ADA 2021: Risk Reduction of Type 2 Diabetes after Gestational Diabetes

The prevalence of underdiagnosed prediabetes and type 2 diabetes mellitus (T2DM) plays an active role in gestational diabetes.

Gestational diabetes mellitus (GDM) is caused when the mother’s body cannot produce and utilize the necessary insulin to sustain glycemic control while pregnant. Rates of recurrent GDM are as high as 30-84% and are predominant in racial/ethnic minorities. GDM national costs were up to $1.56 billion in 2017, and lifelong risk for diabetes is ten times higher in those with GDM. The linear risk for type 2 diabetes increased by 20% chance in 10 years postnatal, 40% in 30 years, and 60% in 50 years. The criteria for diagnosis of GDM are the occurrence in the second or third trimester and performing an oral glucose tolerance test with fasting results between 95-125 mg/dL.  

Can we prevent type 2 diabetes in women who have gestational diabetes? The answer is yes, as Dr. Kerri Lynn Knippen explains at the ADA mini-symposium about prevention strategies to reduce the risk of type 2 diabetes from current studies related to GDM. The original diabetes prevention program (DPP) studied 350 women with impaired glucose tolerance tests and a history of GDM for an average of 3 years. The study found that intensive lifestyle intervention resulted in a 53% lower risk for T2DM, and metformin was 50% successful over the placebo group at reducing risk for T2DM. The long-term follow-up of the diabetes prevention program outcomes study (DPPOS) continued the observational period for seven years to assess continuous interventions of the lifestyle and metformin groups. Lifestyle reduced the risk of T2DM development by 35%, and metformin lowered the risk of T2DM by 40% over a ten-year cumulative period.  

American Diabetes Association standards of care for women with GDM currently include lifestyle modifications, weight loss and physical activity counseling, rescreening at 4 to 12 weeks postpartum and 1 to 3 years for glycemic control outcomes, breastfeeding, birth spacing, and metformin if indicated. Dietary lifestyle interventions that have demonstrated a benefit in preventing T2DM are the Mediterranean diet, DASH diet, access to a dietician, and medical nutrition therapy. The findings are not limited to T2DM prevention but also benefit cardiovascular health outcomes. For every 100 minutes of physical activity, there is a 9% lower risk of T2DM, and 150 minutes per week can lower the risk of T2DM by 47%. Pregnancy or postpartum weight gain are associated with an earlier progression of T2DM. Breastfeeding has not only cardiometabolic benefits but has been associated with improved glucose tolerance after GDM. There is a 40% decrease in the chance of developing T2DM if women breastfeed for some time greater than three months.  

A cross-sectional study conducted in 2018 by Knippen, et al., which is currently unpublished, assessed 332 women with current GDM in the third trimester for provider communication about diabetes risk and their outcomes. The readiness to engage in healthcare protective behavior is essential to investigate for a greater understanding of the risk perception impact. 47% of women with current GDM in the third trimester had not had a health care provider discuss postpartum risk reduction. Dieticians or diabetes educators accounted for 55% of the originating communication. Provider communication about diabetes risk doubled the likelihood of screening access to and follow-up healthcare visits. Lack of information can attribute to the altered risk perception and behaviors of women in the postpartum period.  

Evidence suggests and supports the importance of early intervention during and after pregnancy. However, the postpartum follow-up and screening rates are lower than 50%.  Many factors can affect this, such as motivation, healthcare access, personal issues, and permissive factors. These factors have resulted in poor quality diets, reduced physical activity, and reduced breastfeeding durations. Healthcare providers need to improve communication strategies to increase risk perception, increase readiness to engage, and increase participation in healthcare protective behaviors for women with current or a history of GDM. 

Practice Pearls: 

• Type 2 diabetes is preventable in women who have a history of gestational diabetes. 
• The current standard of care for women with gestational diabetes incorporates lifestyle modifications, weight loss, physical activity counseling, rescreening at 4 to 12 weeks postpartum and 1 to 3 years for glycemic control outcomes, breastfeeding, birth spacing, and metformin if indicated. 
• Healthcare providers need to improve communication strategies to increase risk perception, increase readiness to engage, and increase participation in healthcare protective behaviors for women with current or a history of gestational diabetes. 

Knippen KL. Can We Prevent Type 2 Diabetes in Women Who Have Gestational Diabetes? American Diabetes Association mini-symposium. June 28, 2021. (ADA Symposium login required) 

Diabetes Prevention Program (DPP) Research Group. “The Diabetes Prevention Program (DPP): description of lifestyle intervention.” Diabetes care vol. 25,12 (2002): 2165-71 

Jasmine Dumontier-Hiott, PharmD Candidate 2022, University of South Florida Taneja College of Pharmacy