by KMom
Copyright © 1998-2007 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. The GD web section 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
"Glucose intolerance that is first diagnosed during pregnancy is termed gestational diabetes mellitus. The definition is ambiguous, and the treatment controversial. Most important, the threshold at which glucose intolerance adversely affects the course of pregnancy and increases the risk of future diabetes in the mother and her child is not known....we think the optimal care for women with gestational diabetes remains to be defined."
(From an editorial by Anne Dornhorst and Joanna C. Girling in The New England Journal of Medicine, November 9, 1995, Volume 333, Number 19)
Gestational Diabetes is a very important topic in pregnancy and childbirth, and represents a great deal of the money, time, research, and interventions that are currently invested in pregnancy in the world.
Some providers believe that GD is a grave health threat, some believe it does not exist at all, and some take a wait-and-see position. This controversy, however, is rarely discussed with pregnant women despite their obvious pressing concern for the matter. Unfortunately, rarely are pregnant women privy to the backwaters of obstetric controversy.
Therefore, this series of FAQs (Frequently Asked Questions lists) is designed to discuss the GD controversy in great detail, as well as to give practical coping information to women currently going through GD. It is different in purpose and scope than most of the other resources for laypeople that can be found on GD, which tend to be more simplistic and limited in breadth of information.
Because these GD FAQs tend to be different in scope and purpose, this introductory section was added to explain what these GD FAQs are, what they aren't, how they came about, and the controversy of consumer-generated healthcare information.
Instead of a concise summary of GD and the traditional way to treat it, this FAQ is intended to:
As noted, this series of FAQs are not like most of the other resources available on GD. Most information on GD for laypeople tends to be simple explanations of the traditional conservative medical view of GD. The purpose of these resources is basically to reassure women with GD, give them basic information about possible concerns with GD, and produce a compliant patient who will not question any treatment protocols. Conversely, this FAQ seeks to present a less simplistic view of GD.
The purpose of this FAQ is not to convince women one way or another about GD and its controversies. Its purpose is not to produce compliant patients or rebellious, non-compliant patients. Its purpose is simply to present information about GD controversies that is generally not available to most pregnant women, to lay out the arguments for various points of view, to present research so that women can examine the scientific evidence for themselves, and to point the way for further research and information so that women can make up their own minds.
This FAQ also has practical support information about living with GD, coping with insulin, understanding nutritional recommendations, increasing the odds for breastfeeding success, etc. It seeks to support women by answering the most common questions women with GD usually have. It also seeks to address follow-up questions many women have after the baby has been born.
Finally, this FAQ seeks to examine the specific issues unique to heavy women with GD. Most obstetric and endocrinologic medical sources are quite fat-phobic and condescending. Therefore, what little information there is on obese women with GD is usually negative and judgmental. This FAQ seeks to fill in that void and provide size-neutral information and support that is accurate but non-judgmental.
This FAQ is about the controversies surrounding gestational diabetes. It is NOT intended to be a short, clear introduction to GD! If what you want is a concise summary of gestational diabetes and the traditional approach to treating it, then you would be best served by reading other websites, like these listed below:
If you want a summary of the American Diabetes Association's recommendations on gestational diabetes mellitus, then try the ADA clinical practice recommendations at http://www.diabetes.org/for-health-professionals-and-scientists/cpr.jsp. Find the recommendations for Gestational Diabetes, which are updated every year or two.
Remember that not all organizations agree on the proper handling of GD. For example, the ADA's recommendations tend to be very conservative, and the recommendations of the American College of Obstetricians and Gynecologists (ACOG) do not always agree with them. Furthermore, many of both of these groups' recommendations have been questioned by other influential groups; for example, the U.S. Preventative Services Task Force and the Canadian Task Force on the Periodic Health Examination both state that there is insufficient evidence to justify universal GD screening.
So when reading the ADA or ACOG recommendations, remember that disagreement abounds and none of this is set in stone. But if you want the traditional view of managing GD, the ADA recommendations are a good way to get it.
Another detailed resource is the article, "Gestational Diabetes: Detection, Management, and Implications" by Dr. Darcy Barry Carr and Dr. Steven Gabbe (Clinical Diabetes, Jan-Feb. 1998). It can be found at www.diabetes.org/clinicaldiabetes/v16n1j-f98/pg4.htm.
This FAQ came about because Kmom was diagnosed with GD in her first pregnancy and treated in the traditional manner. In researching GD's implications for her second pregnancy, Kmom was surprised to find that there were very strong criticisms of the traditional approach to GD, that the current definition of GD is a fairly recent phenomenon in obstetrics, and that not all resources recommend the same treatment protocols when GD is diagnosed.
Kmom was shocked that there was not a clear consensus in the medical community on the proper handling of GD (as she was led to believe), and that treatment protocols varied tremendously from one provider to the next. In interviewing doctors and midwives for her second pregnancy, she found a huge variation in how they planned to handle the GD, should it recur. In trying to find enough research to make a sensible choice of which treatment protocols would be best the second time around, she was frustrated by the skewed, one-sided viewpoints of the problem presented by both sides of the controversy.
Traditional medical tomes and websites about GD written for the patient tended to over-simplify, patronize the intelligence of the mother, and ignore any of the controversies in treatment that embroil the research community. It seemed aimed at producing a compliant, meek patient who would never question her treatment (no matter how invasive or difficult) and often employed scare tactics and worst possible scenarios which, in reality, rarely happen.
On the other hand, the alternative approaches to GD seemed also bent mostly on rhetoric rather than substance. Some ignored the body of evidence that GD might actually be a problem, citing only the evidence the seemed to support their point of view and ignoring the rest.
Both sides seemed mainly to engage in rhetoric, ridicule, and highly subjective statements when writing about the opposite point of view. This is not helpful to women trying to sift through all the information and make objective decisions about their care.
What was needed was a resource which calmly and fairly looked at both sides of the controversy, cited research studies yet was written for the layperson (instead of the medical researcher), discussed the issues in clear but not patronizing tones, and helped the mother determine the important issues to discuss with her provider.
As far as Kmom knows, this resource does not exist. There was no one resource that she could find that paid proper and fair attention to both sides of the argument. As a result, Kmom was forced to go to the medical research herself and do her own analysis and review. After seeing the same questions about GD over and over again on pregnancy lists, Kmom saw the need for FAQs to answer pregnant women's most common questions, give them empowerment for asking further detailed questions, and information to assist them in doing their own research to help make decisions about their treatment course.
These set of FAQs are an attempt to bring several points of view into one resource and to represent each side fairly (with corroborating research references), while delineating the differences in treatment that can occur. It is hoped that this can then lead women to do further research on their own, question their providers more competently so they can participate more fully in their own care decisions, and give them coping strategies should they encounter difficulties along the way. Since Kmom is a larger woman and that is the focus of this website, special attention is also paid to issues pertaining to women of size and GD. However, women of average size should also find plenty of pertinent information in this FAQ.
These FAQs have had an evolution of their own; most have undergone periodic updating, and new FAQs are planned. The majority of the GD FAQs were written several years ago and need updating for reviewing the latest research and for stylistic revision. However, the bulk of Kmom's writing in recent years turned to prenatal testing issues and cesarean and VBAC issues, reflecting Kmom's real-life pregnancy journeys. In addition, Kmom has four young children and multiple outside commitments that make it difficult to keep all of the FAQs as updated as she'd like.
Therefore, regrettably, some of the GD FAQs may not contain the very latest GD research. Still, most of the information remains valid and Kmom has left up the older FAQs for the benefit of those new to the topic of GD. She urges women to do their own research to supplement the FAQs on this website. Use the research resources on this website to give you the basics to do your own research (without waiting for Kmom) on whatever topic you need so that you can discuss it further with your provider.
The Controversy of Consumer-Generated Healthcare Information
Disclaimer: Kmom is not an expert on gestational diabetes, nor is she a doctor or medical professional. She does NOT intend to give medical advice.
Any time a layperson looks into medical research there is a danger of misunderstanding or misinterpretation of the data. Kmom fully acknowledges this and cautions readers not to treat this resource as too much of an authority on GD or jump to injudicious conclusions.
Health information obtained over the internet must be subjected to a very critical eye, since much of it is erroneous or misrepresented. Kmom acknowledges upfront that she is not a medical provider nor an obstetrics/endocrinology specialist, only a layperson interested in further exploring the research on the subject.
Some medical associations have been actively discouraging consumers from considering any website information except that which comes from officially approved medical groups; this is reasonable on the surface since there are a lot of online quacks giving questionable information. Readers SHOULD ask hard questions about the information, the author, the sponsor, the purpose of the website, and the reliability and up-to-date nature of the sources quoted.
However, if one relies solely on medical associations for information (as they advocate), laypeople will rarely be exposed to the treatment controversies that are argued vehemently in the medical journals. Because they won't know about treatment differences, they may even end up being mistreated for their health concern. Many doctors are very uncomfortable with the thought of patients learning that their recommended way is not the only way, that treatment recommendations vary GREATLY from one provider to another, and that medical knowledge is not as secure and well-proven as we want to think it is.
Furthermore, it should be noted that medical treatment changes all the time and some past recommendations have been proven to be dangerous. This is particularly true in obstetrics. For example, it was once argued that DES and thalidomide were perfectly safe for pregnant women (they weren't and caused great harm), that low-calorie/low-protein/low-salt diets combined with diuretics were the best way to prevent pre-eclampsia (it actually caused or made pre-eclampsia worse), that formula-feeding was healthier than breastfeeding (formula-fed children as a group clearly have more health problems), etc. There are numerous other examples of such problems caused by mainstream, widely-accepted medical advice of the past.
It must be recognized that medical treatment standards DO change over time and sometimes unsafe recommendations have been made as part of "mainstream" medical advice and practices. Unfortunately, it takes many years before these are overturned and many women are harmed before standards are changed.
This problem seems especially strong in childbirth issues, yet this is an area where women are expected to be the most compliant and unquestioning. It may reflect an unconscious sexism towards women; once their uteri are occupied, some doctors expect women to put their brains aside and simply trust their provider completely and follow all recommendations unquestioningly.
A woman who was recommended major surgery for another issue would probably seek second and third opinions and look for outside information before agreeing to such a drastic course, yet when a c-section is recommended a pregnant woman rarely questions it or seeks another opinion, even though we know that about half of all c-sections are unnecessary.
If a woman experiences a pregnancy complication, everyone assumes she should acquiesce to whatever treatment the doctor recommends, even though the treatment could conceivably present more risk than the complication. The issues of treatment regimens are often seen as being 'too complex' for her to understand, and her ability to read and inform herself enough to choose responsibly is denigrated. She is seen by many in the medical profession as too hormonal and too emotional to make fully rational, informed choices, and some doctors see themselves as having to save her from herself, or worse, save the baby from its irrational mother.
Nancy Wainer Cohen in Open Season notes that:
According to Jay Katz, doctors believe that a better appreciation of the uncertainty of medical knowledge will only make patients anxious and nervous. Sharing the burdens of decisions with patients will create new tensions in the area of authority and autonomy. Insistence on the doctor's authority has "stifled any serious exploration as to whether physicians and patients can interact; patients are seen as children whose capacity for choice is fully impaired."...In the late 1950s, judges began to ask a revolutionary new question: Are patients entitled not only to know what the doctor proposes to do, but also to decide whether an intervention is acceptable in light of its risks and benefits and the available alternatives, including no treatment?...Dr. Robert Howard says that we have entered an era of medicine and law in which patients are to be considered responsible and capable people--which means they have the primary responsibility for the physical and emotional care of their bodies. (as quoted by Nancy Wainer Cohen, Open Season, New York: Bergin & Garvey, 1991)
This certainly doesn't mean that 'all doctors are bad', that no doctors can be trusted to treat women as partners in decision-making, or that a woman should never ask her provider for counsel regarding important decisions. Of course there are great doctors out there, ones that are not afraid of women empowering themselves and taking part in their own care decisions! It simply means that there is a tendency towards paternalism and condescension that seems to be particularly strong in obstetrics, as if once a woman is pregnant her ability to make thoughtful and reasoned choices is compromised.
Some providers are particularly threatened by the idea of women questioning the appropriateness of certain treatment protocols, and whereas this is more accepted now in other medical fields like cancer treatment, it is still very new and controversial in obstetrics. Many OBs are offended at women researching obstetric controversies, questioning standard protocols, or seeking alternatives to traditional care. Some are especially critical if laypeople research and write about this information with others via the internet.
Since some information on the internet is unreliable, of course some of this concern is understandable. But to say that all information should only come from traditional medical societies means that treatment controversies will largely go unexamined by the public, and babies and mothers may suffer as a result (as they have in the past).
Kmom does not feel that laypeople are disqualified from investigating medical controversies and sharing the information they find, only that it must be done responsibly, with fairness to all sides. Research studies should be cited whenever possible, and consumers should be reminded to beware the source of the information and engage their critical questioning skills.
Kmom believes that contrary to conventional thinking, pregnant women are PRECISELY the people who should be informing themselves fully about pregnancy controversies; not only are they making decisions for themselves, but also for the lives of their unborn children. It is critical that all proposed interventions (or non-interventions) be examined carefully and with the knowledge that these choices are not always beneficial or even benign. Doctors are not gods and medical issues are not black and white. People need to be involved in the decisions about their health care, and most especially when the issues fall in the 'gray' area of contradictory information, like GD.
Again, Kmom does not intend to give medical advice, only present in one location some of the divergent thinking about GD that can be found in order to further empower the GD mom and allow her to become a partner in her own care, plus pass along some practical considerations that others have found useful in handling minor GD concerns. She has tried very hard to present a fair representation of as many sides of the GD controversy as she can.
After presenting the various arguments, Kmom felt free to add in her own opinion------her judgments on the controversies as they stand, or after much thought what SHE chose to do on her GD choices and why. She felt it was important to clearly delineate objective information from opinion, so she has tried to clearly label her judgments within the FAQs as opinions.
This is not intended to influence women towards any particular school of thought, or to imply that anyone should choose the same choices she did. It is just intended to share what Kmom believes after much thought, and why. She fully supports people choosing their own path, whether it diverges from her opinions or not. Do your own research and consult your own providers to decide what is the best course for YOU. Caveat Emptor.
Note: There will be some repetition of information between web sections, since not all readers will read all sections. Kmom strongly encourages readers to read all sections in order to get a broader view of the subject, but urges them to be patient when material is repeated from time to time in an attempt to be more complete within each section.
Also remember that this is a controversy that is EVOLVING and constantly changing as more research is done. It's always possible that Kmom missed something new or important. The website will be updated as she learns new info, but she encourages people to do their OWN research as well. Take responsibility and become a partner in your own care!
Website Disclosure Information: This website is written and sponsored by Kmom, a childbirth educator and freelance writer who has read extensively about obesity, pregnancy, and related topics (including gestational diabetes) in both the lay and medical literature, as well as in 'alternative' childbirth education sources. This is not a commercial website; Kmom does not make any money off of this website and does not endorse any products mentioned herein.
The purpose of this website is simply to present further information for women to consider in their healthcare treatment and give resources so that women can pursue their own investigation. It is important to remember that all online health resources should be looked at with a discerning and critical eye. This website does not offer any medical advice, and none should be inferred from it. Please don't write and ask for advice.
This website presents both facts and opinions. It tries in particular to present more than one point of view so that readers may see arguments for many sides of an issue. Kmom makes every effort to label opinions and personal experience as such. Kmom also presents references and resource lists so that others may investigate further and make up their own minds. Caveat Emptor.
Copyright © 1998-2007 KMom@Vireday.Com. All rights reserved. No portion of this work may be reprinted, reproduced, or sold, either by itself or as part of a larger work, without the express written permission of the author; this restriction covers all publication media, electrical, chemical, mechanical or other such as may arise over time.