If you are pregnant and living in a western country, at some point between week 24 and 28 of your pregnancy, you will be invited to come to the lab first thing in the morning. The nurse will draw some blood to measure your fasting blood sugar and promptly give you a drink containing 75g of glucose (that's about twice as much sugar as in a can of coke 🥴). You will then have to stay in the lab and wait for your blood sugar to be measured again in 1 hr and in 2 hrs.

Not your ideal way to spend a morning? I get it. I've been there too (and being given the choice between orange or lemon flavour is no consolation!)

Rest assured though, it's all for a good cause.

According to the International Diabetes Association, 

1 in 6 babies worldwide is born to a mother with diabetes.

While some of those mothers already had diabetes before getting pregnant, the vast majority (84%) developed gestational diabetes during pregnancy.

Given the high prevalence of this condition and the importance of catching it early, all pregnant women in Belgium and in most western countries are invited to this "Oral Glucose Tolerance Test" (OGTT)).

What exactly is "gestational diabetes"?

Our body regulates what goes on in our blood very tightly. When it comes to sugar (aka "blood glucose") the body wants that to be between 70-140 mg/dl. For an average adult, that is equivalent to about 1 - 1.5 teaspoons of sugar. Not more, not less.

The food we eat frequently contains much more glucose than that and it all enters our bloodstream from our gut in one go. When the body sees that, the first thing it must do is get the sugar out of the blood (and into our cells).

Too much sugar floating in the blood is not good news. It sticks to things, causing damage to the organs, to the vessels and, in the case of a pregnant person, too much passes to the baby's blood.

If, for whatever reason, the body is not able to get the sugar out of the blood quickly and more than what it ideally wants stays floating around at all times, it is called "diabetes".

When you get the results of your OGTT, what the doctor is looking for is that your blood glucose level is:

• less than 92 mg/dl fasting,
• less than 180 mg/dl at 1 hr,
• less than 153 mg/dl at 2 hr.

If you are above any one of these cut-offs, you will be told that you have gestational diabetes.

I know that this is not the news you want to hear during a checkup. As someone who has been there and has come out the other end, I want to reassure you that you can go on to have a normal pregnancy and a healthy baby. In fact, most people do.

That said, however, it is important to be proactive and manage this condition well.

Why is it important to know?

"Knowledge is power" and knowing whether you have gestational diabetes allows you to take control of your diet and lifestyle and to avoid potential complications.

When you have too much glucose floating in your blood and passing to the baby this can lead to:

• your baby growing too large, which could result in a more difficult delivery and increased likelihood of a caesarean section,
• an increased risk of preterm birth.
• an increased risk of pre-eclampsia (high blood pressure during pregnancy).
• your baby having low blood sugar (hypoglycemia) shortly after birth.
• your baby having a higher risk of being overweight or obese and developing type 2 diabetes in later life.

"I have gestational diabetes. Now what?"

In Belgium and most western countries, every woman with gestational diabetes is followed closely by her healthcare team. You will have regular appointments with your endocrinologist, nurses and dietician at the hospital who will explain to you what you need to do to have a healthy pregnancy and a healthy baby.

You will be asked to keep track of your blood sugar levels with the help of a glucose meter that you will receive from the hospital. You will measure your blood sugar daily when you wake up as well as before and after every meal, noting what you eat.

The goal will be to keep your blood glucose within a healthy range, ensuring that the baby does not receive excess glucose.

Although this is not normally provided by healthcare systems, I highly recommend investing in a continuous glucose monitor. It costs approximately 60 eur for a 2 week sensor and will give you invaluable information on the effects of foods on your blood glucose that you will never be able to get from simple finger pricks.

As you progress in the pregnancy your insulin resistance will increase which can make it harder to keep your blood sugar in range. A regular follow-up with your healthcare team is thus a good idea. In some cases, if diet alone is not sufficient, insulin may become necessary.

After delivery you will have to come back to the lab and repeat the OGTT to check whether your blood sugar has normalised.

What does it mean for your long term health if you are diagnosed with gestational diabetes?

While in most cases, blood sugar normalises after delivery and gestational diabetes "goes away", having had gestational diabetes is an indication of being at a higher risk of developing type 2 diabetes later in life.

Why is that?

Pregnancy, wonderful as it is, is nonetheless a time of stress for the body. When the body is under stress, i.e. it has to do extra things to those it normally does, this can reveal underlying issues that may not have been visible prior.

Gestational diabetes is one such thing. It "appears" during pregnancy and may "disappear" after delivery, but it points to the fact that the body may already be struggling with blood sugar regulation on some level.

The progression to Type 2 diabetes is a very gradual process. We do not just wake up one day and, 🧨bam, we have Type 2 diabetes. What precedes is decades of being in the grey zone.

• We start (in the white zone) as metabolically healthy,
• We then enter the light grey zone where our body is beginning to have trouble processing glucose into energy, i.e it becomes "insulin resistant". At this point our blood glucose would appear normal in a blood test, but in order to keep it so our body must work harder and harder by making more and more insulin to force the glucose to enter the cells.
• Then we enter the darker grey zone, where the body, despite all its efforts can no longer remove glucose out of the blood properly and a prediabetes diagnosis is given. A blood test will show that there is more glucose in our blood than what is optimal. 

If at this point the root cause of the problem is not removed,

• We will progress to Type 2 diabetes where there is too much sugar floating around in the blood at all times and serious damage can eventually result to our organs and vessels.

What the stress of pregnancy does, is move us a bit further along the grey area spectrum.

It is picked up in a blood test as "gestational diabetes". 

After delivery, we are likely to return back to where we were. Gestational diabetes has provided us with a "glimpse into the future". 

If nothing changes in terms of the lifestyle triggers that pushed our body into the grey zone in the first place, chances are that, with time, our body will progress deeper into the grey zone.

Whether we end up with a type 2 diabetes diagnosis or not down the line will depend on various factors. Diet, physical activity (or rather lack thereof), stress, genetics all play a role.

If you leave your doctor's office with a gestational diabetes diagnosis, take that as an opportunity.

(Not everyone is so lucky - unfortunately a huge number of people worldwide have diabetes, pre-diabetes or insulin resistance and have no idea that they do).

You have been given the gift of knowledge. Now you can take control and reshape the course of events to enjoy many healthy years with your beautiful baby.