Dear Dr. Nicholson: I am finding it difficult to eat healthy foods during my pregnancy. With morning sickness and diabetes, I find I am eating erratically, sometimes a lot, other times not at all.  I’d like to learn about proper eating, diet and nutrition during my pregnancy.

Morning sickness refers to the nausea and vomiting that occurs during early pregnancy. Morning sickness is common; almost 9 out of every 10 pregnant women experience nausea and/or vomiting.  Symptoms usually begin at 5 to 6 weeks of pregnancy, peaking at 9 weeks and subsiding by 16-20 weeks (4^th to 5th month of pregnancy). Nausea and vomiting in any pregnancy can cause fatigue, marked changes in glucose levels, early weight loss and lack of energy. Among women with diabetes, these symptoms can be much more severe.  Wide changes in glucose levels can affect the health status of the mother. Low blood sugar levels (often referred to as hypoglycemia and blood glucose < 70 mg/dl) can make one feel shaky, have your “heart pound” or cause you to have dizziness or to pass out. Morning sickness does not usually harm the baby unless it associated with severe maternal weight loss due to the inability to eat a sufficient amount of calories.  Mild weight loss due to morning sickness is not harmful to the baby.

The cause of morning sickness is not completely understood. Some researchers suggest that it is due to hormones secreted from the placenta. We know that some foods can worsen the severity of nausea and vomiting. Fatigue, stress, and traveling are also thought to be factors affecting nausea and vomiting in early pregnancy.

If you are experiencing morning sickness, you can take several steps to reduce your symptoms and eat a healthy diet:

• Talk with your doctor about the amount of nausea and/or vomiting that you are experiencing. Your provider will want to know how many times you are vomiting each day and the types and amounts of foods you are eating. Your provider will discuss possible changes you can make in your diet and discuss over-the-counter remedies and prescription medications that are available to alleviate your symptoms.
• Avoid foods that may cause or exacerbate your symptoms. You may find that many of the foods you previously ate are now making you sick. The odor or taste of certain foods may trigger your nausea. You should avoid these foods until your symptoms subside.
• Eat bland foods. When you feel nauseated, bland foods like sugar-free gelatin, soup, ginger ale, and saltine crackers can soothe your stomach. Ginger teas are often helpful in reducing nausea. Avoid spicy foods or liquids that are acidic (i.e. fruit juices). You do not need to avoid these foods during your entire pregnancy, but avoiding them at this stage may make a big difference in how you feel.
• Eat small meals throughout the day and drink plenty of fluids.  Eating smaller meals during the day (usually 3 meals and 3 snacks) provides an opportunity to avoid hunger, burn calories and maintain steady glucose metabolism. Eating smaller meals throughout the day helps you to avoid an empty stomach which can help to reduce nausea and vomiting. 
• Eat high, protein, small carbohydrate foods. Food such as wheat toast, peanut butter, apple slices, nuts, cheese, crackers, cottage cheese and yogurt are high in protein. They can serve as snacks or as part of your meals to help you maintain steady glucose levels and avoid hunger.
• Avoid environmental triggers. Avoid environmental odors, such as smoke, paint or cleaning chemicals.

Information that your doctor can provide:

• Your doctor can provide information on medications to treat your morning sickness. Commonly used medications include Pyroxidine (Vitamin B6) and Odansetron (Zofran). Your doctor will assess your symptoms and diabetes status before recommending or prescribing these medications.
• Assess your glucose levels and weight. Depending on the changes in your diet and weight, your doctor may make adjustments to your diabetes medications.
• Remember to always discuss your symptoms with your doctor. Managing your morning sickness, maintaining a healthy diet and keeping your glucose levels under control deserves a strong partnership with you and your doctor.

Dr. Nicholson is an Associate Professor in the Department of Obstetrics and Gynecology at the University of North Carolina at Chapel Hill. She is a board-certified obstetrician-gynecologist and a perinatal epidemiologist. Through funding from the American Diabetes Association (ADA), Dr. Nicholson has developed a postpartum-specific weight loss intervention, First WIND (Weight-loss Interventions after Delivery), for women at risk for type 2 diabetes which was piloted among urban-based women in Baltimore City. She was previously an investigator with the Johns Hopkins Evidence-Based Practice Center where she was the PI of the task report on Labor and Postpartum Management of Gestational Diabetes, funded through the Agency for Healthcare Research and Quality. Dr. Nicholson is a member of the ACOG National Committee on Health Care for Underserved Women, the US Preventive Services Task Force, and the NC Diabetes Advisory Council.