The Impact of a Cultural Lifestyle Intervention on Metabolic Parameters After Gestational Diabetes Mellitus A Randomized Controlled Trial

Gestational diabetes education management interventions implemented across Arabic-speaking countries: A systematic scoping review

Background The prevalence of Gestational Diabetes Mellitus (GDM) in Arabic-speaking countries varies from 1.2 % (Jordan) to almost 40 % (Saudi Arabia). Untreated GDM increases the risk of poor maternal and neonatal health outcomes. Objective This systematic scoping review aims to examine the current literature to determine the effectiveness of interventions designed to manage and prevent GDM across Arabic-speaking countries. Design Systematic scoping review. Methods Employing the PRISMA-ScR and the AND-EAL for study quality and bias assessment, a comprehensive review of the literature was conducted using 12 databases and search terms relevant to GDM interventions conducted across the League of Arab states. The search period includes intervention studies published up to and including August 31st, 2024. Findings Eight studies met the inclusion criteria. Interventions conducted included those modeled on the Health Behavior Change model, Theory of Reasoned Action and the PRECEDE model, constructs of Social Cognitive Theory including self-efficacy, GDM self-management, lifestyle management and BASNEF model-based empowerment. The intervention studies had positive effect on GDM knowledge, self-efficacy, A1C levels, quality of life, maternal and neonatal outcomes. Conclusion Prevention and management of GDM is important in addressing maternal and neonatal health outcomes. Interventions designed with a theoretical framework and those that are culturally tailored are more likely to elicit behavior change.

The long-term general practice healthcare of women with a history of gestational diabetes: A Scoping Review Protocol

Introduction

Gestational Diabetes Mellitus (GDM) is a hyperglycaemic condition diagnosed during pregnancy. GDM is strongly associated with future development of type 2 diabetes and cardiovascular disease. Lifestyle and pharmacological interventions can reduce the risk of developing type 2 diabetes. General practice is the recommended setting for long-term follow-up of women with a history of GDM. However, rates of follow-up are suboptimal. The evidence around long-term general practice healthcare for women with a history of GDM has not previously been reviewed.

Aims

The aim of this scoping review is to explore the current evidence base for the long-term care of women with a history of GDM in general practice.

Study Design

The study described by this protocol is a scoping review. The study design was informed by Joanna Briggs Institute methodology.

Methods

Empirical qualitative and quantitative research studies published since 2014 will be identified from a search of the following databases: MEDLINE (Ovid), EMBASE (Elsevier), CINAHL, PsycINFO, Academic Search Complete and SocIndex. The review will identify key characteristics of the literature. Framework analysis will be used to map the findings against the Chronic Care Model, a primary care-based framework that sets out the core components for optimal long-term healthcare.

Results

A numerical descriptive summary (using frequencies) will describe the overall extent of literature, and the range and distribution of its component parts, including the geographical and economic settings, research methods, interventions, outcomes and findings. The qualitative analysis will map interventions and descriptions of care to components of the chronic care model. Research gaps will be reported, and research needs and priorities will be suggested.

Conclusion

The findings of this scoping review will have the potential to inform future research efforts in the area.

Registration

This protocol has been registered in Open Science Framework ( https://osf.io/bz2vh).

Impact of postpartum physical activity on cardiometabolic health, breastfeeding, injury and infant growth and development: a systematic review and meta-analysis

OBJECTIVE

To examine the relationship between postpartum physical activity and maternal postnatal cardiometabolic health, breastfeeding, injury, and infant growth and development.

DESIGN

Systematic review with random-effects meta-analysis and meta-regression.

DATA SOURCES

Eight online databases were searched up until 12 January 2024.

ELIGIBILITY CRITERIA

Studies of all designs in all languages were eligible (except case studies and reviews) if they contained information on the population (postpartum people), intervention (frequency, intensity, duration, volume, or type of exercise, alone ('exercise-only') or in combination with other intervention components (eg, dietary; 'exercise+co-intervention'), comparator (no or low volumes of physical activity), and outcomes: hypertension, diabetes, cardiometabolic risk factors (systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, high density lipoproteins, low density lipoproteins, and triglycerides, glycated hemoglobin (HbA1C), glucose and insulin concentration), breastfeeding (breast milk quality and volume), infant growth (length and weight) and development, or postpartum injury.

RESULTS

46 unique studies (n=8766 participants) from 20 countries were included. Moderate certainty of evidence showed exercise+co-interventions reduced the odds of developing diabetes by 28% (7 randomised controlled trials (RCTs), n=2496; OR 0.72 95% CI 0.54, 0.98, I2 12%), reduced SBP (10 RCTs, n=2753; mean difference (MD) -2.15 95% CI -3.89 to -0.40, I2 73%) and DBP (9 RCTs, n=2575; MD -1.38 95% CI -2.60 to -0.15, I2 66%) compared with controls. Infant growth and development, breast milk quality and quantity, and risk of injury were not different between exercise and control groups.

CONCLUSIONS

Physical activity improves cardiometabolic health without adversely impacting breast milk supply or quality, infant growth or maternal injury.

Impact of postpartum physical activity on maternal anthropometrics: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis examined the relationship between postpartum exercise and maternal postpartum anthropometrics.

DESIGN

Systematic review with random-effects meta-analysis and meta-regression.

STUDY ELIGIBILITY CRITERIA

Online databases were searched from database inception until 12 January 2024. Randomised controlled trials (RCTs) written in any language were eligible if they contained information on the population (postpartum women and people); intervention (frequency, intensity, duration, volume or type of exercise, alone ('exercise-only') or in combination with other interventions (eg, dietary; 'exercise+cointervention')); comparator (no exercise) and outcomes (anthropometric measures including weight, postpartum weight retention (PPWR), body mass index (BMI), fat mass, lean body mass (LBM), body fat percentage, waist circumference, hip circumference or waist-hip ratio).

RESULTS

64 RCTs (n=12 684 participants) from 20 countries were included. Moderate to high certainty of evidence showed that exercise-only interventions reduced weight by 1.34 kg (18 studies, n=771; 95% CI -2.06 to -0.61, I2 0%), BMI by 0.73 kg/m2 (14 studies, n=662; 95% CI -1.21 to -0.25, I2 60%) and fat mass by 1.55 kg (5 studies, n=135; 95% CI -3.01 to -0.09, I2 0%) compared with no exercise. The duration of the exercise interventions ranged from 3 months to 3 years. Dose-response analysis found 560 MET-min/week of exercise (eg, 120 min/week of brisk walking) was associated with 1 kg/m2 reduction in BMI. Low certainty of evidence showed that exercise-only interventions had no effect on LBM (5 RCTs, n=135; standardised mean difference -0.13; 95% CI -0.48, 0.21, I2 0%) compared with no exercise.

CONCLUSIONS

These findings highlight physical activity as an effective intervention to improve postpartum anthropometrics and reduce PPWR.

PROSPERO REGISTRATION NUMBER

CRD42022359282.

Lifestyle intervention to prevent type 2 diabetes after a pregnancy complicated by gestational diabetes mellitus: a systematic review and meta-analysis update

BACKGROUND

Women with prior gestational diabetes mellitus (GDM) are at increased risk of type 2 diabetes, and lifestyle intervention (LSI) offered a decade after pregnancy is effective in preventing diabetes. However, since diabetes frequently onsets in the initial years following pregnancy, preventive actions should be implemented closer to pregnancy. We aimed to assess the effect of lifestyle interventions, compared to standard care, in reducing the incidence of diabetes following a pregnancy complicated by GDM.

METHODS

We searched the Cochrane Library, Embase, MEDLINE, and Web of Science from inception to July 21, 2024, to identify randomized controlled trials (RCTs) testing LSI to prevent diabetes following gestational diabetes. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We evaluated the risk of bias with the Cochrane Collaboration Risk of Bias tool RoB-2 and the certainty of the evidence with GRADE methodology. We used the DerSimonian-Laird random effects pooling method and evaluated heterogeneity with the I2 statistic and the Chi2 test.

RESULTS

We identified 24 studies involving 9017 women. In studies without high risk of bias (18 studies; 8,357 women), LSI reduced the incidence of diabetes by 19% (RR = 0.81; 95%CI 0.71.0.93). The effect was significant and more protective (RR = 0.78; 0.65, 0.94) in studies evaluating women with GDM identified specifically as at a higher risk of diabetes, compared to those intervening on women with GDM irrespective of risk (RR = 0.85; 0.70, 1.04). Similarly, when expressed in absolute terms, the overall number needed to treat (NNT) was 56 considering all studies, 71 for women with GDM irrespective of risk, and 31 for women with GDM at high risk. The intervention produced a lower weight gain (mean difference=-0.88 kg;-1.52, -0.23 for all studies; -0.62 kg;-1.22, -0.02 for studies without high risk of bias). The effects were robust in sensitivity analyses and supported by evidence of moderate certainty for diabetes and weight change.

CONCLUSIONS

LSI offered to women with GDM following pregnancy is effective in preventing type 2 diabetes, despite the small postpartum weight change. The impact of LSI on incidence reduction was greater for women with GDM at a higher diabetes risk.

PROSPERO

Registration number CRD42024555086, Jun 28, 2024.

Process Evaluations of Interventions for the Prevention of Type 2 Diabetes in Women With Gestational Diabetes Mellitus: Systematic Review

BACKGROUND

Gestational diabetes mellitus (GDM) is characterized by hyperglycemia in pregnancy and typically resolves after birth. Women with GDM have an increased risk of developing type 2 diabetes mellitus (T2DM) later in life compared to those with normoglycemic pregnancy. While diabetes prevention interventions (DPIs) have been developed to delay or prevent the onset of T2DM, few studies have provided process evaluation (PE) data to assess the mechanisms of impact, quality of implementation, or contextual factors that may influence the effectiveness of the intervention.

OBJECTIVE

This study aims to identify and evaluate PE data and how these link to outcomes of randomized controlled trials (RCTs) of T2DM prevention interventions for women with GDM.

METHODS

A systematic review was conducted to identify studies published from 2005 to 2020 aiming to capture the most recent DPIs. Five electronic bibliographic databases (Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, Embase, PubMed, and MEDLINE) were searched to identify relevant studies. Inclusion criteria were published (peer-reviewed) RCTs of DPIs in women with a current diagnosis or history of GDM. Exclusion criteria were studies not published in English; studies where the target population was women who had a family history of T2D or women who were menopausal or postmenopausal; and gray literature, including abstracts in conference proceedings. The Medical Research Council's PE framework of complex interventions was used to identify key PE components. The Mixed Method Appraisal Tool was used to assess the quality of included studies.

RESULTS

A total of 24 studies were included; however, only 5 studies explicitly reported a PE theoretical framework. The studies involved 3 methods of intervention delivery, including in person (n=7), digital (n=7), and hybrid (n=9). Two of the studies conducted pilot RCTs assessing the feasibility and acceptability of their interventions, including recruitment, participation, retention, program implementation, adherence, and satisfaction, and 1 study assessed the efficacy of a questionnaire to promote food and vegetable intake. While most studies linked PE data with study outcomes, it was unclear which of the reported PE components were specifically linked to the positive outcomes.

CONCLUSIONS

While the Medical Research Council's framework is a valuable source for conducting systematic reviews on PEs, it has been criticized for lacking practical advice on how to conduct them. The lack of information on PE frameworks in our review also made it difficult to categorize individual PE components against the framework. We need clearer guidance and robust frameworks for conducting PEs for the development and reporting of DPIs for women with GDM.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020208212; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=208212.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-https://doi.org/10.1177/16094069211034010.

A Systematic Review and Meta-Analysis of Type 2 Diabetes Prevention Through Lifestyle Interventions in Women with a History of Gestational Diabetes-A Summary of Participant and Intervention Characteristics

Objectives: We aimed to review the effect of lifestyle interventions in women with a history of gestational diabetes mellitus (GDM) based on the participants and intervention characteristics. Methods: We systematically searched seven databases for RCTs of lifestyle interventions published up to 24 July 2024. We included 30 studies that reported the incidence of type 2 diabetes mellitus (T2DM) or body weight. A random effects model was used to calculate the relative risk and mean difference with a 95% confidence interval. Subgroup analyses were conducted for participants' characteristics (age, body mass index (BMI)) and intervention characteristics according to the Template for Intervention Description and Replication (TIDieR). Results: A greater T2DM risk reduction was seen in trials that started within one year postpartum, in participants with a mean baseline BMI of 30 kg/m2 or more, or based on behavioral change theory. For body weight reduction, studies on participants with a mean baseline BMI of 25 kg/m2 or more or ones that included electronic/mobile delivery (text message, web, phone call) were more effective. Conclusions: Diabetes prevention trials in women with a history of GDM are more effective when commencing within one year postpartum, underpinned by behavior change theory, and in participants with overweight or obesity.

Postpartum life interventions to prevent type 2 diabetes in women with gestational diabetes: A systematic review and meta-analysis

AIMS/INTRODUCTION

Type 2 diabetes mellitus is a major metabolic disease that seriously endangers life and health, but women with gestational diabetes mellitus are at increased risk for developing type 2 diabetes mellitus. This study aimed to evaluate the effectiveness of postpartum lifestyle intervention on the prevention of type 2 diabetes mellitus, and the effect of lifestyle intervention on glycemic outcomes and anthropometric measures.

MATERIALS AND METHODS

We searched PubMed and other databases to retrieve articles published before May 21, 2023, on randomized controlled trials of postnatal lifestyle interventions (diet and/or physical activity) in women with gestational diabetes mellitus. We estimated the pooled odds ratios using fixed or random effects models and conducted a subgroup analysis of the different intervention methods to explore differences in the different lifestyle interventions.

RESULTS

The review included 17 randomized controlled trials. Overall, lifestyle changes started after a pregnancy complicated by gestational diabetes mellitus an 11% (RR = 0.89; 95% CI: 0.74-1.07) reduction in diabetes risk; significant differences were found for weight (MD = -1.33; 95% CI: [-1.76; -0.89], P < 0.00001) body mass index (MD = -0.53; 95% CI: [-0.74, -0.32], P < 0.00001), and waist circumference change (MD = -1.38; 95% CI: [-2.12; -0.64], P = 0.0002) but not for fasting glucose (MD = -0.06; 95% CI: [-0.19; 0.06], P = 0.32), 2 h glucose (MD = -0.12; 95% CI: [-0.30; 0.06], P = 0.19), and hemoglobin A1c (MD = -0.11; 95% CI: [-0.23; 0.02], P = 0.09). Subgroup analyses showed no significant differences in the effects of different lifestyle interventions on the incidence of type 2 diabetes, blood glucose levels, and anthropometric parameters.

CONCLUSION

Our comprehensive meta-analysis of lifestyle interventions can improve modifiable anthropometric measures in women with gestational diabetes. We need further research to provide more intensive lifestyle intervention, more scientific intervention methods, and to reduce the incidence of type 2 diabetes in patients with gestational diabetes.

Preventing Type 2 Diabetes after Gestational Diabetes: A Systematic Review Mapping Physical Activity Components using the Socio-Ecological Model

OBJECTIVES

Gestational diabetes commonly occurs during pregnancy and increases lifetime risk of type 2 diabetes following pregnancy. Engaging in physical activity postnatally can reduce this subsequent risk. Interventions aiming to increase physical activity after gestational diabetes may not address the wide range of post-pregnancy barriers. A socio-ecological approach highlights the need to include multi-level factors such as social, community and organisational factors. The aim of the review was to map intervention components to prevent type 2 diabetes after gestational diabetes using the socio-ecological model as a framework and investigate how physical activity changes align with different intervention components utilised.

METHODS

Eligible studies included any study type within 5 years of a gestational diabetes diagnosis and targeted physical activity. A systematic search of MEDLINE, Cochrane Library, Web of Science, CINAHL Complete, and Scopus was conducted in October 2022. Results were categorised based on whether findings demonstrated no increases, non-statistically significant increases or statistically significant increases in physical activity.

RESULTS

Forty-eight studies were included (37 different interventions). Thirty-eight studies were assessed as "adequate" quality, only two studies were "good" quality, and the remaining were limited quality. Mixed physical activity outcomes were observed across components used at the intrapersonal level, with components across other levels of the socio-ecological model showing more increases in physical activity. Intervention components within the social and organisational levels, for example childcare provision, providing group-based sessions and offering remote delivery, were more often present in interventions with physical activity increases.

CONCLUSIONS FOR PRACTICE

Future interventions targeting physical activity after gestational diabetes should aim to include social and organisational-level components in their intervention design. This systematic review was registered in PROSPERO (ID: CRD42021272044).

The efficacy of interventions to prevent type 2 diabetes among women with recent gestational diabetes mellitus-A living systematic review and meta-analysis

BACKGROUND

While previously considered a transient condition, with no lasting adverse impact, gestational diabetes mellitus (GDM) is now a well-established risk factor for developing type 2 diabetes mellitus (T2DM). The risk of developing T2DM appears to be particularly high in the first few years after childbirth, providing a compelling case for early intervention. This review provides an up-to-date systematic review and meta-analysis to assess the effectiveness of interventions to reduce incidence of T2DM in women with a recent history of GDM.

METHODS

The search was conducted on October 20, 2023 with an annual surveillance planned for the next 5 years to maintain a living systematic review. The inclusion criteria were randomized controlled trials of any type in women within 5 years of GDM-complicated pregnancy that reported outcomes of T2DM diagnosis or measures of dysglycemia with a follow-up of at least 12 months.

RESULTS

Seventeen studies met our inclusion criteria and have been included in this review. There were 3 pharmacological and 14 lifestyle interventions. Intervention was not associated with significant reduction in the primary outcome of T2DM (risk ratio, 0.78; 95% confidence interval [CI]: 0.43-1.41; p = 0.41; I2 = 79%) compared with the control group (placebo or usual care). However, meta-analysis of the four studies reporting hazard ratios suggested a reduction in diabetes incidence (hazard ratio, 0.68; 95% CI: 0.48-0.97; p = 0.03; I2 = 31%).

CONCLUSION

This review provides equivocal evidence about the efficacy of interventions to reduce the risk of T2DM in women within 5 years of GDM-complicated pregnancy and highlights the need for further studies, including pharmacotherapy.

The impact of a culturally adapted lifestyle intervention on the glycaemic profile of mothers with GDM one year after delivery - a community-based, cluster randomized trial in Sri Lanka

BACKGROUND

A woman with a history of GDM has a high risk of developing type two diabetes (T2DM) in her future life. Lifestyle modifications are known to attenuate the progression of GDM to T2DM. Therefore, the aim of this study was to assess the impact of a simple, cost effective, culturally acceptable lifestyle intervention programme on the trajectory towards T2DM in women with a history of GDM.

METHODS

This cluster randomized trial was conducted in 100 postpartum women in three selected districts of Sri Lanka. The subjects were divided into intervention (n = 50) and control groups (n = 50) by cluster randomization method. A culturally adapted protocol (comprised of dietary and physical activity modifications) was administered to the intervention group. The glycemic profile was assessed using fasting and 2-hour post-OGTT plasma glucose and HbA1c, and insulin resistance by HOMA-IR at baseline and after one year of intervention.

RESULTS

The mean age (SD) of the subjects in the intervention and control groups were 33.0 (5.1) and 34.3 (6.5) years respectively. All glycemic and insulin resistance parameters (i.e. Fasting plasma glucose- FPG, 2-hour post-OGTT plasma glucose, HbA1c and HOMA-ir) were comparable (p > 0.05) between the two groups at baseline. FPG, 2 h post OGTT, HbA1c and HOMA-ir values between intervention vs. control (p) at 12 months were 87.3 vs. 123.2 (< 0.01); 106.5 vs. 156.1 (0.01); 5.3 vs. 6.8 (< 0.01) and 0.9 vs. 2.3 (< 0.01) respectively. All glycemic parameters showed a significant reduction in the intervention group at 12 months compared to baseline. In contrast, the control group showed a significant increase in FPG, 2-hour post-OGTT plasma glucose and HbA1c at 12 months compared to baseline. In multiple linear regression model adjusted for age, parity and family history, the control group showed an approximately 33 times risk of developing insulin resistance compared to the intervention group.

CONCLUSION

The culturally acceptable and individualized lifestyle intervention was able to produce remarkable reductions in glycaemic and insulin resistance parameters among postpartum women with a history of GDM.

TRIAL REGISTRATION

Ethical clearance was obtained from the Ethics Review Committee of the University of Sri Jayewardenepura, Sri Lanka (ERC 52/14), Sri Lanka Clinical trial registration number Sri Lanka Clinical Trials Registry (SLCTR/2015/021 date 25.09.2015).

The effectiveness of pharmacological and lifestyle interventions to reduce the risk of diabetes and hyperglycaemia following gestational diabetes: A systematic review and meta-analysis

AIMS

To synthesize the available evidence to better understand the effectiveness of interventions to prevent or delay hyperglycaemia and Type 2 diabetes mellitus (T2DM) postnatally in women with current or previous gestational diabetes mellitus (GDM).

METHODS

We searched five databases up to December 2020 for primary peer-reviewed articles reporting postpartum glycaemic outcomes in women with (previous) GDM following pharmacological or lifestyle intervention. Outcomes were relative risk of T2DM or continuous measures of glycaemia, change or at follow-up. A minimum of two studies evaluating the same intervention-outcome combination were needed to conduct meta-analyses, otherwise studies were described narratively. Meta-regression was used to evaluate whether associations varied by additional variables. We assessed risk of bias using the Critical Appraisal Skills Programme checklist. PROSPERO record CRD42018102380.

RESULTS

We included 31 studies in the review with a total sample size of 8624 participants, and 26 studies in meta-analyses. Two-thirds of studies followed up participants at 1 year or less. Pharmacological interventions were associated with reduced risk of T2DM (0.80 [95% CI 0.64-1.00], n = 6 studies), as were lifestyle interventions albeit with a smaller effect size (0.88 [95% CI 0.76-1.01], n = 12 studies). Dietary and physical activity interventions were associated with a small reduction in fasting plasma glucose, particularly in longer interventions, but inconsistent effects were seen for other continuous outcomes.

CONCLUSIONS

Although possibly due to chance, interventions to reduce hyperglycaemia after GDM may be effective. Future research should improve understanding of how interventions affect glucose control and how to optimise interventions for this population.

The Impact of a Lifestyle Intervention on Postpartum Cardiometabolic Risk Factors Among Hispanic Women With Abnormal Glucose Tolerance During Pregnancy: Secondary Analysis of a Randomized Trial

BACKGROUND

Women with abnormal glucose tolerance during pregnancy are at risk for cardiovascular disease (CVD), with higher rates among Hispanics. However, studies on the impact of lifestyle interventions on postpartum CVD profiles are sparse.

METHODS

This is a secondary analysis of a controlled trial among a subsample of Hispanic women with abnormal glucose tolerance participating in Estudió PARTO (Project Aiming to Reduce Type twO diabetes; mean age = 28.2 y, SD: 5.8) who were randomized to a culturally modified Lifestyle intervention (n = 45) or a comparison Health and Wellness intervention (n = 55). Primary endpoints were biomarkers of cardiovascular risk (lipids, C-reactive protein, fetuin-A, and albumin-to-creatinine ratio) and insulin resistance (fasting insulin, glucose, HbA1c, homeostasis model assessment, leptin, tumor necrosis factor-alpha, and adiponectin) measured at baseline (6-wk postpartum) and 6 and 12 months.

RESULTS

In intent-to-treat analyses, there were no significant differences in changes in biomarkers of CVD risk or insulin resistance over the postpartum year. In prespecified sensitivity analyses, women adherent with the Lifestyle Intervention had more favorable improvements in insulin (intervention effect = -4.87, SE: 1.93, P = .01) and HOMA-IR (intervention effect = -1.15, SE: 0.53, P = .03) compared with the Health and Wellness arm. In pooled analyses, regardless of intervention arm, women with higher postpartum sports/exercise had greater increase in HDL-cholesterol (intervention effect = 6.99, SE: 1.72, P = .0001).

CONCLUSIONS

In this randomized controlled trial among Hispanic women with abnormal glucose tolerance, we did not observe a significant effect on postpartum biomarkers of CVD risk or insulin resistance. Women adherent to the intervention had more favorable changes in insulin and HOMA-IR.

Lifestyle Interventions to Prevent Type 2 Diabetes in Women with a History of Gestational Diabetes: A Systematic Review and Meta-Analysis through the Lens of Health Equity

BACKGROUND

Type 2 diabetes mellites is one of the health problems disproportionally affecting people with low socioeconomic statuses. Gestational diabetes mellites increases the risk of type 2 diabetes by up to ten-fold for women. Lifestyle interventions prevent type 2 diabetes in women with prior gestational diabetes. However, it is unknown if similar effectiveness can be expected for all population subgroups.

OBJECTIVE

This study aims to assess the prevention of type 2 diabetes in women with prior gestational diabetes using population characteristics according to the PROGRESS (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital) criteria.

METHODS

MEDLINE, CINAHL, EMBASE, PubMed, PsycINFO, Web of Science, and EBM Reviews databases were searched for interventional studies of diet, physical activity, or behavioural interventions published up to 21 February 2023. Random effects subgroup meta-analysis was conducted to evaluate the association of population characteristics and intervention effects.

RESULTS

All studies were conducted in high-income countries or middle-income countries. Two-thirds of the studies reported on race/ethnicity and education level. Less than one-third reported on place (urban/rural), occupation, and socioeconomic status. None reported on religion or social capital. Studies from high-income countries (MD = -1.46; 95% CI: -2.27, -0.66, I2 = 70.46, p < 0.001) showed a greater reduction in bodyweight compared with the studies conducted in middle-income countries (MD = -0.11; 95% CI: -1.12, 0.89, I2 = 69.31, p < 0.001) (p for subgroup difference = 0.04).

CONCLUSION

There are significant equity gaps in the evidence for the prevention of type 2 diabetes in women with prior gestational diabetes due to reports on population characteristics being poor. Interventions may be less effective in reducing bodyweight in women from middle-income countries compared to high-income countries. Collecting and analysing data related to equity is needed to understand the effect of lifestyle interventions on type 2 diabetes for different population subgroups.

Gestational diabetes mellitus, follow-up of future maternal risk of cardiovascular disease and the use of eHealth technologies-a scoping review

BACKGROUND

Globally, gestational diabetes mellitus complicates 1 in 6 pregnancies and increases future risk of type 2 diabetes and cardiovascular disease in the affected women. There is a lack of consensus on the optimal follow-up of these women. eHealth is emerging as a health care tool, but its practical utility and advantages over standard care in the follow-up after pregnancy complications remains to be determined. Our aim was to systematically review the existing literature on cardiovascular follow-up after gestational diabetes, the utility of eHealth technology for this purpose, and to identify research gaps.

METHODS

We performed a systematic scoping review following a published protocol and the Joanna Briggs methodology for studies up until May 2022. Four databases were searched: Ovid MEDLINE, Embase, Maternity and Infant Care, and Cochrane Database of Systematic Reviews. Primary research articles and systematic reviews were included in the final analyses. Two reviewers independently screened abstracts and performed full text assessment. Data was extracted using a data charting form. In all stages of the process, if consensus was not reached, a third reviewer was consulted. The findings from the data charting process provided the basis for summarizing the findings from the included studies.

RESULTS

The search of the databases generated 2772 hits. After removing duplicates and manually adding a total of 19 studies, reviews, and guidelines, a total of 2769 titles and abstracts were screened, and 97 papers underwent full-text review. In the final analyses, 15 articles and 12 systematic reviews were included, whereas guidelines are presented as supplementary material. No studies were identified that examined follow-up regarding long-term overall cardiovascular risk after gestational diabetes. Various lifestyle interventions were tested for individual cardiovascular risk factors, with diverging effects. eHealth technologies were found acceptable by participants but had no consistent, statistically significant effect on relevant health outcomes.

CONCLUSIONS

This scoping review of the existing literature revealed neither an established systematic cardiovascular follow-up strategy for women after gestational diabetes nor evidence that eHealth technologies are superior to conventional follow-up. Further research into the utility of eHealth in cardiovascular follow-up after complicated pregnancies should include longer-term follow-up and core cardiovascular outcomes.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this scoping review was published at Open Science Framework (osf.io/p5hw6).

Factors associated with compliance to the recommendations for postpartum diabetes mellitus screening among women with gestational diabetes mellitus

OBJECTIVE

Since women with GDM have an increased risk to develop type 2 DM, a 75 g OGTT is recommended 6-12 weeks postpartum for all women with GDM. However, screening rates remain low. The aim of this study was to find factors affect the rate of postpartum DM screening.

MATERIALS AND METHODS

A retrospective cohort study between 2016 and 2017 at the Soroka Medical Center, comparing women with GDM who underwent postpartum DM screening test to those who did not.

RESULTS

257 women who had a diagnosis of GDM and met the inclusion criteria were included. 53 (20.6%) had a postpartum DM screening test and 204 (79.4%) did not complete the postpartum DM screening. Women who underwent a DM screening postpartum were more likely to be older, with significantly higher rates of vacuum-assisted delivery, more likely to be diagnosed with GDMA2 as compared to GDMA1 during pregnancy and, with high probability of receiving recommendations for screening at a postpartum visit.

CONCLUSIONS

The rates of postpartum DM screening for women with GDM are low and need to increase. Age greater than 25, vacuum delivery, GDMA2, and having received a recommendation for postpartum screening increased the likelihood of undergoing a postpartum DM screening.

Lifestyle intervention for the prevention of type 2 diabetes in women with prior gestational diabetes: A systematic review and meta-analysis

AIM

To determine whether current evidence supports lifestyle intervention for type 2 diabetes (T2D) prevention in women with previous gestational diabetes (GD).

METHODS

We systematically searched MEDLINE/PubMed, Web of Science, EMBASE, The Cochrane Library, International Pharmaceutical Abstracts, Global Health, Sinomed and Clinicaltrials.gov for randomized controlled trials (published from 1 January 1950 to 14 December 2022) comparing lifestyle intervention with standard care in women with previous GD. Our primary outcome was incident T2D, with pooled estimates calculated by a fixed-effects model.

RESULTS

Of 1652 studies identified, 13 were eligible and were included in our analysis (N = 3745 women). Compared with standard care, lifestyle intervention yielded a reduction of 24% in the incidence of T2D (relative risk 0.76 [95% CI 0.63-0.93]). Meta-regression analyses revealed no impact of the duration of lifestyle intervention (P = .81) or baseline body mass index (P = .90) on the observed reduction in incident T2D. Importantly, this published literature shows evidence of publication bias on funnel plot and Egger test (P = .048).

CONCLUSIONS

Current published evidence suggests that lifestyle intervention can reduce the risk of T2D in women with prior GD. However, this finding should be interpreted with caution in the presence of documented publication bias.

Ethnic differences in response to lifestyle intervention for the prevention of type 2 diabetes in adults: A systematic review and meta-analysis

The risk of type 2 diabetes mellitus (T2DM) varies by ethnicity, but ethnic differences in response to diabetes prevention interventions remain unclear. This systematic review and meta-analysis assessed ethnic differences in the effects of lifestyle interventions on T2DM incidence, glycemic outcomes (fasting glucose, 2-h glucose, HbA_1c ), anthropometric measures (weight, BMI, waist circumference), and lifestyle behaviors (physical activity, energy intake, energy from fat, fiber intake). MEDLINE, EMBASE, and other databases were searched (to June 15, 2020) for randomized and non-randomized controlled trials on lifestyle interventions (diet and/or physical activity) in adults at risk of T2DM. Ethnicity was categorized into European, South Asian, East and Southeast Asian, Middle Eastern, Latin American, and African groups. Forty-four studies were included in meta-analyses. Overall, lifestyle interventions resulted in significant improvement in T2DM incidence, glycemic outcomes, anthropometric measures, physical activity, and energy intake (all P < 0.01). Significant subgroup differences by ethnicity were found for 2-h glucose, weight, BMI, and waist circumference (all P < 0.05) but not for T2DM incidence, fasting glucose, HbA_1c , and physical activity (all P > 0.05). Few studies in non-European groups reported dietary intake. Lifestyle interventions in different ethnic groups may have similar effects in reducing incidence of T2DM although this needs to be confirmed in further studies.

"I Had to Rediscover Our Healthy Food": An Indigenous Perspective on Coping with Type 2 Diabetes Mellitus

Type 2 Diabetes Mellitus (T2DM) is disproportionally prevalent among the Bedouin minority in Israel, with especially poor treatment outcomes compared to other indigenous groups. This study uses the perspective of the Bedouins themselves to explore the distinct challenges they face, as well as their coping strategies. The study is based on an interpretive interactionist analysis of 49 semi-structured interviews with Bedouin men and women. The findings of the analysis include three themes. First, physical inequality: the Bedouin community's way of coping is mediated by the transition to a semi-urban lifestyle under stressful conditions that include the experience of land dispossession and the rupture of caring relationships. Second, social inequality: they experience an inaccessibility to healthcare due to economic problems and a lack of suitable informational resources. Third, unique resources for coping with T2DM: interviewees use elements of local culture, such as religious practices or small enclaves of traditional lifestyles, to actively cope with T2DM. This study suggests that there is a need to expand the concept of active coping to include indigenous culture-based ways of coping (successfully) with chronic illness.

The Effect of Lifestyle Intervention on Diabetes Prevention by Ethnicity: A Systematic Review of Intervention Characteristics Using the TIDieR Framework

Lifestyle intervention is effective in preventing type 2 diabetes mellitus (T2DM), but the efficacy of intervention components across different ethnic groups is less clear. This systematic review examined the effects of intervention characteristics of lifestyle interventions on diabetes incidence and weight loss by ethnicity using the Template for Intervention Description and Replication (TIDieR) framework. MEDLINE, EMBASE and other databases were searched for randomized and non-randomized controlled trials on lifestyle interventions (diet and/or physical activity) in adults at risk of T2DM. Ethnicity was categorized into European, South Asian, East and Southeast Asian, Middle Eastern, Latin American and African groups. Forty-five studies (18,789 participants) were included in the systematic review and 41 studies in meta-analysis. Meta-analysis showed a high number of intervention sessions was significantly associated with a greater reduction in diabetes incidence (P = 0.043) and weight (P = 0.015), while other intervention characteristics including intervention provider and delivery format did not alter the outcomes (all P > 0.05). Additionally, narrative synthesis showed long-term interventions (≥12 months) were associated with significant diabetes risk reduction for all ethnic groups, while short-term interventions (<12 months) were more effective in weight loss in most ethnic groups. There may be ethnic preferences for the optimal number of intervention sessions.

Comparing the Efficacies of Telemedicine and Standard Prenatal Care on Blood Glucose Control in Women With Gestational Diabetes Mellitus: Randomized Controlled Trial

BACKGROUND

Gestational diabetes mellitus (GDM) can usually be well controlled by health education and lifestyle management, resulting in better pregnancy outcomes. However, standard clinical prenatal care, which consists of clinic visits every 2 weeks, may not provide sufficient management for women with GDM. Telemedicine demonstrates a potential to fill this gap.

OBJECTIVE

The objective of this study was to investigate whether health education and lifestyle management delivered through a WeChat group chat was more effective in controlling blood glucose (BG) than standard clinical prenatal care among women with GDM.

METHODS

In this multicenter randomized controlled trial, women with GDM diagnosed by an oral glucose tolerance test between 23 and 30 (+6) gestational weeks were randomized to a WeChat group chat-based BG management group or a routine clinical prenatal care group. The primary outcome was the change in the glycemic qualification rate during the follow-up period in both groups. The secondary outcomes were pregnancy outcomes.

RESULTS

A total of 309 women with GDM participated in the trial, with 162 women randomized to the control group and 147 to the intervention group. No significant differences in baseline characteristics were found between the control and intervention groups. Participants were further divided into 4 groups according to gestational weeks at enrollment for further analysis. The glycemic qualification rate of the intervention group was higher than that of the control group at nearly all time points in Groups 1 to 3, among which 3 time points reached statistical significance: Group 1 at T3 (54.8% vs 83.3%) and Group 2 at T3 (62.5% vs 80.0%) and T7 (75.0% vs 100%). The glycemic qualification rate gradually increased as gestational weeks progressed in both groups, regardless of the intervention method. None of the pregnancy outcomes measured, including delivery mode, premature rupture of the membranes, preterm birth, infant's birth weight, and postpartum hemorrhage, were significantly different between the control and intervention groups.

CONCLUSIONS

This multicenter randomized controlled trial that assessed women with noninsulin-dependent GDM demonstrated that additional instant messaging platforms, such as WeChat, used for health education and lifestyle intervention in China tend to be more effective for BG control than standard clinical prenatal care alone.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03748576; https://clinicaltrials.gov/ct2/show/NCT03748576.

Preventing Type 2 Diabetes in Women with Previous Gestational Diabetes: Reviewing the Implementation Gaps for Health Behavior Change Programs

Gestational diabetes mellitus (GDM) places a woman at high risk of developing subsequent type 2 diabetes mellitus (T2DM), particularly in the first 5 years postpartum. Engaging women in health behavior change during this period is challenging and current diabetes prevention programs were developed for middle-aged adults, all of which have limited the evidence on successful implementation for this high-risk population. In this review, we will first summarize the effects of existing diabetes prevention programs in women with a history of GDM. Second, we suggest that the programs need to be modified according to the facilitators and barriers faced by this population. Third, we propose that improving program penetration, fidelity, and participation is critical for population-level success. Finally, we outline the research priorities to improve the implementation of diabetes prevention programs for postpartum women with a history of GDM.

The Role of Health Literacy in Postpartum Weight, Diet, and Physical Activity

Background: Postpartum weight retention is a significant contributor to obesity in women, adverse perinatal events in subsequent pregnancies, and chronic disease risk. Health literacy is known to impact health behaviors. The study aimed to identify the health literacy domains utilized in postpartum weight management interventions and to determine their impact on weight, diet and physical activity in postpartum women. Methods: We searched MEDLINE, CINAHL, EMBASE, PSYCINFO, and EBM databases. We included random control trials of lifestyle intervention in postpartum women (within two years post-delivery) published up to 3 May 2019. Subgroup analyses were performed to determine the effect of health literacy domains on outcomes. Results: Out of 5000 studies, 33 studies (n = 3905) were included in the systematic review and meta-analysis. The health literacy domain self-care (skills and knowledge) was associated with a significant reduction in body weight (mean difference (MD) −2.46 kg; 95% confidence interval (CI) from −3.65 to −1.27) and increase in physical activity (standardized mean difference (SMD) 0.61; 95% CI 0.20 to 1.02). No other health literacy domain was associated with significant outcomes in weight, energy intake, or physical activity. Conclusions: Health literacy skills such as knowledge of self-care are effective in improving weight and in increasing physical activity in postpartum women. The efficacy of other health domains was not supported.

An evaluation of the impact of lifestyle interventions on body weight in postpartum women: A systematic review and meta-analysis

The established efficacy in postpartum lifestyle interventions has not been translated into better outcomes. This systematic review and meta-analysis assess the penetration (the proportion of women invited within the target population), implementation (fidelity), participation (the proportion of those invited who enrolled), and effect (weight loss compared to controls) (PIPE) of randomized controlled trials of lifestyle interventions in postpartum women (within two years after birth). MEDLINE, EMBASE, Pubmed, and other databases and clinical trial registries were searched up to the 3rd of May 2019. Data was extracted from published reports and missing data was obtained from study authors. The quality of the studies was appraised using the Cochrane Risk of Bias tool (2·0). Main outcomes were the PIPE impact metrics and changes in body weight. Thirty-six trials (49 publications) were included (n=5,315 women). One study provided sufficient information to calculate the population penetration rate (2·5%). All studies provided implementation (fidelity) information, but over half had low program fidelity. The participation rate was calculated for nine studies (0·94% to 86%). There was significant change in body weight (mean difference (MD) (95% confidence interval, CI) of -2·33 (-3·10 to -1·56). This highlights the inadequacy of conventional RCTs to inform implementation. Future research should broaden methods to pragmatic trials.

Obtaining evidence base for the development of Feel4Diabetes intervention to prevent type 2 diabetes - a narrative literature review

BACKGROUND

Feel4Diabetes was a school and community based intervention aiming to promote healthy lifestyle and tackle obesity for the prevention of type 2 diabetes among families in 6 European countries. We conducted this literature review in order to guide the development of evidence-based implementation of the Feel4Diabetes intervention. We focused on type 2 diabetes prevention strategies, including all the phases from risk identification to implementation and maintenance. Special focus was given to prevention among vulnerable groups and people under 45 years.

METHODS

Scientific and grey literature published between January 2000 and January 2015 was searched for relevant studies using electronic databases. To present the literature review findings in a systematic way, we used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. A complementary literature search from February 2015 to December 2018 was also conducted.

RESULTS

The initial review included 27 studies with a follow-up ≥12 months and 9 studies with a follow-up ≥6 months and with a participant mean age < 45 years. We found out that interventions should be targeted at people at risk to improve recruiting and intervention effectiveness. Screening questionnaires (primarily Finnish Diabetes Risk Score FINDRISC) and blood glucose measurement can both be used for screening; the method does not appear to affect intervention effectiveness. Screening and recruitment is time-consuming, especially when targeting lower socioeconomic status and age under 45 years. The intervention intensity is more important for effectiveness than the mode of delivery. Moderate changes in several lifestyle habits lead to good intervention results. A minimum of 3-year follow-up seemed to be required to show a reduction in diabetes risk in high-risk individuals. In participants < 45 years, the achieved results in outcomes were less pronounced. The complementary review included 12 studies, with similar results regarding intervention targets and delivery modes, as well as clinical significance.

CONCLUSION

This narrative review highlighted several important aspects that subsequently guided the development of the Feel4Diabetes high-risk intervention. Research on diabetes prevention interventions targeted at younger adults or vulnerable population groups is still relatively scarce. Feel4Diabetes is a good example of a project aiming to fill this research gap.

TRIAL REGISTRATION

clinicaltrials.gov NCT02393872, registered 20th March 2015.

What Are the Most Effective Behavioural Strategies in Changing Postpartum Women's Physical Activity and Healthy Eating Behaviours? A Systematic Review and Meta-Analysis

Successful implementation of postpartum lifestyle interventions first requires the identification of effective core components, such as strategies for behavioural change. This systematic review and meta-analysis aimed to describe the associations between behavioural strategies and changes in weight, diet, and physical activity in postpartum women. Databases MEDLINE, CINAHL, EMBASE, and PsycINFO were searched for randomised controlled trials of lifestyle interventions in postpartum women (within 2 years post-delivery). Strategies were categorised according to the Behaviour Change Technique Taxonomy (v1). Forty-six articles were included (n = 3905 women, age 23-36 years). Meta-analysis showed that postpartum lifestyle interventions significantly improved weight (mean difference -2.46 kg, 95%CI -3.65 to -1.27) and physical activity (standardised mean difference 0.61, 95%CI 0.20 to 1.02) but not in energy intake. No individual strategy was significantly associated with weight or physical activity outcomes. On meta-regression, strategies such as problem solving (β = -1.74, P = 0.045), goal setting of outcome (β = -1.91, P = 0.046), reviewing outcome goal (β = -3.94, P = 0.007), feedback on behaviour (β = -2.81, P = 0.002), self-monitoring of behaviour (β = -3.20, P = 0.003), behavioural substitution (β = -3.20, P = 0.003), and credible source (β = -1.72, P = 0.033) were associated with greater reduction in energy intake. Behavioural strategies relating to self-regulation are associated with greater reduction in energy intake.

Ethnicity and Metabolic Syndrome: Implications for Assessment, Management and Prevention

The metabolic syndrome (MetS) is a constellation of cardiometabolic risk factors that identifies people at increased risk for type 2 diabetes and cardiovascular disease. While the global prevalence is 20%–25% of the adult population, the prevalence varies across different racial/ethnic populations. In this narrative review, evidence is reviewed regarding the assessment, management and prevention of MetS among people of different racial/ethnic groups. The most popular definition of MetS considers race/ethnicity for assessing waist circumference given differences in visceral adipose tissue and cardiometabolic risk. However, defining race/ethnicity may pose challenges in the clinical setting. Despite 80% of the world’s population being of non-European descent, the majority of research on management and prevention has focused on European-derived populations. In these studies, lifestyle management has proven an effective therapy for reversal of MetS, and randomised studies are underway in specific racial/ethnic groups. Given the large number of people at risk for MetS, prevention efforts need to focus at community and population levels. Community-based interventions have begun to show promise, and efforts to improve lifestyle behaviours through alterations in the built environment may be another avenue. However, careful consideration needs to be given to take into account the unique cultural context of the target race/ethnic group.

Systematic review of effectiveness and cost-effectiveness of lifestyle interventions to improve clinical diabetes outcome measures in women with a history of GDM

OBJECTIVE

Lifestyle interventions have been shown to be both effective and cost-effective in reducing diabetes and metabolic risk in high-risk populations. We systematically reviewed the effectiveness and cost-effectiveness of lifestyle interventions on anthropometric, glycemic and cardiovascular outcomes in women with previous gestational diabetes mellitus (GDM).

METHOD

Relevant randomized control trials (RCT) were identified by searching multiple electronic databases through 20th June 2018. Data were pooled using random-effects models. The review protocol was registered on the PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42018108870).

RESULTS

Twenty-one studies met the inclusion criteria and 16 studies with outcome data were analyzed in the meta-analysis. No RCT studies included cost-effectiveness data on lifestyle interventions. The pooled estimate for postpartum weight showed a significant mean reduction in the intervention arm (-1.8 kg [95% CI: -2.9, -0.6; p = 0.002; I² = 92.2%; p < 0.05]). Further, the effect of lifestyle intervention on weight change was significantly greater in studies of longer duration. Most of the other endpoints had modest improvements but only anthropometric endpoints were statistically significant. However, there was high heterogeneity between the studies.

CONCLUSIONS

Lifestyle interventions showed statistically and clinically significant improvements in anthropometric outcomes. However, more research is needed to explore lifestyle effects on glycemic and cardiovascular risk factors and to establish cost-effectiveness. Methodologically sound, large scale studies on diverse ethnicities and with longer follow-up would establish the real effect of lifestyle interventions to reduce diabetes risk in women with previous GDM.

Lifestyle Intervention for the Prevention of Diabetes in Women With Previous Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis

Background: Type 2 diabetes is increasing among the young, and gestational diabetes (GDM) offers a unique opportunity for diabetes prevention. We aimed to systematically review postpartum randomized trials to summarize the benefits of lifestyle interventions for women with previous GDM. Methods:We searched for RCTs involving women with previous GDM that compared lifestyle interventions-diet, physical activity or breastfeeding-at postpartum with usual care up to May 2018. Results:Of 1,895 abstracts identified, we selected 15 studies investigating incidence of diabetes or changes in glycemia. Most interventions focused on changes in diet and physical activity, only one also on incentive to breastfeeding. Meta-analysis of 8 studies investigating incidence of diabetes revealed a homogeneous (I² = 10%), reduction of 25% (RR = 0.75; 95%CI: 0.55-1.03) borderline statistically significant. Only trials offering intervention soon after delivery (< 6 months post-partum) were effective (RR = 0.61; 95%CI: 0.40-0.94; p for subgroup comparison = 0.11). Overall, no benefit was found regarding measures of glycemia. Although moderate reductions in weight (MD = -1.07 kg; -1.43-0.72 kg); BMI (MD = -0.94 kg/m²; -1.79 -0.09 kg/m²); and waist circumference (MD = -0.98 cm; -1.75 -0.21 cm) were observed, effects were larger with longer follow-up. Conclusions:Summary results of the available evidence support benefits of lifestyle interventions at postpartum for women with previous GDM. Benefits, although smaller than those of major trials based in older subjects receiving intensive interventions, appear clinically relevant for this young subset of woman. Further studies are needed to improve the quality of the evidence and to further tailor interventions to this specific setting.