majority of damage from frank diabetes occurs in the early years before it is discovered, when there are no symptoms. Finding it as soon as it happens could possibly save you a lot of grief and complications later. In addition, even if developing NIDDM is inevitable, if you can delay its occurrence or its severity, you may be able to lengthen your life and improve its quality, since the longer a person has diabetes, the more common and severe its complications usually are. And perhaps you'll be able to prevent its development completely!

Risk Factors and Rates of Diabetes

What do the various studies say about the rate of progression from gd to NIDDM? Well, results vary strongly, but an increased rate is certainly QUITE consistent between studies. Following is a summary of just a few studies on the subject; many more can be found in a search of the literature. 

[NOTE: Remember as you read these studies that Impaired Glucose Tolerance (IGT) is a borderline state just below 'true' or 'frank' diabetes. Often IGT and diabetes are lumped together for testing and labeling purposes. Also note that the rate of progress of diabetes is extremely high in some ethnic populations but not nearly as high in other populations, and that much of the research about progressing from gd to NIDDM is primarily done in these highest-risk populations.]

Greenberg et al. Gestational Diabetes Mellitus: Antenatal Variables as Predictors of Postpartum Glucose Intolerance. Obstetrics and Gynecology. 86(1):97-101, July 1995.

94 women with gd returned for a 75g GTT at 6 weeks post-partum. Postpartum glucose intolerance occurred in 34% (18% impaired glucose intolerance, and 16% overt diabetes). No single variable was predictive in all cases. Of those who had diet-controlled gd, only 3% had IGT and 0% had diabetes; of those who needed insulin, 25% had IGT and 26% had diabetes. Those who needed insulin had 17x the risk for impaired tolerance, while those who had the combined effect of needing insulin, had some post-meal numbers above 150, and had an initial screening level above 200 had almost a 20x risk.

Henry et al. Long-Term Implications of Gestational Diabetes for the Mother. Baillieres Clinical Obstetrics and Gynaecology. 5(2):461-483, June 1991.

"Using life table techniques, 17 years after the initial diagnosis of GDM, 40% of women were diabetic compared with 10% in a matched control group of women who had normal glucose tolerance in pregnancy. The incidence of diabetes was higher among women who were older, more obese, of greater parity and with more severe degrees of glucose intolerance during pregnancy. Diabetes also occurred more commonly among women who had a first-degree relative who was diabetic, in women born in Mediterranean and East Asian countries, and in those who had GDM in two or more pregnancies."

Steinhart et al. Gestational Diabetes is a Herald of NIDDM in Navajo Women. High Rate of Abnormal Glucose Tolerance after GDM. Diabetes Care. 20(6): 943-7, June 1997.

A retrospective analysis of 111 GDM deliveries in Navajo women over a 4-year period was conducted approximately 10 years after the start of the survey period. A life-table analysis was developed to estimate the probability of NIDDM after GDM. 58% had developed Impaired Glucose Tolerance (IGT) by the end of the study period, while 42% had developed NIDDM. Patients who developed NIDDM had greater Body Mass Indices, parity (# of kids), and infant weights. Fasting bG >105 and recurrence of GDM were associated with getting NIDDM. A life-table analysis estimated a 53% likelihood of having NIDDM at an 11-year follow-up.

Cypryk et al. Evaluation of Carbohydrate Metabolism in Women with Previous Gestational Diabetes Mellitus. Ginekologia Polska. 65(12):665-70, December 1994.

70 women who had experienced GDM in the previous 10 years were given a combination of a GTT and a glycosylated hemoglobin test to check their present carbohydrate metabolism. 19% had IGT and 54% had diabetes. The presence of diabetes or IGT significantly correlated with the number of past pregnancies, observation time and indirectly with family history of diabetes. [They also checked for other risk factors such as obesity, hypertension, and trimester in which GDM was diagnosed; apparently these did not significantly correlate with subsequent IGT or NIDDM.]

Kaufmann et al. Gestational Diabetes Diagnostic Criteria: Long-Term Maternal Follow-Up. American Journal of Obstetrics and Gynecology. 172(2 Pt 1):621-5, February 1995 .

331 patients who had had gd by either the National Diabetes Data Group criteria or the Coustan and Carpenter criteria (which are more strict and identify more patients) from the period of 1975 to 1988 were followed up (maximum interval was 15 years, some were much less). About 25% of each group had developed diabetes at follow-up. Predictive factors included the GTT fasting value, the number of GD pregnancies, the time to follow-up, and pre-pregnancy weight index. (The study concludes, by the way, that the lower criteria of Coustan and Carpenter should be used in order to identify more women who would develop diabetes later.)

Kjos et al. Predicting Future Diabetes in Latino Women with Gestational Diabetes. Utility of Early Postpartum Glucose Tolerance Testing. Diabetes. 44(5):586-91, May 1995.

671 Latina women who had had GD pregnancies 5-7 years earlier BUT who tested negative shortly after birth for diabetes were re-tested for diabetes. Life table analysis showed that 47% of these Latina women had developed diabetes within 5 years. The study notes that the post-partum GTT provided the best discrimination between high-risk and low-risk individuals.

In other studies, rates vary. In one study, 90% of gd moms returned to normal glucose tolerance postpartum, while 8% had IGT and 2% continued with diabetes. In another study, 30-50% of GDM women had developed diabetes or IGT within 3-5 years postpartum, a very high rate. In yet another study (Coustan) only 30% of GDM women had developed IGT or diabetes within 7-10 years. So results certainly can vary strongly; don't take any of these rates as a certain predictor of YOUR chances. 

Still, overall, it is clear that women who have had gd often--but not always--progress to type II diabetes within a few years. If you had more severe levels of gd, needed insulin, had difficulty controlling your levels, or had gd in two or more pregnancies, your chances seem to be much higher, and you seem to have a stronger chance of developing NIDDM within a very few years postpartum. For these women, GD seems to be part of the continuum of the development of diabetes. For women with less severe gd, it may or may not be part of the continuum of NIDDM and further study is needed.

Different resources list the risks somewhat differently, but all sources find that family history, ethnicity, weight, etc. are other consistent risk factors. According to the book, Managing Your Type II Diabetes, you are more at risk of developing NIDDM if you have parents or a sibling with NIDDM (about a 40% risk). If you are African-American, Latino, Pacific Islander, Alaskan Native, or especially American Indian, you have a higher risk as well (2-3 times the risk, according to some sources). Those with high blood pressure or abnormal blood fat levels (cholesterol, HDL/LDL, triglycerides) also have increased rates of diabetes and also fit the classic profile for the insulin-resistance malady, Syndrome X. People who are sedentary also are at greater risk, as are 'overweight' people, especially those with heavy concentrations of abdominal fat..

It is important to point out that these things do not CAUSE diabetes, but they are correlated with them (occur more often with these conditions). If fat caused diabetes, for example, all fat people would have diabetes and no skinny people would get NIDDM, and this is not true at all. However, weight and diabetes are associated, but why is unclear. It could be that weighing 'too much' exacerbates the insulin resistance, or it could be instead that the metabolic condition that causes diabetes and insulin resistance makes you more prone to being 'overweight', or the two could be inextricably intertwined in a vicious circle. But don't let anyone tell you that being fat CAUSED your diabetes; this is not true. It may add to the problem but it does not CAUSE it. Many very fat people are not diabetic at all at any age. Weight alone is not the key.

However, it is likely that if you are genetically susceptible, gaining weight probably increases your risk. It's not enough to simply have the diabetes gene (or genes); it's thought that some environmental factor needs to also be present in order for that gene to express itself. What is unknown at this time is whether it is the fat itself that is the problem, the sedentary lifestyle of some fat people, the high-fat or high-carb diet of some fat people, the accumulation of central abdominal fat, a significant weight gain in adulthood, or the habit of yo-yo weight loss and regain. This last factor is rarely looked at due to the prejudices of the obesity and diabetes researchers, but needs to be carefully examined, since some evidence does indeed exist that it could be an influence as well (see next section). What is needed is some objective research that tries to separate weight from lifestyle factors, but this is sorely lacking. In all likelihood, it is a combination of factors, weight among them, that leads to diabetes.

There is one good bit of news in all this doom and gloom. Obese type II diabetics tend to have far fewer complications of diabetes than leaner type II diabetics, even at similarly high blood sugar levels. It's small comfort, but it is something. Dr. Paul Ernsberger and Dr. Paul Haskew wrote in their article, "Rethinking Obesity: An Alternative View of its Health Implications" (Journal of Obesity and Weight Regulation, Summer 1987):

"There is also evidence that adiposity is a protective factor in maturity-onset Type II diabetes...In an 18-year follow-up study, Turkington and Weindling separated diabetics over the age of 45 into 3 groups. The first group had high levels of endogenous insulin, despite fasting blood glucose levels averaging 218 mg/dl, and 90 percent of them were obese. None of these 178 patients developed retinopathy or sensory neuropathy. The second group had similar hyperglycemia, but lower insulin levels. Only 7 percent were obese and there was a high prevalence of diabetic complications. A third group developed insulin-dependent diabetes during follow-up. None of these 71 patients was obese. Thus, fat diabetics tend to be less insulin-dependent and to have fewer complications than leaner diabetics. Other studies have confirmed the negative relationship between body weight and disease severity in diabetics. Relatively lean diabetics are up to three times more likely to suffer from retinopathy than fatter diabetics...This resistance to complications in fat diabetics is associated with decreased mortality in prospective studies. In the University Group Diabetes Program, Type II diabetics with higher body weights...who were treated with placebo had a lower 5-year mortality rate (2.8%) than leaner diabetics (7.2%). Lower mortality among fat diabetics was also seen in the insulin-treated group (3.0% versus 9.6%)...The reduced complications and mortality associated with obese hypertension, Type IIb diabetes, or hyperlipidemia does not mean that these conditions are entirely benign in fat people, nor does it mean the diabetics and hypertensives should be encouraged to overeat and gain weight, since this may worsen their problems. Instead, the association between adiposity and these conditions should be put in perspective in light of their more favorable course in the obese."

Although fat diabetics tend to have less severe complications, it is important NOT to deny the potential danger of the disease or to be inattentive to treating it. Diabetes is a serious disease, and the majority of diabetics tend to die from heart disease. The longer and more severely you have the disease, the more complications you tend to get. ALL gd moms need to assume that they are at risk for NIDDM and take what action they can to delay or prevent its occurrence, while still monitoring frequently (every year at least, more often for severe cases). 

If they plan a further pregnancy, they need to make absolutely certain that their blood glucose is normal BEFORE conceiving, and they need to be retested for gd early in the subsequent pregnancy. It is possible to avoid gd in subsequent pregnancies (Kmom did it) or to have it less severely through proactive health action, but the odds are that the gd will recur and perhaps earlier. Careful monitoring and prenatal care will be important. For more information, see the web section on Planning a Subsequent Pregnancy.

 

Recognizing Type II Diabetes

There are a number of signs of Type II Diabetes (NIDDM) that occur once the disease is well-established, but it is often 'silent' at the beginning, which is why it can cause so much harm. Years of hyperglycemia take its toll on the body, causing damage to the heart, kidneys, vascular system, eyes, etc., but usually without strong symptoms at first.

Symptoms to Watch For

A general feeling of fatigue and 'unwellness' persist frequently, and the patient usually experiences a number of colds or other chronic illnesses that never quite go away completely or recur often. Yeast infections may recur frequently (though not always), and may occur vaginally or topically (on the skin, especially in the feet, under the breasts, in the bellybutton, under the belly, etc.). Bladder infections are more frequent, too. Sugar is often craved very strongly, since the body starts to crave energy yet cannot access the excessive energy (high bG) already in the blood. Some patients report being very hungry at times.

Once the disease is well-established, the classic symptoms become excessive thirst, copious urination (especially at night), frequent infections (especially skin, gum, or bladder infections), drowsiness and fatigue, blurred vision, cuts and bruises that are slow to heal, tingling or numbness in hands or feet, or sudden weight loss. Remember that most people are generally asymptomatic for a number of years, and onset of a pattern of these symptoms often indicates the disease has been present for some time. This is why it is particularly important to get tested regularly, so that if it does develop, it can be caught as early as possible.

Special Care Concerns

There are a number of health concerns to be more vigilant about if you are at risk for diabetes. Researchers have recently found that gum disease and other dental problems are more of a risk in diabetics, and are often associated with heart disease as well. So those at high risk for diabetes should be very vigilant about their dental care. Get out that dental floss!

Good blood flow to the extremities is also an issue for some diabetics or pre-diabetics. Hands and particularly the feet and legs should be carefully watched to be sure that sores heal regularly and do not become infected, and problems with blood flow or feeling in the extremities should be promptly reported to your provider. Regular exercise is one way to keep up or improve blood flow to the extremities, and since it also helps improve blood sugar levels in many people, regular daily exercise should be one of the mainstays of a person at-risk for diabetes.

Since recurrent infections are common with diabetics or pre-diabetics, you should watch carefully for these as well. Bladder and vaginal infections in particular become very common in some people (but not all). An occasional infection should not be panicked over, since many people experience an occasional infection, but a pattern of frequent or recurrent infections should be a signal for further testing and careful observation of your blood sugar levels.

High blood pressure or blood lipids is also more common among many diabetics, so this should be monitored regularly as well. Since menopause is a time when blood pressure, cholesterol, or blood sugar tends to worsen, women nearing menopause should have particularly vigilant testing. 

At this time, the jury is still out as to whether hormone replacement therapy is indicated in women at risk for diabetes, particularly large women whose estrogen levels may already be elevated. Some research indicates it may be particularly beneficial, while other voices urge more caution in its use. Time will probably clarify this issue better, so be sure to research it again as you approach menopause. Doctors tend to be very quick to jump on the 'quick-fix-through-a-pill' bandwagon, so be very careful and thorough in your decision-making process, just in case.

 

Tests for Diabetes

There are a number of tests to check for diabetes, and recommendations vary as to which are best. The most commonly ordered tests include the fasting blood sugar test, the postprandial blood sugar test, the glucose tolerance test, the random blood glucose test, and the glycosylated hemoglobin test. Each of these has advantages and disadvantages. 

The most commonly used test is the fasting blood glucose, but using fasting levels alone is controversial and some doctors prefer to use it in conjunction with other tests. However, whatever test is used, the results can at least give you an idea of your basic blood glucose levels, though it is important to know the context of these results. The following is a basic summary of the various tests and their contexts; for more thorough information, consult the section on GD: The Numbers Game.

Fasting Test

As noted, the most commonly used test is the fasting draw, probably because it is one of the cheapest and easiest. This involves an overnight fast and a blood draw. Most labs require a fast of approximately 12 hours, no more and no less.  Doctors are not always very strict about this but should be; variations in duration can alter test results. 

It is important to have a good snack with protein (but no sugar etc.) shortly before starting the 12 hour fast, but only water thereafter. Not even gum, coffee, or mints are permitted, since these can all raise the results. Smoking can also raise the results.  You should follow your normal routine for this test; if you are a morning person, have the test done first thing in the morning when you would normally eat, but if you are a late-night person, getting up early for a test at an abnormal time of day for you is probably not a good idea either. Whenever you schedule your test, just time your fast to last for 12 hours. At about 12 hours, you should have your blood drawn (from your arm) and the results sent to a LAB for testing. (Portable monitors can give a general idea of results, but they are NOT accurate enough for diagnosis and should always be backed up by lab results).  If your readings are abnormal or borderline, always consult your doctor for further information and guidance!

In a NON-PREGNANT person: 

It is important to note that the weakness of a fasting test is that it is simply a one-time snapshot of your blood glucose (bG) levels on THAT day, and it is easy to get either higher or lower numbers than normal due to other circumstances such as stress, illness, amount of time since eating, etc. If you have an abnormal or borderline result on your test, you should always consult your provider and also request a repeat test.

Postprandial Test

The fasting test measures only how your blood sugar does after a period of not eating, yet some people with blood sugar problems have perfectly normal fasting results but trouble clearing the glucose from their systems adequately after eating. It is possible to test normal on a fasting test and yet still be having high blood sugar after meals, which may also have long-term effects on your body. Therefore, another test that doctors sometimes use is the postprandial blood glucose test

This involves eating a meal and then drawing blood exactly 2 hours later to check to see if your system is adequately clearing the glucose from your system. Normal results on this test are: 

The weakness of this test is that not all meals are equal, and it is difficult to standardize results for varying meals. However, if the meal is of average size and not excessively carb-laden, a <120 mg/dl cutoff is usually fine to use. Another weakness is that this is also simply a one-time snapshot of your bG values, and stress, illness, etc. may also influence these results.  

Oftentimes, a fasting blood glucose test is used in combination with a postprandial test.  This allows the doctor to be sure that your bG levels overnight are normal, and that your response to eating is also normal.  It is probably best to utilize both fasting and postprandial tests periodically to evaluate your glucose tolerance status.

Glucose Tolerance Test

Because of the desire for standardized test materials, some providers use a Glucose Tolerance Test (GTT), although this is somewhat less common now. In this test, a special drink of 'glucola' (sugar water that tastes like soda pop) is given after a fasting blood sugar test is first taken.  Then blood draws are taken over a period of a couple of hours.

In the test for non-pregnant people, the test lasts for two hours and the glucose load is 75g.  The test is longer for pregnancy and the glucose load is heavier (100g test lasting for three hours). Due to cost and time concerns, the GTT is usually not used to test people who are probably normal, but mostly commonly with those suspected of having a problem.

In the past the GTT was the most common method for diagnosing diabetes, but the standards were changed recently amidst some controversy. The new recommendations mostly use fasting tests instead of the GTT. This is controversial because there are a number of people who have normal fasting levels but who will have elevated postmeal levels, and the reliance of mostly fasting levels will not detect and treat those people. For this reason, many doctors still use the GTT regularly in individuals at very high risk of diabetes or who they suspect may have bG problems. 

Your doctor will probably mostly order fasting tests for you as you grow older, but may throw in periodic GTTs or postprandials to be sure those numbers are normal as well. Because standards are changing, consult your provider as to what constitutes 'normal' on the GTT.

Random Blood Glucose Test

Another test that is sometimes done is the random blood glucose test. In this, a blood draw is taken at any time of day, regardless of fasting or not. It is important to remember that this cannot be done within two hours of a meal or the results will be higher due to eating. This test should only be done after at least 2 hours (preferably three) have elapsed after eating a normal meal. 

The advantage of this test is that you don't have to fast for the test, it is quick and easy to do, and it checks to see if the blood glucose has adequately cleared your system between meals (in diabetics it often remains elevated). The disadvantage of this test is that, like the other tests, it can be easily influenced by stress, illness, caffeine, smoking, etc., and that it does not test the normalcy of your bG after meals or fasting. If you have a random reading diagnostic of diabetes, they usually want to confirm this with another test to rule out lab errors, and often will follow up with a GTT or fasting test as well.

Glycosylated Hemoglobin Test

An excellent test to get is the glycosylated hemoglobin test (abbreviated as HbA1c), because it is the best overall measure of blood sugar control. This test measures the amount of sugar sticking to the hemoglobin in the red blood cells; the higher the level of blood sugar, the more sugar attaches to the red blood cells. 

What this test does, more or less, is measure your average blood sugar over the space of about 2 months or so, and therefore gives a clearer long-term picture of your bG status. It will reflect your OVERALL bG status, both fasting, just after meals, and between meals. It is probably the best test for establishing normal bG levels, but it is not always used because it can be more expensive and not all insurances will cover it. 

HbA1c test results are usually expressed in terms of percentages:

However, the exact definition of 'normal' varies from lab to lab. It is important in the HbA1c test to ask for your specific lab's norms, since different labs can differ a bit in their results. Your provider can interpret your results for you.

Fasting Insulin Test

One other test that may be appropriate for some to consider is the fasting insulin test. This test measures how much insulin is in your body when fasting.  (There are other insulin resistance tests as well, but this is the most common.)

A fasting insulin test may be particularly appropriate for women with PolyCystic Ovarian syndrome (PCOS) or women who have a few symptoms of PCOS but not others. In these women, excess amounts of insulin may be present in the body despite perfectly normal bG levels.  Some studies have found that abnormal fasting insulin test results tend to indicate a predisposition to insulin resistance and diabetes, so women who have abnormal results on this test should probably be tested for diabetes more often or consider drug treatment (Metformin, Avandia) to increase their sensitivity to their insulin. 

However, this test is by no means universal even among those who treat PCOS patients regularly, and may be hard to get covered by an insurance company. It is certainly not a required test, and only time will tell its utility, but it is one more in an arsenal of tests to consider if you are at special risk because of problems like PCOS.  It is Kmom's opinion that most women with a past history of gd should probably strongly consider getting a fasting insulin test.

Summary of Blood Glucose Test Options

Most doctors currently choose yearly fasting tests to keep track of your blood sugar, and may supplement these with other tests if you are at especially strong risk or your numbers are borderline. Periodic HbA1c tests are probably also wise, since they represent a more accurate overall picture, but how often to do these is a judgment call. Whatever test is used, ask for your test results and the diagnostic levels used, and be sure to get a copy of these for yourself, even if all is well.

Even with regular testing, it is still wise to continue eating on a modified gd food plan and to modify other lifestyle factors as possible. Since diabetes does occur more often in some groups of women, it is best to be very proactive about preventing/treating it, especially if you fall into higher-risk categories such as women with PCOS, heavy women, Hispanic or Native American women, or women with a family history of diabetes.

 

Preventing/Minimizing Diabetes Risks

Do you just have to sit around and wait to get NIDDM, or is there anything you can do to help prevent or delay it? Yes, there ARE proactive measures you can take to lessen your risk. There are no guarantees as to whether or how much these will help you, but they are worth considering. 

It is only sensible to have frequent monitoring postpartum and also pursue sensible proactive health measures. Certainly, ignoring the problem could possibly do a great deal of harm. Panicking or over-reactionary measures, on the other hand, can possibly do more harm than good. Careful consideration of all courses of action is very important. 

Here are some possible ideas to consider:

1. Increase your activity levels significantly.

Exercise is THE most important method of lowering blood glucose levels and increasing insulin sensitivity, and its beneficial effects continue even after the exercise has ceased for the day. This cannot be emphasized strongly enough! 

The book, Managing Your Type II Diabetes, states that exercising 3-5 times a week can reduce the risk of diabetes by up to 40 percent. This is extremely significant. The benefits of daily exercise has also been confirmed by a study in the Journal of the American Medical Association (March, 1998). A Swedish study found 50% fewer subjects with IGT progressing to NIDDM over a 6 year period with a structured exercise program (Eriksson et al., Diabetologia, 1991).

Another study by Lehmann et al. in Therapeutische Umschau in December 1996 found that "Increased physical activity delays the onset of NIDDM or even prevents the disease in about 50% of susceptible individuals (positive family history of NIDDM, body-mass index >25, hypertension or gestational diabetes)...Improved glucose tolerance has been achieved in type II diabetic patients in as little as one week with an exercise program. The beneficial effect of regular exercise on glucose control appears to reflect the cumulative effect of transient improvement in glucose tolerance following each individual bout of exercise. Increased insulin sensitivity is lost after as little as three days of inactivity."

To be beneficial, the exercise should be daily, at least 30 minutes long, and activities as easy as a brisk walk are sufficient. Exercise increases glucose uptake, decreases insulin resistance, and improves blood lipids. Neglecting exercising should not go longer than every other day, since glucose uptake benefits are lost in periods longer than 2-3 days apart. 

It is Kmom's opinion that EXERCISING IS THE MOST IMPORTANT THING A GESTATIONAL DIABETIC CAN DO TO LESSEN HER CHANCES OF GETTING NIDDM. Just do it! Find an exercise program that you can do daily and for the rest of your life.

2. Breastfeed your baby.

Although the main thrust of diabetes research has neglected this area, there is some research that breastfeeding may help delay or prevent NIDDM. "Lactation, even for a short duration, has a beneficial effect on glucose and lipid metabolism in women with gestational diabetes. Breastfeeding may offer a practical, low-cost intervention that helps reduce or delay the risk of subsequent diabetes in women with prior gestational diabetes." (Kjos et al., Obstetrics and Gynecology, 1993.)

Not all doctors and diabetes educators are aware of this research, but such an easy and otherwise beneficial method of possible prevention should not be overlooked! And the added benefit is that breastfeeding may help prevent development of diabetes in your child, too, although the research is not yet completely conclusive on this yet. Certainly it has special benefits in overcoming the hypoglycemia and hyperbilirubinemia that can occur in the baby of a gestational diabetic. Considering its other numerous benefits to both mother (less breast cancer, less osteoporosis, etc.) and child (fewer ear infections, fewer allergies, fewer intestinal problems, less asthma, etc.), breastfeeding should be strongly considered. 

However, since many of the typical protocols surrounding gd deliveries can interfere with breastfeeding and many diabetes providers give only lip service to it but in reality are less than supportive, be sure to read the web section on Gestational Diabetes and Breastfeeding for help in getting around barriers to breastfeeding.

3. Eat healthfully.

Although it's normal to want to have some treats now that your blood sugar levels are probably back to normal post-partum, don't go overboard. Be sensible and moderate as much as possible, and continue the same eating patterns you had on your diabetic food plan. You probably don't need to be quite as strict and limited, but in general, you will want to continue with similar guidelines. 

Keep your breakfasts fairly small, carb-wise, and be SURE to include protein. Try to have smaller meals so as not to overload your pancreas with too much demand at once, yet also eat more frequent small snacks, so your bG doesn't dip too much between meals. Eat every 4 hours or so to keep your bG more even, and carefully consider the number of carbs you eat at any one time. Continue with a small bedtime snack that includes protein, so that your bG levels don't dip too low in the night, and be very moderate in your approach to carbohydrate-intense foods like sweets.

It's a misconception that diabetics cannot have sweets----to non-pregnant diabetics, they are a carb like any other. (In a pregnant state, you want to avoid sweets, because the added burden of placental hormones makes you too prone to large spikes of bG, but when not pregnant, sweets are okay in moderation.) You can still have ice cream or cookies or whatever----but you want to be sure that you don't overload on them so that you don't have a huge carb load for your pancreas to struggle to process. 

No one is sure what causes genetically-prone people to become Type II diabetics, but at least some theorize that constant overloads of carbs that cause your pancreas to overwork to produce sufficient insulin levels may be a factor, as well as large swings of blood sugar from high to low and back. Constant, even blood sugars---- euglycemia----should be your goal.

4. Eat smart.

Roughly follow your gd food plan, but if you're going to have a treat, do it intelligently. All treats are NOT created equally!  

Some treats are worse than others in terms of carb load and insulin demand. A piece of pumpkin pie, for example, is a lot better choice than a piece of blueberry pie. In pumpkin pie, there are carbs from the sugar and from the single crust, while pumpkin is a vegetable with minimal carbs yet is a terrific source of vitamin A. Blueberry pie, on the other hand, has carbs from TWO crusts, all that sugar, and the sweet carb-intensive berries themselves. It can have a significantly higher carb load than the pumpkin pie. One piece of fruit pie like this plus a glass of milk often has nearly the amount of carbs in those ultra-sweet Glucose Tolerance Tests (the 100g load)! 

In another example, cheesecake or ice cream can be a better choice than sorbet because they generally have fewer carbs, and usually have more fat in them to help slow down the absorption of the carbs. (Of course, you must remember that diabetics are at high risk for heart problems so you don't want to overdo on fat levels, either, but an occasional splurge is different than daily high intake of fats.)

The key is not to declare that all treats are off-limits forevermore---that is unrealistic and unlikely to be followed. Instead, allow yourself occasional treats-----but eat smart and choose them wisely. And enjoy them...no guilt allowed! Guilt and a dieting mentality is also more likely to make you overindulge. Approach them as a food like any other. Use them occasionally and in moderation, and when you have them, ENJOY the hell out of them!

5. Lower your fat intake and increase your fiber intake.

High-fat diets may make susceptible people more insulin-resistant. You do not want to pare your intake down to the super low-fat diet levels (like less than 10%) since fats also help slow down blood sugar rise, but between 20-30% is reasonable. An easy way to start this is to use skim or 1% milk and other lower-fat products, and cut down on the obvious things like the amount of beef eaten, taking the skin off of chicken, etc. Use canola or olive oil instead of other oils, and be sparing. Cut down on butter or margarine use, though you do not have to cut it out completely (find the margarines that do not have trans-fatty acids). Limit your intake of 'bad' fats, like saturated fats from animal foods (butter, chicken skin, etc.) and concentrate your intake on polyunsaturated fats and monounsaturated fats.

Try counting your fat grams on a typical day and compute out what percentage of your calories you are consuming through fat. You can adjust your fat intake if needed from there, and decide how to prioritize the amount of fat you want to eat. In addition, increase the amount of high-fiber foods you eat, since it is thought that high-fiber foods tend to cause smaller, slower rises in blood sugars. Use brown rice instead of white, whole-wheat or other breads instead of white, etc. as much as possible. 

Again, it's not a question of all-or-nothing, but a question of moderation and prioritizing. A registered dietician can help you figure the proper amounts of fats to consume for your situation; you should have a complete blood panel done before your consultation to help her prioritize for your particular needs. People who have normal blood lipids (cholesterol, triglycerides, high-density lipoproteins, low-density lipoproteins, etc.) may be able to tolerate higher levels of fats (especially the 'good' fats) in comparison with people who have high or borderline lipid levels, who may need careful counseling in how fat intakes influence blood lipids.

6. Control your weight.

It is clear that gaining weight is very harmful to bG levels, so gd moms should make every effort to avoid gaining. One study showed that gaining weight between pregnancies increases your chances of developing gd in the next pregnancy (Moses, Diabetes Care, 1996). Another study showed that women had 2x the risk for developing NIDDM for every 10 lbs. they gain after their gd pregnancy (Peters et. al, Lancet, 1996). It seems clear that you should definitely avoid gaining weight in order to minimize your risks.

What is less clear is whether you should make an effort to lose or instead emphasize improved habits and focus on weight stability. It's important to note that nearly every resource emphasizes the importance of losing weight, and it's true that weight loss, in the short term, does help bG levels for a percentage of people. What is less certain is the long-term impact, since most weight loss is followed by a regain, even in so-called 'sensible' diets. It is known that weight-cycling is detrimental to both blood pressure levels and various blood fat levels, and there is some evidence that weight-cyclers may develop more diabetes, and sooner (see below). So the risks and the benefits have to be 'weighed' carefully, and the individual circumstances of each person considered.

For some people, it may make sense to lose some weight, though the emphasis should be on lifestyle changes and healthy habits, rather than on an arbitrary scale number. For others, it may make more sense to avoid the yo-yo merry-go-round and focus instead of good habits and a stable weight, since weight loss is actually more likely to make chronic yo-yoers gain in the long run and that is known to be a problem. 

This is NOT what most diabetes resources tell you, but they may be unable to see past their own biases about weight and recognize that in many cases, weight loss and subsequent weight cycling may be more harmful than staying at a higher but stable weight. On the other hand, each woman must look at her own lifestyle and history and decide for herself. For some people, weight loss may be the right choice. See the section below for cautions to consider if you decide weight loss is for you.

7. Those at very high risk may want to consider experimental therapy.

There are some experimental trials going on now to discover if prophylactic (preventative) use of insulin or other drugs could cut the rate of diabetes development and/or complications. In these trials, people who are already borderline or deemed at high risk are being given insulin or oral drugs such as Metformin (Glucophage) or Avandia long before before they even develop diabetes or Impaired Glucose Tolerance. Remember, there are risks to these experiments, and the results are unknown. Each person has to calculate the possible benefits and harm that could come from participating in experiments such as these, and decide for herself how much risk she can tolerate.

For example, exogenous insulin is known to raise blood pressure somewhat and sometimes results in weight gain; who knows what the results of years of prophylactic use will be? On the other hand, it might help reduce or prevent complications; that's why a controlled trial is important. There are a number of trials being developed and run now that investigate whether use of insulin prophylactically before true diabetes actually develops is beneficial in delaying or preventing the disease, but it will take years before any outcome is known.

Almost all drugs have side effects; it is unknown whether the benefits that might accrue from prophylactic use of anti-diabetogenic drugs would outweigh the risks and potential side effects of years of exposure to these chemicals. For example, Rezulin was initially reported to be very beneficial to many people, but was taken off the market when liver damage was reported in more patients than previously indicated. More often, the drug of choice these days is Metformin (glucophage), which seems to have fewer side effects and long-term risks, at least so far. As of this writing, Metformin has shown some promise in helping to prevent or delay development of NIDDM, but more research is needed before any conclusions can be reached, and harm from long-term use is unknown at this point. Read the package insert and consult your provider for further information.

It should be noted that one side benefit of Metformin is a return to ovulation for some pre-menopausal anovulatory women with insulin resistance. This may be of particular interest to women with PCOS (PolyCystic Ovarian syndrome) who have difficulty ovulating. Another important advantage is that Metformin seems to cut the high PCOS miscarriage rate significantly.  However, there is little study of the risks of taking these drugs just before and during early pregnancy. 

At present, most doctors are prescribing Metformin until the woman has been confirmed as having conceived, and then taking the mother off the medication. What effect this medicine has on the early days of pregnancy is appallingly understudied, but since it helps many women achieve pregnancy who struggled before, many are willing to overlook the potential risk.  A few doctors are willing to continue Metformin all through pregnancy, and although it has not been thoroughly studied, some (but not all) preliminary reports seem promising. However, the idea of exposing tiny fetuses to a fairly-untested drug is scary, and Metformin should not be used during nursing, so it's probably best to wait for more information before this practice is adopted uniformly.  

It's important to remember that prophylactic use of Metformin and other drugs to prevent the onset of diabetes is still being studied; its effectiveness for this is not convincingly established as of yet. A person might spend years being exposed to higher levels of these chemicals and their risks, yet receiving few balancing benefits in return. At this time, prophylactic effectiveness is totally hypothetical and unproven, but there may be women willing to tolerate the risks in hopes of possibly preventing diabetes. In particular, the risks may be balanced by significant benefits in women with PCOS, since the short-term data for use with PCOS looks promising. However, long-term data is simply not available at this time and so caution is probably wise.

Also remember that your decision may be influenced by whether you want to have more children and whether you are breastfeeding; insulin is compatible with both pregnancy and lactation but oral hypoglycemic drugs are not always compatible. One article that focused on the prevention of gd and NIDDM (Simmons, 1996 Australian and New Zealand Journal of Obstetrics and Gynecology) notes that, "Drug studies have also been attempted, but these demonstrated no effect and would be inappropriate in women wishing to become pregnant in the future." New drugs are always being developed that might help, so it remains an option to consider if you are done having children. 

Some people will be willing to try experimental drugs, while others want to avoid unproven therapies. A decision on whether or not to undertake therapy like this can only be made on an individual basis, considering your own medical and family history, and in consultation with your health provider. Kmom strongly discourages against becoming a 'guinea pig' for science unless a person is extremely well-informed and cognizant of the risks of experimental treatment.

 

The Weight-Loss Dilemma

"Weight loss does not necessarily improve health. Dieters, especially yo-yo dieters, who make up about 90 percent of the dieters in this country and whose weight is in constant fluctuation, have a risk for type II diabetes (the most common kind) and for cardiovascular disease that is up to twice that of 'overweight' people who remain fat." Big Fat Lies, Glen A. Gaesser, PhD

Diabetes educators routinely recommend that their obese gestational diabetes patients lose weight in order to reduce their risks of developing NIDDM. It is certainly true that losing weight does seem to improve blood glucose levels---in the short term. Even a loss as small as 5-10% of their total body weight seems to improve bG levels---but the long-term effect is not as well-known. Since the vast majority of dieters will regain the weight plus more, how valuable is this really? And how dangerous is it? What effect does yo-yoing have on insulin resistance and development of diabetes? How much of the improvement of blood glucose levels during weight loss is attributable to improvement in lifestyle factors as opposed to the actual weight loss itself? Will losing the weight and then regaining result in a worsening of the risk for NIDDM?

These are all vital questions that go largely unanswered by the diabetes research community. They continue to focus on short-term studies that show the benefits of losing weight, but do not follow-up on what happens to these research subjects years later---how many regained the weight, what the effects of this was on their disease, and what their mortality/morbidity rates were compared with weight-stable individuals of similar characteristics. It is obvious that more research is needed in this area!  

Some research seems to show benefits of weight loss, but there is also some research that shows that yo-yo dieters have higher rates of diabetes and heart disease. This, too, is not completely conclusive yet either, and needs further confirming studies, just as weight loss benefit studies need more confirmation and long-term follow-up. Some of the information on the risks of yo-yoing is included below in order to point out the possible risks of weight loss and because this information is rarely included elsewhere, BUT it is just too early to make definitive statements one way or another at this time. Each person will have to evaluate the risks and benefits for herself individually.

It would be irresponsible not to note in this section that nearly ALL the major medical journals and experts will recommend that you lose weight in order to minimize, delay, or prevent the development of NIDDM.  Most experts promote weight loss, even in modest amounts, as the first-line defense against NIDDM. To be fair, since Kmom is a staunch size-acceptance activist, it could be that her size-acceptance bias unconsciously blinds her to the best recommendations for larger women. On the other hand, it could also be that the fat-phobic biases of researchers (very pronounced in those in the endocrinology field!) blind them to the risks of weight loss and cycling.

For example, most diabetes educators point out that ~50% of fat women (60% of very fat women) who had gd will go on to develop NIDDM, while only 25% of average-sized women who had gd will go on to develop NIDDM. This is widely used as a rationale for fat women to lose weight. However, this examines the risk for fat women vs. thin women; it does NOT examine the risk for fat women who lose weight and then regain it, as most will do. This statistic implies that if fat women lose weight their risk of developing NIDDM drops to 25%, but the data for that is extremely limited and has not been rigorously examined and re-checked. 

In one study (O'Sullivan, as quoted in Henry, 1991), gd women who lost weight and kept it off had their rate of diabetes drop to 28%, nearly that of women who were never heavy, but does not address the rate of diabetes in women whose weight cycled. It's possible that the risk of 60% for very fat women is so high because of weight cycling. From this extremely limited information, the benefits of weight loss CANNOT be confirmed or denied. Further study that specifically addresses weight loss and weight cycling and their effects on development of NIDDM in fat women is needed.

Of the weight loss research that exists on people who are already diabetic, it is clear that weight loss--even a small amount---does often improve blood sugar levels and related readings for a certain percentage of diabetics.  However, it should be noted that NOT ALL diabetics are helped by weight loss. There seems to be a distinct group that is strongly sensitive to even small weight changes and is greatly aided by weight loss ("responders"), and other diabetics who do not seem to respond well to weight loss ("non-responders").  

Watts (1990) found that about 40% of obese diabetics studied were "responders" and had their blood sugar levels significantly improved by modest weight loss (about 20 lbs.), while the other 60% were "non-responders" and did not show any real improvement in blood sugar levels with a similar weight loss.    Other research seems to show that at most, up to 50-60% may respond to weight loss, while the rest do not.  And study after study shows that weight loss, especially for diabetics, is particularly difficult and rarely permanent.

Some health experts have begun to note reservations about weight loss issues; the New England Journal of Medicine ran an editorial in January 1998 that noted cautiously that perhaps "the cure for obesity may be worse than the condition," although they still recommend a modest weight loss for people with diabetes. The field of endocrinology is not likely to agree anytime soon with this softening of the position on dieting; the push is definitely towards losing weight as prevention.

Kmom's own experience of yo-yoing and her anecdotal observation that a number of acquaintances did not develop diabetes while at higher weight levels but did rapidly develop it after a large weight loss (when it would be expected to improve glucose levels instead but did not) leads her to include a section speculating on the possible problems that weight-loss recommendations might incur. It is difficult to oppose the near-unanimous recommendations of the diabetes experts, yet deep convictions about the overlooked dangers of weight cycling lead her to include this section so that people can make their own choices. It would be wrong to exclude this information--a balanced picture is important. Only after learning of the pros AND cons can large women make an informed sensible decision for THEIR choices. Kmom will continue to update this section as she finds further information, pro and con, about weight loss/weight cycling and diabetes.

The Risks of Weight Cycling: Overall Mortality

Although the medical oath is to "First, Do No Harm," most medical professionals are so unconsciously biased that they cannot consider that losing weight can be anything but benign or beneficial. Only rarely can they even contemplate that their recommendations to lose weight can do more harm than good. 

In reality, there is strong evidence that weight cycling is quite harmful. Frances M. Berg, a registered dietician and author, notes in her book Health Risks of Weight Loss that mortality tends to increase with weight loss. She details a number of studies pointing out this risk and suggests that this area needs further study. She writes,

Despite the fact that weight loss brings improvements in health risk factors such as blood pressure, cholesterol and blood glucose, there is considerable evidence that weight loss may increase risk of early mortality instead of decreasing it...Scientists from the Centers for Disease Control and Prevention in Atlanta and others informed the [1992 NIH Conference] panel there is little evidence that weight loss lowers mortality rates. On the contrary, most studies show weight loss in the general population is associated with increased risk of death...The Centers for Disease Control NHANES I Follow-up study, reported by Elsie Pamuk, PhD, an epidemiologist at the CDC in Atlanta, found weight loss associated with increased risk of death for both men and women, also for cardiovascular and noncardiovascular diseases. The more weight lost, the higher the risk.

Dr. Pamuk later states (as quoted in Berg's book), "The general assumption has been that weight loss is helpful...but perhaps maintaining stable weight will be found to be the best course."

In his book, Big Fat Lies, Glen A. Gaesser, PhD. examines a study that found a significantly higher risk of mortality among those participants who lost weight.

Perhaps the most powerful of all the studies to have found a connection between weight loss and higher mortality is the one done by Dr. Steven Blair (of The Cooper Institute for Aerobics Research in Dallas) and four of his colleagues, which was published in the Annals of Internal Medicine in 1993. Over 10,500 men aged thirty-five to fifty-seven who were classified as being at high risk for heart disease were enrolled in the Multiple Risk Factor Intervention Trial in 1973. Generally speaking they were overweight and had high blood pressure and high cholesterol. Beginning in the mid-1970s they were weighed one to three times a year for six to seven years. By 1985, when the total mortality figures were compiled, the results were unequivocal: Weight loss, even for a group of men who would seem to be the optimum beneficiaries of a weight loss intervention program, was dangerous. In the group as a whole, men who had a net loss of more than 5 percent of their body weight (about nine to ten pounds or more for most of these men) during the six- to seven-year period when weight was measured, had a mortality rate from cardiovascular disease that was 61 to 242 percent higher than men whose weights remained within 5 percent of their initial body weight. Among a subgroup of men who initially were up to about twenty pounds above average weight (BMIs between 26 and 29), a net weight loss of more than 5 percent of body weight during the follow-up period was associated with a cardiovascular disease mortality rate that was 195 percent higher than that of men with similar BMIs who did not lose weight.

Another study that found increased rates of mortality among those who lost weight was the famous Framingham study. Gaesser summarizes this too:

After more than three decades of follow-up measurements that included biannual body weight measurements, those Framingham subjects whose body weights yo-yoed the most had up to a 100 percent greater risk of death from heart disease than those whose weights fluctuated the least!

At this time, there is a finally a flurry of interest and research about weight cycling.  A number of studies have shown increased risk with weight cycling, although not all have.  Then again, some studies define weight cycling so minimally that a strong effect is not likely to appear.  They need to concentrate especially on chronic weight cycling with large variations up and down, which is probably the group most at risk and least likely to maintain weight loss successfully long-term.  Another problem is separating the effects of intentional weight loss vs. the effects that might result from smoking, serious illness, etc.  But even so, there is data to support that chronic yo-yo dieting for intentional weight loss in non-smokers is harmful.   

The consensus at this point by leaders in the field (who, it must be pointed out, are often paid consultants to weight loss companies) is that at this point, the dangers of weight cycling are not fully proven to their satisfaction and they do not recommend that people stop their weight loss attempts.  They do concede that enough data exists showing weight cycling to be a problem that more research investigating it needs to be done, but won't publicly state that weight cycling may be harmful.  For now, this issue has yet to be definitively decided in research, but women who are considering significant dieting need to consider that the effects of weight loss may not be all be benign.

The Risks of Weight Cycling: Diabetes-Specific Risks

If weight loss leads to yo-yoing, the worst-case scenario is that this might increase insulin resistance compared with simply maintaining a stable (but higher) weight.  French (1996) found that those who lost weight and maintained the loss permanently strongly decreased their risk for diabetes, but adults who gained a lot or had significant weight fluctuations had a significantly increased risk for developing diabetes.  Holbrook (1989) and Morris and Rimm (1992) also found that weight fluctuation was associated with higher rates of diabetes.

Gaesser also cites in his book the famous Harvard Alumni Study, where Dr. Ralph Paffenbarger tracked health and mortality facts about almost 17,000 Harvard alumni who entered the university between 1916 and 1950. As the men died, statistics were kept on the causes of death and risk factors and mortality rates were compared.

In 1988, when the most recent follow-up information was gathered, the alumni were asked how frequently they had dieted and how many times during their lifetime they had lost less than five, ten, twenty, or thirty or more pounds. When all the weight loss attempts and total pounds lost were tallied, those alumni who had a net loss of more than eleven pounds between 1962 and 1977 actually had a cumulative weight loss of ninety-nine pounds---which of course means they had also gained a considerable amount of weight over the years! The health consequences of this yo-yoing were striking: Compared with men who maintained fairly stable body weights, those who had lost and gained the most total pounds had an 80 percent higher rate of heart disease, and a 123 percent higher rate of type II diabetes. Similar results were found for yo-yoers who had ended up with a net gain of more than eleven pounds---which suggests that it is not net gain nor loss that is dangerous, but the yo-yoing itself. Indeed, those alumni who stated that they dieted frequently, or all the time, had nearly double the risk for type II diabetes, hypertension, and coronary heart disease compared with their former classmates who said they never dieted.

A very famous study that is often used to point out the 'dangers' of obesity was detailed by Drs. Paul Ernsberger and Paul Haskew in their 1987 issue of The Journal of Obesity and Weight Regulation, Rethinking Obesity: An Alternative View of its Health Implications. This is a classic case of the prejudice of the researchers blinding them to alternative implications of their findings.

Another study more directly demonstrated that loss-regain cycles shorten life. Nearly 200 fat men were placed on total fasts, some for more than two months, the rest from three to eight weeks. After release from the hospital the men regained the weight they had lost, often with a few extra pounds. As they regained, 80 percent developed diabetes; one-half of these cases were severe. Fully 25 percent died, mainly of heart disease. Their death rate during the follow-up was up to 13 times higher than equally heavy men in large-scale studies of the general population in Norway and Denmark. Incredibly, the deaths of these crash dieters have been widely cited as proof that obesity is highly dangerous and as justification for dangerous surgical treatments...The astronomical death rate of crash dieters who regain their lost weight suggests that the hazards associated with fatness may be mainly related to rapid loss and regain of weight, not to obesity itself.

In another part of his book, Gaesser notes that:

Since approximately nine out of every ten adult-onset diabetics--the people suffering the ultimate outcome of insulin resistance--are indeed medically classifiable as overweight, it does seem plausible that weight is the the problem. If that were true, however, then reducing to a nonoverweight condition would be the necessary cure...the health problems associated with insulin resistance--type II diabetes, hypertension, high blood cholesterol and triglycerides--can all be remedied without conforming to weight guidelines of any kind, even by those who remain significantly obese. Conversely weight loss diets such as the low-carbohydrate plans that have been so popular over the years...do not cause these problems to go away and may in fact worsen them significantly...Being fat is not the problem. Fat is the symptom. The two primary causes of insulin resistance are a sedentary lifestyle and a high-fat, high-sugar diet."

He suggests focusing on lifestyle, not on the scale. Improve the dietary and lifestyle factors that worsen insulin resistance and work on them instead, and let the scale do what it will. This seems to be a more sensible, moderate approach, though each person will need to judge the best course for herself based on her own personal history.

The Journal of the American Dietetic Association, in its 1994 article, Nutrition Recommendations and Principles for People with Diabetes Mellitus, agrees, saying:

The emphasis for medical nutrition therapy in type II diabetes should be placed on achieving glucose, lipid, and blood glucose goals. Weight loss and hypocaloric diets usually improve short-term glycemic levels and have the potential to increase long-term metabolic control. However, traditional dietary strategies, and even very-low-calorie diets, have usually not been effective in achieving long-term weight loss; therefore, emphasis should be placed instead on glucose and lipid goals.

In other words, improve lifestyle factors and focus on metabolic goals instead of weight loss. Can this really make a difference, or is weight loss really the key factor? Most diabetes clinics still place the emphasis on weight reduction, but there ARE a few clinics now that do not push weight loss but focus on lifestyle factors instead. These clinics seem to be helping their clients anyhow, in spite of the de-emphasis on weight loss. Gaesser goes on to note in his book [emphasis is his]:

...Type II diabetics can do a great deal to minimize or even "cure" their condition through proper diet and exercise regimens, because such programs are very effective at dealing with several of the problems caused by insulin resistance--problems that affect not just diabetes but heart disease as well...Since type II diabetics are very commonly obese, and the diet and exercise programs that frequently help to alleviate their health problems often result in weight loss as well, it has been assumed that obesity itself is a major part of those problems, weight loss the solution. If weight loss were such a crucial aspect in solving these problems, however, then one would expect to see a good correlative relationship between the amount of weight lost and the improvements it is generally thought to be responsible for. But in fact many program and studies have found that such improvements can come about when little or even no weight is lost, so long as certain key changes in activity and diet are made...The point is: It is possible to greatly improve or even "cure" diabetes and other serious health problems while still remaining markedly overweight...We now know that most obese people can completely normalize such disorders as high blood pressure, high blood fats, and insulin resistance while still remaining obese. Moreover, chances are they will be healthier if they stay that way, rather than trying to conform to any arbitrary height-weight standards. To do so, especially by dieting, may be injurious to their health...those who diet to lose weight are likelier to develop heart disease, high blood pressure, and type II diabetes than those who never diet.

He goes on to cite two studies (one at Pritkin Longevity Center in California, one at Duke University) that show tremendous improvements in blood glucose, blood lipids, and blood pressure among type II diabetics who completed a short program in lifestyle modification. Although some small weight loss was attained, participants were still quite obese at the end of the program, yet their improvement was quite significant. Thus, he reasons, the improvement in condition may be more attributable to lifestyle changes than to the small weight changes that occurred as a side effect, and perhaps diabetes providers would be better served by emphasizing lifestyle changes over weight loss as a goal. Clearly, more research needs to be done to clarify the role and effect of weight loss versus lifestyle change in treatment and prevention of diabetes.

This theme is also echoed by Frances Berg, editor of "Healthy Weight Journal".  In a 1998 editorial about a series of articles on weight loss and diabetes, she also wrote about the failure of most weight-loss programs for diabetics, and alternative non-diet therapies for diabetics.  

Weight loss has been the first line of traditional treatment for diabetes, and close on its heels came the dread "diabetic diet" handout sheet. The combination led to frustration and ongoing power struggles between many patients, families, and health care providers. Most patients fail to lose weight in a lasting way no matter how hard they try, many simply give up trying to mold their lives around a prescribed diet, and others respond in bizarre ways such as withholding insulin to control weight and fasting before checkups to improve readings. As a result, they live with guilt and shame, feeling defective, unworthy, and criticized -- more miserable after than before the treatment.   Now, thankfully, both the weight loss decree and the rigid diet are gone. In its 1997 paper, the American Diabetes Association (ADA), advised flexibility in diet, saying that nutrition therapy should be individualized with consideration given to usual eating habits and other lifestyle factors. And it states clearly that even though weight loss can improve glycemic control for people with type 2 diabetes, most are not successful and if they do lose, regain the weight, and that such unsuccessful attempts increase health risks. 
   Even the National Institute of Diabetes and Digestive and Kidney Diseases, bent on reducing obesity statistics at any cost, seems to have acquiesced in at least some of the changed policies. 
   The diabetes specialists writing in this and the next issue of the Healthy Weight Journal take the new advice even farther. They call for stable weights and self-empowerment for people with diabetes, and say glycemic control is better and patients are happier. 
   These clinicians work on the leading edge of a new movement. They support diabetic patients in determining their own goals. They emphasize patient strengths and help them lead normal lives, without the stress and guilt that is frequently inflicted by more rigid methods. 
   Donna Ciliska presents convincing evidence that weight loss treatment has failed to help obese diabetic patients and causes worsening of symptoms for many. This is supported by recent World Health Organization studies that looked at diabetes in nine centers worldwide over 11 to 14 years and found, for type 1, the highest mortality rates in those at lowest weights, and for type 2, that stable weight appeared beneficial as reported in our May/June 1996 issue. 
   This is a brave new world of rapidly evolving health care that may seem a bit scary if you are a provider. Old policies may feel safer and be so integrated into health care systems that they are difficult to dislodge. It is timely to ask, "Are changes in diabetic treatment needed in the institution I'm affiliated with?" 

Gone are the simplistic answers of yesteryear.  No longer should weight loss be considered the panacea and automatic first mode of treatment.   Instead, a detailed history of a person's weight gains and losses should be considered, along with honest information about a person's nutritional intake and exercise habits.  Only then, in the contest of this information, should decisions about possible treatments be made.

Making The Choice For Yourself: Factors To Consider

Not all fat people are alike, and not all are fat for the same reasons. It's important to consider personal history and other factors when making an important decision like this.  

People who have a good chance of losing weight and keeping it off forever probably would benefit greatly from the weight loss prescription; those who have a strong history of yo-yoing may not benefit and might even be harmed by the weight loss prescription.  When it comes to deciding whether or not to lose weight, one size does NOT fit all!

If you were average-sized as a child and only gained weight as an adult, you have a greater chance of losing weight and keeping it off. If you gained weight through the course of several pregnancies but previously were much thinner (and consistently so), your chances of losing are good too.  People who clearly have terrible food habits and who are very sedentary can almost certainly drop quite a bit of weight by improving their habits and generally have the most success in long-term weight reduction.  These are the people who are most likely to benefit from weight loss efforts, though of course there are still risks even so. 

There are others who might have some success with dropping at least some weight.  If you have a true eating disorder and truly compulsively overeat, then therapy may just help you to overcome that and you might drop some weight. Sometimes, women who were sexually abused and gained weight as a protective device (this is true of some---but not all!---larger women who were abused) are able to drop some by dealing with the abuse issues, though it is a mistake to think that weight has only to do with abuse issues or that all women with abuse issues would lose weight 'if only they dealt with their problems'. A few women who have obvious metabolic issues can sometimes lose at least some weight if these medical conditions are diagnosed and addressed properly.  This group would probably benefit at least somewhat from some loss, as long as emotional or medical issues are addressed adequately.

On the other hand, if you were fat all during your childhood and being fat runs strongly in your family, then your chances of losing weight permanently to 'ideal' sizes are quite low. If you were moderately chubby at one point, but have gotten fatter over the course of a number of failed diets, you have likely raised your setpoint and probably will no longer see 'moderately chubby' again on a permanent basis. However, you might be able to lose a smaller amount and keep it off.

If your weight has swung by large amounts of more than ~30-50 lbs., however, you are probably a yo-yo dieter and the chronic yo-yoing may have made you fatter than nature ever intended you to be.  Unfortunately, it is highly unlikely that you will ever get to and stay at an 'ideal' weight permanently. Embarking on yet another weight loss scheme is likely to only make you fatter in the long run, which IS more likely to cause problems with the diabetes. Yo-yo dieters seem to be the people most likely to be at significant risk from the usual advice to lose weight, especially those whose 'yo-yo' variations are quite wide.  It is this group that may benefit instead from stabilizing their weight and avoiding another yo-yo excursion.

Diabetes educators point out rightly that fad diets are notoriously bad for you and that's why people yo-yo on these. 'It takes a commitment to a whole new permanent lifestyle in order to lose weight and keep it off', they contend, and imply that if you only have the proper commitment and program, you will lose weight and keep it off permanently. 

It is true that fad diets and other dieting quackeries ARE going to fail in the long-run. But it must be noted that even the 'sensible lifestyles' that diabetes educators promote do not have a very good track record for permanent weight loss either. The so-called experts are WRONG when they imply that permanent loss is simply a mathematical equation of calorie intake and output. It is not. The equation is far more complex than that and truths seem to vary from person to person. 'One Size Fits All' is not true for clothes or for weight treatment programs!

Any program that you go on that is unrealistically harsh, or relies on fasting, food substitutes like meal powders or pre-packaged meals, extremely low quantities of certain foods (super low-fat or super low-carb, etc.), very low calorie diets (less than 1200 calories per day), or other such gimmicks is GOING to fail in the long run and will probably have a negative impact on your health. Dieticians pretty much agree that you need to avoid these! On other 'therapies', however, there is likely to be some disagreement.

For example, a few women with insulin resistance (most notably, women with PolyCystic Ovarian Syndrome) have noted some success with the "Zone" or other low-carb programs. It is worth investigating into further, but Kmom cautions that low-carb diets are a recurring fad that has been around for decades in various guises.  Previous forms have actually increased cholesterol levels and caused many other problems. THIS particular low-carb program could be different than the others, since it does have some notable changes, and the anecdotal improvements that many PCOS women have noted while on the "Zone" program are certainly worth looking carefully at. On the other hand, the diabetes educator Kmom questioned about the "Zone" program was very dubious about its claims and approach, and many dieticians' organizations have come out against extremely low-carb diets like the Atkins program. 

Frankly, further investigation is needed and no conclusions can be made at this point, but Kmom urges people to be cautious. Low-carb diets are a known fad that recirculate every few years and any 'new' version must be carefully researched. That doesn't mean that Kmom endorses or condemns the "Zone", just that caution seems reasonable. In particular, the more extreme low-carb programs (like the Atkins program) are probably NOT sensible or healthy in the long run.

Although there are a few 'bariatric experts' and endocrinologists who contend that bariatric (weight loss) surgeries can help many obese people, the statistics on the usual surgeries done in the past are very poor indeed. These are generally quite dangerous, have serious side effects and morbidity, are still not very effective in the long-term, and should be avoided at ALL costs. Some of the newer procedures seem less dangerous than previous procedures (and a few are even reversible), but at this time, it is probably extremely unwise to consider any of these procedures. 

Although it is very trendy these days to lose a great deal of weight with weight loss surgery, the long-term data is not in yet.  Many weight loss procedures seem very promising at first, with highly favorable personal stories and research circulating about them-----at FIRST. Experience shows that with every new 'miracle' surgery, long-term data show much more risk and side effects than originally noted.  Most bariatric surgical patients do show at least some significant weight regain long-term, and most require a long-term food intake that is at or near starvation levels (around 1000 calories per day).   

Common sense should tell you that any procedure that requires a long-term intake at or near starvation levels, inhibits the full absorption of nutrients, does not allow you to get your full nutrition through regular food, and requires nutritional supplements for full nourishment is not exactly most optimal for health. In a few cases, the dangers of weight loss surgery may be outweighed by the dangers of medical conditions, but for most people, weight loss surgery is NOT a good choice for long-term health.  It is currently the newest fad for weight loss, but one that is likely to show great harm long-term.  Kmom strongly cautions against the simplistic lure of these latest fad weight loss surgeries!

Similarly, weight loss medications such as Fen-Phen, Redux, Meridia, or Xenical are poor choices as well, even though many endocrinologists have urged obese diabetics to use these. Although people lose slightly more while on these medications than when not on them, they tend to regain quickly once the medications are done. Long-term use of these medications is not recommended because this is when health damage begins to accrue significantly, yet this is what would need to occur for the weight loss to be permanent.

Remember the lessons of Fen-Phen! It seemed to be the latest 'miracle', and MANY diabetics were urged to take it. The experts assured us that the risk was low, the complications for most people minimal, and the benefits significant. And then research showed that the risks were NOT as low as touted, the complications far more common than previously thought, and the benefits dubious in the long-term. People DIED because they believed in this latest weight-loss pill from doctors, and others were permanently damaged. 

Studies showed that people who took the drugs short-term probably suffered very little damage (although there were some cases where harm occurred after very short-term exposure), but people who took it for more than a few months had much higher rates of complication and damage than previously thought.  Those who took it for extended periods had quite high rates of problems. Remember, although these drugs help you lose slightly more weight while on them than without them, long-term use is generally the most dangerous, and the weight usually returns if you stop the drug. So what's the benefit?

The history of dieting in America is FILLED with the newest drug, diet, or weight loss surgery that is supposed to be "THE" fix and cure, with 'promising' preliminary results and glowing testimonials.  Yet every single one of them in the past has turned out in the long run to be ineffective at best and extremely dangerous at worst. It is possible that they may discover a drug or procedure eventually that will significantly help obesity without endangering us more, but it's EXTREMELY important to approach any such new developments very cautiously indeed, given the past record of harm. If you get an endocrinologist or diabetes educator who pushes you to consider weight loss surgery or drugs in order to prevent or control diabetes, RUN in the opposite direction and find a new doctor who is not size-phobic and understands adequately the DANGERS of these approaches.

Some drugs remain on the market, new ones have been added, and even more are now in the FDA approval process, but many size-acceptance organizations strongly caution against the use of these. They have been rushed through the approval process by government committees filled with people who have a vested economic interest in the pharmaceutical companies that make them, and they have NOT been proven safe for long-term use. Their apparent 'lack of harm' is highly questionable, especially when much of the research is done by those who have the most to benefit from the drug.  The whole Fen-Phen debacle is an example of this--it was rushed through approval despite strong objections from some experts, then turned out disastrously for a number of people who simply wanted to drop a little weight.  

The whole mentality of taking a pill or surgically mutilating your body in order to 'fix' a weight problem is problematic anyhow. If you have poor habits and lifestyle, fix that instead of taking a pill or getting cut open! If changing lifestyle helps you to lose weight, then great--it wasn't meant to be there and you are better off without the weight. If improving habits and lifestyle don't help you lose much weight, then you were not meant to be thin anyhow, and at least you have healthy habits now. Strive instead to maintain those healthy habits and a consistent weight, and that will probably be healthier in the long run than trying to meet an impossible 'ideal weight' standard through starvation, drugs, or surgery.  Use a little common sense!

Most diabetes educators promote 'sensible lifestyle changes' as the way to lose weight instead, blithely ignoring the fact that most of us have done the sensible approach already, and it failed as badly as the fad approaches. Sensible lifestyles are ALWAYS a good idea and Kmom approves of them heartily. However, the expectation of dieticians that this will solve your weight 'problem' is false. 

The fact remains that most diets fail, regardless of whether they are sensible diets or fad diets. The only way to reduce your weight is through hypocaloric diets and there is ample evidence that these cause a metabolic slow-down that eventually result in a regain of weight anyhow----plus more. Simply lowering your intake while increasing your output helps some people, but more often is not enough for many others to reduce down to 'ideal' sizes permanently, and even relatively 'sensible' approaches may be dangerous if done severely enough or too long/often. Dieticians and many doctors like to pretend that a 'sensible' program will help you lose down to an ideal weight (or close) if you really stick to it; they ignore the fact that these programs have an extremely high failure rate too. When sensible approaches fail, therefore, in their mind it must be the dieter's fault, not the program's, and so they blame the victim.

For chronic yo-yo dieters, chances are extremely strong that a big push for weight loss will only end up packing on more weight in the long run, yet that loss/regain cycle will increase their risk for hypertension, high blood lipids, and possibly diabetes. Still the doctors and dieticians continue to recommend diets, 'sensible' or not, regardless of a person's personal dieting history. If you had cancer, it is unlikely they would recommend an operation that had only a 5% chance of succeeding and a strong chance of making things even worse, yet with obesity, they don't hesitate to bully you into a procedure that is as unlikely to work and may even make things worse.

Kmom's personal opinion is that instead of a blanket recommendation to lose weight, the woman and her providers sit down and consider the woman's own unique history and situation. If you only gained weight as an adult, it might make sense to try and lose it----slowly and moderately, while concentrating on improving exercise etc. levels. If you have lousy habits, it makes great sense to improve these things, and chances are, at least some weight will come off. If, on the other hand, you are a chronic yo-yo dieter, have dieted your way up the scale, and have never experienced any length of time at a stable weight, it might make more sense to improve lifestyle factors (without resorting to hypocaloric or restrictive diets) and concentrate on maintaining a stable weight instead. Or perhaps you might choose to try and lose a small amount of weight and then stabilize it, though of course this could also potentially activate another yo-yo cycle if not carefully done.

No matter what your decision is about losing weight, it is extremely important to pursue lifestyle improvement through increasing exercise and more sensible eating practices. Whether or not this results in weight loss is relatively immaterial. The improvement in lifestyle alone may be enough to help prevent or delay diabetes, or to minimize its effects. Although Kmom is strongly dubious of the blanket recommendation for all heavy women to lose weight after gd, she STRONGLY promotes more attention to improving lifestyle factors and habits.  However, the weight loss choice is one that must be made by each individual after careful consideration of past history and lifestyle.  

What If I Choose To Try To Lose Weight

Since 40-60% of established diabetics are 'responders' and see their blood sugar levels improve with some weight loss, many doctors feel it might be worth trying to see if you are one of those responders.  If, after much consideration, you feel strongly about losing weight, consider trying for moderate weight adjustment (as noted above), which is more likely to last longer and less likely to be as dangerous. Many obese diabetics see an improvement with only a mild degree of weight loss (although of course it may be the improvement in lifestyle factors that make the improvement rather than the weight loss itself).  

Dieticians and diabetes educators often note that a loss of 15-20% of body weight is often enough to improve blood glucose levels significantly, even if you never get near your 'ideal' body weight. For a 250 lb. woman, this amounts to a loss of about 35-50 lbs, which is still a lot and could set off another yo-yo cycle. It may be better to attempt a milder loss of about 10-20 lbs. (about 5-10%) instead and then stabilize. 

Again, lack of stability could ADD to the problem, so set your goals with that in mind. Find a level that is clearly achievable without shocking your body into lowering its metabolism or going into starvation mode. The American Dietetic Association article quoted above (Nutrition Recommendations and Principles for People with Diabetes Mellitus, 1994) states that:

Mild to moderate weight loss (5-10kg [10-20 lb]) has been shown to improve diabetes control, even if desirable body weight is not achieved. Weight loss is best attempted by a moderate decrease in energy intake and an increase in caloric expenditure. Moderate caloric restriction (250-500 kcal less than average daily intake) is recommended.

However, remember that this is the recommendation for non-lactating women. In women who are breastfeeding, hypocaloric intake has been proven to lessen supply and endanger breastfeeding. Since breastfeeding itself often promotes weight loss while still consuming more calories (and improves blood glucose and HDL cholesterol levels), breastfeeding should be strongly encouraged in gd mothers, particularly larger gd mothers. After breastfeeding is well-established (at least 2-3 months post-partum), the mother who is determined to try to lose weight in addition to the normal loss should cut back slowly and moderately while increasing exercise.

The Breastfeeding Answer Book from La Leche League recommends increasing activity levels and cutting back 100 calories per day from food intake. No more than 4 lbs. per month should be lost, dieting should not be started within the first two months post-partum, and an intake of at least 1800 calories per day is recommended. The Subcommittee on Nutrition during Lactation writes: "Encourage at least 1800 kcal/day. Calcium, multivitamin-mineral supplements, or both may be advised...Intakes below 1500 kcal/day are not recommended at any time during lactation...Liquid diets and weight loss medications are not recommended."

While many registered dieticians may know of these recommendations for lactating women, not all do. Many diabetes educators, in their zeal to 'reform' or 'fix' you, may try to place you on strongly restrictive dietary regimens. These are probably not a good idea at any time, but they are especially ill-advised during breastfeeding. 

Do NOT let health providers bully you into inadequate intake or the folly of weaning early/not nursing in order to alter your dietary intake. Breastfeeding confers far too many health benefits to both mother and baby to consider omitting nursing or weaning early for these purposes, especially considering the dubious long-term effects of weight cycling. Breastfeeding your baby long-term is far too advantageous to you and to baby to cut off early in order to diet, or to endanger by lowering intake too much. Any provider who encourages you to do so does NOT know the research and is not breastfeeding friendly/knowledgeable. You might want to switch providers in such a case. 

Remember, the American Academy of Pediatrics recommends breastfeeding for at least the first year (and longer if desired) and the World Health Organization recommends it for at least two years. If you have decided to make a serious attempt at weight loss, you might want to ease into it gradually by cutting back just slightly after a few months, a bit more after 6 months, and then cutting back more after weaning. Again, however, do not let the specter of weight loss or possible future diabetes keep you from nursing as long as you want; remember that breastfeeding burns up a lot of calories per day and improves metabolism, and it is a proven anti-diabetogenic factor.

If you do decide to diet at some point, remember to be sensible and careful. The American Dietetic Association article listed above notes that the goals of nutrition therapy include improving metabolic control, achieving normal level blood glucose levels (or as close as possible), achievement of optimal serum lipid levels, and

...provision of adequate energy for maintaining or attaining reasonable weights for adults...[or for] increased metabolic needs during pregnancy and lactation...Reasonable weight is defined as the weight an individual and health care provider acknowledge as achievable and maintainable, both short-term and long-term. This may not be the same as the traditionally defined desirable or ideal body weight.

Kmom repeats that this concept of reasonable weight may be an important one. Very few large-sized women can say they have maintained their weight--any weight---for any long-term period. It may be more important to have weight stability rather than trying to lose down to your supposed 'ideal' body weight. Over many years of dieting, a woman's setpoint is often raised, and many women have no idea of what their 'reasonable weight' may be. Instead of concentrating on a specific weight loss goal, concentrate instead on good habits, more exercise, and achieving optimal blood pressure and blood lipid levels. Your 'reasonable weight' will probably follow.  

Kmom suggests strongly that the first, most optimal course is to improve health habits and find a weight that you can stay stable at, whether that represents your present weight or a slightly lower weight that you will aim for. YOUR reasonable weight is the one that you can maintain over a long time, using reasonable activity levels that you can sustain over long periods, and a caloric intake and food balance that you can easily live with EVERY day for the rest of your life. Hypocaloric approaches are not likely to fall in this category. Exactly how many calories YOU need can only be figured out through experimentation. The point is not to feel deprived, not to go on a diet, and not to risk another yo-yo cycle which could be dangerous to your health. 

Losing a little weight might help if you are one of the group of 'responders' whose blood sugar clearly responds to weight, but MODERATION and IMPROVEMENT OF LIFESTYLE FACTORS are the key.

 

Improving Lifestyle Factors, One At a Time

One Step at a Time

It can be very overwhelming to try to change one's lifestyle all at once, and to many of us, it smacks of the whirlwind dieting attempts of our past or the efforts of fat camps/diet clinics to "reform" us. We often have very negative associations with them, and we are painfully aware of the high failure rate of these "reformations". 

However, due to the risk of subsequent NIDDM, it would be foolish not to look at ways in which we can improve our lifestyles. The question is finding a way in which we can do it in a way that is acceptable to us, able to be maintained over the long-term, and is self-initiated rather than a "reform" attempt.

For some women, the best thing is to change everything at once in a sweeping lifestyle metamorphosis. If that's true for you, go for it. However, it's the experience of many more women that this kind of sweeping change is unlikely to last long-term and is often approached with resentment and dread and sometimes even binge-eating. 

For many women, any changes that might be needed are better approached a bit at a time, in smaller, manageable steps, though with a FIRM commitment to the long-term. Your chances of developing diabetes overnight are pretty small; small changes over time cumulatively may be just as effective (or even more effective) as large changes done sooner, which tend to be abandoned more often. Don't take years to accomplish your changes, obviously, but it may not be that everything must be accomplished at once.

Exercise

It is clear from research that EXERCISE is the most important lifestyle factor. Perhaps you could start with that, if it's something you need to improve. If you are pretty inactive, start by taking a 20-30 minute walk. If getting out with a new baby is a hassle, walk around your house with the baby in a sling (they love this!). Or walk every other day if you can't seem to make it out each day. The importance is not in the total length of time but in the FREQUENCY and REGULARITY of your exercise. If you go every other day reliably, that's better than running a mini-marathon for a few weeks and then stopping or getting sporadic. If you find it impossible at first to exercise daily, start with every other day and make it your goal to work your way up to daily. Or start with a smaller length of time and set a goal to increase your time commitment as baby gets older.

Walking is the best exercise for many of us. It is low-impact and not likely to cause injury, no special equipment is needed, it's free, and we can take our babies along with us in the sling or the stroller (babies usually prefer slings at first, or a carseat strapped safely into a stroller). You can set your own pace, get a little fresh air for you and your baby, get a little togetherness time with your spouse, or take some time for thinking too. It's the most accessible exercise and the one most likely to be kept up long-term. Kmom highly recommends starting with walking, assuming you are given the physical OK by your health provider.

Many of us have had terribly negative experiences with exercise instructors, coaches, or PE teachers who want to reform or 'fix' us. You may need to deprogram some of your negative past associations with exercise. Learn to rediscover the active child you once were, the one who loved to dance and walk and skip and play. ALL small children love to be active in their own ways, but many of us lose this enjoyment through negative feedback and hassling, or feel that only certain types of activity count as "real" exercise. 

Find the activities that you enjoy, and reclaim the joy in movement that was once yours. Large women CAN and DO find joy in movement again; tune out the negative programming that has accumulated over the years. Don't let the fat bigots of the past win; RECLAIM YOUR RIGHT TO ENJOY ACTIVITY AT ANY SIZE!!!!!!

Find a way to be active on a regular basis, from walking each day, taking a dance class on certain nights, swimming laps each week, doing water aerobics, taking up yoga or tai chi or karate, running stairs at home, or simply dancing around the house with your baby in your arms. Or better yet, do a combination of these. It doesn't really matter WHAT you choose, as long as you do something on a REGULAR basis, religiously.  

And if something throws you off-track for a while (illness, family emergency, laziness, circumstances, whatever), it does NOT mean you've failed. Most people experience these periodic lapses, even devoted athletes. Simply see it as a minor interruption in a bigger overall pattern. Don't focus on being perfect, but on the OVERALL regularity over a long period of time. So you couldn't manage to get out as much as you should this week? In the long-term, that's just a blip in your pattern. As long as you pick your pattern back up, it's not that big a deal. DROP THE GUILT ROUTINE and just concentrate on health and long-term improvements.

Nutrition

As far as food goes, start by reforming one or two habits. Unlike most dieticians and doctors, Kmom does not assume that you are standing in a closet, stuffing down bags of doughnuts and pop-tarts, or that you eat a wagonload of fried food and never touch vegetables. Most of us actually have fairly reasonable diets and some are even malnourished from years of dieting. Stop judging yourself by the unreasoning perfection standards that NOBODY meets, thin or fat. That's part of the 'diet mentality' and needs to be excised from your life. 

Your goal from now on is not to live on salads alone forever and never eat another French fry or ice cream cone. Nearly everyone, registered dieticians included, have their favorite indulgences! But food should not rule your life, either positively or negatively. If you swear off all sweets forever but spend much of your days drooling at Dairy Queen commercials or feeling angry because your weight means you can't ever have any ice cream, then food IS still ruling your life, and that way is not healthy either. The key is to find a happy medium.

DUMP THE DIET MENTALITY of having to be perfect or feeling guilty when you are "bad." Realize that a long-term lifestyle approach means that sometimes you are going to indulge, and that some indulgence is not a problem. Even overt diabetics can occasionally have sugar or other treats, if they plan them into their intake. You do NOT have to swear off your favorite foods forever.  You simply need to be moderate.

REGULAR constant indulging or unhealthy indulging like that of a binge, on the other hand, IS a problem. This indicates that you are still stuck in the 'diet mentality' or possibly that you have an eating disorder that needs to be addressed. Many women who declare themselves "diet-free" for the rest of their lives find that many of their previous bad food habits actually die away over time and there was no true eating disorder. Once the cycle of deprivation/overindulgence is broken, they find that they can indulge in favorite foods reasonably, without having to squirrel it away for later or in anticipation of not having it again. 

On the other hand, if you have a true eating disorder, it is imperative that you seek help. Eating disorders often worsen after the birth of a baby, and this could be especially bad given a history of gd. If you have an eating disorder, get help! But don't assume, as many medical professionals do, that if you are fat, you must automatically have an eating disorder. Some do, and some do not.

Of course you should work to improve your diet! EVERYBODY SHOULD WORK ON IMPROVING THEIR DIET, thin or fat. There are very few people in Westernized societies who could not improve their dietary intake a bit.  Take an honest look at your food intake and see where it could be improved. Leave the guilt and judgment about food behind; honestly assess what you eat and what needs to be improved.   

Then target one or two areas to pay attention to first, such as consumption of excessive carbohydrates. Try not to eat more than 2-4 servings of carbohydrates (milk, starches, fruits) at any one meal, and be sure to eat your carbs with protein, as always. Try to avoid big breakfasts full of carbs. Don't skip meals. Just like in your gd plan, aim to eat smaller but more frequent meals, with the aim of keeping the blood sugar as steady as possible.  

Are you eating the requisite amounts of veggies each day? Most people don't. Start with adding more veggies to your life---and not just the peas and corn type either, which are really carbs in disguise! There is some research indicating that malnourishment or deficit in certain vitamins can contribute to insulin resistance, so be sure you are getting adequate dosages of nature's purest and best vitamins----vegetables. (You should be consuming 3-5 per day, preferably erring on the higher side, and as fresh as possible.) Fresh fruits are also important, but be sure to count them towards your carb totals.

Cut down the amount of fat in the diet by using low-fat dairy products whenever possible. Be sure you are getting adequate amounts of high-fiber foods. Cut out most or all white-flour products, if you consumed these before. Simply reducing or completely cutting out white-flour products is one of THE most helpful things you can do for reducing your blood sugar and improving insulin uptake!  Really work on reducing highly refined carbs in your diet.

Find ways to compromise that you can live with. You don't have to cut out your favorite treats, just try to prioritize and be moderate. For example, although drinking skim milk is an excellent way to cut down on calories and fat daily, some people just HATE skim milk. (Kmom does!) So try 1% milk as a compromise, and try not to drink it at most meals so as not to add to the carb totals of the meals. Instead use it as a snack or at bedtime, or give it up if you are not particularly enamored of milk. Similarly, try the naturally lower-fat string cheeses for most of your cheese intake, but indulge in regular cheddar cheeses at times too if you wish---without guilt! The point is that you need to find a way to cut down on fat and carbs and calories, but in a reasonable, non-odious way that doesn't make you feel deprived or angry, and still allows some compromise for you to have things that are important to you.

Ask yourself what things you MUST have in order not to feel deprived, angry, and likely to retaliate or overdo. It is vitally important to a long-term success that you understand what foods or behaviors are most important to you personally, and what is less vital. Begin by modifying the easier-to-change habits and leave the others alone for a bit. You can always re-evaluate their importance down the line and either keep or modify them then. But forcing yourself to go cold-turkey on every single little thing is most likely to cause you to go off the program later. 

Examine your lifestyle honestly, find what things you are willing to consider changing, find out what things you are absolutely unwilling to change, and find out where you can prioritize or negotiate a compromise position. Be moderate in your approach, yet always honest. A program that is suitable for YOU will evolve in time, and you can adjust it as needed.

Kmom's Story

I have a long and unpleasant history of yo-yo dieting.  The weight variations started small (and were from 'sensible diets'!), but over time got bigger and bigger, until it was apparent that this was really unhealthy for me, mentally and physically.  I eventually decided that stabilizing at a higher weight was the better choice, and it did seem to improve my health, as my cholesterol dropped 50 points after I stopped dieting!  I concentrated then on eating when I was hungry, indulging if I wanted to but without overdoing, and generally going back to a healthier attitude towards food. 

So after my gd pregnancy, the idea of going on a permanent 'diet' of life-long deprivation horrified me. After the pregnancy was over, I indulged in my favorite treats---mostly moderately, but with a bit of desperation coloring my enjoyment. I was very angry that my much-cherished peace with not dieting and accepting myself as I was seemed to be at an end, and I felt my psyche trying to return to that deprivation/indulgence mode of dieting---something I had overcome a long time ago. I felt a strong psychological urge to consume every sweet in existence in anticipation of the day when I could never have them again. I didn't indulge that urge, but it was really depressing to feel food regaining panic power over me after years of a more healthy approach.

I did try changing my exercise patterns, however. I began trying to walk regularly, though a colicky baby made this a real challenge! The trick was in changing the pattern of exercise. Previously, I had never been completely sedentary, but my exercise was more sporadic rather than reliably regular. So that was the first pattern I set out to work on---REGULAR exercise. It was a struggle at first and I only went out every other day, but it was my first permanent change.  I still felt that exercising regularly was a drag, because I was still associating it with trying to lose weight, but I did it anyhow.  Gradually, doing it regularly became part of my life. 

But I dreaded the necessity of eating on the gd food plan for a full *9* months next time, and wondered how I would last. Regular exercise I could do---but no sugar for 9+ months!??! Augh!!  Although I try not to overdo sugar, I do enjoy it and certainly did not want to go without it completely for that long.  I started to feel those deprivation twinges again.

In preparation for my second pregnancy, after reading so much about the importance of a good diet and daily exercise, I reluctantly began stepping up my lifestyle improvements. I was terrified that my gd would recur extremely early and that I would need insulin. My goal for the pregnancy was simply to avoid insulin and overly-cautious delivery protocols at the end; maintenance of superb blood sugars throughout seemed to be my best bet for both. So I monitored every single day, worked up to walking at least a mile EVERY single day, and followed my gd food plan from before conception. The registered dietician and I did manage to find a way to work in a piece of pumpkin pie at the holidays so I didn't feel totally bereft, and that small amount of treat seemed to keep down the deprivation panic that had plagued me in the first pregnancy. And fortunately, the exercise and food plan worked so well I avoided gd entirely in the second pregnancy! Yahoo!

After the gd test came back negative in that pregnancy, I was tempted to have a fling, and for about half a week, I did have a few small treats. Eventually, though, I decided to stay the course and that it was really not so bad after all---I could stick it out for another 3 months to ensure a healthy baby, just in case my gd might recur late in pregnancy. So I kept up my routine with just a little more leeway as long as my numbers were good. I did keep a list of promised treats once the baby was delivered, but to my surprise, after the baby was delivered I didn't rush out and have those treats. Eventually, when I wanted one, I worked it back in, but with less desperation than after the first pregnancy. 

So I began to look more into modifying my diet as a pre-emptive strike against diabetes, but without the extremism which might set off another deprivation panic. Could I actually find a more moderate course?

I began really reading labels to understand the carb content of the foods I was eating, which proved enormously helpful. I began examining my priorities---food habits that if threatened would make me feel extremely deprived and might cause problems with long-term compliance. I looked more into making sure I got a more well-rounded, balanced diet each day, but without freaking out or feeling guilty if I had an occasional day without enough vegetables or with a bit more indulgence than usual. I began to look at food intake as a continuum over time instead of a pass/fail daily report card (part of the old diet mentality that had managed to stick around these many years).

I examined what trade-offs I was and was not willing to make in food choices. For example, I knew that I really needed to increase my vegetable intake, yet I knew that I was probably not going to comply in this unless I could add margarine to some of them. Although needing to trim my fat intake a bit, I was willing to make this trade-off, feeling that adequate intake of vegetables was more important at this stage than trying to learn to like them tasteless and rubbery. I switched to 1% milk in order to lower other fat intake somewhat (I cannot stand skim; 1% was my compromise) and other lower-fat dairy products. I'm sure it doesn't completely compensate for the margarine on my veggies, but I felt it was a reasonable exchange and didn't amount to huge amounts of extra fats. I also switched to margarines that do not contain trans-fatty acids in order to lessen my risk a bit more.

Plenty of habits did not need changing, and I was pleased to recognize how many things I was already doing just fine! Most dieticians (and the public) have the perception that fat people eat completely unhealthy and need to be totally reformed, when many of us actually practice quite a few good habits. It was an important part of the healing process to recognize that a number of the usually-recommended changes were already part of my lifestyle and had been for years. 'So there', I gloated virtuously!

Other habits I decided I did need to change. For years, I drank pop regularly, though my consumption was not really very excessive. For my first pregnancy I had switched to fruit juice, thinking that that was a much healthier choice. Bzzzzt!! Fruit juice has the same effect on blood sugar that pop does, and can add up to some HUGE carbs---read the labels! So with great sadness, I virtually gave up both fruit juice and pop. I found I missed juice but did not really miss pop. 

I also gave up drinking milk at most of my meals in order to lower the carb 'hit' taken at one time. I was baffled at first at what I was going to drink instead of milk, juice, or pop, but breastfeeding helped me rediscover the joys of water. (AAAH!) In my childhood home, water was always taken lukewarm because my mother cannot tolerate ice; I have absolutely no desire for tepid water and so I never liked drinking water at meals. But breastfeeding in the summertime taught me the joys of ICEWATER again, and I've really been converted. Now I actually drink the 6-8 glasses of water per day you are supposed to consume! And I am usually quite happy to substitute this for juice and pop and even milk at times. However, I do still enjoy orange juice (I just try to watch how much I drink), and once in a blue moon I might also have some root beer. But I have really lost my taste for most pop and recognize that it really is *terribly* unhealthy as a food, truly 'liquid candy' as they say. If I'm going to indulge a sweet tooth, I'd prefer it to be on other things besides pop, something I truly enjoy instead.

Along with juice and soda, I also mostly gave up other favorite carb-intense foods like muffins, bagels and (to a lesser extent) cold cereal. I was aghast upon reading the labels at how many carbs these contain, and decided that I'd rather spend my carb allowances on other things most of the time. I still have these things periodically but it's the exception rather than the rule now. I can live with it because the foods are not forbidden to me; I just aim for a far lower consumption of them. I struggle the most with limiting cereal, so I do keep some of the more low-carb options around for when I do want cereal.

Primarily, though, I concentrate more on food patterns rather than on eliminating any specific foods. I roughly estimate my carbs at meals, trying to stay within a reasonable load, and ALWAYS consume protein when having carbs, something I often omitted in the past (especially at breakfast). I try to eat smaller meals but more frequently, whereas in the past I tended to eat two large meals in the day instead. I still tend to eat two meals these days, but with a less intense carb load, and now I include a snack between them and sometimes at bedtime in order to keep my blood sugars from swinging too much on either side. 

I try to keep sweet indulgences within limits (but I'll *never* give up ice cream completely!) and have reduced down the fat intake some, though I might consider going a bit lower in the future. One VERY important thing I have done is increased my vegetable, fruit, and high-fiber food intake significantly, and I eat more vegetarian and whole foods regularly.  We now grow some of our own vegetables in the summertime (so as to get more nutrient value to them), and I really have worked at getting in at least 5 fruits and veggies on most days (and sometimes 8 or 9!).  Since I have never much liked veggies, that's real progress for me!

Some people choose to go on a low-carb diet, especially since these have anecdotally been shown to help women with PCOS. I am highly dubious of the virtues of the extreme low-carb plans, have seen a number of indications from various sources that these may actually be harmful, and so do not ever plan to follow these. Nor do I religiously follow the more moderate carb programs, but I certainly DO believe in reducing carb intake somewhat. Again, due to my extreme yo-yo diet history, I do NOT choose to try to lose weight, just work on keeping carb intake more moderate and reasonable. I feel that this is a safer and saner approach, but your mileage may vary.

I have increased my daily exercise mileage over time and now average walking one to two miles most days, have also added water aerobics/lap swimming to my regime, and yoga when I have time.  I have finally been able to rediscover my joy in exercise again after many years of total resentment towards it; it feels wonderful to enjoy it again. Most of the time, I don't begrudge the exercise time and necessity, and feel I accomplish quite a lot of thinking and writing during it, or use the time for heart-to-heart talks with my spouse. I have really grown to love lap-swimming in particular---it's a great form of meditation!  All in all, it has worked out very well indeed and I am most pleased to have regained my joy for movement again.

Are there still more habits I could change? Yes, I'm sure a picky dietician would want me to further reduce my fat intake, completely eliminate red meat, cut out all sweet treats, put away the salt shaker, blah blah blah. (They're NEVER satisfied!) I am not willing to make these changes at this time, and since my blood pressure and cholesterol levels are already *fine* I don't feel compelled to change these anytime soon. The changes I have made are sufficient for now. Too many at once might make me feel deprived and 'diet-y' again. With my extreme history of yo-yoing long ago, the last thing I am willing to do is to risk another yo-yo cycle. I feel strongly that, for me, dieting is the WRONG thing to do. I am unwilling to do NOTHING, but I am not willing to diet either. So this represents a healthy improvement in lifestyle factors that is moderate, realistic, and able to be maintained over the long-term (which it has been, since my third child's birth quite a while ago---and yes, I avoided gd in the third pregnancy too!).

Each person's life and situation is different. Each woman must sit down and honestly assess her physical, emotional, and health needs and desires, and then design a program that is unique to her situation. It is hoped that my decisions will give others some ideas of moderate compromises that can be considered in lifestyle factors, but your choices certainly do not have to be the same as mine. Best wishes in finding a path that is right for YOU! ---kmom

 

General Diabetes Resources

King, Revers and Winn Medical Group

A group of physicians, dietitians, and diabetes educators specializing in a non-diet approach to the treatment of food-sensitive diseases such as diabetes and high cholesterol. "A place where your weight is not the issue, your health is!"

Fat Acceptance Diabetics List

A fat-acceptance list for people with diabetes; non-dieting emphasis. Since most diabetes groups and organizations strongly push dieting and weight loss, and often contain a great deal of fat-phobic comments and misconceptions, this is a valuable support group for fat diabetics who are into size-acceptance and want to explore treatment options that do not include strenuous dieting.

Diabetes Newsgroups

Public access newsgroup that discusses all of the issues surrounding diabetes, offers emotional support, etc. Serves both type I and type II diabetics, tends to be extremely conservative, and tends to push weight loss and dieting as the best treatment option for type II diabetics. However, despite these limitations, is a great source for information, debate, and support. Also has some excellent Frequently Asked Questions lists.

Diabetes Websites

 

Other Resources 

Healthy Weight Journal - Scientific journal that takes a more neutral look at obesity and weight-loss issues.  

 

References

[Note: Not all references discussed in this FAQ are present here, since this would result in an overwhelming amount of references.  That is why some study citations are listed in more complete form in the text of the FAQ.]

General Diabetes References

Diabetes A to Z: What You Need to Know About Diabetes, Simply Put, American Diabetes Association, Inc. Alexandria, Virginia: American Diabetes Association, 1996. To order, write to the ADA, 1970 Chain Bridge Road, McLean, VA 22109-0592, or call 1-800-232-3472.

Wareham, NJ and O'Rahilly, S. The Changing Classification and Diagnosis of Diabetes. Editorial. British Medical Journal. August 8, 1998. 317:359-360. Can be found online at www.bmj.com.

Alternative Views of Obesity

Ernsberger, Paul and Paul Haskew. Rethinking Obesity: An Alternative View of its Health Implications. Journal of Obesity and Weight Regulation. 6(2): 84-85, Summer 1987.

Superb, must-read article challenging the traditional view of obesity as a disease and weight loss as the cure. The authors are professors associated with various medical schools. Some of the article's citations are a bit dated (it's from 1987) but the overall presentation clearly shows that the dangers of obesity and the all-out effort to 'fix' obesity through weight loss at any cost are more questionable than previously thought. Does not overlook the risks of obesity or minimize them, but looks honestly at the data, methodology and prejudices of many obesity researchers (many have conflicts of interest) as well as the dubious research on the 'benefits' of weight loss. An excellent resource.

Gaesser, Glenn A. Big Fat Lies: The Truth About Your Weight and Your Health. New York: Fawcett Columbine, 1996.

Book that centers discussion around the problem of insulin resistance and its relationship to weight and dieting. Although the book is a bit patronizing in tone and certainly has an agenda to promote (the author's approach to improving insulin resistance and general health), it still is a good resource for largely sensible information about fatness and health, size-acceptance, the importance of exercise regardless of weight, the dangers of weight cycling, insulin resistance and its role in disease, and the importance of excellent nutrition in long-term health and in improving insulin resistance. The author is a PhD who is an associate professor of exercise physiology.

Berg, Frances M. Health Risks of Weight Loss. Hettinger, North Dakota: Healthy Weight Journal, 1995.

Another superb, must-read resource that re-examines carefully the usual prescription of weight loss as solution for the risks of obesity. Concludes that often the risks of weight loss are quite substantial and overlooked. Takes a consumer approach to looking at the weight-loss industry, examining the safety and efficacy of various weight loss approaches, as well as government's role in regulating them. Examines the research literature about obesity and weight loss as well; is fair in examining the risks of obesity as well as the risks of weight loss. The author is a licensed nutritionist and Adjunct Professor at the University of North Dakota School of Medicine. She is the editor of Healthy Weight Journal. This book is highly-recommended by the Journal of Nutrition Education, and was selected by CHOICE, American Library Association, as an "outstanding academic book of the year."

GD and Later Development of Diabetes

Peters, RK et al. Long-Term Diabetogenic Effect of Single Pregnancy in Women with Previous Gestational Diabetes Mellitus. The Lancet. January 27, 1996. 347(8996):227-30.

Studied 666 mostly Hispanic women who had gd and then attended a high-risk family planning clinic, with a sub-study of 87 of these women who went on to have a subsequent pregnancy after a gd pregnancy. 91% of those who were tested had gd recur, an extremely high rate. Then it went on to compare the rate of progression to Type II Diabetes (NIDDM) in the women who had had a subsequent pregnancy and the women who did not have a subsequent pregnancy. To their surprise, they found that the women who had one additional pregnancy had a more than threefold risk of developing NIDDM compared to the women who did not have an additional pregnancy. Notes that in the general population, parity (# of kids) has been shown to have little effect on the development of NIDDM. Speculates that in a group of women with a high genetic tendency towards diabetes, however, the influence of a single pregnancy may offer a "metabolic insult" to the system and may increase the rate of progression towards diabetes. Notes that this has not been shown in other studies and more study is needed, and further study is also needed to see if this effect holds in other ethnic populations (Hispanics have an extremely high rate of type II diabetes). Also notes that in this study, each 10 lbs. gained after pregnancy almost doubled the risk for developing NIDDM; notes that in the *much* smaller group that lost weight after pregnancy, there was the lowest risk for developing NIDDM (although conclusions are limited because of the small sample size of this group). It's very important not to jump to conclusions on this study too soon; this is a PRELIMINARY STUDY and may not hold up to further examination, or it may be true more for certain high-risk populations than for all populations. Don't choose NOT to have more kids because of this one study but do be aware of its implications, if it turns out to be true.

Greenberg et al. Gestational Diabetes Mellitus: Antenatal Variables as Predictors of Postpartum Glucose Intolerance. Obstetrics and Gynecology. 86(1):97-101, July 1995.

94 women with gd returned for a 75g GTT at 6 weeks post-partum. Postpartum glucose intolerance occured in 34% (18% impaired glucose intolerance, and 16% overt diabetes). No single variable was predictive in all cases. Of those who had diet-controlled gd, only 3% had IGT and 0% had diabetes; of those who needed insulin, 25% had IGT and 26% had diabetes. Those who needed insulin had 17x the risk for impaired tolerance, while those who had the combined effect of needing insulin, had some post-meal numbers above 150, and had an initial screening level above 200 had almost a 20x risk.

Henry et al. Long-Term Implications of Gestational Diabetes for the Mother. Baillieres Clinical Obstetrics and Gynaecology. 5(2):461-483, June 1991.

"Using life table techniques, 17 years after the initial diagnosis of GDM, 40% of women were diabetic compared with 10% in a matched control group of women who had normal glucose tolerance in pregnancy. The incidence of diabetes was higher among women who were older, more obese, of greater parity and with more severe degrees of glucose intolerance during pregnancy. Diabetes also occurred more commonly among women who had a first-degree relative who was diabetic, in women born in Mediterranean and East Asian countries, and in those who had GDM in two or more pregnancies." Specifically, 68% of women who needed insulin in pregnancy developed subsequent diabetes, and 35% of women with a first-degree relative with diabetes also developed diabetes. Parity was only significant in women who had had 5 or more babies (13.5% became diabetic). Macrosomia (large baby) was not a significant predictor of subsequent diabetes. Of those who had further pregnancies, 47% had gd recur, and of that 47%, 31% went on to become diabetic eventually and 18% developed IGT (i.e. half developed some permanent glucose intolerance). Of those whose gd did NOT recur, subsequent diabetes occurred in only 4%, but this rate was still about 3x the rate of the control group (no gd).

Steinhart et al. Gestational Diabetes is a Herald of NIDDM in Navajo Women. High Rate of Abnormal Glucose Tolerance after GDM. Diabetes Care. 20(6): 943-7, June 1997.

A retrospective analysis of 111 GDM deliveries in Navajo women over a 4-year period was conducted approximately 10 years after the start of the survey period. A life-table analysis was developed to estimate the probability of NIDDM after GDM. 58% had developed Impaired Glucose Tolerance (IGT) by the end of the study period, while 42% had developed NIDDM. Patients who developed NIDDM had greater Body Mass Indices, parity (# of kids), and infant weights. Fasting bG >105 and recurrence of GDM were associated with getting NIDDM. A life-table anaylsis estimated a 53% likelihood of having NIDDM at an 11-year follow-up.

Cypryk et al. Evaluation of Carbohydrate Metabolism in Women with Previous Gestational Diabetes Mellitus. Ginekologia Polska. 65(12):665-70, December 1994.

70 women who had experienced GDM in the previous 10 years were given a combination of a GTT and a glycosylated hemoglobin test to check their present carbohydrate metabolism. 19% had IGT and 54% had diabetes. The presence of diabetes or IGT significantly correlated with the number of past pregnancies, observation time and indirectly with family history of diabetes. [They also checked for other risk factors such as obesity, hypertension, and trimester in which GDM was diagnosed; apparently these did not significantly correlate with subsequent IGT or NIDDM.]

Kaufmann et al. Gestational Diabetes Diagnostic Criteria: Long-Term Maternal Follow-Up. American Journal of Obstetrics and Gynecology. 172(2 Pt 1):621-5, February 1995 .

331 patients who had had gd by either the National Diabetes Data Group criteria or the Coustan and Carpenter criteria (which are more strict and identify more patients) from the period of 1975 to 1988 were followed up (maximum interval was 15 years, some were much less). About 25% of each group had developed diabetes at follow-up. Predictive factors included the GTT fasting value, the number of GD pregnancies, the time to follow-up, and pre-pregnancy weight index. (The study concludes, by the way, that the lower criteria of Coustan and Carpenter should be used in order to identify more women who would develop diabetes later.)

Kjos et al. Predicting Future Diabetes in Latino Women with Gestational Diabetes. Utility of Early Postpartum Glucose Tolerance Testing. Diabetes. 44(5):586-91, May 1995.

671 Latina women who had had GD pregnancies 5-7 years earlier BUT who tested negative shortly after birth for diabetes were re-tested for diabetes. Life table analysis showed that 47% of these Latina women had developed diabetes within 5 years. The study notes that the post-partum GTT provided the best discrimination between high-risk and low-risk individuals.

Mohamed, N and Dooley, J. Gestational Diabetes and Subsequent Development of NIDDM in Aboriginal Women of Northwestern Ontario. International Journal of Circumpolar Health. 1998. 57 Supplement 1: 355-8.

Followed up on 332 gdm pregnancies from the Sioux Lookout Zone between 1985-1995; 61 of these pregnancy charts were randomly selected for review. Found a HUGE rate of progress to NIDDM in a very short time. >70% of the women developed NIDDM within 4 years of a gd pregnancy. It's also important to note that 88% of these women presented with no symptoms except high blood sugar that was not causing any other obvious problems; if they had not had regular follow-up testing, they would probably would have had the diabetes for a long time before developing symptoms that would have led to diagnosis and treatment. Thus, follow-up testing is extremely important for early detection.

Buchanan, TA et al. Gestational Diabetes: Antepartum Characteristics That Predict Postpartum Glucose Intolerance and Type 2 Diabetes in Latino Women. Diabetes. August 1998. 47(8):1302-10.

Examined prenatal characteristics for their ability to predict diabetes or IGT within 6 months after delivery in a Latina population. 10% had diabetes, 50% had IGT, and 40% were normoglycemic within 6 months postpartum. Diagnosis of gd before 22 weeks, weight gain after pregnancy, and several highly technical sub-analyses of GTT testing were predictive of glucose intolerance postpartum. Highlights importance of the role of pancreatic beta-cell dysfunction in predicting postpartum glucose intolerance.

Stowers, JM et al. Long-Range Implications for the Mother: The Aberdeen Experience. Diabetes. 1985. 34(Suppl.2):106-110.

Examined 112 women with Impaired Glucose Tolerance (IGT) after pregnancy (not all of them were labeled as having gd in pregnancy but quite probably had it) and their long-term prognosis. About 2/3 were treated with diet only (but seen regularly and given dietary advice about reducing their risk), and 1/3 were given dietary treatment plus Chlorpropamide (a sulfonylurea drug, designed to produce more insulin from the body). After long-term follow-up (12-22 years), only about 7% of the whole group had overt diabetes and only 35% had IGT (remember, they ALL started with it, so this is an excellent result!). "Factors associated with deterioration in glucose tolerance included age at diagnosis and follow-up and initial fasting plasma glucose (FPG) level [over 105 mg/dl], but obesity was less important, although it was associated with an increased rate of vascular complications." So obesity did not worsen glucose tolerance significantly in this particular study (esp. notable since the most obese subjects were older, and age was found to be correlated), nor did parity (# kids) have any correlation. The particular medication used in this study was not found to have any preventive effect. The weakness of this study is that it had no control group that did NOT receive any treatment or dietary advice, so conclusions are limited. However, the long-term results are much better than many other studies' results; this is probably partially because Northern European populations have less diabetes than other ethnic groups, and probably partially because attention to dietary issues improved outcome. The author also cites a study by Sartor et al (1980) that shows that when no diagnosis of IGT was given to a study group, the rate of overt diabetes 10 years later was 29%. However, when the diagnosis of IGT was given along with dietary advice, the subsequent prevalence of diabetes was only 13%. So while this is not conclusive proof that dietary changes can prevent or delay diabetes, it is certainly encouraging evidence! (Note that we speak of dietary changes only, not weight loss.)

Body Weight and Diabetes

O'Sullivan, JB. Body Weight and Subsequent Diabetes Mellitus. Journal of the American Medical Association. August 27, 1982. 248(8):949-52.

Classic early study of body weight after gdm pregnancy and subsequent development of NIDDM. Basically found that obesity did not increase rate of diabetes significantly in fat women who had not experienced a gdm pregnancy, but that in women who experienced a gdm pregnancy, obese women did develop NIDDM at higher rates. Basically found that 47% of obese gd moms went on to diabetes within the 10-16 year follow-up period, whereas only 26% of 'normal-weight' gd moms went on to diabetes. Of the most overweight subjects (those >140% of 'ideal' weight) the rate was even higher, with nearly 60% developing diabetes in 15 years as opposed to 25% of 'normal-weight' gd moms. Several items are important to note here, however. Although this data is often cited as reason for women to lose weight, the effects of weight cycling are not documented. Those who lost weight and kept it off reportedly developed diabetes at a rate of 28%, a big improvement.  However, again, this does not address the women who lost weight and then regained, as most do.  Did the weight loss attempt hurt or help the women who were not able to maintain the loss?  This is a very vital question, and one that is not answered here.  Still, this study serves as a cautionary that obese gd moms need to be watched very carefully postpartum, and should certainly be working on lifestyle factors. Among these lifestyle factors to consider is weight loss, but a blanket recommendation for dieting may not be justified either. More study is needed. {Also of note in this study is that parity, i.e. # of pregnancies, did not influence the subsequent development of diabetes.}

Long, SD et al. Weight Loss in Severely Obese Subjects Prevents the Progression of Impaired Glucose Tolerance to Type II Diabetes. Diabetes Care. May 1994. 17(5):372-375.

Performed bariatric surgery (gastric bypass) in 109 morbidly obese individuals with IGT, and then compared their rate of progression to diabetes compared to 27 subjects with IGT electing not to have the surgery. The wt. surgery patients were followed for about 6 years, the non-surgery patients for about 4 years. The surgical patients developed diabetes at a much lower rate--the authors estimate the 'prevention' rate at >30-fold, and contend that this proves that weight loss does prevent the progression of IGT to NIDDM. However, study noticeably does not address the short- or long-term morbidity of subjects who had surgery, and does not establish whether this seemingly positive bG improvement actually translated to improved lifespan etc. compared with controls. Furthermore, the control group was extremely small (so the data would skew more easily), heavier on average, and smoked and drank more. Still, the reduction of the number of patients that could be expected to progress on to diabetes is impressive, but the glaring omission of data re: morbidity among the surgery patients is significant too. Bariatric surgery should only be considered with utmost caution.

Watts, NB et al.  Prediction of Glucose Response to Weight Loss in Patients with Non-Insulin-Dependent Diabetes Mellitus.  Arch Intern Med.  April 1990.  150(4):803-806.

135 obese patients with NIDDM who had lost at least 9.1 kg (20 lbs.) were examined for predictors of improvement in plasma glucose levels after weight loss.  41% of patients were "responders", meaning they had significantly improved plasma glucose levels after weight loss, even after only slight weight loss.  However, 59% were "non-responders" whose plasma glucose levels did not improve even with weight loss.  "We conclude that, in contrast to conventional teaching, many patients with non-insulin-dependent diabetes mellitus will not have any improvement in plasma glucose levels after a 9.1 kg weight loss."  However, a substantial minority will, and this will often show up quickly with even small weight changes. 

Holbrook, TL et al.  The Association of Lifetime Weight and Weight Control Patterns with Diabetes Among Men and Women in an Adult Community.  Int J Obes.  1989.  13(5):723-729.  

Examined 886 men and 1114 women, aged 50+ between 1984-87.  Those who were underweight as children or teens had higher rates of diabetes as adults, especially those classified as overweight now.  (In other words, those who were thin as youngsters and gained a lot of weight later on had the highest risk for diabetes.)   Weight gain OR fluctuation of 10 lbs or more between the ages of 40 and 60 significantly increased diabetes rates, as did significant weight gain after age 18.  Exercise as the only means to control weight was associated with a significantly reduced diabetes rate.  

French, SA et al.  Weight Loss Maintenance in Young Adulthood: Prevalence and Correlations with Health Behavior and Disease in a Population-Based Sample of Women Aged 55-69 years.  Int J Obes Relat Metab Disord.   April 1996.  20(4):303-310.  

Studied weight change patterns of early adulthood and association with disease later on.  Those who were overweight at age 18 but who maintained a stable weight had a risk for diabetes and hypertension higher than those who were normal weight and stable.  Overweight women who lost and maintained the loss had the same risk for diabetes and hypertension as normal weight stable women.  However, weight loss followed by regain was associated with higher odds of disease relative to weight stability in both overweight AND normal weight women.  The highest risk was associated with continuous weight gain or initial weight gain that was maintained. 

Morris, RD and Rimm, RA.  Long-Term Weight Fluctuation and Non-Insulin-Dependent Diabetes Mellitus in White Women.  Ann Epidemiol.  September 1992.  2(5):657-664.

8232 white females who were members of TOPS (Taking Off Pounds Sensibly) between the ages of 40 and 50 were studied to see if long-term weight fluctuation was associated with NIDDM.  An index of weight fluctuation was developed.  Weight fluctuation, waist-hip ratio, relative weight, and family history all showed increased risk for diabetes.  "The results suggest that the magnitude of long-term weight fluctuation is associated with the development of NIDDM."


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