Note: This interview script has been edited and modified from the original video for the purpose of articulation and cohesion.
Questions:
- What are Hyperglycemia and Gestational Diabetes?
- How do you diagnose diabetes? Does everybody go for a test?
- Why is it important to do the Glucose Challenge Test (GCT)? People try to limit hospital visits due to COVID-19.
- At what weeks do the Glucose Challenge Test (GCT) need to be taken during pregnancy, is it during 24, 28, or later towards 30 weeks?
- The next common question patients ask is do I really need to start medication? And does it have any side effects?
- What is the possibility of or how common is it for someone who had developed Gestational Diabetes to become Type 2 Diabetic after delivery? Is it related to pregnancy in any way as after your delivery you have a high potential to have it?
- Could you also add some information for parents with slightly older kids about how Diabetes is diagnosed in children, how common it is and from what age they need to be aware of it?
- How do you recommend managing meals in a traditional Nepali home with traditional cuisines?
- We know that each condition manifests in a patient in different ways, could you elaborate on how one needs to consult their respective doctors before consuming medicines?
- Please tell us something about your Rehabilitation Center and its holistic programs.
1. What are hyperglycemia and gestational diabetes?
When you check your blood sugar (aka blood glucose) and its level is higher than normal, that is called hyperglycemia (aka diabetes). Diabetes during pregnancy is called gestational diabetes.
Gestational diabetes is serious because the baby may get congenital issues like anomalies and/or develop other complications, especially if the expecting mom is already diabetic or previously diagnosed with Type 2 or Type 1 diabetes before pregnancy. It’s very important to monitor blood sugar levels throughout pregnancy. If you get diagnosed with diabetes as soon as you’re pregnant (before your 24th week), then most of the time, we need to start medication and immediately start insulin because at that time the baby’s organs are being formed and if there is high blood glucose, you might end up with some congenital anomalies.
2. How do you diagnose diabetes? Does everybody go for a test?
According to the guidelines for Nepal, all the people who are planning to get pregnant or are pregnant need to get our blood tested sooner because we have a high incidence, as high as 1 in 4. It used to be 1 in 5 a few years ago and now it’s almost 1 in 4 which means 25% of people, the young women who are getting pregnant are prone to get gestational diabetes. So it’s very important to get yourself tested.
In Gestational Diabetes Mellitus (GDM), the blood glucose does not exceed 126 while fasting and 200 postprandial. These are higher levels than the normal population which is 95 and 120 respectively, and lower than the numbers needed to diagnose as Type 2.
If you want to know 100% if you have or don’t have gestational diabetes, then get yourself tested with the Oral Glucose Tolerance Test (OGTT). For this test, you have to go on an empty stomach, and the medical team checks your blood glucose by giving you 75 gm of glucose to consume. At each hour or 2-3 hours, they check your blood glucose levels to see if that 75 gm of glucose brought your blood glucose high or not.
But sometimes you cannot come to do an OGTT. So instead, we give a Glucose Challenge Test (GCT). For this test, you do not have to be on an empty stomach, and the medical team gives you 50 – 75 gms of glucose to consume, and they give you that with whatever you have eaten to see how much this glucose makes your blood sugar level high.
3. The most common question with patients is why do the Glucose Challenge Test (GCT)? They try to limit hospital visits due to COVID-19.
So GCT is a more convenient test rather than a gold standard OGTT because it does give you an idea to see if you’re on a higher range or you’re in a good enough range. You do not need to be fasting to do the GCT while you do need to fast for the OGTT.
4. In what weeks does the Glucose Challenge Test (GCT) need to be taken? Is it at week 24, 28, or even later towards 30 weeks?
You can do blood tests before, as soon as you get pregnant, and in each trimester, but what you cannot miss is getting tested during the 24th – 28th week because that is when the maximum people will show high blood glucose.
Sometimes it can come at 32 weeks also. Just because it did not come in the 24th – 28th weeks, it does not mean that now you can eat whatever you like and consume sugar as you like because doing that can raise your blood glucose so you always have to eat healthily.
If you have a higher risk, meaning positive family history, overweight, sedentary lifestyle, multiple pregnancies, and are 35 or older age, then you can do GCT usually in each trimester.
5. The next common question patients ask is, “Do I really need to start medication? And does it have any side effects?”
It ultimately depends on your blood glucose levels and HbA1c. HbA1c means we will observe the average of how much sugar is in your body in the past 3 months. We have a lot of studies that show that HbA1c above 6 in pregnancy will affect the fetus. So if it is above 6 you need to take medication and if the blood sugar is above 200 you need to take the medication. And if it is early on, like if you just got pregnant and the sugar is already high then you need to take the medication– It’s just Metformin, and you take half the dose which is 500 mg bd which is a safe dose. And the rest is insulin.
But as soon as we talk about insulin, people get scared and they are reluctant to take it and fear that it’s going to affect the baby. But what we need to know is that insulin is just a hormone, the same as what your body makes or would make if you were not diabetic. It is supposed to be made in your pancreas but because your own body cannot make it we’re just giving it from outside. We have to understand that insulin is the safest, a natural hormone and that is why doctors no matter how much time, energy, and how much we get scolded or blamed, know that’s best for you and safe for the baby and that’s why we encourage and push for insulin therapy as soon as we know that your sugar is not getting under control.
When a doctor is trying to tell you to eat healthily and be happy as we want good things for your baby and then you can’t go home and become sad that you have diabetes. That’s not going to be good for you as well as your baby. So we need to take care of your mental health as well as your physical health equally. You need to exercise. Now we have enough instructors and we have help to do exercises correctly during pregnancy. You can get your dietitian or nutritionist to help you to eat what’s healthy.
6. What is the possibility of or how common is it for someone who has developed Gestational Diabetes to become Type 2 Diabetic after delivery? Is it related to pregnancy in any way as after your delivery you have a high potential to have it?
Gestational Diabetes usually comes around 24 – 28 weeks, and as soon as you deliver, it goes away. Most people get off medication and insulin on the day they deliver. Sometimes it might take a week or 10 days but if you’ve done the right things then usually it should go away. One needs to be careful at least for 2 years of eating a healthy diet, but try to practice healthy living for life.
But there are also misconceptions in people when I tell them they have gestational diabetes that will go away as soon as you deliver as it’s hormonal and you shouldn’t worry about it. So they do everything correctly, they eat right, they exercise and the reports are good after the delivery. But then as soon as they’re home, they start eating heavy oily and sugary foods and they come back after 3 months complaining about diabetes. Even if you didn’t have gestational diabetes and if you eat like that then there is a high chance you can get diabetes.
7. Could you also add some information for parents with slightly older kids about how Diabetes is diagnosed in children, do they get it and how common is it, and from what age do they need to be aware of it?
Parents are always worried if diabetes will be inherited by the baby and in some cases, thyroids too. There is something called fetal programming. If you are diabetic when you are pregnant then because of fetal programming, the baby is at risk to develop Type 2 diabetes later in life after 35 years and above, but not when the baby is born.
On the contrary, when the baby is born he/she won’t have high blood glucose, but what we are worried about is the baby getting low blood glucose. What happens is that the high blood glucose from the mother stimulates the baby’s pancreas and produces more insulin and then the baby gets low blood glucose. Then it can get seizures or complications due to low blood glucose but not because of high blood glucose.
Childhood obesity is changing as children now are not eating healthy, eating junk food, not exercising or playing outside, and are always on their mobile or laptops or computers. They might become Type 2 diabetic due to their lifestyle. We as a society have too much access to food as we’re going to parties, going out to eat, having lots of sugary food, not doing much exercise, getting stressed out a lot, having abnormal sleeping hours, overworking and so on and that doesn’t translate well in your life for mental and physical health.
8. So how do you recommend managing meals in a traditional Nepali home with traditional cuisines?
I advise the patients to choose healthier options, not starving or completely depriving themselves but also knowing the science behind breastfeeding and portion control. Some mothers are concerned that if they don’t eat much, they might not produce enough breast milk. But breast milk is secreted by the prolactin hormone. As soon as the baby is on your nipple, the sucking effect stimulates the brain to produce prolactin hormone and that’s how breast milk will be produced.
Everything is about good communication. We know that feeding in our culture is a way to show love but if we had diabetes during pregnancy, we have to make friends and family aware that you need to take care of the body well to heal and become healthy but it’s not that you don’t appreciate their gestures. We must try and explain to them that it’s not healthy for you to eat like that. You must have a healthy balance in food and eat what’s healthy. You can just keep up the healthy diet that you were on when you were in a pre-pregnancy or prepartum state. If you eat healthy after postpartum for at least 3 to 6 months then it will wear off your chances of getting Type 2 diabetes in the future for both you and the baby.
9. We know that each condition that manifests in a patient varies, so could you elaborate on how one needs to consult their respective doctors before consuming medicines?
Everybody’s diabetes is not the same so everybody’s medication is also not going to be the same, everybody’s lifestyle or calorie nutrition is not going to be the same, so not only do you need to find a doctor, but you need a team of doctors. Sometimes I might be the endocrinologist telling you to eat fewer carbohydrates but the gynecologist might think that the baby’s growth is not as expected, so they can tell you that you need more protein or more supplements. To balance their suggestions, you might need a dietitian.
So everything is patient-centric and each patient is unique in their way. Although 2 people might have the same disease and the same diagnosis, the treatments for each might be completely different. It is also really important to consult all your doctors before starting or stopping your medication. And also whenever you talk to one doctor, make sure you tell the other doctor that you’ve been to this doctor and you’re taking these medications and bring those medications with you so that there are no potential errors.
10. Please tell us something about your Rehabilitation Center and its holistic programs.
There’s something called Diabetes Rehabilitation. Rehabilitation is the action of restoring someone to a healthy or normal life through training and therapy after illness, addiction, or trauma. This is something I am passionate about introducing to society because I’ve realized that in these past 15 years of practice, the prescriptions are not working as efficiently as they should. I realized that as a doctor the advice I give my patients is difficult for most people as they don’t know how to do it practically and also lack the motivation. Because there is so much involved in diabetes like mental health, nutrition, diet, calories, cooking, time management, etc., diabetes rehabilitation can help in a good way by teaching the young and old, diabetic or non-diabetics how to live healthily, how to cook, how to portion control, celebrate festivals without feeling distressed, how much to exercise even with physical limitations like your knees or back problems, or how to do physio to help recover.
Writer Details:
Dr. Dina is Consultant Endocrinologist at Norvic International Hospital and Siddhi Polyclinic. She is interested in Diabetes and Thyroid disorders in pregnancy. Dr. Dina completed her MBBS and MD in Internal Medicine (Endocrinology) from Tianjin and Dalian in China. She also completed further training in Clinical attachment for Neuroendocrine from Oxford, UK and Oslo, Norway. She is the current President for DEAN (Diabetes and Endocrine Association of Nepal), and SAFES (South Asian Federation of Endocrine Societies). She loves traveling and trekking to new places.
