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Welcome back to On Health, everyone! I’m thrilled to have you here today for a conversation that touches on something so many of us may never think about until we have to—gestational diabetes. But I want to start by asking you to reflect: how much do you think about the connection between what you eat and how your body feels, especially during pregnancy? It’s a question we don’t often pause to ask ourselves, but it can make all the difference in shaping a healthy future for ourselves and our little ones.
I remember when I first started practicing as a midwife—way back in the '80s—there was barely a whisper about how nutrition could impact pregnancy. I taught my first prenatal nutrition class in 1990, and the hunger for information was almost palpable. It’s amazing to me that, fast forward to today, we’re still facing a gap in understanding just how much food and lifestyle choices affect both mom and baby. But here’s the thing—there’s so much hope and possibility when we’re armed with the right information, and today’s guest has dedicated her life to providing just that.
I’m beyond excited to introduce you to Lily Nichols. Lily is a registered dietitian, nutritionist, and certified diabetes educator who is passionate about making pregnancy health both understandable and achievable. Her journey into this work is rooted in a deeply personal mission: she saw firsthand how powerful nutrition could be in preventing complications like gestational diabetes, and she wanted to share that knowledge with as many women as possible. Her books, Real Food for Gestational Diabetes and Real Food for Pregnancy, have helped countless women take control of their health during such an important time.
In today’s episode, Lily and I dive deep into some powerful truths about gestational diabetes—how it’s on the rise but, more importantly, how it can be prevented and even reversed with simple, mindful changes. We’ll talk about why so many women still aren’t given this information, how the right nutrition can truly change the trajectory of your pregnancy, and practical steps anyone can take. We’ll even touch on how blood sugar testing is done differently around the world—and why those differences matter.
Whether you’re pregnant, planning to be, or just curious about how your body responds to food, there’s so much to take away from this conversation. It’s about more than just numbers on a blood test; it’s about learning to listen to your body, trust yourself, and make small changes that have a lasting impact on your health—and the health of your baby.
So grab a cup of tea, settle in, and let’s get into this empowering and eye-opening conversation with Lily Nichols. I think you’re going to walk away feeling hopeful, informed, and ready to take charge of your health in a whole new way.
Transcript (edited for clarity and length)
Aviva: Hey everyone, and welcome back to On Health. I'm really excited to be here with you today, and I'm especially excited to bring you today's special guest. When I first taught a prenatal nutrition class, it was back in 1990. My first class was this group of childbirth educators—there were about 25 of them—and, no pun intended, they were starving for information. When I started midwifery in 1981 and into the early years of my practice, there was literally one book by one doctor, Thomas Brewer, that talked about prenatal nutrition and the importance of nutrition for addressing and preventing complications we’re often told are just things that happen in pregnancy, like gestational diabetes and preeclampsia.
So, I’m thrilled to have my guest today, Lily Nichols. She’s a registered dietitian, certified diabetes educator, researcher, and author with a passion for evidence-based nutrition, particularly for women’s health and perinatal care.
Lily's work is well-known for being research-focused, thorough, and sensible. She’s the founder of the Institute for Prenatal Nutrition, co-founder of the Women's Health Nutrition Academy, and the author of three incredible books: Real Food for Fertility, co-authored with Lisa Hendrickson-Jack (who I’ve also had on the show before), and Real Food for Pregnancy and Real Food for Gestational Diabetes. Lily’s bestselling books have helped tens of thousands of mamas and babies. Her work is not only in her books, but also in courses on maternal nutrition. She’s been so influential in academic and professional circles that her work has even impacted international prenatal nutrition policies.
Lily also writes a fantastic blog, and when she’s not writing or teaching, you can find her spending time outdoors with her husband and two children, gardening, or sharing her down-to-earth recipes on Instagram. Lily, thank you so much for being here today. It’s such a delight to chat with you.
Lily: Thank you! I’m so happy to be here. And likewise, I’m grateful for all your work and your incredible contributions to women’s health, and of course, for writing the foreword for Real Food for Fertility. That was such a treat.
Aviva: It was a treat for me too! I say yes to very few things, so that was truly an honor. All right, let’s dive in. We’re going to talk about gestational diabetes today. We have about 50 minutes, and I really want to dig in. There are so many reasons why this is such an important conversation. But first, why do you feel gestational diabetes is a compelling topic that we need to be talking more about? I know you wrote a whole book on it, and I believe you have a course on it as well. How common is it here in the U.S.?
Lily: Well, the statistics vary depending on the studies and diagnostic criteria used, but you’ll commonly see rates between 5-10% of pregnancies. When you use more stringent criteria, the rates can go up to 18-22%. This means gestational diabetes (GDM) is a condition experienced by many women, and it’s the most common pregnancy complication by far.
In some circles, especially in midwifery, I’ve heard people question if gestational diabetes is a real condition, or they say things like, “Blood sugar just runs a little higher in pregnancy.” And sure, the diagnosis and treatment can sometimes feel over-medicalized, which can lead to a cascade of unnecessary interventions, much like what we see in labor and birth. But despite these concerns, it’s important to recognize that gestational diabetes is a real condition. And what’s most significant is that how it’s managed can make a huge difference in pregnancy outcomes.
Aviva: I love that you said that because I totally agree. So often, a diagnosis of GDM feels like doom and gloom—it’s terrifying for women. They think, “My whole pregnancy is ruined, and now I have all these risks for me and my baby.” But, as you said, it’s more like the warning light in your car that goes off telling you something needs attention. If we approach it with the right tools—nutrition, lifestyle changes, and proper management—many women can have healthy pregnancies and healthy babies, despite the diagnosis. I’ve seen this countless times in my practice.
Lily: Exactly! It’s so important to remember that our blood sugar actually trends lower in pregnancy compared to when we’re not pregnant. So, when we see blood sugar start to rise, it’s a sign that something in the system is off, but it’s not the end of the world. With proper care, outcomes can be just as positive as in pregnancies without GDM.
Aviva: For those who might be new to this topic, can you explain what gestational diabetes actually is?
Lily: Gestational diabetes can be described in a few ways. One definition is elevated blood sugar that first develops during pregnancy. Another is elevated blood sugar that’s first recognized during pregnancy—meaning it may have been there beforehand but wasn’t diagnosed. And a third definition I really like is “carbohydrate intolerance during pregnancy.” This speaks to the body's difficulty managing higher amounts of carbohydrates without resulting in elevated blood sugar. This definition is helpful because it shows where the issue lies and what needs to be addressed in terms of diet and carbohydrate intake.
Aviva: Absolutely. And we know there are predisposing factors, like polycystic ovary syndrome (PCOS), which we’ll talk more about later. We also know that pregnancy changes how we metabolize blood sugar due to shifts in insulin, cortisol, and other hormones. This can challenge our ability to maintain normal blood sugar levels, which is why gestational diabetes can show up.
I’d love to hear your thoughts on why we’re seeing an increase in GDM diagnoses in recent years.
Lily: Well, universal screening for GDM wasn’t always a thing, so we’re catching more cases now. But we also have to consider the rise in blood sugar and insulin dysregulation in the general population. Around 48-52% of Americans now have some form of diabetes or pre-diabetes, and many cases are undiagnosed. The rise in GDM could partly be because we’re catching more cases, but it’s also due to an increase in processed foods, high-carb diets, and insulin resistance. One way we’re seeing this is through hemoglobin A1C testing in early pregnancy.
Aviva: Yes, let's talk about hemoglobin A1C. I use this test early in pregnancy because waiting until 24-28 weeks for the glucose tolerance test feels too late. By then, we’re halfway through pregnancy. What’s your take?
Lily: I’m a huge fan of using A1C in the first trimester. If it’s elevated—meaning in the pre-diabetic range—there’s almost a 98% chance the woman will fail the glucose tolerance test later on. I worked with the California Diabetes and Pregnancy Program, where we used A1C early on to identify those at risk. If someone has a high A1C in the first trimester, we treat it like GDM right away, giving us two-thirds of the pregnancy to manage it, rather than diagnosing it in the second trimester when we’ve lost valuable time.
Aviva: That’s exactly it. And I don’t want to scare anyone listening—whenever you get started with treatment, it’s great—but we know that by mid-pregnancy, baby’s development is already well underway, and the earlier we can catch and address GDM, the better for both mom and baby.
Would you walk us through what happens for babies when GDM isn’t well-managed? Let’s keep it real but not scary—what are the risks and why is early intervention so important?
Lily: Babies of mothers with GDM are exposed to elevated blood sugar, and since the placenta doesn’t filter out excess glucose, they experience the same spikes that mom does. This can cause the baby’s pancreas to produce more insulin, leading to a condition called macrosomia, or larger-than-average birth weight. This isn’t just about baby being bigger; it’s about increased fat deposition, particularly around the abdomen. These babies are at higher risk for birth complications, like shoulder dystocia during delivery.
Additionally, high blood sugar levels can affect lung development, leading to respiratory issues. After birth, babies can experience hypoglycemia, where their blood sugar drops too low because their bodies are still producing a lot of insulin in response to the high sugar levels they were exposed to in utero.
Aviva: And there’s also the long-term risk of insulin resistance, right? These babies are at higher risk of developing type 2 diabetes later in life because their metabolism was programmed in utero.
Lily: Yes, exactly. Babies born to mothers with GDM are more likely to develop insulin resistance and metabolic issues as they grow. This is why it’s so important to manage GDM effectively, both for immediate pregnancy outcomes and for long-term health.
Aviva: Now, let's talk testing. A lot of women ask about alternatives to the standard glucose tolerance test, like the jellybean test. What do you think about that?
Lily: There are different testing methods worldwide, and many countries use a simpler, single-step test that’s done fasting, which is more accurate. In the U.S., we do a two-step process—a glucose challenge test with 50 grams of sugar followed by a 3-hour test if you “fail” the first one. But the problem is, if you’ve just had lunch or a glass of juice before the test, your blood sugar might already be elevated, leading to a false positive. I also have issues with the unnecessary additives in the glucose drink. If someone wants to avoid that, there’s the Fresh Test, which is a cleaner option.
Aviva: And for those who eat low-carb, there’s a higher chance of a false positive, right?
Lily: Yes, exactly. If you’re on a low-carb diet, your body might not handle a sudden large sugar load well, leading to a false positive. Some people used to recommend increasing carb intake for a week before the test, but those guidelines have been dropped since most Americans eat plenty of carbs. However, if you’re low-carb, you might want to consider alternatives or just monitor your blood sugar at home.
Aviva: And continuous glucose monitors (CGMs) can be really helpful for that, right? With a CGM, you can track how your blood sugar responds to different meals in real time.
Lily: Absolutely. CGMs let you see not just the spike, but how long it lasts and how quickly your blood sugar comes back down. That’s really useful, especially for fine-tuning your diet and seeing what works best for you.
Aviva: Last question before we wrap up—let’s talk protein. What are your recommendations for
Lily: I generally recommend aiming for 1.2 to 1.5 grams of protein per kilogram of body weight. In later pregnancy, you’ll want to aim for the higher end of that range, especially if you have blood sugar issues. Protein helps balance blood sugar and keeps you full longer.
People are often surprised by how much protein they need. Most prenatal guidelines for protein intake are outdated and were developed before we had pregnancy-specific data. A 2015 study found that our guidelines missed the mark by as much as 73%. In reality, pregnant women need significantly more protein than those guidelines suggest, particularly in the later stages of pregnancy.
Aviva: Wow, that’s a huge gap! So, let’s break it down. What are some examples of high-protein foods that pregnant women can include in their diet to help meet these goals?
Lily: Sure! So, for some easy, practical options:
- 6 ounces of salmon or any fatty fish will give you about 40 grams of protein.
- A 3-ounce serving of chicken breast gives you about 21 grams.
- Eggs are a great option too—two eggs will give you around 12-14 grams of protein.
- Half a cup of cottage cheese offers 14 grams of protein.
- A cup of Greek yogurt can provide 20 grams.
- For plant-based options, half a cup of tofu will give you about 10 grams, and half a cup of cooked lentils or beans gives around 9 grams of protein.
So, it’s really about building meals where these protein sources take center stage. You can add eggs to a salad or smoothie or have a good piece of fish with roasted veggies. Small adjustments can add up and make a significant impact on blood sugar regulation.
Aviva: What are your thoughts on using protein powder in pregnancy? I know some women, especially if they’re struggling with nausea or food aversions, find it hard to get enough protein.
Lily: I think protein powder can be helpful as a supplement, but not as a substitute for whole foods. I usually recommend keeping it to one serving per day unless someone has really severe nausea or hyperemesis, and smoothies are all they can handle. It’s important to make sure the protein powder is high quality, free from unnecessary additives, and ideally organic. I like the NorCal organic protein powders because they source their ingredients responsibly, so you’re not worrying about things like arsenic, which can be a concern with some plant-based proteins, particularly rice protein.
Aviva: That’s such an important point. You want to ensure you’re getting clean, safe products, especially during pregnancy. I love that advice—use protein powders as a supplement, not a primary source of nutrition. So, before we wrap up, I have one last question I always love to ask my guests. If you could go back and give advice to your younger self, what would you tell her?
Lily: Hmm, that’s a great question. I think I’d go back to my early twenties and tell myself, “Don’t be afraid to speak your mind and tell the truth.” When I was younger, I think I held back a bit more, worried about stepping on toes or ruffling feathers. But now, I’ve learned that being honest and speaking up—especially when it comes to women’s health and nutrition—is so important. We need more people willing to challenge the status quo.
Aviva: That’s beautiful, and so true. Your work has made such a huge impact because you’re not afraid to tell the truth and bring a more holistic, evidence-based perspective to the conversation. Thank you for that, and for being such an incredible advocate for mamas and babies.
Everyone listening, make sure to check out Lily’s work. She has an amazing blog, books, and courses—there’s so much valuable information that can make a real difference in how you approach nutrition in pregnancy and beyond.
Lily, where’s the best place for people to find you?
Lily: The best place is my main website, lilynicholsrdn.com. There, you’ll find links to my books, free resources like a three-part video series on gestational diabetes, and more. I also help train practitioners, so for those looking to dive deeper into prenatal nutrition, I have a full mentorship program called the Institute for Prenatal Nutrition. You can find all of that on my site. And you can also follow me on Instagram—my handle is @lilynicholsrdn.
Aviva: Wonderful! Thank you so much, Lily. It’s been such a pleasure having you on the show today.
Lily: Thank you so much, Aviva. It’s been great being here.
Aviva: And thank you to everyone who tuned in to listen today. Be sure to check out Lily’s incredible body of work—her blog, books, courses, all of it is so packed with helpful information. And don’t forget to subscribe to On Health and leave a review if you’re enjoying the podcast. I’ll see you next time!
Aviva (closing remarks): I hope you enjoyed this episode and that it helped you feel seen and heard, and maybe even brought some “aha” moments your way. Please share the love by sending this episode to a friend or someone in your life who could benefit from the kinds of things we talk about here. Make sure to follow me on Instagram @dr.avivaromm and join the conversation, and to avivaromm.com where you can also sign up for my free newsletter for tips on taking back your health.
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