Candy twists as an alternative to the glucola beverage in gestational diabetes mellitus screening

Published:November 13, 2014DOI:


      Screening for gestational diabetes mellitus commonly uses an oral glucose challenge test with a 50-g glucola beverage and subsequent venous puncture. However, up to 30% of pregnant women report significant side-effects, and the beverage is costly. We hypothesized that equivalent glucose loads could be achieved from a popular candy twist (Twizzlers; The Hershey Company, Hershey, PA) and tested it as cost-effective, tolerable alternative with a test of equivalency.

      Study Design

      The glucose equivalent of the 50-g glucola was calculated as 10 candy twists. We initially used a triple crossover design in nonpregnant patients whereby each subject served as her own control; this ensured the safety and equivalency of this load before using it among pregnant subjects. We then recruited pregnant women with an abnormal screening at 1 hour (glucose challenge test) in a double crossover design study. Subjects consumed 10 candy twists with a 1-hour venous blood glucose assessment. All subjects subsequently completed the confirmatory 3-hour glucose tolerance test. Sensitivity, specificity, positive predictive values, negative predictive values, false-referral rates, and detection rates were calculated.


      At ≥130 mg/dL, the sensitivity (100%) was the same for candy twists and glucola. However, the false-referral rate (82% vs 90%), positive predictive value (18% vs 10%), and detection rate (18% vs 10%) were improved for candy twists when compared with the 50-g glucola beverage.


      Our results indicate that strawberry-flavored candy twists are potentially an equally effective screening test, compared with the gold standard glucola beverage but lead to fewer false-positive screens and therefore could be a cost-effective alternative.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. American College of Obstetricians and Gynecologists: Committee on Practice Bulletins. Gestational diabetes mellitus. ACOG Practice Bulletin no. 137.
        Obstet Gynecol. 2013; 122: 406-416
        • Coustan D.R.
        Gestational diabetes.
        in: National Institutes of Diabetes and Digestive and Kidney Diseases. Diabetes in America. 2nd ed. NIDDK, Bethesda, MD1995 (NIH Publication no. 95-1468: 703-17)
        • Hanna F.W.F.
        • Peters J.R.
        Screening for gestational diabetes: past, present, and future.
        Diabet Med. 2002; 19: 351-358
        • Crowther C.A.
        • Hiller J.E.
        • Moses J.R.
        • McPhee A.J.
        • Jeffries W.S.
        • Robinson J.S.
        Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group: effect of treatment of gestational diabetes mellitus on pregnancy outcomes.
        N Engl J Med. 2005; 352: 2477-2486
        • Battista M.D.
        • Hivert M.F.
        • Duval K.
        • Bailargeon J.P.
        Intergenerational cycle of obesity and diabetes: how can we reduce the burden of these conditions on the health of future generations?.
        Exp Diabetes Res. 2011; 2011: 596060
        • Dabelea D.
        • Snell-Bergeon J.K.
        • Hartsfield C.L.
        • et al.
        Increasing prevalence of gestational diabetes mellitus over time and by birth cohort: Kaiser Permanente of Colorado GDM Screening Program.
        Diabetes Care. 2005; 28: 579-584
        • Hunt K.J.
        • Schuller K.L.
        The increasing prevalence of diabetes in pregnancy.
        Obstet Gynecol Clin North Am. 2007; 34: 173-199
        • Boyd K.L.
        • Ross E.K.
        • Sherman S.J.
        Jelly beans as an alternative to a cola beverage containing fifty grams of glucose.
        Am J Obstet Gynecol. 1995; 174: 1889-1892
        • Lamar M.E.
        • Kuehl T.J.
        • Cooney A.T.
        • Gayle L.J.N.
        • Holleman S.
        • Allen S.R.
        Jelly beans as an alternative to a fifty-gram glucose beverage for gestational diabetes screening.
        Am J Obstet Gynecol. 1999; 181: 1154-1157
        • Kauffman R.P.
        • Castracane V.D.
        • Peghee D.
        • Baker T.E.
        • Van Hook J.W.
        Detection of gestational diabetes mellitus by homeostatic indices of insulin sensitivity: a preliminary study.
        Am J Obstet Gynecol. 2006; 194: 1576-1584
        • Dornhorst A.
        • Frost G.
        Jelly-beans, only a colourful distraction from gestational glucose-challenge tests.
        Lancet. 2000; 355: 674
        • American Diabetes Association
        Gestational diabetes mellitus.
        Diabetes Care. 2001; 24: S77-S79
        • Ali S.
        • Dornhorst A.
        Diabetes in pregnancy: health risks and management.
        Postgrad Med J. 2011; 87: 417-427
        • Yogev Y.
        • Metzger B.E.
        • Hod M.
        Establishing diagnosis of gestational diabetes mellitus: impact of the hyperglycemia and adverse pregnancy outcome study.
        Semin Fetal & Neonatal Med. 2009; 14: 94-100
        • Herring S.J.
        • Oken E.
        Obesity and diabetes in mothers and their children: can we stop the intergenerational cycle?.
        Curr Diab Rep. 2011; 11: 20-27
        • Ben-Haroush A.
        • Yogev Y.
        • Hod M.
        Epidemiology of gestational diabetes mellitus, and its association with type 2 diabetes.
        Diabet Med. 2004; 21: 103-113
        • Yessoufou A.
        • Moutairou K.
        Maternal diabetes in pregnancy: early and long-term outcomes on the offspring and the concept of “metabolic memory.”.
        Exp Diabetes Res. 2011; 2011: 218598
        • Catalano P.M.
        • McIntyre H.D.
        • Cruickshank J.K.
        • et al.
        The Hyperglycemia and Adverse Pregnancy Outcomes Study: associations of GDM and obesity with pregnancy outcomes.
        Diabetes Care. 2012; 35: 780-786
        • Dennedy M.C.
        • Dunne F.
        The maternal and fetal impacts of obesity and gestational diabetes on pregnancy outcome.
        Best Pract Res Clin Endocrinol Metab. 2010; 24: 573-589
        • Landon M.B.
        • Spong C.Y.
        • Thom E.
        • et al.
        A randomized trial of treatment for mild gestational diabetes.
        N Engl J Med. 2009; 361: 1339-1348
        • Landon M.B.
        Is there a benefit to the treatment of mild gestational diabetes mellitus?.
        Am J Obstet Gynecol. 2010; 202: 649-653
        • Racusin D.R.
        • Crawford N.S.
        • Andrabi S.
        • et al.
        Twizzlers as a cost-effective and equivalent alternative to the glucola beverage in diabetes screening.
        Diabetes Care. 2013; 36: 169-170
      2. “NDST 2013 Nutrient Totals Report.” University of Minnesota Nutrition Data System for Research. Available at: Accessed Jan. 28, 2014.

        • Carpenter M.W.
        • Coustan D.R.
        Criteria for screening tests for gestational diabetes.
        Am J Obstet Gynecol. 1982; 144: 768-773
        • Coustan D.R.
        Making the diagnosis of gestational diabetes mellitus.
        Clin Obstet Gynecol. 2000; 43: 99-105
        • Metzger B.E.
        • Buchanan T.A.
        • Coustan D.R.
        • et al.
        Summary and recommendations of the Fifth International Workshop-Conference on gestation diabetes.
        Diabetes Care. 2007; 30: 251-260
        • Pepe M.S.
        • Etzioni R.
        • Feng Z.
        • et al.
        Phases of biomarker development for early detection of cancer.
        J Natl Cancer Inst. 2001; 93: 1054-1061
        • Kopelman P.G.
        Obesity as a medical problem.
        Nature. 2000; 404: 635-643
        • Samaras K.
        • McElduff A.
        • Twigg S.M.
        • et al.
        Insulin levels in insulin resistance: phantom of the metabolic opera.
        Med J Aust. 2006; 185: 159-161
        • McAuley K.A.
        • Williams S.M.
        • Mann J.I.
        • et al.
        Diagnosing insulin resistance in the general population.
        Diabetes Care. 2001; 24: 460-464
      3. The HAPO Study Cooperative Research Group: hyperglycemia and adverse pregnancy outcomes.
        N Engl J Med. 2008; 358: 1991-2002
      4. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2011;34(suppl1):S62-9.

        • American College of Obstetricians and Gynecologists
        Screening and diagnosis of gestational diabetes mellitus. ACOG Committee Opinion on obstetric practice no. 504.
        Obstet Gynecol. 2011; 118: 751-753
        • Rouse D.J.
        Marry old and new guidelines.
        Am J Obstet Gynecol. 2011; 204: 371-372