Post-partum weight loss and glucose metabolism in women with gestational diabetes: the DEBI Study

Clinical and Metabolic Characterization of Women With Gestational Diabetes Mellitus Within the First Year Postpartum

Context

Women with gestational diabetes mellitus (GDM) have an increased risk of long-term complications, including impaired glucose metabolism, type 2 diabetes (T2DM), cardiovascular disease, and obesity. In current clinical practice, a 1 size fits all approach to GDM is applied, although heterogeneity among women with GDM has been recognized.

Objective

To give the most adequate preventive care and postpartum (PP) guidance, we aimed to make a metabolic characterization and identify subgroups of women with previous GDM within the first year PP.

Methods

In this prospective cohort study, we collected data in gestational week 34-38, at 3 months, and 1 year PP on women with GDM who participated in a PP follow-up program in Central Region Denmark from April 2019 to December 2022.

Results

In total, 1270 women were included in the program in late pregnancy. Of the 768 women participating in either the oral glucose tolerance test 3 months PP (n = 545) or the 1-year follow-up (n = 493) or both (n = 261), 608 (79.2%) were normoglycemic, 137 (17.8%) had prediabetes, 20 (2.6%) had T2DM, and 3 (.4%) had developed T1DM. More than 40% of the women gained weight in the first year PP compared with their pregestational weight.

Conclusion

Our study shows that 20.8% of women with GDM who volunteered to participate in a clinical follow-up program developed prediabetes or diabetes (T1DM and T2DM) within the first year PP. The GDM diagnosis encompasses a heterogenetic group of women and a deeper characterization may provide an opportunity for a more personalized risk assessment to prevent the progression to T2DM.

Impact of postpartum weight change on metabolic syndrome and its components among women with recent gestational diabetes mellitus

BACKGROUND

While postpartum weight changes may affect the levels of metabolic parameters, the direct effects of weight changes in the postpartum period on changes in the prevalence rates of metabolic syndrome and its components remain unstudied. This study aimed to investigate the effects of postpartum weight changes between 6 weeks and 6 months on changes in the prevalence rates of metabolic syndrome and its components in women who have recently experienced gestational diabetes mellitus.

METHODS

This prospective cohort study included 171 postpartum women with recent gestational diabetes mellitus, who underwent serial weight and metabolic risk factor assessments at 6 weeks and 6 months postpartum. Weight changes between these time points were classified as weight loss (> 2 kg), weight stability (± 2 kg), or weight gain (> 2 kg). Metabolic syndrome comprised the following metabolic risk factors: large waist circumference, elevated blood pressure, elevated fasting plasma glucose levels, high triglyceride levels, and low high-density lipoprotein cholesterol levels.

RESULTS

Of the 171 women in our cohort, 30 women (17.5%) lost > 2 kg of body weight, while 85 (49.7%) maintained a stable weight and 56 (32.8%) gained > 2 kg. The weight loss group experienced significant changes in the prevalence rates of the following metabolic risk factors compared to the weight stability and weight gain groups: large waist circumference (% change: - 26.7 vs - 5.9 vs 5.4, respectively; p = 0.004), elevated fasting plasma glucose levels (% change: - 3.4 vs 18.9 vs 26.8, respectively; p = 0.022), and high triglyceride levels (% change: - 30.0 vs 0 vs - 7.2, respectively; p = 0.024). A significantly greater decrease in the prevalence of metabolic syndrome was also found in the weight loss group than in the other two groups (% change: - 20.0 vs 11.8 vs 14.2, respectively; p = 0.002).

CONCLUSIONS

Weight changes from 6 weeks to 6 months postpartum significantly altered the prevalence rates of metabolic syndrome and its components in women with recent gestational diabetes mellitus. Early postpartum weight loss can reverse metabolic risk factors and reduce the prevalence of metabolic syndrome.

TRIAL REGISTRATION

Thai Clinical Trials Registry: Registration no. TCTR20200903001. Date of registration: September 3, 2020. Date of initial participant enrolment: September 7, 2020.

Elevated HbA1c on universal prenatal screening is associated with decreased postpartum weight retention

OBJECTIVE

To determine the association of an elevated hemoglobin A1c (HbA1c) as part of an early pregnancy universal screening protocol and postpartum (PP) weight retention in the absence of a diagnosis of diabetes.

METHODS

This is a retrospective cohort study of patients who underwent universal HbA1c screening with initial prenatal labs (≤16 weeks) over a 2-year period (2016-2018) at a single urban tertiary care center. An elevated HbA1c was defined as 5.7-6.4%. All patients who delivered ≥32 weeks with documented weights at first prenatal visit, delivery, and PP visit were included. Patients with preexisting or gestational diabetes, multiple gestation, fetal demise, or no glucose tolerance screening were excluded. Body mass index (BMI) was calculated and gestational weight gain was assessed by National Academy of Medicine (NAM) guidelines. The primary outcome was PP weight retention among patients with normal versus elevated HbA1c.

RESULTS

2,284 patients met inclusion criteria, of whom 2015 (88.2%) had a normal HbA1c and 269 (11.8%) had an elevated HbA1c. Compared to patients with a normal HbA1c, patients with an elevated HbA1c were more likely to be non-Hispanic black, multiparous, or publicly insured. They were also more likely to enter pregnancy obese. Patients with an elevated HbA1c gained less weight during pregnancy compared to those with normal HbA1c; however, this was no longer significant after adjusting for pre-pregnancy BMI. In both groups, almost half of patients exceeded NAM guidelines for gestational weight gain during the pregnancy. Patients with an elevated HbA1c had significantly less PP weight retention (2.2 vs. 4.5 kg, p < .001) compared to patients with a normal HbA1c. After adjusting for differences in baseline characteristics, the association between HbA1c and PP weight retention remained significant (B = -0.86, p < .003). More patients in the elevated HbA1c group returned to their pre-pregnancy weight or less by the PP visit. In all BMI categories, those who exceeded NAM guidelines had greater postpartum weight retention compared to those that met guidelines.

CONCLUSION

Among patients not diagnosed with diabetes, elevated HbA1c in early pregnancy is associated with similar gestational weight gain but significantly less postpartum weight retention compared to those with normal HbA1c.

Barriers to and enablers of postpartum health behaviours among women from diverse cultural backgrounds with prior gestational diabetes: A systematic review and qualitative synthesis applying the theoretical domains framework

AIMS

Racial and ethnic disparities exist in gestational diabetes prevalence and risk of subsequent type 2 diabetes mellitus (T2DM). Postpartum engagement in healthy behaviours is recommended for prevention and early detection of T2DM, yet uptake is low among women from diverse cultural backgrounds. Greater understanding of factors impacting postpartum health behaviours is needed. Applying the Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation-Behaviour (COM-B) model, our aim was to synthesise barriers to and enablers of postpartum health behaviours among women from diverse cultural backgrounds with prior GDM and identify relevant intervention components.

METHODS

Databases, reference lists and grey literature were searched from September 2017 to April 2021. Two reviewers screened articles independently against inclusion criteria and extracted data. Using an inductive-deductive model, themes were mapped to the TDF and COM-B model.

RESULTS

After screening 5148 citations and 139 full texts, we included 35 studies (N = 787 participants). The main ethnicities included Asian (43%), Indigenous (15%) and African (11%). Barriers and enablers focused on Capability (e.g. knowledge), Opportunity (e.g. competing demands, social support from family, friends and healthcare professionals, culturally appropriate education and resources) and Motivation (e.g. negative emotions, perceived consequences and necessity of health behaviours, social/cultural identity). Five relevant intervention functions are identified to link the barriers and enablers to evidence-based recommendations for communications to support behaviour change.

CONCLUSIONS

We provide a conceptual model to inform recommendations regarding the development of messaging and interventions to support women from diverse cultural backgrounds in engaging in healthy behaviours to reduce risk of T2DM.

Executive summary of evidence and consensus-based clinical practice guideline for management of obesity and overweight in postpartum women: An AIIMS-DST initiative

INTRODUCTION

Postpartum obesity is a public health concern. There is a need to counsel women about their postpartum weight management, accounting for various barriers they face. Limited literature in the Indian context underscored the need to develop the clinical practice guideline to be used by healthcare providers in Indian healthcare settings.

METHODS

The guideline was formulated by following the standardised methodology proposed by the National Health and Medical Research Council. Various steps such as identification of the patient population, assembly of the guideline development groups, identification of the key clinical questions, guideline development methods, grading the quality of evidence and recommendations and guideline translation were carried out to develop and validate the clinical practice recommendations.

RESULTS

The evidence and consensus-based clinical practice guideline has been developed, providing recommendations for key topics of interest for first-line treatment of obesity (lifestyle-related management). Recommendations focus on screening and initiating discussion with overweight and obese postpartum women as well as those who had normal pre-pregnancy body mass index but have retained excessive weight in the postpartum period. Recommendations highlight the evaluation and management of dietary, physical activity and breastfeeding behaviour. Recommendations also account for behavioural modification techniques to improve adherence to the prescribed weight management advice. Duration and frequency of follow-ups as well as the advice to be disseminated have also been discussed in the recommendations.

CONCLUSION

The guideline provides clinical practice points that can be used by healthcare providers, postpartum women and policymakers for opportunistic screening and management of postpartum obesity.

Pregnancy Complications Can Foreshadow Future Disease—Long-Term Outcomes of a Complicated Pregnancy

During gestation, the maternal body should increase its activity to fulfil the demands of the developing fetus as pregnancy progresses. Each maternal organ adapts in a unique manner and at a different time during pregnancy. In an organ or system that was already vulnerable before pregnancy, the burden of pregnancy can trigger overt clinical manifestations. After delivery, symptoms usually reside; however, in time, because of the age-related metabolic and pro-atherogenic changes, they reappear. Therefore, it is believed that pregnancy acts as a medical stress test for mothers. Pregnancy complications such as gestational hypertension, preeclampsia and gestational diabetes mellitus foreshadow cardiovascular disease and/or diabetes later in life. Affected women are encouraged to modify their lifestyle after birth by adjusting their diet and exercise habits. Blood pressure and plasmatic glucose level checking are recommended so that early therapeutic intervention can reduce long-term morbidity. Currently, the knowledge of the long-term consequences in women who have had pregnancy-related syndromes is still incomplete. A past obstetric history may, however, be useful in determining the risk of diseases later in life and allow timely intervention.

Metformin for Preventing Type 2 Diabetes Mellitus in Women with a Previous Diagnosis of Gestational Diabetes: A Narrative Review

Women with a history of gestational diabetes mellitus (GDM) are at greater risk of developing type 2 diabetes mellitus (T2DM) when compared with women who have not had GDM. To delay or prevent T2DM, guidelines recommend regular screening in the primary care setting and lifestyle interventions that are largely focused on dietary and physical activity modifications. As the postpartum period can be challenging for women, uptake and engagement in screening and lifestyle interventions have been poor. Poor uptake and engagement places women with a history of GDM at heightened risk for future morbidity and development of T2DM. Metformin has been a longstanding and safe treatment for the control of blood glucose in people with T2DM. Research has supported the efficacy of metformin, used as an adjunct to a lifestyle intervention or as a stand-alone treatment, in preventing T2DM in people at high risk of T2DM. Findings from longitudinal studies have demonstrated the potential for metformin to reduce conversion to T2DM when used by women with a previous diagnosis of GDM. This review examines the potential effectiveness of metformin to reduce the incidence of T2DM among women with a previous diagnosis of GDM in the "real-world" setting.

Specific amino acids but not total protein attenuate postpartum weight gain among Hispanic women from Southern California

There is a high prevalence of obesity and type 2 diabetes in the United States, particularly among Hispanic women, which may be partly explained by failure to lose gestational weight during the postpartum period. Previous work indicates that protein and amino acids may protect against weight gain; therefore, this study examined the impact of dietary protein and amino acid intake on changes in postpartum weight and the percent of women meeting the Estimated Average Requirement (EAR) for these dietary variables among Hispanic women from the Southern California Mother's Milk Study (n = 99). Multivariable linear regression analysis was used to examine the associations between protein and amino acid intake with change in weight after adjusting for maternal age, height, and energy intake. Women's weight increased from prepregnancy to 1-month and 6-months postpartum (71.1 ± 14.6 vs. 73.1 ± 13.1 vs. 74.5 ± 14.6 kg, p < .0001). Although dietary protein was not associated with weight change (β = -1.09; p = .13), phenylalanine (β = -1.46; p = .04), tryptophan (β = -1.71; p = .009), valine (β = -1.34; p = .04), isoleucine (β = -1.26; p = .045), and cysteine (β = -1.52; p = .02) intake were inversely associated with weight change. Additionally, fewer women met the EAR values for cysteine (11.1%), phenylalanine (60.6%), and methionine (69.7%), whereas most women met the EAR values for tryptophan (92.9%), valine (96.0%), and isoleucine (94.9%). Study results indicate that several essential and conditionally essential amino acids were associated with postpartum weight loss, with a significant portion of women not meeting recommended intake levels for some of these amino acids. These results highlight the importance of postpartum maternal diet as a potential modifiable risk factor.

Combined analysis of gestational diabetes and maternal weight status from pre-pregnancy through post-delivery in future development of type 2 diabetes

We examined the associations of gestational diabetes mellitus (GDM) and women’s weight status from pre-pregnancy through post-delivery with the risk of developing dysglycaemia [impaired fasting glucose, impaired glucose tolerance, and type 2 diabetes (T2D)] 4–6 years post-delivery. Using Poisson regression with confounder adjustments, we assessed associations of standard categorisations of prospectively ascertained pre-pregnancy overweight and obesity (OWOB), gestational weight gain (GWG) and substantial post-delivery weight retention (PDWR) with post-delivery dysglycaemia (n = 692). Women with GDM had a higher risk of later T2D [relative risk (95% CI) 12.07 (4.55, 32.02)] and dysglycaemia [3.02 (2.19, 4.16)] compared with non-GDM women. Independent of GDM, women with pre-pregnancy OWOB also had a higher risk of post-delivery dysglycaemia. Women with GDM who were OWOB pre-pregnancy and had subsequent PDWR (≥ 5 kg) had 2.38 times (1.29, 4.41) the risk of post-delivery dysglycaemia compared with pre-pregnancy lean GDM women without PDWR. No consistent associations were observed between GWG and later dysglycaemia risk. In conclusion, women with GDM have a higher risk of T2D 4–6 years after the index pregnancy. Pre-pregnancy OWOB and PDWR exacerbate the risk of post-delivery dysglycaemia. Weight management during preconception and post-delivery represent early windows of opportunity for improving long-term health, especially in those with GDM.

Risk Factors for Progression From Gestational Diabetes to Postpartum Type 2 Diabetes: A Review

Gestational diabetes mellitus (GDM) complicates 6% to 8% of pregnancies and up to 50% of women with GDM progress to type 2 diabetes mellitus (DM) within 5 years postpartum. Clinicians have little guidance on which women are most at risk for DM progression or when evidence-based prevention strategies should be implemented in a woman's lifecycle. To help address this gap, the authors review identifiable determinants of progression from GDM to DM across the perinatal period, considering prepregnancy, pregnancy, and postpartum periods. The authors categorize evidence by pathways of risk including genetic, metabolic, and behavioral factors that influence progression to DM among women with GDM.

Translating Research on Diabetes and Obesity in Pregnancy Into Prevention: The 2019 Norbert Freinkel Award Lecture

Epidemiological studies on the intergenerational transmission of hyperglycemia and obesity via in utero exposure have established the scientific foundation for the vicious cycle of diabetes and obesity. The findings compel us to address an urgent public health question: how do we break this vicious cycle and implement upstream prevention strategies that are feasible for patients and health care delivery systems? To address this question, it is necessary to work across a continuum of translational research from basic science, epidemiology, and efficacy trials to pragmatic trials, which, along with evaluations of health programs, may lead to implementation of positive changes in clinical care. Three strategies for translating research on diabetes and obesity in pregnancy into prevention are discussed: 1) identifying diagnostic criteria of gestational diabetes mellitus (GDM) practicable in clinical settings to implement treatment and prevention, 2) examining trends in the prevalence of diabetes in pregnancy and related complications across racial/ethnic groups to plan prevention efforts, and 3) developing and evaluating scalable upstream diabetes and obesity prevention interventions. Upstream preventive interventions aimed at breaking the vicious cycle are discussed. Areas of future research needed to break the vicious cycle are identified. Evaluating the effectiveness of programs for the management of pregnancy hyperglycemia is necessary to reduce complications. Understanding racial/ethnic differences in the pathophysiology of GDM and its complications will be important for risk stratification. Pragmatic trials in real-world clinical settings for upstream prevention are needed to break the vicious cycle at the population level. Finally, leveraging basic science with intergenerational studies will inform targeted interventions.

Added sugar and sugar-sweetened beverages are associated with increased postpartum weight gain and soluble fiber intake is associated with postpartum weight loss in Hispanic women from Southern California

BACKGROUND

Obesity prevalence remains high in the United States, and there is an increased risk among women who do not lose their gestational weight gain during the postpartum period. Indicators of dietary carbohydrate quality including added sugar consumption, glycemic load, and glycemic index have been linked with weight gain, whereas fiber may protect against obesity. However, these dietary factors have not been examined during the postpartum period.

OBJECTIVES

The aim of this study was to determine whether dietary sugars and fiber intake were associated with changes in postpartum weight.

METHODS

We examined Hispanic women from the longitudinal Southern California Mother's Milk Study (n = 99) at 1 and 6 mo postpartum. Maternal assessments included height, weight, and dietary intake based on 24-h diet recalls. We used multivariable linear regression to examine the relation between maternal diet and change in postpartum weight after adjusting for maternal age, height, and energy intake.

RESULTS

Higher intake of added sugar was associated with postpartum weight gain (β: 0.05; 95% CI: 0.004, 0.10; P = 0.05). In addition, a half 8-ounce (8 fluid ounces = 236.6 mL) serving per day increase in soft drinks was associated with a 1.52-kg increase in weight (95% CI: 0.70, 2.34 kg; P < 0.001). A high glycemic index (β: 0.25; 95% CI: 0.07, 0.42; P = 0.006) and glycemic load (β: 0.04; 95% CI: 0.002, 0.08; P = 0.04) were associated with postpartum weight gain. Higher soluble fiber was associated with a decrease in postpartum weight (β: -0.82 kg; 95% CI: -1.35, -0.29 kg; P = 0.003) and the negative effects of added sugar, sugary beverages, and high-glycemic-index and -load diets were partially attenuated after adjusting for soluble fiber intake.

CONCLUSIONS

Increased consumption of added sugar, sugar-sweetened beverages, and high-glycemic diets were associated with greater weight gain in the first 6 mo postpartum. In addition, increased consumption of soluble fiber was associated with postpartum weight loss, which may partially offset the obesogenic effects of some dietary sugars.

Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART)

BACKGROUND

There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM).

METHODS

In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed.

RESULTS

At least 296 participants and approximately 75 peer supporters will be enrolled.

DISCUSSION

Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes.

TRIAL REGISTRATION

The ClinicalTrials.gov registration number is NCT03689530.

Predictors and consequences of weight retention in the early and late postpartum period in women with gestational diabetes

AIMS

To assist preventive strategies, we investigated the predictors and consequences of postpartum weight retention (PPWR) in the early and late postpartum period in women with gestational diabetes (GDM).

METHODS

862 women with GDM between 2011 and 2019 were prospectively included. We investigated PPWR at 6-8 weeks (n = 862) and at 1-year (n = 259) postpartum. Potential predictors included gestational weight gain (GWG), weight, BMI, and glucose control parameters during and after pregnancy.

RESULTS

Mean PPWR at 6-8 weeks and 1-year postpartum were 4.6 ± 5.7 kg and 4.0 ± 7.4 kg. The proportion of women with PPWR at 6-8 weeks and at 1-year postpartum were 81% and 66.4% respectively. At 6-8 weeks postpartum, women with PPWR had higher pre-pregnancy weight, 7.5 ± 0.2 kg higher GWG and higher postpartum weight (all p ≤ 0.02), without presenting metabolic differences. At 1-year postpartum, there were no differences in anthropometric parameters before and during pregnancy between women with or without PPWR, except for a 4 ± 0.4 kg higher GWG (p < 0.001). However, women with PPWR had increased postpartum weight and BMI, higher fasting glucose and more pronounced increase in Δfasting glucose and ΔHbA1c at 1-year postpartum (all p ≤ 0.03). GWG predicted higher PPWR at both 6-8 weeks and at 1-year postpartum (all p < 0.001).

CONCLUSION

Women with PPWR had increased anthropometric parameters and adverse metabolic consequences at 1-year postpartum. GWG was the most relevant predictor of PPWR.

Lifestyle information and access to a commercial weight management group to promote maternal postnatal weight management and positive lifestyle behaviour: the SWAN feasibility RCT

Background

Increasing numbers of UK women have overweight or obese body mass index scores when they become pregnant, or gain excessive weight in pregnancy, increasing their risk of adverse outcomes. Failure to manage postnatal weight is linked to smoking, non-healthy dietary choices, lack of regular exercise and poorer longer-term health. Women living in areas of higher social deprivation are more likely to experience weight management problems postnatally.

Objectives

The objectives were to assess the feasibility of conducting a definitive randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of lifestyle information and access to a commercial weight management group focusing on self-monitoring, goal-setting and motivation to achieve dietary change commencing 8–16 weeks postnatally to achieve and maintain weight management and positive lifestyle behaviour.

Design

The design was a randomised two-arm feasibility trial with a nested mixed-methods process evaluation.

Setting

The setting was a single centre in an inner city setting in the south of England.

Participants

Participants were women with body mass index scores of > 25 kg/m2 at antenatal ‘booking’ and women with normal body mass index scores (18.0–24.9 kg/m2) at antenatal booking who developed excessive gestational weight gain as assessed at 36 weeks’ gestation.

Main outcome measures

Recruitment, retention, acceptability of trial processes and identification of relevant economic data were the feasibility objectives. The proposed primary outcome was difference between groups in weight at 12 months postnatally, expressed as percentage weight change and weight loss from antenatal booking. Other proposed outcomes included assessment of diet, physical activity, smoking, alcohol consumption, body image, maternal esteem, mental health, infant feeding and NHS costs.

Results

Most objectives were achieved. A total of 193 women were recruited, 98 allocated to the intervention arm and 95 to the control arm. High follow-up rates (> 80%) were achieved to 12 months. There was an 8.8% difference in weight loss at 12 months between women allocated to the intervention arm and women allocated to the control arm (13.0% vs. 4.2%, respectively; p = 0.062); 47% of women in the intervention arm attended at least one weight management session, with low risk of contamination between arms. The greatest benefit was among women who attended ≥ 10 sessions. Barriers to attending sessions included capability, opportunity and motivation issues. Data collection tools were appropriate to support economic evaluation in a definitive trial, and economic modelling is feasible to quantify resource impacts and outcomes not directly measurable within a trial.

Limitations

The trial recruited from only one site. It was not possible to recruit women with normal body mass index scores who developed excessive pregnancy weight gain.

Conclusions

It was feasible to recruit and retain women with overweight or obese body mass index scores at antenatal booking to a trial comparing postnatal weight management plus standard care with standard care only and collect relevant data to assess outcomes. Approaches to recruit women with normal body mass index scores who gain excessive gestational weight need to be considered. Commercial weight management groups could support women’s weight management as assessed at 12 months postnatally, with probable greater benefit from attending ≥ 10 sessions. Process evaluation findings highlighted the importance of providing more information about the intervention on trial allocation, extended duration of time to commence sessions following birth and extended number of sessions offered to enhance uptake and retention. Results support the conduct of a future randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN39186148.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Associations of appetite sensations and metabolic characteristics with weight retention in postpartum women

Postpartum weight retention (PPWR) is an important risk factor for long-term obesity. Appetite may be a key factor regulating PPWR. The objectives of this study were to determine the associations between (i) PPWR and appetite; and (ii) appetite, lactation, and metabolic characteristics. Data from 49 women at 9 months postpartum contributed to this cross-sectional analysis. Energy expenditure was assessed in a whole-body calorimetry unit for 24 h. Appetite sensations were rated using visual analogue scales. Lactation (min/day) was measured using a 3-day breastfeeding diary. PPWR was negatively associated with fullness (β ± SE; R² = -2.97 ± 0.72; 0.661; P < 0.001), and satiety (-2.75 ± 0.81; 0.617; P = 0.002), and was positively associated with hunger (2.19 ± 1.02; 0.548; P = 0.039), prospective food consumption (PFC; 2.19 ± 0.91; 0.562; P = 0.021), and composite appetite score (CAS; 0.34 ± 0.09; 0.632; P = 0.001). Lactation was associated with higher CAS (39.68 ± 15.56; 0.365; P = 0.015), hunger (3.56 ± 1.61; 0.308; P = 0.033), and PFC (4.22 ± 1.78; 0.314; P = 0.023), and with reduced sensations of fullness (-4.18 ± 1.94; 0.358; P = 0.038) and satiety (-3.83 ± 1.87; 0.295; P = 0.048). Lactation was associated with appetite, which in turn was related to PPWR. Appetite control should be explored to support postpartum weight management strategies. Novelty Postpartum weight retention was associated with appetite sensations, which were assessed throughout the day under conditions in which energy intake and expenditure were precisely matched. Lactation and other maternal metabolic factors, including carbohydrate oxidation and physical activity level may play a role in controlling appetite during the postpartum period.

Diabetes after pregnancy prevention trials: Systematic review for core outcome set development

Diabetes prevention intervention studies in women with previous gestational diabetes have increased, but no consensus exists on core outcomes to support comparisons and synthesis of findings. We aimed to systematically catalogue outcomes in diabetes after pregnancy prevention interventions with the goal of developing a core outcome set. Embase, Medline, Cochrane Library, Cochrane Pregnancy and Childbirth Trials Register, and CINAHL were searched from inception to October 2017. Post‐partum lifestyle and diabetes screening intervention studies in women with previous gestational diabetes and/or their families were eligible. No limits were placed on intervention type, duration, or location. Two authors independently screened and performed data extraction on outcomes, measurement tools, and relevant study characteristics. We analysed data from 38 studies (29 randomised controlled trials and 9 pre–post intervention evaluations) comprising 12,509 participants. Most publications (80%) occurred between the years 2012 and 2017. Among 172 outcomes, we identified 36 outcome groups and classified them under three domains: health status (body weight, body composition, diabetes risk, cardiometabolic risk, diabetes development, mental health, pregnancy outcomes, and fitness), health behaviours (dietary, physical activity, diabetes screening, behaviour change, and breastfeeding), and intervention processes (implementation). The health status domain contained the most commonly reported outcomes, but measurement tools were very heterogeneous.

Despite the recent explosion in diabetes after pregnancy prevention studies, large variation in outcomes and measurement methods exists. Research is needed to define a core outcome set to standardise diabetes after pregnancy prevention interventions. The core outcome set should engage a wide group of stakeholders to identify impactful indicators for future trials.

Protocol for a two-arm feasibility RCT to support postnatal maternal weight management and positive lifestyle behaviour in women from an ethnically diverse inner city population: the SWAN feasibility trial

Introduction

A high BMI during and after pregnancy is linked to poor pregnancy outcomes and contributes to long-term maternal obesity, hypertension, and diabetes. Evidence of feasible, effective postnatal interventions is lacking. This randomised controlled trial will assess the feasibility of conducting a future definitive trial to determine effectiveness and cost-effectiveness of lifestyle information and access to Slimming World® (Alfreton, UK) groups for 12 weeks commencing from 8 to 16 weeks postnatally, in relation to supporting longer-term postnatal weight management in women in an ethnically diverse inner city population.

Methods/analysis

Women will be recruited from one maternity unit in London. To be eligible, women will be overweight (BMI 25–29.9 kg/m²) or obese (BMI ≥ 30 kg/m²) as identified at their first antenatal contact, or have a normal BMI (18.5–24.9 kg/m²) at booking but gain excessive gestational weight as assessed at 36 weeks gestation. Women will be aged 18 and over, can speak and read English, expecting a single baby, and will not have accessed weight management groups in this pregnancy. Women will be randomly allocated to standard care plus lifestyle information and access to Slimming World® (Alfreton, UK) groups or standard care only. A sample of 130 women is required.

Feasibility trial objectives reflect those considered most important inform a decision about undertaking a definitive future trial. These include estimation of impact of lifestyle information and postnatal access to Slimming World® (Alfreton, UK) on maternal weight change between antenatal booking weight and weight at 12 months postbirth, recruitment rate and time to recruitment, retention rate, influence of lifestyle information and Slimming World® (Alfreton, UK) groups on weight management, diet, physical activity, breastfeeding, smoking cessation, alcohol intake, physical and mental health, infant health, and health-related quality of life 6 and 12 months postnatally. An embedded process evaluation will assess acceptability of study processes and procedures to women.

Ethics/dissemination

London–Camberwell St Giles Research Ethics Committee, reference: 16/LO/1422. Outcomes will be disseminated in peer-reviewed journals and presentations at national and international conferences.

Trial registration

Trial registration number: ISRCTN 39186148. Protocol version number: v7, 13 August 17. Trial sponsor: King’s College London.

Postpartum problems in primary care: Focus on postpartum depression and diabetes

Postpartum depression and diabetes are common diagnoses affecting many childbearing women annually. Nevertheless, disease management by the primary care provider can be complicated by late entry to care or insufficient care. Pharmacotherapeutic interventions must be initiated appropriately to address the disease progression while supporting breastfeeding. This study explores the course of postpartum depression and diabetes in a postpartum woman using the case study application and analysis along with interventions and education that can help primary care providers in reducing the complications that come from undiagnosed depression and diabetes in the postpartum period.

Effects of isolated soy protein and strength exercise training on exercise performance and biochemical profile in postpartum mice

OBJECTIVE

Postpartum women are at an increased risk for obesity and metabolic diseases because of excessive weight gain during pregnancy and weight retention after delivery. Maintenance of good nutrition and regular physical activity is used as a therapeutic approach for promotion of health and well-being in postpartum women. The aim of this study is to assess the independent and additive effects of isolated soy protein (ISP) and strength exercise training (ET) on weight management, exercise performance and health maintenance in postpartum mice.

DESIGN AND METHODS

Thirty-two postpartum mice (ICR, 14-weeks old) were divided into four groups (n = 8 per group): Group 1 mice were the sedentary control with vehicle (SC), Group 2 mice were the sedentary control with ISP supplementation (8.95 g·kg^-1, SC + ISP), Group 3 mice received vehicle with exercise training (ET) and Group 4 mice received isolated soy protein with exercise training (ISP + ET). Animals in the ET and ISP + ET groups underwent strength exercise training for 6 weeks, 5 days a week. Exercise performance was evaluated by forelimb grip strength and exhaustive swimming time, as well as by changes in body composition and biochemical parameters at the end of the experiment.

RESULTS

Combined intervention of ISP and ET increased lean muscle mass and prevented body weight and fat elevation. The grip strength and exhaustive swimming time of the ISP + ET group were significantly higher than the other groups. The ISP + ET group showed significantly decreased serum levels of lactate, ammonia and creatinine phosphate kinase (CPK), and increased glucose level after the 15-min swimming test. The serum levels of aspartate transaminase (AST), triglyceride (TG) and creatinine after sacrifice were significantly decreased in the ET + ISP group. ISP combined with ET promoted fat oxidation in brown adipose tissue (BAT) as evidenced from the increased utilization of plasma and BAT tissue triglyceride.

CONCLUSIONS

We suggest that long-term supplementation with ISP can have a wide spectrum of bioactivities on health promotion, performance improvement and fitness. ISP with ET conferred better energy utilization, improved biochemical profiles and may be an effective ergogenic aid in strength training.

Early life environment influences the trajectory of post-partum weight loss in adult female rats

RESEARCH QUESTION

The physiological processes of pregnancy and lactation require profound changes in maternal metabolism and energy balance. The timescale of metabolic reversion after pregnancy, in particular post-partum weight loss, is highly variable between individuals. Currently, mechanisms influencing post-partum metabolic recovery are not well understood. The hypothesis tested here is that, in common with other metabolic and obesity-related outcomes, capacity for post-partum weight loss is influenced by developmental programming.

DESIGN

Adult female Wistar rats exposed to a maternal low-protein diet in utero then weaned onto a control diet post-natally (recuperated group) were compared with controls. Adult females from both groups underwent pregnancy at 3 months of age. Weight changes and metabolic parameters during pregnancy and lactation were compared between control and recuperated groups, and also with non-pregnant littermates.

RESULTS

Pregnancy weight gain was not different between the control and recuperated groups, but post-partum recuperated animals remained significantly heavier than both post-partum control animals (P<0.05) and their non-pregnant recuperated littermates (P<0.05) at the end of lactation. Post-partum recuperated animals had more intra-abdominal fat mass (P<0.05) and higher serum triglyceride concentrations (P<0.01) than controls. Post-partum recuperated animals also had increased expression of IL6, NRF2 and ALOX12 (key regulators of inflammation and lipoxygenase activity) in the intra-abdominal adipose tissue compared with control groups.

CONCLUSIONS

Mothers who themselves have been exposed to adverse early life environments are likely to have slower metabolic recovery from pregnancy than controls. Failure to return to pre-pregnancy weight after delivery predisposes to persisting sequential inter-pregnancy weight gain, which can represent a significant metabolic burden across a life course involving several pregnancies.

Effects of the interaction between glycated haemoglobin genetic risk score and postpartum weight reduction on glycaemic changes: A gene-weight interaction analysis

AIM

To investigate the effects of the interaction between glycated haemoglobin (HbA1c) genetic risk score and weight changes during and after pregnancy (postpartum weight reduction and gestational weight gain) on long-term glycaemic changes in the largest cohort of women with a history of gestational diabetes mellitus (GDM).

METHODS

This was a retrospective cohort using the baseline data from the Tianjin Gestational Diabetes Mellitus Prevention Programme. A genetic risk score was established by combining 10 HbA1c-related single-nucleotide polymorphisms, which were identified by genome-wide association studies. General linear regression models were applied to evaluate the effect of interaction between HbA1c genetic risk score and weight changes during and after pregnancy (postpartum weight reduction and gestational weight gain) on glycaemic changes.

RESULTS

'A total of 1156 women with a history of GDM were included in this respective cohort study. Statistical differences in pre-pregnancy weight, pre-delivery weight and postpartum weight were evidenced across different groups of postpartum weight reduction. After adjusting for covariates, statistical significance for changes in HbA1c level was only observed in the postpartum weight reduction <5 kg/y group (P = 0.002), and a significant effect of interaction between HbA1c genetic risk score and postpartum weight reduction on long-term changes in HbA1c was evidenced (P interaction = 0.01). In women with postpartum weight reduction ≥8 kg/y, those with a lower HbA1c genetic risk score had a greater decrease in HbA1c level.

CONCLUSIONS

HbA1c genetic risk score interacts with postpartum weight reduction to affect long-term changes in HbA1c levels among women with a history of GDM.

Effects of a Lifestyle Intervention During Pregnancy and First Postpartum Year: Findings From the RADIEL Study

CONTEXT

Women with a history of gestational diabetes (GDM) have a sevenfold risk of developing type 2 diabetes.

OBJECTIVE

To assess the effects of a lifestyle intervention during pregnancy and first postpartum year on glucose regulation, weight retention, and metabolic characteristics among women at high GDM risk.

DESIGN

In the Finnish Gestational Diabetes Prevention study, trained study nurses provided lifestyle counseling in each trimester and 6 weeks, 6 months, and 12 months postpartum.

SETTING

Three maternity hospitals in the Helsinki area and one in Lappeenranta.

PATIENTS

In total, 269 women with previous GDM and/or a prepregnancy body mass index ≥30 kg/m2 were enrolled before 20 gestational weeks and allocated to either a control or an intervention group. This study includes the 200 participants who attended study visits 6 weeks and/or 12 months postpartum.

INTERVENTION

The lifestyle intervention followed Nordic diet recommendations and at least 150 minutes of moderate exercise was recommended weekly.

MAIN OUTCOME MEASURE

The incidence of impaired glucose regulation (impaired fasting glucose, impaired glucose tolerance, or type 2 diabetes) during the first postpartum year.

RESULTS

Impaired glucose regulation was present in 13.3% of the women in the control and in 2.7% in the intervention group [age-adjusted odds ratio, 0.18 (95% confidence interval, 0.05 to 0.65), P = 0.009] during the first postpartum year. There were no differences between the groups in weight retention, physical activity, or diet at 12 months postpartum.

CONCLUSIONS

A lifestyle intervention during pregnancy and the first postpartum year successfully reduced the incidence of postpartum impairment in glucose regulation.

Inflammatory Markers in Older Women with a History of Gestational Diabetes and the Effects of Weight Loss

The purpose of this study was to compare systemic inflammation in older women with a history of gestational diabetes (GDM) who developed impaired glucose tolerance (IGT) or type 2 diabetes (T2DM) to that in those with normal glucose tolerance (NGT) and to determine, in these women, the effect of weight loss (WL) induced by diet and exercise training on systemic inflammation and adipokine levels. This was a longitudinal clinical investigation of overweight/obese (BMI: 32 ± 1 kg/m²) women (59 ± 1 years) with a GDM history (n = 19) who had normal glucose tolerance (NGT, n = 7) or IGT/T2DM (n = 12). Women completed 6 months of weight loss induced by diet and exercise and underwent VO₂max, body composition, blood draw, glucose tolerance testing, and 2-hour hyperinsulinemic-euglycemic clamps (40 mU·m^-2·min^-1). Glucose utilization (M) was 42% higher in the NGT group (P < 0.05). CRP was two-fold higher in the IGT/T2DM group than that in the NGT group (P < 0.01). Adiponectin levels were 59% higher in the NGT group than those in the IGT/T2DM group (P < 0.01). IL-6sR was higher in the NGT group (P < 0.01). The women lost body weight, body fat, visceral fat, and subcutaneous abdominal fat (P < 0.001). Fasting glucose (P < 0.05), fasting insulin, glucose, and insulin AUC decreased (all P < 0.005) after the intervention. M increased by 21% (P < 0.05). CRP (-16%) and TNFR1 (-6%) tended to decrease, whereas TNFα, IL-6, SAA, and adiponectin did not change in the group. In conclusion, older women with a history of GDM who have developed IGT or T2DM have higher CRP and reduced adiponectin levels despite similar BMI and total and abdominal obesity to those with NGT. Six months WL induced by diet and exercise improves body composition and increases insulin sensitivity without a significant modification of inflammatory markers and adiponectin levels.

Designing a lifestyle intervention to reduce risk of type 2 diabetes in postpartum mothers following gestational diabetes: An online survey with mothers and health professionals

OBJECTIVE

The aim of this study was to identify what components of a postpartum lifestyle intervention would engage postpartum mothers who had a diagnosis of gestational diabetes.

STUDY DESIGN

Two online surveys were conducted, one involving postnatal mothers with GDM (n=83), and a second for health professionals (n=46).

RESULTS

Seventy-eight percent of mothers were aware that healthy eating, exercise and weight management were all important to reduce risk of subsequent type 2 diabetes. However, 80% of women in this survey were not ready to engage in a postpartum lifestyle intervention within the first 6 months of giving birth; in contrast 52% of health professionals recommended they should be engaged in the first six weeks. Group sessions were the most commonly chosen format to deliver an intervention (30%). A community setting was preferred to a medical one. Mothers wanted recipe ideas (95%) in preference to general dietary advice (76%) or cooking skills courses (39%). Walking was the main form of exercise for 79% of mothers in this sample. Women highlighted difficulty in focusing on their own health goals because of competing demands of looking after a baby (41% agreed, Median 3, IQR 2), tiredness (65% agreed, Md 4, IQR 1) and the need for childcare (64% agreed, Md 4, IQR 2).

CONCLUSION

A walking programme, recipe ideas and weight monitoring may be useful components when designing a postpartum lifestyle intervention. Barriers to engagement are evident and the intervention should allow women to engage at a time that is appropriate for them.

From Sea to Shining Sea and the Great Plains to Patagonia: A Review on Current Knowledge of Diabetes Mellitus in Hispanics/Latinos in the US and Latin America

The past two decades have witnessed many advances in the prevention, treatment, and control of diabetes mellitus (DM) and its complications. Increased screening has led to a greater recognition of type 2 diabetes mellitus (type 2 DM) and prediabetes; however, Hispanics/Latinos, the largest minority group in the US, have not fully benefited from these advances. The Hispanic/Latino population is highly diverse in ancestries, birth places, cultures, languages, and socioeconomic backgrounds, and it populates most of the Western Hemisphere. In the US, the prevalence of DM varies among Hispanic/Latino heritage groups, being higher among Mexicans, Puerto Ricans, and Dominicans, and lower among South Americans. The risk and prevalence of diabetes among Hispanics/Latinos are significantly higher than in non-Hispanic Whites, and nearly 40% of Hispanics/Latinos with diabetes have not been formally diagnosed. Despite these striking facts, the representation of Hispanics/Latinos in pharmacological and non-pharmacological clinical trials has been suboptimal, while the prevalence of diabetes in these populations continues to rise. This review will focus on the epidemiology, etiology and prevention of type 2 DM in populations of Latin American origin. We will set the stage by defining the terms Hispanic, Latino, and Latin American, explaining the challenges identifying Hispanics/Latinos in the scientific literature and databases, describing the epidemiology of diabetes-including type 2 DM and gestational diabetes mellitus (GDM)-and cardiovascular risk factors in Hispanics/Latinos in the US and Latin America, and discussing trends, and commonalities and differences across studies and populations, including methodology to ascertain diabetes. We will discuss studies on mechanisms of disease, and research on prevention of type 2 DM in Hispanics/Latinos, including women with GDM, youth and adults; and finalize with a discussion on lessons learned and opportunities to enhance research, and, consequently, clinical care oriented toward preventing type 2 DM in Hispanics/Latinos in the US and Latin America.

The MC4R genotype is associated with postpartum weight reduction and glycemic changes among women with prior gestational diabetes: longitudinal analysis

The genetic variants near the Melanocortin-4 receptor gene (MC4R), a key protein regulating energy balance and adiposity, have been related to obesity and glucose metabolism. We aimed to assess whether the MC4R genotype affected longitudinal changes in body weight and glucose metabolism biomarkers among women with prior gestational diabetes mellitus (GDM). The MC4R genotype, postpartum weight reduction, and glycemic changes between after delivery and pregnancy were assessed in a cohort of 1208 Chinese women who had experienced GDM. The adiposity-increasing allele (C) of the MC4R variant rs6567160 was associated with greater postpartum increase of HbA1c (β = 0.08%; P = 0.03) and 2-hour OGTT glucose concentrations (β = 0.25 mmol/L; P = 0.02). In addition, we found an interaction between the MC4R genotype and postpartum weight reduction on changes in fasting plasma glucose (P-interaction = 0.03). We found that the MC4R genotype was associated with postpartum glycemic changes; and the association with fasting glucose were significantly modified by postpartum weight reduction in women who had experienced GDM.

Long-Term Effects of Pregnancy Complications on Maternal Health: A Review

Background: Most pregnancy-related medical complications appear to resolve at delivery or shortly thereafter. Common examples are preterm labor, placental abruption, preeclampsia, and gestational diabetes. Women who developed such complications are known to be at increased risk of developing similar complications in future pregnancies. It has recently become evident that these women are at an increased risk of long term medical complications. Methods: A search through scientific publications in English regarding the association of obstetric complications and long-term maternal illness. Results: There is a clear association between various obstetric complications and long-term effects on maternal health. Conclusions: Women with a history of adverse pregnancy outcomes are at increased risk of cardiovascular and metabolic diseases later in life. Data increasingly links maternal vascular, metabolic, and inflammatory complications of pregnancy with an increased risk of vascular disease in later life.

Lifestyle interventions for the treatment of women with gestational diabetes

BACKGROUND

Gestational diabetes (GDM) is glucose intolerance, first recognised in pregnancy and usually resolving after birth. GDM is associated with both short- and long-term adverse effects for the mother and her infant. Lifestyle interventions are the primary therapeutic strategy for many women with GDM.

OBJECTIVES

To evaluate the effects of combined lifestyle interventions with or without pharmacotherapy in treating women with gestational diabetes.

SEARCH METHODS

We searched the Pregnancy and Childbirth Group's Trials Register (14 May 2016), ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) (14th May 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

We included only randomised controlled trials comparing a lifestyle intervention with usual care or another intervention for the treatment of pregnant women with GDM. Quasi-randomised trials were excluded. Cross-over trials were not eligible for inclusion. Women with pre-existing type 1 or type 2 diabetes were excluded.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. All selection of studies, data extraction was conducted independently by two review authors.

MAIN RESULTS

Fifteen trials (in 45 reports) are included in this review (4501 women, 3768 infants). None of the trials were funded by a conditional grant from a pharmaceutical company. The lifestyle interventions included a wide variety of components such as education, diet, exercise and self-monitoring of blood glucose. The control group included usual antenatal care or diet alone. Using GRADE methodology, the quality of the evidence ranged from high to very low quality. The main reasons for downgrading evidence were inconsistency and risk of bias. We summarised the following data from the important outcomes of this review. Lifestyle intervention versus control groupFor the mother:There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of hypertensive disorders of pregnancy (pre-eclampsia) (average risk ratio (RR) 0.70; 95% confidence interval (CI) 0.40 to 1.22; four trials, 2796 women; I² = 79%, Tau² = 0.23; low-quality evidence); caesarean section (average RR 0.90; 95% CI 0.78 to 1.05; 10 trials, 3545 women; I² = 48%, Tau² = 0.02; low-quality evidence); development of type 2 diabetes (up to a maximum of 10 years follow-up) (RR 0.98, 95% CI 0.54 to 1.76; two trials, 486 women; I² = 16%; low-quality evidence); perineal trauma/tearing (RR 1.04, 95% CI 0.93 to 1.18; one trial, n = 1000 women; moderate-quality evidence) or induction of labour (average RR 1.20, 95% CI 0.99 to 1.46; four trials, n = 2699 women; I² = 37%; high-quality evidence).More women in the lifestyle intervention group had met postpartum weight goals one year after birth than in the control group (RR 1.75, 95% CI 1.05 to 2.90; 156 women; one trial, low-quality evidence). Lifestyle interventions were associated with a decrease in the risk of postnatal depression compared with the control group (RR 0.49, 95% CI 0.31 to 0.78; one trial, n = 573 women; low-quality evidence).For the infant/child/adult:Lifestyle interventions were associated with a reduction in the risk of being born large-for-gestational age (LGA) (RR 0.60, 95% CI 0.50 to 0.71; six trials, 2994 infants; I² = 4%; moderate-quality evidence). Birthweight and the incidence of macrosomia were lower in the lifestyle intervention group.Exposure to the lifestyle intervention was associated with decreased neonatal fat mass compared with the control group (mean difference (MD) -37.30 g, 95% CI -63.97 to -10.63; one trial, 958 infants; low-quality evidence). In childhood, there was no clear evidence of a difference between groups for body mass index (BMI) ≥ 85th percentile (RR 0.91, 95% CI 0.75 to 1.11; three trials, 767 children; I² = 4%; moderate-quality evidence).There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of perinatal death (RR 0.09, 95% CI 0.01 to 1.70; two trials, 1988 infants; low-quality evidence). Of 1988 infants, only five events were reported in total in the control group and there were no events in the lifestyle group. There was no clear evidence of a difference between lifestyle intervention and control groups for a composite of serious infant outcome/s (average RR 0.57, 95% CI 0.21 to 1.55; two trials, 1930 infants; I² = 82%, Tau² = 0.44; very low-quality evidence) or neonatal hypoglycaemia (average RR 0.99, 95% CI 0.65 to 1.52; six trials, 3000 infants; I² = 48%, Tau² = 0.12; moderate-quality evidence). Diabetes and adiposity in adulthood and neurosensory disability in later childhoodwere not prespecified or reported as outcomes for any of the trials included in this review.

AUTHORS' CONCLUSIONS

Lifestyle interventions are the primary therapeutic strategy for women with GDM. Women receiving lifestyle interventions were less likely to have postnatal depression and were more likely to achieve postpartum weight goals. Exposure to lifestyle interventions was associated with a decreased risk of the baby being born LGA and decreased neonatal adiposity. Long-term maternal and childhood/adulthood outcomes were poorly reported.The value of lifestyle interventions in low-and middle-income countries or for different ethnicities remains unclear. The longer-term benefits or harms of lifestyle interventions remains unclear due to limited reporting.The contribution of individual components of lifestyle interventions could not be assessed. Ten per cent of participants also received some form of pharmacological therapy. Lifestyle interventions are useful as the primary therapeutic strategy and most commonly include healthy eating, physical activity and self-monitoring of blood glucose concentrations.Future research could focus on which specific interventions are most useful (as the sole intervention without pharmacological treatment), which health professionals should give them and the optimal format for providing the information. Evaluation of long-term outcomes for the mother and her child should be a priority when planning future trials. There has been no in-depth exploration of the costs 'saved' from reduction in risk of LGA/macrosomia and potential longer-term risks for the infants.

Transitioning the Adult with Type 2 Diabetes From the Acute to Chronic Care Setting: Strategies to Support Pragmatic Implementation Success

Scientific evidence is available to guide the how to of medications management when patients with diabetes are hospitalized or present to the Emergency Department. However, few clinical trials in the diabetes field have addressed the execution, coupled with established implementation effectiveness evaluation frameworks to help inform and assess implementation practices to support the transition in care. These deficiencies may be overcome by (1) applying the principles of implementation and delivery systems science; (2) engaging the principles of human factors (HF) throughout the design, development, and evaluation planning activities; and (3) utilizing mixed methods to design the intervention, workflow processes, and evaluate the intervention for sustainability within existing care delivery models. This article provides a discussion of implementation science and human factors science including an overview of commonly used frameworks which can be applied to structure design and implementation of sustainable and generalizable interventions.

Prevention of type 2 diabetes mellitus in women with previous gestational diabetes mellitus

Gestational diabetes mellitus (GDM), defined as any degree of glucose intolerance with onset or first recognition during pregnancy, is characterized by underlying maternal defects in the β-cell response to insulin during pregnancy. Women with a previous history of GDM have a greater than 7-fold higher risk of developing postpartum diabetes compared with women without GDM. Various risk factors for postpartum diabetes have been identified, including maternal age, glucose levels in pregnancy, family history of diabetes, pre-pregnancy and postpartum body mass index, dietary patterns, physical activity, and breastfeeding. Genetic studies revealed that GDM shares common genetic variants with type 2 diabetes. A number of lifestyle interventional trials that aimed to ameliorate modifiable risk factors, including diet, exercise, and breastfeeding, succeeded in reducing the incidence of postpartum diabetes, weight retention, and other obesity-related morbidities. The present review summarizes the findings of previous studies on the incidence and risk factors of postpartum diabetes and discusses recent lifestyle interventional trials that attempted to prevent postpartum diabetes.

Mothers after Gestational Diabetes in Australia (MAGDA): A Randomised Controlled Trial of a Postnatal Diabetes Prevention Program

BACKGROUND

Gestational diabetes mellitus (GDM) is an increasingly prevalent risk factor for type 2 diabetes. We evaluated the effectiveness of a group-based lifestyle modification program in mothers with prior GDM within their first postnatal year.

METHODS AND FINDINGS

In this study, 573 women were randomised to either the intervention (n = 284) or usual care (n = 289). At baseline, 10% had impaired glucose tolerance and 2% impaired fasting glucose. The diabetes prevention intervention comprised one individual session, five group sessions, and two telephone sessions. Primary outcomes were changes in diabetes risk factors (weight, waist circumference, and fasting blood glucose), and secondary outcomes included achievement of lifestyle modification goals and changes in depression score and cardiovascular disease risk factors. The mean changes (intention-to-treat [ITT] analysis) over 12 mo were as follows: -0.23 kg body weight in intervention group (95% CI -0.89, 0.43) compared with +0.72 kg in usual care group (95% CI 0.09, 1.35) (change difference -0.95 kg, 95% CI -1.87, -0.04; group by treatment interaction p = 0.04); -2.24 cm waist measurement in intervention group (95% CI -3.01, -1.42) compared with -1.74 cm in usual care group (95% CI -2.52, -0.96) (change difference -0.50 cm, 95% CI -1.63, 0.63; group by treatment interaction p = 0.389); and +0.18 mmol/l fasting blood glucose in intervention group (95% CI 0.11, 0.24) compared with +0.22 mmol/l in usual care group (95% CI 0.16, 0.29) (change difference -0.05 mmol/l, 95% CI -0.14, 0.05; group by treatment interaction p = 0.331). Only 10% of women attended all sessions, 53% attended one individual and at least one group session, and 34% attended no sessions. Loss to follow-up was 27% and 21% for the intervention and control groups, respectively, primarily due to subsequent pregnancies. Study limitations include low exposure to the full intervention and glucose metabolism profiles being near normal at baseline.

CONCLUSIONS

Although a 1-kg weight difference has the potential to be significant for reducing diabetes risk, the level of engagement during the first postnatal year was low. Further research is needed to improve engagement, including participant involvement in study design; it is potentially more effective to implement annual diabetes screening until women develop prediabetes before offering an intervention.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12610000338066.

Improvements in insulin sensitivity after aerobic exercise and weight loss in older women with a history of gestational diabetes and type 2 diabetes mellitus

PURPOSE

To determine whether a hypocaloric diet alone (WL) or with exercise training (AEX + WL) is effective in improving body composition, fitness, glucose utilization and CVD risk factors in sedentary women with a history of gestational diabetes (GDM) and with type 2 diabetes (T2DM).

MATERIALS AND METHODS

Longitudinal clinical investigation of 25 overweight/obese (BMI: 32 ± 1 kg/m(2)) women (59 ± 1 yrs) with a GDM history (n = 20) or T2DM (n = 5). Women completed 6 months WL (n = 10) or AEX+WL (n = 15) with VO2max, body composition, and glucose tolerance testing. Insulin sensitivity was measured during the last 30 min of 2 h hyperinsulinemic-euglycemic clamps (40 mU·m(-2.)min(-1)) before and after interventions.

RESULTS

Body weight decreased ~7% after WL and AEX+WL (p < 0.001), with an 11-12% decrease in fat mass (p < 0.0001). Visceral fat and subcutaneous abdominal fat decreased 27 and 10% after WL (p < 0.01) and 14 and 11% after AEX + WL (p < 0.05). VO2max increased 16% after AEX + WL (p < 0.001) and did not change after WL. Glucose AUC decreased 14 and 13% after WL (p < 0.05) and AEX + WL (p < 0.01) with a 42% decrease in insulin AUC after AEX + WL (p < 0.01). Glucose utilization increased 25% (p = 0.05) with AEX + WL and 7% with WL.

CONCLUSIONS

A six-month aerobic exercise program combined with moderate weight loss reduces body weight, visceral and subcutaneous abdominal fat, and improves insulin sensitivity in older women who had previously been diagnosed with GDM and those with T2DM. These findings should encourage women with a history of GDM to engage in an active lifestyle and reduce caloric intake to lower the risk for the development of T2DM.

Skeletal Muscle CAP Expression Increases after Dietary Restriction and Aerobic Training in Women with a History of Gestational Diabetes

The purpose is to determine the effects of 6 months caloric restriction and aerobic training (3x/wk) (CR+AEX) on c-CBL associated protein (CAP) gene expression in women with a history of GDM. CAP is involved in cell signaling and protein ubiquitination, and is linked to the development of insulin resistance. Obese (BMI=32 ± 1 kg/m², % fat=46 ± 2, X ± SEM), sedentary (VO2 max=21.2 ± 1.2 ml/kg/min), women aged 52 ± 2 years participated in 6 months D+WL (n=10) with body composition, fitness (VO2 max), and glucose tolerance testing. Insulin sensitivity was assessed during the last 30 min of 2-hour hyperinsulinemic-euglycemic clamps (40 mU.m^-2.min^-1) pre and post interventions. Vastus lateralis skeletal muscle biopsies (n=7) were conducted and CAP, GLUT4 and glycogen synthase (GS) gene expression measured by RT-PCR. No change in FFM by DXA was observed, but body weight decreased 8% with losses of total body fat mass (P<0.05) and a 10% increase in VO2 max (P<0.01). Glucose and insulin areas under the curve by OGTT decreased (P<0.05). Glucose utilization during the clamp increased 27% (23.1 ± 3.8 vs. 29.4 ± 3.6 umol.kg.min^-1, P<0.05). Vastus lateralis skeletal muscle CAP expression increased 21% (P<0.05) but GLUT4 did not. Results suggest that changes in CAP could be involved in the improvement in glucose metabolism with caloric restriction and aerobic training in women with a history of gestational diabetes.

GESTATIONAL DIABETES. OBSTETRICAL PERSPECTIVE

This review discusses current international recommendations for GDM diagnosis and management and argues whether it would be worth considering first, universal screening for GDM in our country, second, updating of management guidelines and third, organized follow-up of women diagnosed with GDM and adoption of lifestyle interventions after delivery that could reduce the onset and prevalence of type 2 DM.

Genetic Predisposition to Polycystic Ovary Syndrome, Postpartum Weight Reduction, and Glycemic Changes: A Longitudinal Study in Women With Prior Gestational Diabetes

CONTEXT

Polycystic ovary syndrome (PCOS) is a common condition in reproductive-aged women and a major female-specific risk factor of obesity, impaired glucose tolerance, and diabetes.

OBJECTIVE

We examined whether the genetic variation predisposing to PCOS affected glycemic changes in women with prior gestational diabetes mellitus (GDM) and whether such an effect was modified by changes in body adiposity, especially during and after pregnancy.

DESIGN, SETTING, AND PARTICIPANTS

This is a longitudinal study in Tianjin, China. We genotyped 7 genome-wide association study-identified PCOS single nucleotide polymorphisms and assessed gestational weight gain and changes in glycemic traits and weight at 1 to 5 years postpartum in 1133 women with prior GDM.

MAIN OUTCOME MEASURES

The main outcome measure was postpartum glycemic changes.

RESULTS

The PCOS genetic risk score significantly interacted with postpartum weight reduction on changes in fasting glucose and 2-h glucose (P for interaction = .032 and .007; respectively) after multivariable adjustment. In women with postpartum weight reduction of ≥ 5 kg/y, the genetic risk score was associated with decreased fasting and 2-h glucose, whereas an opposite genetic effect was found in women who lost less weight. The association between postpartum weight reduction and glycemic improvement was more significant among women with a higher genetic risk score.

CONCLUSIONS

In a large cohort of Chinese women with a history of GDM, our data for the first time indicate that the genetic predisposition to PCOS may interact with postpartum weight reduction on long-term glycemic changes, emphasizing the importance of postpartum weight management in prevention of diabetes in this subgroup of women.

Gestational diabetes: a red flag for future Type 2 diabetes in pregnancy? A retrospective analysis

AIMS

This study sought to understand the relationship between Type 2 diabetes in pregnancy and previous gestational diabetes (GDM), and determine whether a previous pregnancy with GDM was associated with subsequent better pregnancy planning.

METHODS

A retrospective review of medical records of women with Type 2 diabetes in pregnancy was conducted at three teaching hospitals to ascertain whether they had earlier GDM, and to determine whether this is associated with differences in measures of pregnancy planning and diabetes management.

RESULTS

Of 172 index pregnancies affected by Type 2 diabetes, in 76 (44%) cases, the mother had a previous history of GDM. Within this cohort, a diagnosis of 'overt diabetes in pregnancy', made on the basis of a GTT result during pregnancy in the WHO diabetic range with persistent diabetes post partum, was more common among women who had previous GDM than women who had not had GDM (20% vs 7%, P = 0.02). Women who previously had GDM did not exhibit a higher incidence of preconception planning or folate supplementation.

CONCLUSIONS

It is common for women with Type 2 diabetes in pregnancy to have had GDM previously. The diagnosis of GDM is an opportunity to improve future pregnancy planning and outcomes for women with Type 2 diabetes in pregnancy. This goal is yet to be realized.

Prevention of Diabetes after Gestational Diabetes: Better Translation of Nutrition and Lifestyle Messages Needed

Type 2 Diabetes Mellitus (T2DM) and Gestational Diabetes (GDM) are important and escalating problems worldwide. GDM increases the risk of complications in pregnancy and birth, as well as a 1 in 2 chance of developing T2DM later in life. The burden of GDM extends to offspring, who have an increased risk of obesity and diabetes-further perpetuating the cycle of diabetes within families. Clinical trial evidence demonstrates T2DM incidence reduced by up to 50% for women with GDM with nutrition and physical activity changes and the economic modeling suggests cost effectiveness. The key diet-related changes to reduce T2DM risk are reviewed, in addition to breastfeeding. The difficulties associated with the delivery of dietary and lifestyle behaviour change to women after GDM are discussed and focus on: complex healthcare system interactions needed for care delivery; women finding postpartum self-care challenging; and low levels of awareness being present across the board. In addition, studies currently underway to improve care provision in this important area will be examined.