Tanya:

Jessica, thank you so much for joining me today.

Jessica:

Thank you so much for having me, Tanya. I'm super excited to talk diabetes with you. And I, a big, big shout out to your podcast already with such amazing diverse birth worker voices on there.

Tanya:

Thank you. Well, that's what I'm going for. Trying to like, cover all the bases and there's so much to cover, so I should have content endlessly, right? But you are part of that equation. You are someone I've wanted to have on since I started this whole thing because your work is very interesting to me for a number of reasons. I, anyone who knows me knows that I am very passionate about diabetes. I think it comes from a slightly different place than where your interest lies. Although I think your interest is very broad at this point as well. So I definitely want you to tell us all about yourself. And I kind of want you to take us a little bit through your history in chronological order, right? Like so many of us, I don't know if you're one of them, like my being a midwife came out of my having a baby, right? Like, so, like my personal story proceeds my midwife journey. And then of course, there's the things that come in the future. So I don't wanna dictate to you like, tell me this, tell me that. I just want you to tell me your story and then we'll dive into diabetes.

Jessica:

Okay? Sounds good. I was a biology and as we called it women's studies now gender studies major at uc, Santa Cruz. And I knew I wanted to do what was once called women's health. And so I became a nurse midwife about 22 years ago and immediately engaged in full scope public hospital midwifery in New York, which has always been my love. I initially was fascinated with all things normal.

About it, but I was at the same time seeing myself always drawn, wanting to be involved in high risk, although I don't love that term. Birth, high risk pregnancy, high risk birth, because deeply I felt that all people should have access to midwifery care. Mm-Hmm. <affirmative>. So I ha I was a birth junkie and attended many, like more than a thousand births by the time I was pregnant with my daughter. And full disclosure, I have type one diabetes since I was a child. And so in my head though, I thought, Okay, I'm a midwife. I know what there is to know about birth. I'm an expert in my diabetes. I've got this and I have access through my privilege, through my insurance, through my education, to all things I needed. That was my feeling going into it. And was I wrong? I was wrong.

I felt that despite the fact that endocrinologists were expert at diabetes and that the placenta is actually an endocrine organ, I realized later they're not experts in the placenta. <Laugh> and high risk obs are experts in the placenta, but not necessarily in the very detailed orientation between the placenta and someone's diabetes specifically. No one the of the group was, was holistic. And so there was no midwifery presence for me. I got by making a self study of myself just delving in to learn as much as I could on a minute to minute basis about myself. And it was so anxiety producing, but I kept that inside and I took it minute by minute with my blood sugar and I gave birth. And the opposite of postpartum depression happened to me. I was in postpartum elation for the moment of getting that placenta out of my body. But throughout a period of months after that, I ruined on this experience that was so surreal and how I felt like I was a, a human being cut into literally. And I never had a midwife and no one really understood. So as I ruminated on this my husband stopped me one day and said, Why don't you become the solution?

Who you are, the solution if you wanna be? And I thought about that for a while. Do I really wanna be that? But I decided eventually to, after 1400 births, I decided to take a job in, in endocrine practice, a diabetes specific private endocrine practice. So I actually worked in endocrine for three years. And because it wasn't enough, my to know I'm one human, it wasn't enough to know my diabetes. I needed to know the diabetes of many, many people, many pregnant people, many non-pregnant people with all different kinds of diabetes. And it was an incredible, incredible experience to get to work in endocrine for three years. So I became a certified diabetes care and education specialist, and I tremendously missed public hospital midwifery. So once I did that, I went back to my public hospital and started to work in high risk OB and eventually saw all people with diabetes and pregnancy at my hospital.

And I am the perinatal diabetes specialist. I work within a group of people, including doctors, including midwives, our nfm, Dr. Schiffman, and nurses, and provide more holistic care for this group. In that context, I see myself as a remover of barriers. That is what I see myself suited to do with my own privilege, with my own private and public hospital oscillations where I go to a private institution, learn as much as I can, and then come back to the public to try to remove the barriers and improve the care and make it more like the private care. So that is always my goal there. I also started to write guidelines for the 11 public hospitals in New York. I don't wanna glorify that. It was a job that no one wanted to do, and I was perfect for it, so I did it <laugh>. Well, that's

Tanya:

Why you should glorify it because you did something that nobody else wanted to do, and quite frankly, probably couldn't do. So as grueling as that may have been <laugh>, you did something profound.

Jessica:

<Laugh> well wait till they get revised. I'm working on that. They're actually outdated. I'm working on isn't that the proper

Tanya:

Guidelines? They always get outdated. By the time you're done writing them, they're outdated, You're working on the next one. It's terrible.

Jessica:

Yes. And when you're type A, they're never done. Yeah. So it's, it's a bit painful actually. <Laugh>. And then what I also painfully remember learning is that no one actually sits down to read guidelines. That is not what happens. And so one

<Inaudible> speak. And so I began to do that out of necessity to communicate what was in the guidelines. So I started to speak at the public hospitals, at other hospitals in conferences and at NYU and Columbia. And actually held a, a conference on perinatal diabetes, which really had never happened in New York City at nyu and brought together thought leaders in diabetes. Actually, this is interesting cuz usually if you go to a high risk OB conference, there's old people focused on pregnancy and there's maybe one lecture on diabetes. This was all people focused on diabetes through the lens of a pregnancy. So it was a different angle and it was amazing. Now, I also do a little something else which has been missing from the public hospital midwifery, which is doing some coaching and online education for people with specifically type one diabetes from preconception, where they're really still missing so much information that I learned through my own personal journey and through the journeys of, of all the other people I've worked with since then. So I am doing that and I'm working on some more of that kind of online education for a broader group of people with gestational diabetes and type two diabetes as well. So that's sort of on the, in, in the future. So that's what I knew.

Tanya:

Wow, okay. So I knew some of that. Right. But like the bullet points, I didn't know the story behind it, and I'm just even more impressed than I was before. It's so fricking cool what you're doing. And I can relate to some of it, right? I my, with my like weird niche expertise being fitness stuff. It's, I I hear you. Nobody reads the guidelines, nobody like all those things. I'm like, Word. I hear you. This is the truth. <Laugh>. So, Totally. Yeah. It's a, it's a, it's a world when you specialize in something, as I think, especially as a midwife, you find yourself having to just get on your soapbox over and over and over again just to get heard by a small number of people. But here we are on this podcast. This is a great opportunity for both of us. I have so many questions but I'm gonna try to stay organized because I think that we need to start with a bit of a primer on diabetes for our listeners because diabetes terms are super fricking confusing.

Like they are, What does it mean to be a prediabetic? How is that different than being a pre gestational diabetic? And like these words that kind of overlap and people get really, really, really confused. Yes. I think I have a decent handle on this stuff, but clearly I, I have a lot to learn from you as well. So I would love it if you would take us through the definition, but feel free to add in, you know, some tidbits that you think are really critical to go right alongside the simple definition so that people get where we're going with this conversation.

Jessica:

Sure, sure. You are right that the terminology is really confusing. I chalk it up, of course, to the fact that some of the names were provided through OB brains and some of the names were provided through endocrine brains, and they sort of didn't realize their overlap plus. Mm-Hmm. <Affirmative>, they were happening at different times. So segue to prediabetes, which is the most common of all the terms I can define, however, it's the most recent. So when you say pre diabetes was existing along before prediabetes and then prediabetes sort of through that, that, that terminology just was thrown in there very recently. So okay, prediabetes is blood sugar that begins to be elevated, but without the diagnosis of diabetes. What does that mean? It is defined as an A1C between 5.7 and 6.4. And I usually tell people, clinicians, but also, you know, people to actually learn those two numbers because 5.7 and 6.4 being the prediabetes range tells you automatically what is the diabetes range at 6.5, What is the normal range at 5.6 and below?

So prediabetes is 34% of the adult population in the United States. So one in three people has prediabetes in the United States. One in 10 people of that group do know are, are aware, right? So nine out of 10 people in that group are unaware. That's the most recent of the CDC numbers and probably that is improving, but we will not know that for a few more years. So the good news about prediabetes is that it is reversible manageable through the only things that have been studied. It's probably manageable through a lot of different things, but the things that have been studied are loss of five to 7% of body weight, which is often not a lot and 150 minutes a week of exercise, which is easy to say and hard to do, right? <Laugh>. But those are the two things. Nobody said anything about food or stress or sleep, but those are the two things that have been dei in relationships. So the next thing we can define

Tanya:

Before you go on, I'm actually gonna throw a monkey wrench in here and say, I realize that there's another term that doesn't sound as similar, but that I think requires some mention here because it comes up a lot in this realm, is insulin resistance. People are hearing this a lot. And then there's, I, I don't wanna go down this rabbit hole, we can do it on another episode if you're down for it. But when we think about polycystic ovarian syndrome and we talk about insulin resistance, those are times where those words kind of come together and I think people are hearing them. Can you define what that means for people and why that's different then prediabetes or if anyone who's prediabetic might also be insulin resistant or not? I'm kind of thinking that that's a place where people get confused. A second thought and then I'll shut up again, is I think people think that when they, they hear that they're prediabetic, they're like, Whew, I'm not diabetic, I'm fine.

Tanya:

Think people think that I can't swear to it, but I think that's a thought process. And am I, am I onto something or not

Jessica:

<Laugh>? I hope not. I mean, I hope that people don't think it's nothing. It's something I mean there's a lot to say. An A1C that's very slightly elevated can certainly stay that way for years and years on end. And that's not as much a concern. Flagging an A1C at 5.7 to 6.4 is like saying, Let's watch this and let's do these things that we can do to prevent it from progressing. And in addition to the two I mentioned, there's also metformin, which is, is getting to be used more and more often for prediabetes.

Tanya:

So I guess I should say that's the problem I think on the medical side of the equation is I think I hear, let's watch this a whole lot more than I hear. Let's do something about this mm-hmm. <Affirmative> and that's why people walk away going, I'm okay. They said, let's just watch it. I guess that's kind of where I was coming from when I said that. Right,

Jessica:

Right. It's true. It's true. And it probably needs to be altered and at least a discussion that is a little bit more, I don't know what the word is, serious. 

Tanya:

Yeah. Well I think what's happening is doctors, providers in general, we have a tendency to want to like smooth everything out, make sure we don't freak someone out. And I understand that's coming from a really good place, but sometimes in doing that we paint a picture that's like, Oh, okay, I thought you were gonna say something scary, but then you made it sound okay. And Oh, I'm fine. That's kind of the ramification of smoothing it out.

Jessica:

Mm-Hmm. <affirmative>, I agree with you and it's true. There's a discomfort I think that some providers have in making people feel not great when they leave the room even.

Tanya:

Yep, yep. Yeah.

Jessica:

So it's an important distinction and it's important for people to know that you don't want this to progress and there are things you can do to prevent it from progressing.

Tanya:

Okay. So how does that relate to insulin resistance

Jessica:

Real quick, like insulin resistance? Okay, so insulin, there's two ways basically physiologically to reach a state of higher blood sugars, and those are insulin resistance and lack of insulin production. Typically in a picture of developing what is typical is type two diabetes. I mean, using the word type one diabetes. Yeah. But in, in the development of type two diabetes typically starts with insulin resistance, which has many, many causes. Physiologically, which we're not gonna have time, I don't think to no get into, let's not do

Tanya:

That. <Laugh>

Jessica:

Fat, fat, fat cells and, and things like that. So insulin resistance means you are making insulin, you are not using it well because you have elements in your body through inflammation with fat cells, through these things that, that prevent insulin from binding to insulin receptors at an efficient rate. And when it, when that binding happens, the insulin can leave the bloodstream and the blood sugar lowers. So that happens first, which is, and, and this is where like checking insulin levels comes into play in the PCOS picture. But, but, but the point is the insulin starts, insulin production starts to increase in the context of insulin resistance. That's the first feedback mechanism that the body has. So what happens is if you make more insulin, the blood sugar will get lower because there's now more insulin present, even though there's insulin resistance. Then at a certain point after, usually for type two diabetes years and years, insulin production starts to become a problem. And then the blood sugar can no longer stay normalized because you, Yeah. The resistance there, you need a lot more insulin and then you can't produce enough because there starts to be a problem with beta cell insulin production, if that makes sense.

Tanya:

I think that is sufficient for the moment on some other magical day. We can carry that conversation down the fork in the road, but you said the part I wanted you to say, which is that there's a relationship between insulin resistance and ultimately becoming pre-diabetic. And it's kind of like, maybe I'm oversimplifying too much. There are some stepping stones here, but not with all the terms we're talking about. It's like insulin resistance, pre-diabetes type two diabetes. Right. Those stepping stones go together. There's other pathways when it's type one, of course it's different. And then of course when we're talking about pregnancy, there is a relationship, but it's more of a side by side relationship. Right. Rather than like stepping stones. So, Right. I'm just trying to give people a way to visualize these terms rather than just seeing them as like a list that they're supposed to be able to make sense out of.

Jessica:

Right. Right. I think that was a good segue into what we've now defined as type two diabetes, right. In this process. And that is becoming more common has been becoming more common for years, right? So that is actually one in 10 people in our country and one in four are unaware, which is really a large awareness of these things gives midwifery and OB a tremendous opportunity because many times people are seeing midwives seeing OBS as their first line primary care. And so I always encourage people to have A1C at the first prenatal visit in order to find that group who's come to care because of pregnancy. But we know one in four people don't know they have type two diabetes one nine outta 10 people don't know they have prediabetes. So if you put, if you do an A1C at first visit or if you have an A1C at your first prenatal visit, you're gonna find out who's who and not wait for gluco screening, which is much, much later in pregnancy.

Tanya:

Okay. So then there's also the conversation of who should have theola screening at their first or maybe shortly thereafter visit.

Jessica:

Right? That is a whole nother conversation. So that is gestational diabetes screening the way, So, so if you at the first visit, then the a1c, then you've put prediabetes and type two diabetes either on or off,

Right? Because you either have an elevated A1C in the diabetes range, you have an elevated A1C in the prediabetes range, or you have a normal a1c. So you've at least kind of segregated those three groups. Then for the people with diabetes range a1c, you're not gonna give them glu. Instead they can check fingert sticks, they can do all the things that hopefully get a continuous glucose monitor, all the things that can be <laugh>. I know, I know. You and I will have to talk about that at some point this conversation. Yep. Yes. so people with that pre-diabetes range, A1C then should, even in the absence of other risk factors, which we'll talk about it in a moment, should get early glaucoma screening because right, they're coming in with some element of higher blood sugars and then there's the group of people for risk factors, even if the A1C is normal.

Tanya:

But I feel like that's another big, here I am just like, you know, tearing apart our medical system, that's the next big, It's just not done. I can't tell you how many times I've come across people late in pregnancy and I take their history because I'm gonna help them through postpartum and I'm like, Ro row, this person should have had X, Y, and Z.

Jessica:

Right? It's

Tanya:

Crazy. Why can't we get with the program? What's the problem?

Jessica:

Well, I think the list is pretty long. So what I encourage people to do is instead of trying to remember what's on the list of risk factors, and this is not to over people, please have any risk factors, it's every other way around because almost everyone has risk factors, right? So it's elevated bmi, it's a history of any kind of dysglycemia, any kind of elevated a1c, any kind of elevated blood sugar on a chemistry and any kind of gestational diabetes in the past. P C O S is definitely a risk factor. First degree family relative, although two second degrees probably as, as well lack of physical activity is its own risk factors. So there are many, in, in, in my world there are more. And so I do encourage people to, instead of thinking what are the risk factors? I mean, you should think about those anyway, of course mm-hmm because they have many ways that you can address them, but it's a, a think who doesn't need to have early glucola? I think most people do or can benefit from, from having it. So we have gone into gestational diabetes without really defining it. It's actually defined as any high blood sugar that is recognized in pregnancy. So, and I will say it is caused by hormones specifically, and most commonly is caused by progesterone

And placental hormone. The third trimester, which is why the standard time to use the colon to check for diabetes is between 24 and 28 weeks. This is if you have gone through the whole beginning part of pregnancy without having risk factors, without having early a need for early screening. And if you did have early screening and it was in range, then you would have it again at the time that the placenta is rapidly growing between 24 and 28 weeks. So that, and I would say though, people who have it early, I would call if they have a normal a1c, I would call that early onset gestational diabetes, not prediabetes. Okay.

Tanya:

I totally,

Jessica:

I mean, and not past, I'm sorry, not free gestational diabetes. Whew. I'm sorry, I even like messed up my own terminology.

Tanya:

Say it again because then I think I have a leg. No, I want you to repeat it so that it said clearly, but I think I have a question as a provider for you, like I'm raising my hand at a classroom.

Jessica:

So gestational diabetes is high blood sugar meeting criteria for diagnosis of hyperglycemia and pregnancy. So, I call it early onset gestational diabetes when I find someone in the earlier part of pregnancy, presuming they have an normal a1c that is not pregestational diabetes, that is early onset gestational diabetes.

Tanya:

All right, So here's where I'm running into some trouble and maybe I'm operating on some old or inaccurate knowledge. You are being very intentional about not attaching gestational age to what we would call we haven't defined it yet. Sorry guys. We'll get there. A pre gestational diabetic or a gestational diabetic. Whereas I feel that I've always known in air quotes, whatever that means. However, I came to this knowledge that if we diagnose high blood sugar prior to 24 weeks, then that person was very likely a pregestational diabetic and we missed it. That's what I was always taught. And so that's why I've always been neurotic about being that person to figure out who needs proper testing early. Cuz I don't wanna live with the uncertainty of what someone is or isn't. Am I making sense?

Jessica:

Yes. And I've definitely heard that and know that to be a philosophy. I think my philosophy is if you have an A1C at the first visit, you put people on the map of whatever is preexisting. So they either have no pregestational hyperglycemia. If the A1C is 5.7 and below they have pregestational wait for it. Pregestational-prediabetes, woo. Pregnancy, you, you can't make it up. Nope. It's, it's pregestational prediabetes. If they have an A1C at 5.7, 6.4 in the first trimester, or I say both for 20 weeks. Okay. And then but I, I mean I might have made that up. I don't know exactly where that moment is, where we take that A1C and say it's part of the placenta.

Tanya:

I don't think we have to know where it is. Right. I think it's okay to live in the gray. We, midwives are very comfortable living in the gray. I think the place that's most critical is if we see evidence of something early in pregnancy. I'm not even gonna try to define what I mean by early, but if we see evidence of it, we have to say, this didn't just turn on like a light switch. It has been there. Therefore it is very likely pregestational not being caused by the stress of the pregnancy. So while I'm at it, I'm gonna say out loud, and you can always tell me if I'm saying something wrong, cuz this is not my absolute expertise, it's just my interest. I, you know, this, what happens in pregnancy is that pregnancy is inherently a state of becoming insulin resistant even for the most healthy person. And that's something people need to understand.

Jessica:

Yes, yes, it is, it is. It's, it's such a good point. It is. Everything that happens with glycemia and pregnancy has to do with insulin resistance and has to do with the placenta is what it is. I mean, unless you wanna say the corpus luteum that's producing the hormones for the first 12 weeks, Right. That that is actually for people with type one diabetes, that is actually an issue when that corpus luteum dissolves and before the placenta takes over, there's an insulin sensitivity opposed to insulin resistance. The opposite is insulin sensitivity. That is this dip between 8 and 18 weeks when the corpus luteum is gone and before the placenta is starting to take over.

Tanya:

Meaning you need less insulin at that time as a, as a, as someone with type one diabetes.

Jessica:

Yes. Everyone technically does

Tanya:

Everyone I got it.

Jessica:

But all the other bodies are magically just not producing as much. Right.

Tanya:

They're just dealing with it on the fly and we don't really have to think about it. Got it. Yes. Okay. Cool. Cool, cool. All right. I'm gonna, I, I promise to shut up for a few minutes and let you

Jessica:

No, no,

Tanya:

Go back to Pregestational diabetes and I'm gonna try to behave myself. 

Jessica:

Okay. No, no, no, no, no. I love your, your really good at your questions and you're really helpful to somebody who sometimes can I can go off. No,

Tanya:

I think you would be very organized if I would just shut up.

Jessica:

<Laugh>. No.

Tanya:

Carry on.

Jessica:

Okay. Okay. So then type one diabetes, which is, is the one that you're gonna most rarely run into is, is the least common. And it is unrelated in a certain way to all the other diabetes because it is an autoimmune disease in which there is a genetic disposition followed by a cascade of antibodies being produced. And there are antibodies that attack not a very medical term, the beta cells sort of all at once. And there is typically something that happens in childhood, although 50% of people diagnosed with type one diabetes are diagnosed in adulthood. So we don't use those terms anymore of mm-hmm. <Affirmative> juvenile diabetes or insulin dependent diabetes, we don't use any of that. It is type one diabetes. 50% of people get it in childhood and 50% of people get it in adulthood. It is still the least common though. It's becoming more common. A big mystery <laugh>,

Tanya:

What, what is the earliest age that someone becomes noticeably a, a type type having type one diabetes

Jessica:

Having type one diabetes? It can be as it in a few weeks to months old.

Tanya:

Oh, it can be that early?

Jessica:

I mean, there is neonatal diabetes, but it is usually not type one. It is usually a different, cause I only know this type of unusual diabetes from working in a diabetes specific practice, but in general it can be in, in a few months. And usually those babies are born with antibodies already. So but I think the most common time is actually I wanna say 14 is the peak. It's like pre, it's like pub puberty really is the most common time where it peaks and then it sort of declines. So in any case, Pregestational diabetes, which I also think was poorly named because it really takes away how people called themselves all their lives and they become, they have to take on a new name when they become pregnant. But really it is either pregestational type one diabetes or Pregestational type two diabetes. 

Tanya:

Yeah, it's it's totally redundant. It's totally redundant. Yeah.

Jessica:

I think people wanted to put it all in one category, which, you know, people with type one diabetes don't like that, but in any case, people with type two diabetes probably don't like that either. And it's, it's not appropriate. But in, in obstetrics the name of the game is the blood sugar. And so for them, us, them <laugh>, it's like simplifying it by just saying, Okay, this person had diabetes before we met them. The goal is normal, normal blood sugar. It doesn't matter what kind of diabetes they have, but it should be said that the complete diagnosis in pregnancy is pregestational type one diabetes, pregestational type two diabetes.

Tanya:

I've got one more question.

Jessica:

Yes.

Tanya:

We’ve been defining these particularly, you know, the categories of prediabetes and type two diabetes, excluding type one from this comment by A1Cs. Can we also define these by glucose levels? And why or why not should we think that way?

Jessica:

You are so clever. I could answer that question in two minutes or in two hours. 

Tanya:

I'll take the two minute!

Jessica:

So that'll be, try the two. I'm gonna try, It's gonna be hard. This is such a good question. A1C has existed for probably close to 30 years. It was only adopted and used to define prediabetes in the last less than 20 years. Less than 20 years. Up until that point. Blood sugar numbers, blood glucose levels from blood drawn from someone's arm in the lab was what was used. And people were ta fasting was done, people were given the glucola drink and then blood sugars were checked, blood sugar was checked at two hours. This is the same test we use for postpartum people who had gestational diabetes. Mm-Hmm. <Affirmative> that between four and 12 weeks they should have that test. Why? Because the A1C is not relevant when you've just had normal blood sugar for the last many weeks of your pregnancy. So the A1C is gonna pick up that time period and is not relevant in the context of acute blood loss, which happens at birth and various other things. So that, those are the two main ones though. And why we need to use actual blood glucose tests and glucola for the postpartum people. And yes, that can be used as a way to diagnose both prediabetes. And there are numbers for this very, I can tell you what they are, but it doesn't really matter. There are numbers for prediabetes and there are numbers for overt diabetes for both the fasting and the two hour. There's no one hour fasting and two hours it's not used because it's a lot easier to do in a1c. That is the reason it is not used. And you don't have to have people come in fasting, they don't have to drink the cola et cetera. However, more people are diagnosed using the actual blood glucose levels and the glucosa, which is called the OGGT, Oral Glucose Tolerance Test then with a1c, if that makes sense. So with, there are a certain group of people that you might do that on if you are very much thinking they might have diabetes, but their A1C is still normal. That's very small number of people though. I don't want people to go down the rabbit hole thinking about that.

Tanya:

I think what I'm thinking about to make this a little more practical when it comes to whether we're talking about preconception care or interception care or just straight up primary care for the years not having babies <laugh>, is that I'm thinking about the tests that are routinely run on just about everybody who seeks out basic primary care. And most people will have some blood work done fasting, and that's primarily to get a handle on our cholesterol levels and check out what your fasting glucose is. So if somebody goes to their primary and they get a fasting glucose and a hemoglobin a1c, what should their care look like after those results are back if they aren't perfect?

Jessica:

Mm. Such a good question. And that, that does happen actually quite a bit. That does happen quite a bit that people will throw in a complete metabolic panel with a lipid panel on someone who's fasting and that that fasting blood sugar could be, you know, 101 mm-hmm. <Affirmative> and the A1C is 5.6 mm-hmm. <Affirmative>, is that of concern? I think it's an overtime question. That's my quick answer. I think it's an overtime question. Okay. It's like, all right, that's interesting. I don't think that means get a cgm. Have people gotten a CGM for that? Yes. Continuous glucose monitor as a cgm. How have people checked blood sugars after they saw that? Yes. People have. Would that be recommended on a population level as a useful thing to do? Probably not. I would look at the person's hemoglobin and hematocrit to make sure that they're, they don't have like some really significant anemia that might lower the a1c artificially. I would probably do that. And also, like there's, there's various other things that, that can lower an a1c. If you were really concerned, then you could do an OGTT and have them come back again, get a, you'll get a second fasting number, then they'll drink the glucola and they'll see what the number is at two hours. If it's in that 100 low one hundreds, I mean that is pre-diabetes through a method of, you know, it's not a method, it's, it's called impaired fasting glucose. Mm-Hmm. IFGmm-hmm. So that is a thing. What can you do about that? Probably…

Tanya:

Lifestyle. Lifestyle, lifestyle.

Jessica:

Sky is the limit. Yeah. If you're stressing over that result, I would say, the better use of your stress is to probably take a look at the lifestyle issues. And the things I tell people in pregnancy, and this is segueing into a whole other conversation, but many, many people have just that the elevated fasting and, and in some ways because they're eating, you know, they're eating relatively well in pregnancy, they don't have huge jumps in numbers after food and they just have that elevated fasting and the things that can help that are really evening earlier, having a longer fast. We know about intermittent fasting. Right. That's a thing. It doesn't have to be intermittent fasting, like your fasting for 18 hours. It could be for you just maybe it's 12 hours that you stop eating a little earlier and then you let that fasting come down. Exercise, of course, good sleep, sleep cannot be underestimated as a factor specifically in, well I don't know it's specifically in, in all blood sugar, but it's, it is a factor in elevated fasting to have poor sleep.

Tanya:

Yeah.

Jessica:

It's also a factor in the other numbers because when you're sleep deprived, you wanna eat differently and eat more and, and the blood sugar will also be higher after food, but it will definitely be higher fasting with poor sleep. So those are some basic thoughts that you might be, might be worth considering.

Tanya:

I love that. In, in my postpartum program, when we're wrapping up at our last visit, one of the final things I talk to people about is their healthcare from that point on because I find that the time that people accidentally opt out of routine preventative care is postpartum because they were just seen so many times and then they had that postpartum visit and they just don't even know where the reset button is, right? So I talked to people about, well, when did you see your primary care physician? If you have one or a primary care nurse practitioner or whomever, midwives, whomever. When did you see that person for the purposes of sort of a primary care, preventative care check in? And I get them to think about it and then regardless of what the answer is, right, depending on when it was and what they can remember and where we're at with their care at that, you know, 12-ish weeks postpartum point, we find the appropriate point to say, this is probably when you should put on your calendar now that you're due to go back in and get all these things checked out. I just wanna get people on a pattern of awareness. So one of the things you started out talking about is the sheer number of people that don't know, and I actually wonder if you can unpack the reasons people don't know more, Right. I'm assuming making some big assumptions here, but that I think are probably correct, but there's just probably more to add. It's access to care, it's poor care, It's all the things. But so tell me more about that, because our goal here is to get people to find out where they stand in this spectrum.

Jessica:

Abso- I'm nodding my head since you can't see us, I'm nodding my head rapidly here. Yes, yes. It's so important for people not to fall off after they have a baby. And it is the easiest time for them to do that. They have a newborn, they're taken care of, they're stressed. They have all the things, they have things they probably put off because of pregnancy and it, this is so, so common. I would say that, I mean one of the things I've done to address it specifically is I have a video visit at three weeks. This is in the public hospital world, which I so appreciate what you do, Tanya, because it's like you're there for people to remind them of that. But I don't think there's much of that in place. So is having a video it did at three weeks remind and and it depends on the person. There are many people that I see a number of times after that who I, I'm worried about them falling off and so I'll make another appointment in four months or so to just call them and check in. But, but at every single time we talk about what can be done to, if the person has gestational diabetes, what can be done to prevent the development of type two, which we know is at least 50%. It's hard to really get good numbers on that, but it's at least 50% of people with gestational diabetes go on to develop type two diabetes. So how can you be in the 50% that does not? And the most bait, we get down to super basics at that visit because there's so much going on and we're talking about breastfeeding and, and contraception and stitches and bleeding and blood pressure. And we talk about not drinking your food. I can't believe I've gotten this far without saying that I am a big believer and do not drink your food, eat your food. Your food needs to be chewed, starting in your mouth so that you can start the physiologic process of digesting it in a producing insulin. But that

Tanya:

Well also, let's, let's unpack that. No, I think we should unpack one second. <Laugh>. I'll say one thing and then you can add another thought and we'll like leave it at that

Jessica:

<Laugh>. Okay. Okay. Okay.

Tanya:

I think people need to know why because it's such a great point. And people in I think instinctively go, Oh, oh, okay, I get it. But then if they thought one second longer, they might not be able to answer the why on that. And the why is fiber, fiber, fiber, fiber.

Jessica:

<Laugh> fiber, Fiber fiber. Yeah.

Tanya:

Juice your apple and you only drink. The juice of the apple. You just got hit with a massive amount of sugar. But if you eat the apple, the fiber offsets the sugar. That's the simple way I'm gonna put it. You wanna add something to that?

Jessica:

Yes, yes. Well, and in addition, I do think there's a process of, of where the food physically hits in your body. If it's starting in your, in your esophagus, you know,  youve knocked out your system and your possibilities of, of getting the insulin production going. I think if you're chewing, first of all that apple takes a while to chew and the saliva, I'm not an expert- But you know, the saliva is produced and it signals that there's food coming, right. It is an enzyme of, of your GI system that is starting the process and the insulin production is related to that. So it just gives more time for the body to do what it needs to do to produce the insulin it needs to produce, even if the exact same amount of insulin, even if you don't have, which it's not cuz you have the fiber that it, it's a timing issue as well as the fiber issue and the reduction of carbohydrate issue. So it's super, it's, it's like the one most important thing. I think otherwise if you do so. I mean they, people learn so much during pregnancy with gestational diabetes. There's no way it's sustainable. And so I'm always thinking about what is sustainable. Even in the, even during pregnancy, what is sustainable? Small, small changes for big results. Small changes for big results. So much can be done with such little change.

Tanya:

I love you.

Jessica:

But if you do one thing, it's that

Tanya:

<Laugh>, I agree with you. It is absolutely the first change I encourage people to make. People should drink almost exclusively water and it's okay to have some coffee and an occasional glass of whatever. Like that's kind of where I leave it with people. Yeah. But like, so doesn't juices you gotta be done with those because not only this whole process that we just talked about, about fiber and insulin, yada yada, liquid calories end up accounting for some of the excess weight that contributes to this. Right. So when people are coming from the mindset of weight loss, which often overlaps with prediabetes and type two diabetes, we can kill two birds with one stone here. I mean it's just a beautiful thing. So anyone listening who's trying to start this journey, this is probably the most critical take home message is don't drink your sugar or your calories.

Jessica:

Yes. Yes. It's like the only non-negotiable and you know what another opportunity is with it. We don't, we can't change the genes we have in our body. Diabetes is genetic, all diabetes has a genetic component. All of it. Yep. And we cannot change that except to not have children. If we're going to have children, we're gonna give our genes to our children. What we can manage is what's in our kitchen. We can't even really manage what's at school or what's at a birthday party, but we can show our children what's in the kitchen and for children to not drink juice and not drink soda is gonna prevent diabetes type two diabetes specifically in them. And that's huge. And not to mention the other things having to do with drinking a lot of calories, which is, you know, weight, weight issues and things like that. So critical if you have energy left in you, then you can talk about moving your body, which is what I, that's my second thing is like find some way, and it doesn't have to be any specific way at all. People don't have to leave their house to move their body. You can put on one song. I used to say two songs. There was something in, I haven't read it, The New York Times this week that talked about two minutes, Two minutes of moving your body after you eat affects your blood sugar two minutes.

Tanya:

Oh absolutely.

Jessica:

It is this minimum of 10 minutes, two minutes.

Tanya:

Yeah. I mean, so

Jessica:

I agree

Tanya:

With you.

Jessica:

It’s a phenomenal opportunity. It is phenomenal opportunity.

Tanya:

I I would love to, I'm I'm gonna look for that because any time I can lower the number I use, I feel like I might have another leg up on success here. Right. Right. Cause I've opted often for the, can you go for a walk after you eat each meal. Like even if it's just a loop around the block, but like, I don't actually know how long it takes somebody to, you know, get outta their apartment and walk around the block and come back and get settled. It ends up probably feeling on. Yeah. It's more disruptive than I give credit to when I say that as if it's easy and I know that. But yeah.

Jessica:

So I, so in that visit, that three week visit, I mean the other piece of it, okay, so don't drink your food, move your body breastfeed if you can for one year. We finally have shown what is so logical about that because we know about the metabolic state of breastfeeding. Right. it is very similar when you think about it in terms of blood sugar. It is like you are on the treadmill basically for the entire time you're breastfeeding, Right. In that metabolic state. And so it has this positive effect on blood sugar. So we finally showed on a population level, this was at Kaiser in tens of thousands of people that the reduction of type two diabetes that happened after people breastfed for a year. So that one. And then seeing a primary care person and actually making that appointment for them because following up and making sure that, and understanding what is the a1c. Always mention that you had diabetes in your pregnancy to your primary care person, so that they know to check an a1c and the official guidelines is between one and is they're more likely to have it done within three years. But to follow it, because I have now been doing the perinatal diabetes long enough that I've seen people come back with their second and third pregnancies and babies and very, very often they have gone from having a perfectly in range A1C to a much higher one. Most often I would say.

Tanya:

So now you're touching on, this is like semi unrelated thought, but I think you'll get where I'm going with this. There's also all this hard data that, you know, we gain a little bit of weight with each pregnancy on a population level that we can't get rid of. So, you know, when somebody has their first baby, even if they're normal weight and they lose most of it, it's very common for someone to never see the weight that they were before that first baby ever again. And then we see that happen with consecutive pregnancies. So in the ballpark, I don't have the research memorized or handy, but in the ballpark of retaining five pounds from each baby and that's gonna be a contributor over the long run. Which hearkens back to what you said before that something as simple as, and I oversimplify just by saying it that way, but of losing 5 to 7% of body weight can get you back out potentially of that prediabetes stage. Imagine what we've got going on when we've got an aging process happening and when we've got childbearing sometimes repeatedly happening, it's sort of a double whammy. Right?

Jessica:

Yes. You want, And the third whammy in, in the context of right now is covid. And what we are seeing is much higher rates of, actually, I don't, I'm sure type two diabetes is in the equation somewhere, but much higher rates of gest diabetes and higher rates of type one diabetes since covid. So we can attribute some of that to, of course in activity and the overall weight issues that people have had to struggle with during this time. And I don't know what explains the type one diabetes thing, but it's a third, it's another thing that it's really currently a problem.

Tanya:

Wow. That's, it's really interesting because it, you know, it makes me think about how varied long covid can be and all of these things that we don't yet understand and it just kind of feels like it fits into that very broad bucket. 

Jessica:

People need more support.

Tanya:

Oh yeah.

Jessica:

You know, people need more support. I mean, I fantasize about having more group care and postpartum care. We're actually working at my public hospital and having a lifestyle medicine practice and be, you know, there is a lifestyle medicine certification that I'm planning to do, but, but to have a lifestyle medicine practice that can specifically, specifically serve people after they've had any kind of diabetes in pregnancy so they can continue to have the support, they have tremendous support during pregnancy. And then our example is even though we're telling them to continue to take care of themselves, we're not there for it. So we're not there giving that support and we need to be, and so we need to have intensive lifestyle management options and support for people after they are pregnant in between, not even talk about pregnancy, the adult needs this, you know, so it is, it's really important and I'm inspired to get involved in that.

Tanya:

Well, on that note, I would love it if you would tell everybody a little bit about the work that you do on your own outside of your, you know, full time job in the hospital system cuz you're doing some really beautiful work and you're flexing your entrepreneurial muscles and these are the midwives that I'm so happy to have in my life because you guys understand, you know, kind of what it is I'm going through and I understand what you're going through. So tell us all a little bit about what you've been out there creating.

Jessica:

Oh, you're too kind, Tanya. My, my entrepreneurial muscle is like I'm picturing like the one neuron in it, tiny little muscle that really needs to go to the gym. So I, it was born out of really the undeniable need to serve people with type one diabetes who still don't have what they need. And I, there's no one else really to give that to them. I am uniquely in a position to do that. And so we do a group for 12 weeks that involves them meeting each other and we have topics week by week. And then I have one on one sessions with them as well. And then we incorporate them with a larger group of mamas with type one diabetes who have been through the whole process before. And it is it's a, it's an amazing thing to bring people together like that because the groups are, are very validating and very few people have had the experiences we've had. So it's a special thing. And in addition, I'm working on some education that is gonna be online for people with gestational and type two diabetes, which we know is also a big group of people who are at times searching for additional services that are missing from, from the standard medical care. And it really is about being holistic and looking at a whole person. So it's more than just high risk OB and endocrine, as I started to say at the beginning. It is about where people are in their mindsets, where people are as far as their basics of their lives, their exercise and their sleep and their stress and how we can work together to optimize things because every person can benefit from midwifery care.

Tanya:

Yeah, totally. I love that. We just keep saying that over and over again, <laugh>. But what you are saying that I think is really beautiful beyond like midwives are awesome, which is true. Is it's what you're offering is community ,support, education and healthcare kind of all wrapped into one. And that to me is the future of healthcare. That's so much of why I do things the way I do. And you're doing, you have a different unique and you have a narrow focus on something in which there is just such incredible need for someone to do what you're doing. But we can't keep putting healthcare in like, you know, a narrow lane and leaving out all those other pieces because it doesn't work. We've seen it over and over and over again over the decades. It doesn't work. You can't deliver just one…

Jessica:

I totally agree

Jessica:

I think of, I think of this visual image of here are the guidelines, which I will know and here is the clinical experience and here is the, the human being. And it's really finding where all those things overlap. Putting the human being at the center of course, but finding where there's a safety in, where the three things overlap.

Tanya:

I love that. I love that. All right. As we move towards wrapping up, I, we have hinted a bunch and I have in many episodes hinted a bunch and still just never really done it. Talked about this whole CGM thing, which I'm super passionate about. And you are too. So I think you're the right person to just take a few minutes and unpack who a CGM is truly indicated for and what people privileged enough to get their hands on one and afford one might do with it. And why, like, let's just have a little bit of a conversation around this because I think some people really get it. There are people out there that are like so super healthy and so super fit and they're obsessed with their CGM and you know what? Good on them. I'm glad you have the resources for it.

Meanwhile, I myself, just to be very clear, I have worn a CGM three times for two weeks each time because I can't afford it. Right? Like, and I, and I don't know if I've ever said this on the show, I have polycystic ovarian syndrome and I flirt with insulin resistance and anyone who knows me knows how much I exercise and how hard I work to eat well, and I still am on this, you know, place where I'm flirting with this. So my interest in CGMs is very personal. And yet I'm not one of those people that wears a CGM all the time, despite how much I like rave about the CGM. So I wanna put this on a continuum of like who really needs one and what the other end of the spectrum looks like when we are looking at the pinnacle of wellness, right?

Jessica:

Mm-Hmm. Such a good question. We're gonna hear more of these questions and more answers. I, in my, in my world, you know, I'm about barriers for people and I work in a world where people have not had access to CGM, who desperately, I it's desperately need, but would benefit on such a high level from CGM. And so I spend a lot of energy trying to bring that kind of private institution care to the public. And I can tell you that Medicaid the Medicaid plans are paying, they've changed their payment as of April of this year and are now being a little bit more lenient in terms of what they'll pay for. But historically it's been people on insulin, specifically on what's called basal bolus insulin. So basal insulin is for your basal metabolic state bolus insulin is for correction or for coverage of meals. So it usually means three, four injections of insulin a day was required to get CGM coverage.

That's hopefully gonna change so that more of that group can have CGM. As far as people who are not on insulin, I think it's about what can people learn from it. And there's a lot to learn. There's a lot to learn. There are many people who go on it for 10 days, 20 days, 30 days, and they see what happens in that time period and they see certain patterns just within that time period that they can then translate that into what they're going to do in the long term. And I think that's really, really valuable. One of the things that it, and so hopefully insurance will get to a place where they might say to, you know, everyone with pre-diabetes and A1C 5.7 to 6.5-4 could have a, you know, 90 days of CGM for example, and learn from it. But it takes, it takes help to learn from it too.

You can't just, it either takes a professional looking at it with someone, or better yet the person who's wearing it, taking notes on what's happening because you don't see, you can't see what's happening in someone's life just by looking at their blood sugars every five minutes. You have to ask how that coordinates with what they're doing. So it's more important for them to have the mindset that they want to learn what the effect is of what they do on, on their blood sugar. And then I think that it could be useful. I do think that we can't ignore the fact that the alerts and the alarms world is real. It's real. People who have these devices lose sleep, increase anxiety, increase things that are the, are counterproductive often to blood sugar. So if you're the type of person who is gonna be, you know, watching over it on a level that's preventing you from sleeping or that's causing you stress, then that might not be the right thing. And I know it's really hard to assess that in yourself. That self assessment is hard cause it's oftentimes those same people who think they're gonna benefit from it, I'm not saying I, I'm not doubting that they, I don't wanna doubt them, but who proposed benefit from it and yet might also have some negative effects of just the over attention paid to to it.

Tanya:

Sure. I get that. Make sense? It does. It totally does.

Jessica:

And it's not covered for them. So right <laugh>

Tanya:

And there, you already kind of said this without support, it doesn't help much. Which is why some of the companies that are out there, these health tech startups that are doing really cool things, it's the startup a little bit more than the device sometimes because without that intensive information and without treating, if you have to be really willing to treat yourself like a science experiment where you only have a sample size of one and you have incredible bias because it's your own body, right? So

Jessica:

Right.

Tanya:

You can run, what I talk to people about who are doing this is, okay, so we saw what happens when you eat this amount of this thing at this time of day having slept this much with this much stress and da da da da da. All the factors, just because you run that experiment again one more time, we still don't know all the things because there's the interplay of too many variables, stress, sleep, illness, yada, yada yada. So while it's super cool to sit down and watch and we can be like obsessed with data, it takes a long time and yet it's really hard to stay that invested for that long. So people I think have to be in a particular mindset when they're, people have to be in a particular mindset when they are gonna trial it for periods of time. You know? And I, yeah, and

Jessica:

It's also been shown that people like a normal, in a normal person, normal people have some high blood sugar sometimes. So, and that is perfectly tolerable to the overall systems of the body. And I don't want to, you know, say that everyone can be like, you know, two hundreds at times or whatever, but it's been noted that people go to 180 who do not have diabetes and who have normal a1c. So I would say it's more about, it might be more about the person who is in that prediabetes range to try to gleam some value in their relationship between what they're doing, what the blood sugar is, to try to cut those, those little mountains down a little bit,

Tanya:

Right? And what I want for the world is not so much that everybody is walking around wearing a CGM 24 7 for the rest of their lives, but rather something that looks a little more like it's, you know, that panel of blood work we talked about, that's the current standard. That maybe a two week use of a CGM and a motivated person who's willing to take notes on their activity and their diet can say two weeks prior to my yearly checkup with a provider that's well versed in preventative medicine, which is not the same thing as just saying primary care. I would like to put in the work and the effort to see where I'm at, at this age, at this weight, at this current lifestyle with how much I work and how much I sleep so that I can see if there's a tweak I'm willing to make to reach some…optimal level of wellness, whatever that is for someone, right? Right. I just want people to take the power back into their own hands and define what level of wellness makes them feel good about themselves.

Jessica:

Love that. Love that. Here, here. And if there weren't so many barriers, the other thing is like, it's, it's a real process to get these things.

Tanya:

Yeah.

Jessica:

So I wish there weren't those barriers for people because I think to get coverage is,

Tanya:

Yeah. But I think we'd have, you know, I hate the word compliance really, That's a horrible word. But I think we would see people doing better with the four times a day finger sticks or whatever the case may be if they just were wearing a CGM. Right. I think we could, yes, we could just do better in general for people because it's so much less taxing. Anyway, whatever. We could talk about this forever obviously, but I just wanted people to hear us kind of banter a little bit about the idea of it. Kinda get a sense of what it is and how we feel about it and why. And I'm sure that this is gonna be evolving greatly for both of us over the years to come as we start to see more data. Because again, these healthcare startups are well poised to give us a lot of data the next few years.

Jessica:

Yes, yes. And I, I look forward to it. I think it's gonna be helping a lot more people.

Tanya:

Yeah, totally. Anyway, is there anything else that we kind of skipped over because I was way too enthusiastic <laugh>, about talking to you that were like that you are, we're like dying to tell people and we just kind of were remiss. I wanna give you a chance to add anything in.

Jessica:

I mean I'm just, I'm thrilled to be here and be able to talk about diabetes that affects half of our population and I am thankful that you see it, how it fits into this much bigger lifestyle picture. Cuz I see it that way too. As much as I love insulin, I also think that the lifestyle piece is so important for everybody. So

Tanya:

Well absolutely. And what you just said kind

Jessica:

Of thank you for also acknowledging that.

Tanya:

Oh my pleasure. I'll make an analogy to what you just said and that is, it's kind of like saying midwives love catching babies, but we also really love preventing pregnancy when that's what someone wants, right? It's like you can have both at the same time, <laugh>.

Jessica:

Yes, yes, yes. I love that analogy. I love that analogy.

Tanya:

Well, I look forward to you creating more products and services and groups and all the things you're doing and I will be sharing you with my audience every step of the way cuz your work is so special to me. Thank you so much for taking the time to talk to me today.

Jessica:

Oh, thank you so much, Tanya. What a pleasure. And I will look forward to the same with you.

Tanya:

Awesome.