Gestational Diabetes: Troubleshooting High Readings

by KMom

Copyright 1998 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 particular web section is designed to help present some ideas for coping with/preventing higher readings. It should be re-emphasized that nothing herein should be considered medical advice.




Trouble-Shooting High Readings: Some Ideas

What To Do If You Get a High Reading: Figuring Possible Causes

What do you do if you get a higher reading than you are supposed to? First off, don't panic. There are any number of factors that can cause an incorrectly high reading, and you need to rule these out before confirming the high reading. Always re-test to confirm a high number! You need to know if there was an error of some kind.

The very first thing you do if you get a high number is to go wash your hands thoroughly and then re-test. Any bits of food on your fingers can significantly affect your numbers. A residue of juice or a drop of fruit pulp on your hand could elevate your readings tremendously. Other substances on your hands might also possibly affect your readings, so washing your hands really well before doing a reading is very, very important. (Kmom's story: I had a couple of readings that were high; upon reflection I realized that I had been cutting up grapes for my toddler before the measurement and gotten busy and forgotten to wash my hands before testing. When I washed and then re-tested, my levels were normal. So it's very important to wash well!)

Other things to look for are housekeeping details about your machine. Is it too hot or cold? Temperature variations can cause inaccurate readings. Did you get enough blood on the strip? Was the vial of strips left open to air and humidity for any length of time? Have the strips exceeded the expiration date? Was your meter checked recently with a glucose test solution to make sure it is operating within normal parameters? All of these things can affect the accuracy of the results.

OK, let's assume you re-tested and came up with the same (or almost the same) number. Now is the time to consider other factors that could have raised your bG. Are you ill? Under a great deal of unusual stress? Stress and illness are major causes of higher-than-normal bG. Did you get enough sleep last night, or were you up with a teething toddler? This can raise bG. Be sure to note any unusual stress or illness in your bG daily log.

Also note any medications that you are taking. Cold medicines, cough drops, and other medications can affect bG readings. Some women take extra progesterone in the beginning of a pregnancy if they are experiencing bleeding or other problems; it is well-known that progesterone can raise bG numbers significantly. This effect should disappear once the progesterone support is dropped at the beginning of the second trimester. Until then, higher bG may just have to be tolerated, as long as it doesn't go too high. Consult your provider. Other medications that may raise bG include glucocorticoids (such as prednisone), terbutaline (used to stop pre-term labor), and perhaps beta-blockers or diuretics. Again, consult your provider.

Look at the timing of your test. How long was it between your bedtime snack and your morning fasting test? Anything less than 8 hours or more than about 11-12 hours can result in a higher number than normal due to a rebound effect. If your results were high after a meal, what time did you start the meal? How long until you tested? You really need to test right at the interval prescribed by your provider or your results are not quite valid. If the interval is too short or too long, the results can be changed. This is NOT a good idea.

Look at the contents of your last meal. Did you eat protein with your carbs? If you are omitting your protein, your carbs will have little to slow down their absorption and will typically cause a spike. While it is possible to move about 1 oz. of the serving elsewhere, do NOT move all of a protein to somewhere else in the day, since this could cause a spike in your bG levels. (Kmom's story: This has happened to me---I sometimes would move my protein portions early on, concentrating them at one or two meals. I did not realize that this was NOT a good idea. So on the days when I moved my breakfast protein to lunch, I often had higher breakfast numbers. On the days when I omitted my nighttime protein in favor of a bigger helping at dinner, I had higher fasting numbers the next day. In gd, you can't really move around your food allowances.)

Another question is how you ate your meal. Did you sit down and eat it all at once, or did it get spread over a big chunk of time? Did you eat your protein first, and then spread out your carbs? Or did you eat your carbs and forget to add in your protein? If you are spreading out your food too much, then your body has not had adequate time to process the carbs, yet you must measure from the beginning of the meal, at least with most providers. So spreading out your meal over too long a time could cause a higher number. Eating the protein first and then the carbs much later could also raise numbers, if you were very late in finishing your piece of fruit, for example. With toddlers in the house, sometimes a parent's meal can get awfully spread out or neglected! If you are tending to your child's needs and forget your own, it's easy to forget to eat your protein or spread your food out too far---something Kmom has done more than once and gotten burned for.

Certain foods can also cause problems. There are the obvious foods that will affect your readings, like cookies or cake and such. If you have one of the 'forbidden' foods, of course you are going to have a bG spike. You need to be honest about that in your bG diary. But other, less obvious foods can be the cause of some spikes, things that seem to be safe. Every person reacts differently to foods; some people can tolerate fruit juice during gd, for example, while most cannot have it at all. Some people cannot have milk first thing in the morning, while others are fine with it. Certain low-fat foods often add sugar to compensate for the missing fats, and these can be a real hidden source of problems. If you have a spike you need to sit down and write out exactly what you ate. Keep track of that and see if there is a pattern to what causes any bG spikes. (Kmom's story: It was through this method that I found that I am fairly sensitive to mayonnaise [especially certain 'lite' types] and that at the end of pregnancy when I am most sensitive, I need to avoid mayonnaise as much as possible. Early in my pregnancies, I can usually tolerate fruit juices without a big rise in bG; by the end, I need to omit them. Some people can tolerate cold cereals; I know that I cannot, though hot cereals are fine for me. Pizza is a big trigger for many people; I tolerate it just fine. You need to find what YOUR trigger foods are.)

Some common trigger foods (besides the obvious sugar foods) are bananas, raisins or any dried fruit, rice (portion control is very important with rice), cooked carrots, potatoes, white bread, pasta (long noodles are supposedly better tolerated than short pasta and overcooking supposedly also makes pasta raise bG more easily), instant potatoes and instant noodles, mayonnaise, fruit juices, muffins, croissants, processed meats, cold cereal, bagels, peanut butters that have sugar in them, pizza, ketchup in more than small amounts, some seasoning sauces, and anything made with a lot of sugar (like certain spaghetti sauces, etc.). Some trigger foods are actually more potent to bG than sugar itself! That doesn't mean that you can't ever eat bananas or raisins, just that you have to be very careful to monitor your reaction to them and if they cause a large spike for you, avoid them or use them in your least-sensitive times. But it should be noted that individual response is extremely variable, and some people are able to tolerate many of these common trigger foods just fine. If you get a high reading, consider whether one of these could be partly responsible.

Low-fiber or refined carbohydrates cause more of a bG spike than high-fiber foods. Whole-wheat bread, for example, is usually better tolerated than white bread, and brown rice is usually handled better than white. Try to eat the high-fiber versions whenever possible. Increasing the amount of fiber in the diet can often help lower overall bG numbers in some people and is better for you anyway.

Excessive amounts of fats, too, are thought by some (but not others) to raise insulin resistance and thus bG. This is a current controversy; fats are known to slow down absorption of carbs, but too many are thought by some to increase insulin resistance too much. Ask your dietician for her opinion.

Also learn to read labels. If the food you ate has any of the "-ose" suffixes (dextrose, maltose, etc.) listed in its ingredients, chances are that you had some sugar and didn't know it. Honey, molasses, fructose, or fruit juice concentrates are also forms of sugar and will raise bG. Sometimes recipes purport to be 'sugarless' and 'healthy', but if they contain apple juice concentrate or honey in place of sugar, it still is a carb and will raise bG similar to sugar. Other times, people have problems with peanut butters that contain sugar, so you should look into the more natural kinds of peanut butter. Every food you eat doesn't have to be totally sugarless, but it should not be one of the first few ingredients. Many breads, for example, have sugar in them, but that doesn't mean that you can't have them. However, if you read the ingredients and one of the first few is sugar or an '-ose' or a syrup, then you should buy another brand of bread.

Check the label to see how much carbohydrate was in the product you ate. Sometimes you eat the wrong serving size and get 2-3 times the carbs without knowing it, or this particular food is extremely carb-dense (like Grapenuts or oatmeal) and you didn't realize it. Every 15g of carbs is one serving. Some breads that look exactly the same may be different in carb content, for example---some breads have the requisite 15 carbs in one slice, while others may have 30 (2 servings of carbs in one piece of bread). Some bagels have 50+ carbs in them (3+ servings)! Muffins can be particularly dangerous because they contain many multiple sources of carbs---flour, fruit, sugar, etc. And many muffins come in sizes bigger than 1 serving. Some muffins may contain 4-5 carbs alone in what looks like one serving. So intelligent label-reading can solve your mystery sometimes too.

Diet foods and foods that seem starch-free can sometimes be hidden sources of starches. Spaghetti sauce, for example, is often thickened with flour or other ingredients, and often is the equivalent of a starch in itself, even without any pasta. Diet pudding or diet fudgesicles also count as a starch serving. Read the ingredients and the carb counts on the labels, even when it's a so-called 'diet' food!

Finally, consider the type and combinations of foods you are eating. Legumes are considered both a protein AND a starch; if you eat a bean burrito, for example, you may be consuming too many starches at once (between the tortilla and the beans). A beef or chicken burrito (sans beans) may be a better choice. Another quirky problem that is often overlooked is the amount of starches in vegetables. You have probably been instructed to consider vegetables such as peas and corn as starch servings; what you may not know is that other vegetables, when combined, may add up to too many carbs and constitute another starch serving. Most vegetables have about 5g of carbs per serving (lettuce/salad is an exception); if you have 3 veggies in a meal, you have 15g of starches, equivalent to another starch serving. So if you are very sensitive to starches, you may want to carefully divide the important vegetable servings throughout the day instead of concentrating them at once. It's important not to omit the veggies because their nutrients are an important part of a healthy pregnancy, but combining three at once may be too much for sensitive individuals. You can check and see how well you tolerate them.


What If You Just Have a High Reading, Without Any Real Rhyme or Reason? What Then?

First, record in your bG diary all the circumstances and food that you can recall around that reading. It may develop into a pattern later on that you can pinpoint. Second, go out and get some exercise to try and lower the bG reading now. You don't need to run a marathon, just do some basic exercise (if your doctor has approved that). Third, report your reading to your provider. If it's only a marginally high reading, it's probably not a big deal, especially if it's post-prandial and not severely high. Fasting spikes are more crucial, at least according to some (but not all!).

Then take action to try and see that another elevated reading doesn't occur. Be scrupulous in your food choices, and err on the side of conservatism. Get your daily walk in, or maybe add another to your day. Exercise is one of the best ways to increase glucose uptake and decrease insulin resistance, so be extremely consistent. If more than one day or so is skipped between walks/exercising, most of the benefits you have gained in increased sensitivity to insulin are lost. If you cannot add more walking or the weather outside is too foul, try some upper-arm exercises inside. Some studies have shown significant benefits to just a little bit of upper-arm exercising a day. Arm circles and arm curls using canned food as weights are often all that's needed. Other household activities such as vacuuming are helpful substitutes when outside exercise is not possible. However, you will need to carefully review any exercise plans with your provider, especially if you are at risk for pre-term labor or having other problems.

Be sure you get all your protein choices for the day, and at the correct times. A few people have found success with adding extra protein, especially at breakfast or at bedtime, though dieticians sometimes caution against adding too much protein. Keep a strict food diary and then call your dietician to see if they can spot a problem you are not aware of.

However, no matter how careful you are, if you have a pattern of higher numbers, you may well need insulin. It is not uncommon for women to start out fine on dietary control alone, and then see a rise in bG as their hormone levels increase later in the pregnancy. According to the American Diabetes Association, about 15% of women go on to need insulin at some point in a pregnancy; in many studies the number is much higher. However, a lot depends on the protocols used by the provider----for example, the diagnostic cutoff used to start insulin (at 105, at 95, at 90, or even lower in a few cases)----and how many other strategies they are willing to experiment with before resorting to insulin. But if you do end up needing insulin, it doesn't mean that you have failed, just that your pancreas cannot create enough insulin anymore to compensate for the insulin resistance from the increasing hormones of late pregnancy. Progesterone in particular peaks in the third trimester a month or more after the usual gd tests, so you may start out fine with dietary control and still end up needing insulin. Either way, it's not a personal failure or victory, just the way your body is able to cope with the pregnancy hormones.

If you have high post-prandial (pp) numbers, some providers are not as concerned, whereas others are much more strict, feeling that high post-prandial numbers are the biggest indicator of the threat of macrosomia. Most providers are not concerned about an occasional borderline high pp number, as long as it does not become a pattern or occur within the period of a week or two. High numbers that are clearly related to sickness or unusual stress will also probably be less worrisome to your provider, unless there is a pattern or it goes on too long. A truly high number (above 150, for example) may also get more of a reaction than one that is borderline (like 125). Successive high numbers are also a greater concern to some providers, so if you have two successive pp readings of 135, they are more likely to be concerned than if you had two 135 readings in one month. A few providers will not be worried about borderline-high post-prandial numbers at all, even in succession, but some will. Discuss it with your provider.

High fasting numbers are much more of a concern to some providers, as good fasting numbers may be the best measure of good fetal outcome (not everyone agrees). If your fasting numbers are over 105, you need insulin. Most providers look for two fasting readings over 105 as grounds for insulin; they may overlook one high reading as a fluke if all your other fastings are clearly much lower. Others, however, are much quicker to act, or they may demand fasting levels that are much lower than 105 (see the section on 'The Numbers Game'). It is generally thought that the optimal fasting level is around 90 or below, but most providers will not put you on insulin unless your numbers start to exceed 105 (95 with other providers). A few will place you on insulin at levels slightly below 90 (one major study even put women on insulin at fastings of 80!), but this is uncommon. It is controversial whether insulin at levels lower than 105 is beneficial; some studies find it to be helpful while others do not. This is an area of strong research interest but inconclusive results as yet (see the section on controversies). If your provider suggests it, be sure to research all sides thoroughly first so you can make a truly informed decision.


What If My Fasting Numbers Are Somewhat High? Is There Anything I Can Do To Help?

If your fasting numbers are closer to the top of the range than you would like, there may be some things that can help improve your numbers. First, consider your bedtime snack. Be sure it has the right amount of protein and carbs in it; omitting the protein can raise your fasting levels, as can too many carbs. Consider also the timing of your bedtime snack. How long is it until your morning measurements? Do you eat the snack long before going to bed or just before? 9-10 hours is the most common desired time lapse for a fasting measurement; shorter or longer can raise the results. Some people have luck with adding a walk just before bedtime, apparently because glucose uptake improves even after the walk is over and lasts for several hours. (Kmom's story: To help with my fasting numbers, I take a walk right before bedtime pretty religiously, and I add an extra protein to my evening bedtime snack. Since we are notorious nightowls, it doesn't bother us to walk late at night, and our kids like it too. But early birds might not like this plan!)

Another possibility is a 'bounce' effect, though this is more often seen in regular diabetics than in gestational diabetics. Some women get a strong surge in bG when they go to bed, and then a strong surge of insulin in response (they tend to be reactive hypoglycemics). This insulin surge can cause a bG crash in the middle of the night, and then the body has to go hunting for other sources of energy for you and for baby. It accesses the energy stored in your liver, and also your fat stores. Your bG can then rise quite sharply, and the advent of the morning hormone surge can raise it even more, resulting in a high morning number when you actually experienced a crash in the middle of the night. Accessing fat stores produces the byproduct of ketones, which may be bad for baby. (See the section on Ketone Testing for more information.) And a spike and then crash and then a new spike in bG is especially bad in gd; the ideal is euglycemia, which means steady blood sugars. It is the swings (and especially the fast ones) that are the worst thing for the pregnancy, besides the obvious hyperglycemia.

One possible way to help a 'bounce' effect is sometimes to add more protein in the bedtime snack (so the carbs are absorbed more evenly and over a longer time) or to drink a glass of milk in the middle of the night, usually about 3 a.m. However, before you try this, you need to document that you are indeed having a crash in the night, so you will have to get up and measure your bG several times in the night and see if you fit the pattern, and also check for ketones in the a.m. Be aware that this pattern of crash in the night and rise in the morning with ketones as a side effect may occur more often shortly after gd is diagnosed as you struggle to get your bG evened out; it often responds well to intervention but may take a week or two to settle down completely. Don't add an extra glass of milk without consulting your provider or dietician, since this could also raise your morning numbers if a crash and bounce effect is not really the source of your problem. But do remember that if you are experiencing highish morning numbers and lots of ketones, you may indeed be experiencing a 'bounce' and this should be discussed with a diabetes expert. Also be sure to read the section on Ketone Testing for more information on that as well.


What If My Post-Meal Numbers Are Somewhat High? Is There Anything I Can Do To Help?

If you have just one occasional high post-meal (post-prandial) number--and it's not severely high--this is not usually something a provider is greatly concerned about. They know that sometimes occasional high numbers happen. Most women experience this at some point. Providers are much more concerned about two consecutive high numbers, two high numbers within the space of a week or two, a very high number (around 150 or more), or a pattern of higher numbers. It's important to remember, too, that some providers are more flexible than others. Some will put you on insulin if you have any two high numbers within a week, even borderline high numbers that might have outside causes. Others are more willing to consider waiting to see if the readings were a fluke, caused by illness or stress, or resolvable with nutritional tinkering. Some will even wait to see a more consistent, long-term pattern before using insulin if the readings are borderline, not too high, and not too frequent.

You need to be careful not to stress out too much over the readings; remember that stress over the readings can be self-defeating because it can also raise those same readings, an irony many critics are quick to point out. The judgmental attitude, invasive treatment approach, and inflexibility of many gd providers can also add to this stress and may actually worsen the very problems they are trying to treat. This is a very legitimate criticism of gd protocols and treatment, but at the same time, it is probably unwise to simply ignore the problem either. Providers need to work to become less rigid and more emotionally supportive of women with gd, and women need to work hard at lowering their stress levels and release as much anxiety as possible over the diagnosis and treatment protocols they must endure.

Conversely, women also need to be very aware of the role of denial and bargaining in the emotional course of gd. Some women are tempted to try and 'fool' the meter by missing readings when they know they will be high or by tinkering with the timing of their readings. Women with a history of eating disorders/bulemia need to especially beware of trying to manipulate readings. There are cases of women with eating disorders disguising problems with their blood sugar and causing severe problems. Most women are not foolish enough to do this, but it's a rare woman who is not tempted to fudge a bit now and then. It's important to recognize that this is a common response, part of a grieving process to disease, but that a mature response is to recognize this impulse and be responsible anyhow. Don't panic from an occasional borderline reading, but if your readings are higher, then it's important to be honest about that and take whatever actions are necessary to fix the problem. Your baby is depending on you.

You definitely need to discuss your higher post-prandial number with your provider and with your registered dietician in particular. Oftentimes, she can help you spot a possible cause or suggest some food strategies to assist you. Again, keep scrupulous notes on what you ate and the circumstances around the high number so you can see if there are any patterns forming. Read the labels of your food to look for hidden sugars that might have affected you. Check the amount of carbs in a serving to see if it exceeds the amount you are supposed to have. Review all of the hints given in the first section to try and trace down the source of the high reading.

If nothing can be cited as the source of the problem, there may be other courses of action before insulin must be used. For example, if all of your readings are fine except for your post-breakfast reading, then it may be possible for you to adjust by removing the milk serving from your breakfast meal (many women are too sensitive to milk first thing in the morning) or reduce your starch servings by one. Adding exercise, even a brief amount, after a trouble meal can often help too. Exercise increases insulin sensitivity and is usually the best strategy, assuming you have no activity restrictions. Adding an extra protein in the a.m. helps some people, too, as well as walking for 20 minutes after breakfast.

A consistently high number after lunch or dinner might be handled by cutting one carb from your total, using a complex carb instead of a simple (i.e., fruit or milk) carb serving, or adding a bit more protein. Generally speaking, mild degrees of hyperglycemia sometimes respond to cutting a bit of carbohydrate and/or adding a bit of protein, so tinkering with the balance of carbs and proteins may be helpful. This is a step sometimes overlooked by providers; there is a push in the nutritional research to experiment with plans of differing carbohydrate amounts and distribution before resorting to insulin in borderline cases. Some providers have found success by reducing the total daily carb intake to around 40% or slightly higher and increasing protein and fat instead (many older gd plans used a 50-60% carb total) or to tinker with limiting carbs during 'trouble' times such as breakfast. Some providers have been able to reduce the number of women needing insulin significantly by reducing the amount of total carbs in the diet and/or the distribution; this is an area ripe for further study. It must be cautioned, however, that a registered dietician should be consulted before changing any servings, since pregnancy requirements are carefully balanced and eliminating some foods may alter the balance of nutrients needed. This is extremely important!

If nothing else helps and readings are consistently high, insulin is probably needed. Don't panic; it's not usually as bad as it sounds! Most women find that control at that point gets much easier once insulin is added, and report that the shots are actually not as bad as they sound, and often are easier than the daily finger-pricks! So don't despair if you need insulin. It's not a personal failure on your part. Be sure to read the web section on using insulin for hints and ideas to make it easier.


References - See the Nutrition Section for references



Copyright 1998 KMom@Vireday.Com. All rights reserved. No portion of this work may be 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.

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