Can a Ketogenic Diet Cure Gestational Diabetes? Here's what the science says

During my first pregnancy, I did what most first-time parents do and attempted total perfection with my diet. I followed ketogenic principles pretty closely, took lots of vitamins, went on walks, and nailed every OB appointment. Kid #1 entered the world perfectly healthy with no complications.

Kid #2? She was a different story.
During that pregnancy, Jacob was doing an away rotation for medical school while I lived with my parents--and with the stress of working from home and watching a toddler, it became all too easy to eat my stress away.
We're talking about entire bags of cheese puffs, candy bars, and ice cream. Not my finest moments.

When I got my gestational diabetes mellitus (GDM) diagnosis, I thought it was an accident. Why? Because I left the doctor's office before I even completed the glucose tolerance test. Pregnancy brain can do that to you.
Then again, cheese puffs probably aren't good for fetuses anyway--so when the doctor broke the news (and wouldn't let me retake the test), it was the kick in the butt I needed to reclaim control over my diet.

WTF is gestational diabetes, anyway?

Gestational diabetes happens to women who experience diabetic symptoms for the first time during pregnancy, usually after 20 weeks of gestation. (Women who have diabetes and then get pregnant have pregestational diabetes.)
Your doctor can diagnose you with gestational diabetes if you display higher-than-normal blood glucose levels during pregnancy.
You know that diet affects blood sugar in the average, non-pregnant person--but can a bad diet cause gestational diabetes? Not necessarily (which makes me feel a little better about my stress-induced cheese puff consumption). In fact, the American Diabetes Association can't draw a clear link between diet and GDM risk, unless you're obese--so the connection between diet and GDM is murky.

That's because, according to the latest theories, GDM happens as a result of hormones that the placenta releases, which can interfere with the mother's insulin function. (Reminder: insulin is the hormone that helps your cells absorb glucose.) Having these hormones in the placenta work against the mother's insulin leads to insulin resistance.
Two specific hormones in the placenta are to blame: human placental lactogen (HPL) and human chorionic gonadotropin (HCG). HPL is anti-insulin and likes to break down fat, causing your liver to release more glucose while your pancreas just can't make enough insulin to keep up with the demand.
In other words, your baby hijacks your chemistry and steals all your sugar to grow (like an evil baby genius). Your blood sugar will read higher than normal, which results in the GDM diagnosis. Thanks, fetus!

Who's at risk for GDM?

As I just mentioned, obesity can influence your GDM risk--but there are other factors at play too.
Some are obvious: if you have a family history of type 2 diabetes or GDM, or had GDM in a prior pregnancy, or have Polycystic Ovary Syndrome (which can mess with your hormones), your risk is higher.
But some of the risk factors get a little funky. For example, if a woman is over 25, is of Filipino or African American descent, or has birthed a large baby in the past, she could be at risk too.
The weirdest part? I only had one of these risk factors (being over 25), so I'm convinced that my diet played a role in my diagnosis--but take this anecdotal evidence with a grain of salt. Even the Mayo Clinic can't say for sure why GDM happens in some women, so maybe I was just an unlucky case or false positive.

Why your doctor screens you for GDM

Some practitioners in the natural health community believe that testing for GDM places unnecessary stress on mothers and shouldn't be performed, likely because there are some studies that suggest it doesn't contribute anything to better birth outcomes.
However, your doctor does have precautionary reasons for initiating the glucose tolerance test. Higher blood glucose during pregnancy is linked to:
  • Higher likelihood of delivery via C-section
  • High blood pressure
  • Preeclampsia
  • Preterm birth
  • Higher risk of the child suffering other health conditions later in life (including obesity, heart disease, and yes, diabetes)
  • Bigger babies, and tougher deliveries (e.g., shoulder dystocia)

Plus, the test is cheap and doesn't harm anyone--the benefits greatly outweigh the costs.
Should you get a glucose tolerance test if you already manage your diet well? Maybe not, but it's good to play it safe. In an abundance of caution, it's nice to know your status when it comes to blood sugar in the event you need to manage it better. (I know it helped me.)
Most people in the general population can easily get caught up in the stress, dietary decisions, and lifestyle influences that can cause elevated blood glucose. Even "healthy" people are prone to higher blood sugar because they consume the excess carbs recommended in the Standard American Diet. So for the average pregnant woman, testing for GDM is a safe and reasonable idea--and even if you have a low-risk pregnancy, one morning of drinking sugar syrup isn't that terrible if there's even the slightest chance it would improve outcomes for your baby.

The typical GDM diet: does it work?

When I got my GDM diagnosis, I had to schedule an appointment with a nutritionist to discuss the recommended dietary guidelines for the remainder of my pregnancy.

Before I even met the nutritionist, I was furious. I feared they would force me to eat tons of carbs and try to shove a low-fat agenda down my throat. I mentally prepared to argue for a higher-fat, lower-carb diet, confess to my past dietary sins (forgive us our cheese puffs), and basically tell them no if they wanted me to do anything I wasn't comfortable with.
I didn't want to follow the guidelines, mainly because there's heavy debate over their efficacy. Some reviews say that none of the existing guidelines help one way or the other, while other studies support GDM diets low in refined carbs. (Plus there are even more studies on entering ketosis, which I'll discuss in a moment.)
Luckily, the RN/nutritionist assigned to me was not as harsh as I expected. Yes, she was obligated to recommend "healthy" foods like beans and Greek yogurt while discouraging high-fat consumption (the biggest shocker was when she said it was ok to drink an occasional sugar-free diet soda…!). Yes, she also made me sign a paper agreeing to track my diet. She also gave me a blood glucose monitor and told me I needed to track my sugar four times a day. However, she also said I could try my way--and stick with it if the numbers supported my case.

Can enter ketosis treat GDM?

I wanted to go full keto. Unfortunately, there is little (if any) evidence right now that suggests that a ketogenic diet can help pregnant women manage GDM--or even lead to better outcomes in a normal pregnancy.
In studies performed on mice, some results suggest that a ketogenic diet could be harmful to an embryo's growth and lead to behavioral changes after birth. Other tests on mice show that ketogenic diets during gestation can raise the chances of "fatal ketoacidosis during lactation," altered brain structure in the fetus, and poorer growth outcomes.
The studies that do support a ketogenic diet during pregnancy focus on treating very specific and uncommon health problems unrelated to GDM (such as this one on children with Pyruvate dehydrogenase complex deficiency--not a condition you hear about every day). These results don't translate well to the average pregnant woman with gestational diabetes.

Beware of anecdotal evidence that suggests a direct connection between a ketogenic diet and a healthy pregnancy--so far there is not sufficient evidence to back it up, which is why most doctors will look super uncomfortable if you say you want to try a keto diet during pregnancy. There are too many variables without enough proof.

How I managed my GDM with a lower-carb diet

Knowing that I couldn't reasonably go full keto, I went with the next best options:
  • I eliminated almost all processed foods
  • I amped up my fat and vegetable intake
  • I limited myself to resistant starches or high-fiber whole grains when I did eat carbs
  • I drank tons of water (and La Croix--lifesaver!)
  • I walked 2-3 times a day
A typical day would have me eating scrambled eggs with Bulletproof Coffee for breakfast, a large salad with avocado dressing and leftover meat for lunch, and more meat and vegetables for dinner (usually with a big scoop of butter or guacamole). Keto pizzas were also a BIG part of my meal routine. ;)

I regularly snacked on hard cheeses, and usually integrated rice or some ultra-grainy bread with my dinner. Then a piece of nice dark chocolate or a handful of nuts here and there. Usually I had to have a small snack before bed to keep my sugar reading steady in the morning.
I tracked all my food in MyFitnessPal (the free version), and logged my blood sugar readings in a separate diabetes tracking app (also free) so I could graph my progress.
I was hovering around 70-80g of carbs a day and felt so much better than I did during my cheese puff days. My doctor was shocked when I showed him my results--which strayed far from my nutritionist's recommendations to eat 150+ grams of carbs per day--and said I could stay the course as long as I kept my numbers in check.
With the green light from my doctor, I never strayed from this diet for the remainder of my pregnancy. I was so motivated to do right by my baby that making better food choices seemed much easier--and playing the pregnancy card made it easy to turn down invitations from well-meaning family members and friends to eat carb-ridden foods. I'm grateful I got that GDM diagnosis because it gave me the motivation to get back on track.

Kid #2 entered the world perfectly healthy with no complications--just like Kid #1.

What to do if you have GDM and want to follow a ketogenic diet

First of all, remember that ketogenic diets are generally not recommended for pregnancy, and there is no evidence that they help manage GDM.
That being said, if you have different ideas of how you want to manage your condition, come prepared when you see your doctor. Use an evidence-based approach like I did and record everything you can about your diet and blood sugar levels. If you can prove to them that you're managing it effectively (regardless of the specific diet you follow), they'll be much more likely to support you.
And even if they don't--nobody can force you to eat anything, especially if it doesn't follow your typical diet, to begin with. If you can prove that your way works better for you, then stick with it--otherwise, keep your mind open and remember that there's no single "right" way to grow a baby.



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