This post is part of our ongoing “Five Questions With” series, in which we interview a pregnancy health and wellness expert on their particular area of focus. Is there an individual or topic you’d like to see featured in “Five Questions With”? Send us an e-mail.

This month, we’re focusing on gestational diabetes. Today, we’re chatting with Lily Nichols, a nutritionist who specializes in gestational diabetes nutrition. Lily is a Registered Dietitian and Nutritionist, a Pilates instructor, and a farmers market aficionado. She is also the author of Real Food For Gestational Diabetes and the online program of the same name.

What is Gestational Diabetes?

If you’ve already done some reading on gestational diabetes, you might think this question has an obvious answer. But, I find that many women don’t fully understand what’s going on inside their body with this diagnosis.

In short, gestational diabetes is commonly described as diabetes that either first develops or is first diagnosed during pregnancy. However, it can also be defined as “insulin resistance” or “carbohydrate intolerance” during pregnancy. The second set of terms more precisely describe what’s going on in the body.

In a state of insulin resistance, a woman is likely unable to tolerate large amounts of carbohydrates in her diet without experiencing high blood sugar. And while technically all women experience some degree of insulin resistance during pregnancy, with gestational diabetes, your blood sugar has surpassed a certain blood sugar threshold that research has shown can increase risks for both mom and baby.

Did I do anything to cause gestational diabetes?

Not necessarily! Many risk factors for gestational diabetes are not within your control – things like family history of diabetes, your age, and heredity (genes) are examples of this. There are some modifiable risk factors – being overweight before becoming pregnant (or gaining too much weight during pregnancy), being vitamin D deficient, a diet high in refined carbohydrates, or not exercising regularly before or during pregnancy can all increase the risk of gestational diabetes. Then again, up to 50% of women with gestational diabetes have none of the classic risk factors!

Playing the blame game after getting diagnosed is inevitable, but usually not productive. What’s important now is to take care of yourself as best as possible, so you and baby stay healthy. Try not to get bogged down by Googling all the potential risks of gestational diabetes. Women with gestational diabetes who are able to maintain normal blood sugar levels are at no higher risk for complications with their baby than women who don’t have gestational diabetes. In other words, being proactive about your health is everything.

Lily Nichols Quote

How is gestational diabetes managed?

Unlike what you’ve read, getting diagnosed with gestational diabetes does not automatically mean you’ll be on medication or insulin. In fact, the primary treatment for gestational diabetes is diet and exercise. When those two aren’t enough to bring the blood sugar levels down to normal, doctors will consider insulin or medication. Sadly, the conventional nutrition advice for gestational diabetes often fails, as I’ll get into in the next question.

What’s wrong with conventional nutrition advice for gestational diabetes?

There are several problems with the conventional gestational diabetes diet, but the most crucial one is the unnecessarily high level of carbohydrates. When I first started working in prenatal nutrition, I was shocked to see the official guidelines for carbs in pregnancy. But, at the time, since this was the accepted norm, I implemented this diet therapy for my patients.

Sadly, many of them had worsening blood sugar and to our mutual disappointment, had to start medication or insulin in order to control their blood sugar. (Side note: Medicine and insulin are useful tools for controlling blood sugar, but I believed we could do more nutritionally before resorting to them.)

This left me wondering, “Did they fail diet therapy, or did diet therapy fail them?” After all, gestational diabetes is called “carbohydrate intolerance” for a reason. Carbohydrates are the primary macronutrient that raises the blood sugar, so why are we suggesting they eat lots of carbohydrates?

Note: Usually, the rationale is based on outdated information regarding ketosis in pregnancy. This topic is so complex that I devote an entire research-heavy chapter to ketones and the carbohydrate-pregnancy controversy in my book, Real Food for Gestational Diabetes and have advanced training on the topic in my online Real Food for Gestational Diabetes Course.

The short answer is that low-level nutritional ketosis is common during pregnancy, does not carry the same risks as starvation ketosis or diabetic ketoacidosis, and does not negativel impact the brain development of a baby.

How is your Real Food Approach for gestational diabetes different?

As you can probably guess from reading my answer to the previous question, my carbohydrate recommendations are different. I don’t believe there’s a one-size- fits-all diet for pregnancy nor is there an “ideal” level of carbohydrates for all women. As a result of my research and clinical work with hundreds of women with gestational diabetes, I’ve found most women (not all!) do best with less carbohydrates than conventional standards. BUT, the diet must be personalized to a woman’s blood sugar and activity levels. The quality and source of carbohydrates are just as important (if not more-so) than the total gram amount.

Second, I emphasize the importance of quality fats in a prenatal diet, rather than a low-fat diet. There are numerous nutrients found in fatty foods that are key for fetal development. This whole notion that “fat is bad” is extremely outdated, yet is somehow still endorsed by conventional medicine and most prenatal nutritionists.

A low-fat diet (or low-saturated fat diet) inadvertently leaves women deficient in a variety of nutrients, including choline, glycine, and fat-soluble vitamins. I cover why these nutrients – and the foods they are found in – are key to a developing baby in Chapter 5 of my book, Real Food for Gestational Diabetes.

Third, I emphasize a real food approach that embraces nutrient-dense foods, including animal foods (from properly-raised animals). It’s not just about eating fewer processed carbohydrates; it’s about replacing those foods with the right things. After all, inadequate micronutrients can lead to blood sugar issues (and a host of developmental problems with baby!), so we have to shift the focus onto real food from quality sources.

Are you interested in taking a deeper dive on this topic with Stephanie Greunke? Join our Whole Mamas Pregnancy Program today to get access to our exclusive webinar on gestational diabetes plus personalized answers to your specific questions.


Lily Nichols is a researcher, speaker, and author with a passion for evidence-based prenatal nutrition and a unique specialty in gestational diabetes. As a Registered Dietitian/Nutritionist and Certified Diabetes Educator, she is the first to advocate for a nutrient-dense, lower carb diet for managing gestational diabetes. Her book, Real Food for Gestational Diabetes, (and online course of the same name), has helped thousands of women have healthy babies – and most without the need for blood sugar-lowering medication. What’s now been dubbed her “Real Food Approach” is currently being used in several research studies. Lily is also creator of the popular blog, www.PilatesNutritionist.comwhich explores a variety of topics related to real food nutrition, mindful eating, digestive health, and of course, pregnancy.