Lower glucose levels

• >30% reduction in insulin dose requirement suggests placental insufficiency. Delivery should be considered very soon.

Higher risk for hypos
This is due to the placenta slowing down at the end of pregnancy

Very common during pregnancy
Symptoms include:

• High glucose levels – particularly fasting
• Bloating
• Vague abdominal, pelvic or perineal pain
• Constipation alternating with diarrhoea
• Incomplete emptying

Managing constipation will improve glucose levels

• Drink plenty of water
• Do some regular exercise
• Eat high-fibre foods

Take aperients every day:

• Movicol 1 – 2 sachets
• Coloxyl 1-2 tablets

Common in pregnancy
More likely if patient is constipated
Can interfere with sleep and this leads to higher glucose levels
Symptoms can include:

• Nausea, vomiting
• Postnasal drip and sinusitis
• Dry cough in the day or night
• Dysphonia
• Poor quality sleep – frequent waking
• Epistaxis
• Palpitations

Over-the-counter antacid medications may relieve symptoms

If symptoms are not improving, trial a proton pump inhibitor eg. Omeprazole, Pantoprazole.
These are safe in pregnancy

Managing reflux can improve sleep quality and improved glucose levels

Treat constipation and reflux

Improve sleep hygiene. See “Sleep”

Carbohydrate is the macronutrient that contributes most to:

• post-prandial hyperglycemia
• post-prandial hypertriglyceridemia
• hyperinsulinemia
  (endogenous and ?insulin dose requirements)
• insulin resistance
• hunger in between meals

The biggest culprits are sugar and high-glycaemic index carbohydrates, which are rapidly absorbed and lead to a post-prandial spike in glucose.
High fibre foods and low-glycaemic index carbohydrates raise the blood glucose level more gently, so are favoured over high-GI carbohydrates.
However, eating large quantities of any carbohydrate will contribute to hyperglycemia. So, reducing carbohydrate intake overall (to less than 100 grams per day) will lead to:

• Improved glucose control
• Reduced endogenous insulin levels
• Reduced symptoms of hyperinsulinemia
  eg. hunger, oedema, hypertension, weight gain
• Reduced serum triglycerides

Minimize intake of:

• Sugar
• Soft drink
• Juice
• High-sugar fruit
• High-GI carbohydrate

Swap high-GI carbohydrates to low-GI carbohydrate foods
Minimize snack foods
Eat low-carbohydrate snacks instead
Eat foods that better satisfy appetite at meals, to reduce the tendency to snack in between

• Protein foods
• Healthy fats
• High fibre carbohydrates

Eat breakfast

Skipping breakfast leads to:

• Raised cortisol levels
• Hypertension
• Tendency to snacking on high-sugar foods later in the day
• Insulin resistance and higher post-prandial glucose levels when carbohydrate is eaten later
• Weight gain

Eating a breakfast that contains protein & healthy fat leads to:

• Better control of appetite, so snacking is less likely during the day
• Improved insulin sensitivity, so glucose levels are easier to manage
• Increased endogenous insulin secretion later in the day, so post-prandial glucose levels are lower

Eat breakfast that contains protein and healthy fats
If your patient is “not a morning person” and feels unable to eat breakfast, try these quick options:

• Slices of cheese
• Leftovers from dinner
• Yoghurt
• Eggs –pre-boiled and stored in the fridge
• A handful of nuts
• 1 slice of toast with:
  
  • Cheese & tomato
  • Peanut butter
  • Avocado & tomato

Eating at night (after dinner) is likely to cause:

• Weight gain
• Poor sleep quality
• Tendency to skip breakfast
• Insulin resistance and high glucose levels on waking

Eat a good-sized dinner that satisfies the appetite effectively

• Include protein and healthy fats. These foods suppress appetite for hours
• Avoid high-sugar desserts. Sugar increases the hunger hormones

Aim to eat low- or no carbohydrate snacks eg. cheese, nuts or olives

Insulin resistance is caused by mitochondrial dysfunction and reduced lean body mass (skeletal muscle). Exercise improves muscle and mitochondrial function, but not all exercise is the same.
The types of exercise that best improves muscle mass and mitochondrial function are:

• Strength exercise
• Interval training

Aerobic exercise (eg. walking and jogging on the flat) does not increase muscle mass and is inefficient in improving mitochondrial function.

Refer your patient to an exercise physiologist for a personalized program matched to their ability and needs.
It should include:

• Interval training
• Strength exercise

Interval training may be as simple as adding a period of fast walking or a hill climb to the usual walk
Strength exercise in the upper body will provide whole-body benefit. This is useful for wheelchair bound patients or those with a foot wound that is being offloaded.

Chronic sleep deprivation causes:

• Insulin resistance and hyperglycemia
• Increased hunger and decreased satiety
• Weight gain
• Hypertension
• Impaired immune function

Sleep deprivation occurs when:

• There is less than 6 hours’ sleep at night
• Sleep is disrupted
• Patient has obstructive sleep apnoea
• Deep, slow wave sleep is reduced
  Eg. light exposure before bed, late bedtime, poor sleep hygiene

Aim for 7-8 hours’ sleep at night

Improve sleep hygiene before bedtime:

• Avoid screens for 1-2 hours
• Avoid alcohol
• Avoid eating large meals
• Avoid caffeine after 5pm
• Avoid drinking lots of fluid
• Take a warm shower
• Exercise during the day
• Daytime sun exposure
• Avoid benzodiazepines

Investigate for OSA if clinically suspicious
Trial medications if sleep deprivation persists:

• Melatonin
• SSRI antidepressants
• SNRI antidepressants

Dental caries and gingivitis are common in people with diabetes due to:

• Hyperglycaemia
• Reduced saliva due to dehydration
• High sugar diet eg. juice, sugar, soft drinks
• Smoking

Poor dental health leads to ?insulin resistance and hyperglycemia due to:

• Increased systemic inflammation
• Pain and sleep deprivation
• Poor diet – you can only eat carbohydrate foods if your teeth are in poor condition

A dentist visit every 6 – 12 months has been associated with a ~1% reduction in HbA1c (Cochrane Systematic Review)

Refer your patient to the dentist

• Any acute dental issues
• Education re: dental health

Ensure regular follow-up with the dentist (every 6-12 months)
Ensure your patient brushes their teeth regularly (2-3 times per day) and uses dental floss
Stop smoking
Avoid foods that cause dental caries:

• Fruit juice
• Dried fruit
• Soft drinks, including diet soft drinks
• Chewy lollies
• Muesli bars

Cut down on high-GI carbohydrate foods
Chewing sugar-free gum can improve saliva flow and improve dental health

Drinking alcohol causes changes in the liver that lead to:

• High triglyceride levels
• Central obesity
• Insulin resistance

Alcohol is derived from sugar, so can cause high blood glucose levels after drinking it.
The alcohols that contain a lot of carbohydrate and lead to high glucose levels are:

• Beer
• Dessert wines
• Mixer spirits that contain soft drink or juice

Alcohols that don’t cause high glucose levels are:

• Spirits eg. rum, gin, vodka, whisky
• Champagne
• Dry wine – red or white

A binge of alcohol will lead to low glucose levels overnight due to alcohol’s effect to reduce hepatic gluconeogenesis

Reduce intake of alcohol to no more than 2 standard drinks in one session

Avoid or minimize high-carbohydrate choices, and opt for one of the following:

• Spirits eg. rum, gin, vodka, whisky
• Champagne
• Dry wine – red or white

If your patient drinks heavily, recommend that they eat a supper at bedtime and check their glucose levels. Minimize the risk of hypoglycaemia by:

• Avoid sulphonylureas
• Change nocte insulin to mane
• Minimize nocte dose of pre-mixed insulin