Nutrition and Diabetes

In order to bring awareness to the importance of nutrition and gestational diabetes for mothers and babies across the Navajo Nation, hosts Amber-Rose discusses these topics with special guest Mary Degnan from Tuba City Regional Health Care Center. In this episode, we discuss the information regarding the diagnosis of gestational diabetes, risk factors, and preventional resources for mothers.  

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Transcript

Introduction 

Ya'at'eeh. Welcome to the MCH podcast, where we discuss maternal and child health topics and provide strategies for improving the health of Navajo families. Amá dóó áłchíní ats’íís baa áháyá baa yadelti (Translation, we will be talking about the health of mothers and children).

Amber-Rose Begay [00:00:05] 

I'm your host, Amber Rose Waters, Hashk’ąąhadzohi nishli, Táchii’nii bashichiin, Tábąąhá dashichei, Naakai Dine’é dashinali. Nataani Nez denashaa. I'm originally from Shiprock, New Mexico, where I live and work at Diné College as a project coordinator of the Diné College Navajo Maternal and Child Health Project. I'm a Navajo woman and mother of two. 

Thank you for joining us today to learn more about maternal and child health on the Navajo Nation. Today, I, along with my guest, Mary Degnan from Tuba City Regional Health Care Center, will be discussing the topic of nutrition and gestational diabetes. 

Let's define gestational diabetes before we start. Gestational diabetes happens only during pregnancy. This can happen because there's not enough insulin in the body, which can make it harder for your body to process blood sugar for energy, instead causing it to rise. This affects the mother and baby's health. There's also type two diabetes, which happens when your body doesn't use insulin properly. But the difference is that type two doesn't happen during pregnancy. 

Thank you for joining us today, Mary. Can you introduce yourself?  

Mary Degnan
My name is Mary Degnan. I'm the director of Healthy Living Diabetes, Education, Clinical Nutrition. Before I took over as director, I was the diabetes and pregnancy case manager here at Tuba City Regional. I held that position for five years. I came from Buffalo, New York to Tuba city, and I didn't really know that much about diabetes in pregnancy, and I didn't realize that this would be my passion as it has for the past five years. So I'm very honored to take part in this program with you guys.  

Amber-Rose Begay
Awesome. Thank you. And can you tell us what kind of information do you share with women who come to you who have gestational diabetes? How do you work with them on that?  

Mary Degnan
Well, the way we work here is I'm actually embedded in the women's health clinic, so we work very closely with the provider. So any woman that is diagnosed with gestational diabetes or preexisting diabetes when they're first pregnant, we kind of work as a team. Health education wise, what I usually do is notify the mom of the gestational diabetes by phone and explain to them what gestational diabetes really is. What we found is that moms hear the word diabetes and while they're pregnant, and it kind of throws them into a panic. So explaining what gestational diabetes is that it's not their fault; it's just the normal changes of pregnancy hormones. And then, we set up an appointment with me to meet one on one to do our initial education. We talk about their diet, exercise, coping mechanisms, and also how to do at-home glucose teaching. Here, in the Navajo Nation as a mostly Western Navajo region, we follow something called the Sweet Success Program. I don't know if anyone else has been familiar with that, but we found that that program has given us a lot of guidance and a great number of resources and educational materials for mom.  

Amber-Rose Begay
Awesome. So is that, I guess, available online or throughout any IHS across Navajo?  

Mary Degnan
Well, actually, the Sweet Success information and resources that I use are free on the Sweet Success Express website and I believe it's sweet Success express dot com, but I can verify that also what that link is to. [Here is the link: http://www.sweetsuccessexpress.org/] But there's a lot of great resources. One of the resources that I use is a booklet called Gestational Diabetes, and it's found on that website. That packet covers everything from what gestational diabetes is the complications of gestational diabetes, and the effects on baby. Also, some of the risk factors that may precipitate gestational diabetes along with a meal plan to follow, going over food to avoid, portion sizing of your carbohydrate foods, label reading, and it gives a nice breakdown of a meal plan also. 

So focusing in on limiting your carbohydrates to one carbohydrate serving at breakfast time because blood sugars are just naturally higher first thing in the morning and then incorporating the, we call it, a consistent carbohydrate meal plan for the rest of the day. So one carb and one protein for your snack, three carbohydrate servings for lunch and dinner, and most importantly, taking a bedtime snack. Carbohydrate differences. When I tell moms to have a bedtime snack, they usually like, “Mmmm, but if I eat something at night, my blood sugars going to be high in the morning, right?” So I explain the whole physiology of, you know, how her body works overnight and what happens when its blood sugar starts to go down that we release more glucose into our system, so the bedtime snack helps. It takes a little convincing, but, you know, once they try it, they see that it helps with the morning blood sugars.  

Amber-Rose Begay
Okay, great. So how is a woman diagnosed with gestational diabetes?  

Mary Degnan
When you're diagnosed with gestational diabetes, in here in Tuba City, we might do it a little differently throughout across Navajo, but in Tuba City, we do a prenatal A1C. So you come in for your pregnancy test, we do an A1C. And if your A1C’s greater than 5.7, we asked to do an early two-hour glucose test. So we do the one-step glucose test. And if that's cleared and it doesn't come back with any of the abnormal values, then, you know, we'll progress and monitor you. And then, at 28 weeks, we have you do another 2-hour glucose test. And I think that's traditionally how most women are diagnosed are at 28 weeks. So we'll do the tool or glucose test, and if one of those values is elevated, you'll get a phone call for me, and we set up the appointment.  

Amber-Rose Begay
And I know you mentioned that one thing that you make clear with pregnant women that have gestational diabetes is that it's not their fault. What other ways can they manage their gestational diabetes, either, you know, food-wise or through physical activity? What kind of advice do you share with them or education?  

Mary Degnan
Besides nutrition and exercise, I also talk about stress management. And a lot of the time, our women are very stressed. There's a lot of, you know, psychosocial economic issues. Sometimes they don't have a safe home environment or, you know, there's a lot of other factors. So it's how to manage stress, how to look at things in a holistic, positive manner. This is, you know, I'm making these sacrifices and these changes for my baby; we look at it in a positive way. You know, it's not like, okay, you're gestational, or this is what's happening; we want to work on how do we link them with services that they need if they need food services. Housing is also a challenge, you know,  I think, across Navajo too, whether we have, you know, ways to help them get adequate housing. Transportation is another stressful issue our moms face, too, is how do we get them to our appointment, and how do we manage and help them out that way?  

Amber-Rose Begay
Okay. Thank you. So can you talk a little bit about how gestational diabetes might affect the baby's health outcomes?  

Mary Degnan
Well, what happens with gestational diabetes, mom's blood sugar is elevated because their pancreas is not releasing enough insulin. So that blood sugar does pass through the placenta to the baby, or I should say, through the umbilical cord, to the baby, and baby gets all the nutrients and the glucose also. So what can happen with the baby is it has its own, like explain to moms, that it has a little baby pancreas which works out its own insulin, and insulin is a storage hormone so that extra sugar gets stored as fat in the baby's abdomen. So we can have what we call large for gestational-age babies. Or what I explain, too, is babies grow a little bit bigger. They're harder to deliver. And I always kind of jokingly say, you know, nobody wants to push out a nine, ten-pound turkey, right? 

So and we explained it that way. We also go through some of the other complications of neonatal hypoglycemia. So when mom delivers baby, and the cord is cut, that baby's source of sugar is gone and only has its own insulin left in the bloodstream. So that can cause low blood sugars for baby, which is scary, you know, for a mom because, you know, if they're symptomatic with low blood sugars, we have to do heel sticks every hour. They might make glucose gel. It might delay breastfeeding, or they might actually need IV dextrose also. So just kind of warning them and giving them these are some of the other complications. Also, warning them about the risk of jaundice with babies also.  

Amber-Rose Begay
Okay. Are there any vitamins and minerals that these women should be aware of during the pregnancy that they should be taking? In addition to physical activity and nutrition?  

Mary Degnan
Yes, folic acid is definitely number one, especially as early in pregnancy as possible. They need that, the need the folic acid for the, you know, to avoid spinal bifida. And of course, iron, iron is always important to take during pregnancy, also because of the increased blood volume in the turnover, red blood cells. Anemia in pregnancy is common. So to take an iron supplement or iron-rich foods. Also, taking vitamin C with that iron tablet also helps increase the iron absorption. Calcium, you know, we need strong bones. That baby is actually leeching the calcium and phosphorus from mom. So we need to make sure that we're taking in enough vitamin D and calcium also. But they're taking their prenatal vitamin. It will include all of those vitamins and minerals as well.  

Amber-Rose Begay
Awesome. Yeah, we definitely encourage, you know, how women should be taking folic acid, whether they're pregnant or not. And definitely I've experienced iron deficiency. When I was pregnant, my mom made me drink a cup of milk every day when I was pregnant. So, what about oral health care? Do you talk about oral health care to any of your clients or mothers?  

Mary Degnan
Yes, especially our patients that are diabetic or pre-preexisting diabetic. I always encourage them to practice good oral care. We actually do give out dental kits, so we give a little form on how to brush your teeth correctly. And, you know, because oral care is so important, you know, and it teaches good habits to not only mom but, you know, encourage it for kids too.  

Amber-Rose Begay
Mm-hmm. Awesome. Yeah, that was actually one of our projects. We actually gave out oral health kits to mothers and their children with this project. So I hope we can continue that because that is such that is actually a priority that we've found in our Navajo MCH needs assessment to improve oral health care for children and mothers who are pregnant or lactating.  

Mary Degnan
You know, we've actually found through our diabetes audit that our dental referrals or our patients actually completing dental exams was rather on the low side. So that's one of our initiatives for our diabetes program to, you know, encourage oral health. We're ordering electric toothbrushes that are battery-operated so that people who don't have electricity can still have the, you know, added value of an electric toothbrush, too.  

Amber-Rose Begay
Oh, that's nice. Yeah. So I know you talk already about like portion size and meal plans and foods to avoid, but can you list maybe some of the foods to avoid.  

Mary Degnan
As a diabetes educator, my philosophy is all foods fit except during pregnancy. So during pregnancy, I ask them to avoid any type of liquid sugars, so sugary beverages, period. At least until they can deliver, avoiding anything that, you know, that's a concentrated sweet. It doesn't mean that they can't celebrate, you know, because, you know, there's birthday parties, you know, there will be up ceremonies. There's a lot of things that incorporating that into your meal plan. But mostly I say, you know, just say no to the sugary beverages.  

Amber-Rose Begay
And what about portion sizes? What do you recommend when it comes to portion sizes?  

Mary Degnan [00:13:35]
Well, with their sweet success little gestational booklet that we hand out, I give them a whole actually a folder of not only explaining what gestational is, but talking about meal planning, food, using a plate method, we teach here with measuring cups. Moms usually get a set of measuring cups after the first visit, so we show them what the portion sizes are. So looking at common foods here that we see with our moms are rice, pasta, beans, a lot of the traditional foods, too, but, they're more cost effective. So, with carbohydrates like rice and pasta is a third of a cup. So when I show moms a third of a cup, I kind of get the oh, that's it. So when I explain to them that that is a serving size, so you get three servings at your lunch or dinner meal. So when I show them, one-third plus one-third equals one whole cup. So then it's like, Oh, okay, I can do that. So talking about listing all their portion sizes in that, also a half a cup of potatoes. And I do always encourage potatoes, especially with the skins on, because the skin has a lot of fiber and iron too. So it's a very iron-rich food. So I get that I can eat a potato? Yeah! That’s because, you know, because it's like I know they're not enemies, but a half a cup of potatoes, a half a cup of beans, chili beans. So we talk about portioning, and I give them examples, and then that booklet that shows them actually lists out serving sizes of your starches, grains, your milk, and your fruit and pasta. Well, that's one other thing I tell them, no juice. Just say away from juice. Eat your fruit, don't drink it. 

Amber-Rose Begay
Yeah. So what are the best foods that you can list that are good?  

Mary Degnan
Well, the best foods. Well, I guess that's a challenging question because what a best foods for me might not be a best food for my patients. It's like I have to meet the patient where they are. So what type of meals do you usually traditionally eat. They probably have younger kids, you know, it's hard to, you know, have your dollars stretched or, you know, eating healthy. So I look, I kind of explain to them, let's say, okay, let's look at what your budget is and what food can you get. So I try not to say this is what I expect you to eat, but what can we plan at? How can we work with what you have? But always encouraging fruits and vegetables, whether they're fresh, frozen, or canned. A vegetable is a vegetable. So if I can get you to eat green beans and you know if it's canned, it's still a vegetable. It's kind of meeting where they are if that makes sense.  

Amber-Rose Begay
Yeah, that's great. That's always best to do when you're working with people is to meet them where they are, especially when it comes to like health care and some of the challenges that we face on the Navajo Nation. That's great. That's a good approach. So what happens once a mother gives birth? So do they have gestational diabetes still? Is that something they still have to, I guess, monitor their nutrition and their babies? What happens?

Mary Degnan
Once they deliver, we know that the placenta is gone. So they actually go back to what we say, a normal state. So they're not actually gestational. They will have that history of gestational diabetes in their medical record. So our goal is to prevent them from becoming type two diabetic because statistics show moms with gestational diabetes has a 50% chance of developing type two diabetes later on in life. So what I do is once they deliver it, I go visit them in our hospital, and we do the, you know, kind of close-up talk. So I explain to them how to reduce your risk for developing type two diabetes. If they want to continue monitoring their glucose, I think that's a great thing if they can do that. If they were on medications during their pregnancy, like a metformin or some of them are on insulin, we discuss, you know, is that something that we want to continue because we think that's valuable? Or do we just continue them on an oral medication after they deliver and their discharged, and then we try to hook them up with our diabetes prevention program. We have a series of labs that we asked to do the two-hour glucose test is one of them. And then lipid panel, the thyroid, CBC, and a complete metabolic panel. So we can do you have them do that when they come back at their six-week postpartum. And then after they do that, we have the, the labs turned over to a provider that is for our diabetes prevention program to kind of meet with them and discuss, you know, this is what we can do to kind of monitor you. So we're trying to continue them through even after delivery and later on, so that way we can prevent that type two from showing up.  

Amber-Rose Begay
Okay, Awesome. Well, I don't have any other questions. We kinda sped through that, which is great, because I think these are all questions that I had about gestational diabetes myself. I, fortunately, haven't had gestational diabetes. But, you know, type two diabetes has been, you know, a concern in my family. I was diagnosed as a pre-diabetic once or twice before, and I've tried to reverse that, you know, through changing my diet and physical activity. I guess it's another question. What do you recommend women with gestational diabetes? What kind of physical activity? And I know the usual, like walking. Is there anything else that they can do?  

Mary Degnan
Well, the way I look at physical activity is any activity you can get in throughout the day. So whether it's housecleaning, washing the dishes, sweeping, you know sweeping the floor, you know, maybe put your hips into it a little bit more. You know, just finding something that they enjoy doing. And as their pregnancy progresses, it does become a little bit more challenging to go for walks, to do activity. So we talk about doing chair exercises, so I give them a handout and we kind of go through, you know, what kind of activity they can do. And during their pregnancy, I always encourage them to do 15 to 20 minutes of exercise after they eat because that's actually shown to help lower your glucose considerably. Exercise is better than insulin.  

Amber-Rose Begay
That's exactly what I've been told as well, is to go for a walk after a big meal.  

Mary Degnan
And some of the mom’s, which is nice when they bring me their glucose logs and I can kind of see she's like oh gosh, I ate a big meal, checked my glucose, it was a little bit high, so I went for a walk, and I couldn't believe how much it brought it down. So it was still within the power of exercise. So now I tell them you still have to eat smart and prevent that high glucose. So, you know, maybe initially, just start exercising right after. That’s what we talk about; we give them a stretchy band so they can kind of work the big muscle groups to help burn more glucose in that as well.  

Amber-Rose Begay
Wow, that's great. I wouldn't have thought chair exercises either. So that's, yeah, that's it. I guess, what we just wanted to know, I guess I was curious about the process, you know, once a woman, you know, takes the test, the glucose test is diagnosed. What happens after that? What happens when she delivers? You know, what could that turn into? Because I don't know too much about this myself. Let’s see, are there any risk factors that could put a woman at risk for gestational diabetes?  

Mary Degnan
Yes, there are some risk factors. First of all, you know, if you have family history of type two diabetes, that's one. If you've had a previous pregnancy of a baby weighing more than nine pounds, that can actually put you at risk for gestational for the next pregnancy. If you're overweight or obese, unfortunately, race is a big factor, you know. So if you are a Native American, Pacific Islander, Asian, or Hispanic, those place you at a higher risk for gestational diabetes.  

Amber-Rose Begay
I think that's all the questions that I have, which is good. I'm glad you were able to answer all of them. I feel like that's very helpful information to share. And I think the most important thing is that, you know, it's not entirely, you know, it's not the woman's fault that they have gestational diabetes. Also that they're, that it can be, you know, managed during their pregnancy and after. So that's really good to know. I think I would be worried about that as a mother to be. So all right.  

Outro 

Ahe’hee. Thanks for listening to the MCH Podcast. For more information about the Navajo MCH project, please visit us on Facebook at the Navajo Maternal and Child Health Project at Diné College.