 Hello everyone. Today, we are going to talk about gestational diabetes and what kind of diet you should be on if you are diagnosed with gestational diabetes. This is Dr. Ahmed Ergin, and I'm an endocrinologist. I am primarily located in Florida. We see patients virtually across Florida. So in this video, we will go ahead and give you a summary of gestational diabetes and what you should be doing for your gestational diabetes for your baby and for your pregnancy. And congratulations on your baby. Hopefully, you will have the best outcomes without getting into any sort of complications that can arise from gestational diabetes. So before we dive into gestational diabetes, how to treat it, and what kind of diet we can actually use, I want to explain something and to be clear. And most of the time, doctors may not go over that with you. And I don't want you to panic over it, but I want you to understand why we really treat diabetes. Because if we do not treat diabetes, I mean gestational diabetes in the sense you may end up having some problems during or after pregnancy, and your baby may be affected. So what are these problems that are potentially can happen if you do not control your gestational diabetes, which is, by the way, is not that hard to do. But if you did not do due diligence and control your diet or use some medications if necessary, then your baby may be large. When the babies are large, that may result in more C-section, because then, as you can imagine, a very large baby will have a difficulty during a natural birth. Even if you try a natural birth, you will really have severe tears and some problems. And occasionally, also babies can get into trouble as well, because when they are trying to go through the vaginal canal, the birth canal, they may have what we call shoulder dystocia, which is the shoulder, you know, basically dislodging and causing nerve problems in the baby and so forth, which are the complications we do not want to really see. That's why most of the time, these large babies end up with C-sections to avoid these type of complications. On the other hand, even before the delivery, a pyrachlansia can happen, which is elevated protein in your urine and elevated blood pressure that can be very severe. And unfortunately, occasionally can cause death of the mother and the baby as well. And after even the delivery, the babies who are born to mothers with gestational diabetes that are uncontrolled tend to have higher risk of diabetes and obesity later in life as well. So babies may also develop low blood sugars right after delivery and can have breathing difficulties as well. Now, hopefully, none of this will happen. And let's move on some of the definitions of gestational diabetes. And we will, right after that, going to have to manage that with the diet and go from there. Now, most of the time, your doctor will test you for gestational diabetes unless you have a history of it or you already have diabetes, but most normal women will be screened for gestational diabetes between week 24 and 28. So at that point, if you are positive, then they will start monitoring your blood sugars more often. Now, how do we really diagnose gestational diabetes? There are two ways of doing that. Some people prefer two-step testing, which is the first step is doing a 50-gram glucose challenge test or tolerance test. And if that is positive, and that only lasts one hour, and then if that's positive, then they will go for the three-hour one with 100-gram of sugar tolerance test. Now, some people prefer one-step approach, which is, in my opinion, easier. And it is only two hours, and you only drink sugar or sugary fluid, 75-gram in total. And then you get diagnosed or not, and that's pretty much one-step test. That's why I like it, because that's less trip to the lab and less problems with waiting around and hanging around. That's not always the fun. And sometimes, you know, patients after drinking so much sugar does not really feel that good either. So, but let's move on to the definitions of the positive testing from these one-step or two-step approaches. Okay, so basically, if you have a one-step approach, which is 50-gram, I'm sorry, two-step approach, we do 50-gram of glucose tolerance first. And in terms of what is positive at the end of one hour, it depends on the doctor's opinion. Now, what I mean by that, there are different thresholds. Some people prefer a lower threshold to diagnose the disease, such as 130 milligram per deciliter, and is 7.2 millimole per liter. I say in millimole, too, because a lot of our viewers are not from the United States, and they request that type of measurement as well. So, you know, 130 is the lowest threshold, and you know, it can be up to as high as 140 milligram per deciliter, which is 7.8 millimole. But as you can imagine, as the threshold goes down, sensitivity becomes higher, but the specificity is less, which means that the false positive diagnosis is common if you use a very low threshold. On the other hand, I still prefer to diagnose women with gestational diabetes at a lower threshold, because there is actually a linear relationship between blood sugars and complications of diabetes. So, the lower the blood sugar, the better. So, as a result, I do not really wait or set up a high threshold to diagnose gestational diabetes. Now, let's move on to the threshold for the second step if you are positive for the first step, or if you're a doctor, things that you're positive for the first step. But before we move on, I will also mention that the 50-gram one-hour glucose result is more than 200. We may not need the second test, just because then we can pretty much confidently tell that there's something seriously wrong, and that can definitely put them to the presumptive diagnosis of gestational diabetes in this case. Okay. Okay, assuming that you have basically failed the 50-gram tolerance test, and your doctor ordered the three-hour glucose tolerance test, then you can look at the results and we will go over it right now. So, basically, if you are getting a 100-gram three-hour glucose tolerance test, the diagnostic criteria is as follows. Your fasting blood sugar of 95 milligram per liter or 5.3 millimole per liter. At one hour, if it is 180 milligram per liter or 10 millimole per liter, at two hours, 155 milligram per liter or 8.6 millimole per liter, 3 hours, 140 milligram per liter or 7.8 millimole per liter. So, what happens is you get this test done in the morning and you fast overnight at least 8 hours. So, glucose concentrations greater or equal to these values if it is two or more points. So, as you can see, we have four points starting at fasting one hour, two hours, and three hours. But if two out of these four are positive, then the diagnostic criteria is met and then we diagnose gestational diabetes. Now, if we do two-hour glucose tolerance test, which is the one-step method, okay, let's look at the one-step method, which I prefer, which is only 75 grams per deciliter, I mean, I'm sorry, 75 grams of carbs load, which is what we call the glucose tolerance test. Then the results will indicate gestational diabetes if the fasting blood sugar is more than 92 milligram per deciliter, which is 5.1 millimole per liter, or if one hour is 180 milligram per deciliter or 9 millimole per liter, two hours, 153 or more, or 8.5 millimole per milliliter. So, the diagnosis of gestational diabetes is made when one or more plasma glucose values meets or exceeds the values we discussed. So, one out of these three, if it is positive, it could be fasting one hour or two hours in this 75 gram oral glucose tolerance test, then we consider that a positive test as well and diagnose gestational diabetes. Now, let's talk about the diet part, which is I am sure you're most concerned about. Now, the diet is really depends on the patient, but I'm going to give you some general guidelines here that you can stick to. Most of the time, pregnant women actually use a lot of carbohydrates and they need more calories than usual. So, most of the time, we recommend them around 175 grams of carbs total in a day. It is not a time that you should be going no carb or a keto type of diet. You have to have carbs because you cannot be in ketosis during pregnancy. There are some studies that actually indicating that if you are staying in ketosis for a long time, your baby's IQ or mental capacity can be affected. So, here we have to find a balance where we prevent the blood sugar spikes at fasting and after meals, but also we do not want to put you at risk of ketosis by restricting your carbohydrates excessively. So, this is a balance we have to find. Not that we have to test your ketones constantly to make sure you're not in ketosis, but we just have to make sure that we are putting on a diet that keeps you out of ketosis, but also prevents your blood sugar being too high. So, we typically recommend to pregnant women to basically eat three to four times a day, main meals, and two to four times of snacks as well. The key here is to keep the carbohydrate load minimum or distributed throughout the day to prevent the blood sugar spikes. Remember, when we test you, we give you a lot of sugar load. The reason we do that, we want to see your tolerance to the sugar. So, if you are having problems at the early stages of the third trimester, then you will have more and more problems as the pregnancy progress. So, that gives us an indication that even a smaller load of glucose will actually spike your blood sugars. So, as a result, we want to give you less carbohydrates. For example, a rule of thumb could be, you know, eating 30 grams of carbohydrates, 30 to 45 maximum per meal, and maybe having 15 to 20 grams of carbs with snacks. So, if you add that up, that will be around, let's say you're eating on average 40 grams, let's say that's 120 grams with meals, and then you're eating 20 grams of carbs with, let's say you do three snacks, that's another 60, that becomes 180 grams of carbs. Again, that's not a lot, and that's actually what you would need, but also your needs depend on how much your blood sugar spike at one hour or two hours after meal, which depend, we have different criteria which will go over how much your blood sugar can go at one hour or two hours after meals, but your fasting blood sugars are also very important. So, what we have to do is, yes, we have certain general guidelines, but your specific goal should also be based on how much your blood sugar is spiking. Now, if your blood sugar is spiking, although we reduced your carbohydrates down to 30 grams per meal, and you're still spiking, then what we have to do is to give you medication, because there is no other choice. We cannot limit your carbohydrates less than 30 grams per meal and less than 15 to 20 grams of carbs per snacks. At that stage, unfortunately, we have to do something. We can't, we sometimes use pills, sometimes we use insulin, but we do everything or take every measure to make sure that your blood sugars at one hour and two hour and fasting are under control to prevent the complications of gestational diabetes. Alright, so how much calories? So, we talked about the carbohydrates, but how much calories in total do you really need during your pregnancy on a day-to-day basis, right? That depends on your BMI. So, BMI is body mass index, which you can just find a calculator online and easily find out what your BMI is, if you already don't know yet. But basically, you calculate your BMI. If your BMI is normal, like between 18.5 and 25, then you can have 30 kilocalories per kilograms. Again, if you are in the American measurement of pounds, which I'm in America, but I have to use kilograms because that's more of a universal measurement. So, you can eat up to 30 kilocalories per kilogram. If you're on the overweight side, which is BMI of more than 25, but less than, I would say, 30-35, 35, I would say. In this case, you are limiting your calories a little bit and I would say 22 to 25 maximum. If you're on the more the heavier side, maybe down to 22 calories, but if you're a little bit overweight, maybe 25 calories or kilocalories per kilogram. If you are overweight, like 35 BMI and above, then you should really reduce your calories to 12 to 15 kilocalories per kilogram. Again, if you're more overweight or obese, we are reducing the kilocalorie per kilogram because, to be honest with you, as the kilogram goes up, we reduce the calories per kilogram. So, that is still somewhat similar to someone who's thinner, but the bottom line is we have to restrict the calories a little bit more if your BMI is higher. So, if you're going by the trimaster specific, let's say the calorie intake, typically in the first trimaster, most women don't really need extra calories. They may be craving things. That doesn't mean that they have to eat extra calories because the baby is very tiny. It doesn't really need much, but then in the second trimaster, your caloric needs will go up to 350 calories per day extra in addition to your pre-pregnancy intake. So, what happens is the appetite really goes up. In pregnancy, women gain a lot of weight sometimes, although even if they don't develop gestational diabetes, just gaining excessive weight and putting up excessive calories during pregnancy can still increase the complications during pregnancy as well. So, obesity or excessive weight gain during pregnancy is a complicating factor as well. So, in the third trimaster, most women require maybe a hundred, 450 kilo calories extra than their pre-pregnancy caloric requirement. So, these are some general guidelines. Again, as an individual patient, you will need to be assessed by your doctor, by your educator, your diabetes coach, or whoever it may be, your dietitian to understand your specific needs. And again, at Sugar MDs, we do that on a day-to-day basis. We can remotely monitor you. We can basically see your numbers even if you don't tell us. So, we have special meters and special blood pressure cuffs and we can actually track everything, even you without recording anything. So, this is a cellular technology. Everything you enter, actually, every time you test, I would say, your blood sugars, it will be automatically recorded in our system. So, we can tell if you're not doing well. We can set certain alarms, your blood sugar goals personally for you, and if your blood sugars are going above the range, we get alerted. So, even if you don't see us or you have another appointment, let's say a couple of weeks later, but things are not going right, we can nail that down even before you talk to a doctor. So, this is the technology at Sugar MDs we have. We have a great support staff that can educate you with your diabetic needs, especially during this challenging period of pregnancy, if you have gestational diabetes. The goal is not to put you on medications and that can be achieved up to 80% of women if the provider, the doctor, the nurses, and the patient work together. And so, that is the goal and if we can achieve that, then we'll be happy to do so. If you have any questions, concerns, let us know. We only serve in Florida and New York as of right now. So, if you're from another state, unfortunately, we may not be able to help you, but we are expanding, so be on the watch out. So, now I'm going to move on what the glucose goals are based on the, based on your gestational diabetes level. So, if you have gestational diabetes, you want to make sure that your blood sugars are less than 95 at fasting. So, the first time you wake up, we want you to be less than 95. And that's actually pretty generous goal. But I say generous because I based this based on what's normal pregnant women actually have. And basically, most of the time, pregnant women wake up with 75 to 80 blood sugars if they do not have gestational diabetes. So, we are trying to keep it less than 95, but hopefully the lower the better. So, if you can get it down to 80 or 75, that is preferable and that is doable as well. And at one hour, if you check your blood sugars at one hour, which may be easier to remember and that's what I prefer typically. So, 140 or below is our goal and 120 or below at two hours is another goal. So, you can stick with the one hour goal or two hour goal. Fasting, we always check. We tell women to check their blood sugars at fasting and one or two hours after meals. I prefer one hour. Some doctors prefer two hours. But even if you don't remember at one hour, you can do that two hours. As long as we know it's a two hour value, you know, we will evaluate accordingly. Typically, two hour values are lower than the one hour values. So, that's why we set the threshold a little bit higher at 140, but most normal women do not spike more than 120 actually even at one hour. So, the lower the better, but our maximum tolerated threshold for one hour blood sugars would be 140 or below at one hour and 120 or below at two hours and the fasting always has to be less than 95. Now, you're going to ask me the question, how am I going to really control my fasting? Because I am sleeping and if my blood sugars is rising at night time and I'm not eating, right, so how are you going to really control the blood sugars? And number one, you can exercise, especially in the evening, that will definitely bring your blood sugars down overnight. On the other hand, you can always use insulin sensitizers if the lifestyle changes is not helping, you'll reduce your carbs, you're exercising three to five times a week, which is recommended and you're still waking up with the fasting blood sugars more than 90-95, then you may need some sort of insulin sensitizer medication, which we use sometimes, you know, metformin is a commonly accepted medication still for patients with diabetes and pregnant, because we know metformin is safe during pregnancy. We also sometimes use galiburide if that does not cause like severe low blood sugars, which it can, and it's not something that I prefer, but it is still in use, so if your doctor prescribes galiburide, don't be mad about it and if it works for you, it works for you. And then the next option would be taking maybe a one injection at night time to bring your blood sugars down overnight is also another acceptable option. Again, when you go on these medications or even on insulin does not mean that you will be stuck with these medications immediately after pregnancy, everything will go back to normal right after pregnancy. Now, of course, when you have gestational diabetes, that tells you that you're at risk of developing diabetes in the future. So it is not a bad idea to actually keep being screened every six to 12 months after pregnancy, since you may develop diabetes. And of course, trying to lose the weight that you have gained during pregnancy, especially if you developed gestational diabetes are very, very important in order to avoid developing real diabetes in the future as well. By the way, I forgot to mention that we had to mention the European values as well for the blood sugar measurement. I am an American doctor and that's the part of problem that we don't deal with the rest of the world. But basically, I have to still tell for the sake of all the audience. So 95 or above we said is not acceptable if you have gestational diabetes and that's around 5.3 millimole per ml. Now, if you are having, you know, like we said, 140 less than one hour, and I'm going to copy that because I'm not really good at this millimole thing. So 140 I think is around 7.8 millimole and 120 milligram per liter equals to 6.7 millimole per liter. So basically that is the conversion rate since I'm getting these questions all the time. Can you please tell us about this conversion and so forth? But Google will answer that question easily for you. You don't want to look into Google for how to treat gestational diabetes, but you may want to look into conversion quickly. That's not going to hurt you at all. Again, everything we talk about here is general guidelines. If you have specific questions, you may ask us if you're one of our patients in a private channel, in a private way, but we do not really publicly answer private questions. It's just that in the United States that's not legal. We cannot do that. It's a violation of patient rights and so forth. So we don't really do that and we cannot do that. So I'm so sorry about that. If you have personal questions, if you live in Florida or New York, we'll accept you as a patient, but law really restricts us in order to give advice to you guys. Although I will still try to give a general advice to you, but I may not just go ahead and just treat your blood sugars online without creating a patient-physician relationship. Now we have a lot of videos about diabetic diet. If you just search on YouTube, diabetic diet and sugar MDS, you will be able to find our videos about the details of general diet guidelines. Again, we look for low glycemic index. We are looking for whole grain. We are looking for the complex carbs. You can search for these terms and try to educate yourself about the carbohydrates that do not really spark your blood sugar too fast. But there is really no established gold standard carbohydrate or diet definition for every pregnant woman with gestational diabetes. It just depends on the patient's culture. The patients believe, patients what they enjoy, what they can do, what they cannot do. Social problems, financial problems can play a factor in the diet as well. So it is hard to dictate one single diet for everyone. But we are giving general guidelines and I hope that helps. Again, I said 30 grams of carbs. That's up to you how to make that 30 grams of carbs per meal. It could be an apple. It could be two slices of whole grain bread if you prefer that. But as long as you stay away from refined sugars, as long as you stay away from bakery, and you stick to healthy foods and try to pay attention to the total amount of carbs you're eating, even if they are healthy, I think you will be successful. Monitoring your blood sugar is the key. Again, you will need to adjust your diet also based on your blood sugars. So you don't have to sweat too much just because you get diagnosed with gestational diabetes. And then your blood sugars are not really spiking and your fastings are okay. Your after meals are okay. You don't have to worry about it. Sometimes fasting blood sugars may be a more of a problem than the after meals. In this case, one single shot of insulin can just take care of this temporarily during the pregnancy. So you and your doctor should work together to create the plan that works best for you without putting you into a box and limiting your life and making you hate pregnancy. So I hope that doesn't happen. And if you are still having problems with gestational diabetes, as I said, we are available in New York and Florida. All you have to do is just call us in that number and you'll be good to go. Again, make sure you remember to subscribe and share this video if you like it and give it a thumbs up and we'll appreciate it. Have a wonderful day and hope you have a great pregnancy and outcome and a great baby.