Postpartum diabetes prevention -
Given that postnatal weight retention increases diabetes risk [ 11 ] and that guidelines recommend postnatal weight management [ 31 , 50 , 51 ], our findings could be interpreted as supporting the potential for a low intensity program to address postnatal weight retention and therefore lower diabetes risk.
We would argue that our findings represent an issue of low penetration and participation in this target group, resulting in low effectiveness. The number of reported DPPs specifically designed for women with prior GDM has risen exponentially, but their effectiveness in reducing diabetes risk has been low to date.
It is clear that for effective weight loss within DPPs, high session frequency and longer program duration and fidelity are needed [ 37 ]. This presents a challenge for women with young families, who commonly cite a lack of time as a major barrier to engagement [ 17 ].
Nevertheless, a lower frequency of sessions can be effective for diabetes prevention—when delivered over longer periods of time and where penetration and participation rates are higher [ 37 , 47 ]—which is important when looking to sustainability or scaling up a program for health service delivery.
Central to the issue of penetration and participation is the design of randomised trials, which leads to the recruitment of highly selective populations. One of the largest DPPs in women with previous GDM comes from a study by Ratner and colleagues [ 7 ]; systematic reviews consistently [ 41 , 52 , 53 ] identify this study as high-quality evidence for the role of a DPP in this population, but the generalisability of the results from the population recruited is rarely discussed.
Clearly, their diabetes risk was higher, their child care demands lower, and the chance of engagement greater. It is to be expected that their diabetes risk and their risk perception were likely to be quite different from those of Ratner et al.
The recently published GEM trial [ 25 ] provides us with a more real-world perspective on the comparative effectiveness at the health service level. There are some lessons to be learnt from the factors contributing to the low effect size seen.
The relatively low intervention engagement in MAGDA-DPP is reflected in an accordingly low level of behavioural change and resulting weight change. Attending and completing weight loss interventions are known correlates to achieving weight loss [ 54 , 55 ]; when people leave a program early, their skills and coping strategies for achieving and sustaining weight loss are likely to be underdeveloped [ 56 , 57 ].
Risk perception is another important influence on engagement with lifestyle behaviour change [ 36 ]. At the individual session, a risk algorithm was used to demonstrate the risk of developing diabetes to participants.
Risk algorithms are highly age-dependent; most women were normoglycemic, so it is possible their interpretation was that they did not need to worry about their risk of diabetes until they were older. Strengths of this randomised trial include the length of follow-up after the active intervention, good retention rates, the fidelity measures included in the intervention design, and the rigorous data collection methodology.
Limitations of the MAGDA-DPP study include the low level of participation in the intervention group sessions along with overall low levels of penetration and participation, as defined by the PIPE metric [ 37 ].
Although relatively extensive consultation work was undertaken prior to MAGDA-DPP implementation literature review, qualitative interviews with the population of interest [ 18 ], piloting of the program materials in postnatal women who had gestational diabetes , it is possible that a broader qualitative exploration of issues relating to penetration, compliance, and program delivery may have yielded stronger engagement and possibly better outcomes.
The diabetes risk profiles for MAGDA-DPP participants were surprisingly low considering the body of evidence behind GDM being a strong risk factor for T2DM development [ 3 , 11 ]. It is also possible that those who agreed to participate were a lower-risk group, with healthier baseline behaviours.
The observed magnitude of the difference is similar to the magnitudes reported in other studies of lifestyle interventions [ 25 , 41 ], and we believe it is important to add the result of this study to the accumulating knowledge about the utility of lifestyle modification programs in mothers with prior GDM.
Our trial explored the effect of offering a DPP in the first year postnatally and showed that it was ineffective.
Telephone- or web-based interventions that can adapt to the time demands of raising a young family may have more successful participation rates [ 23 , 25 ] and may have the advantage of being less resource intensive and more suited to scale-up, but it is unlikely that they will be as effective as programs offered to women with the high-risk characteristics of those in the study by Ratner et al.
The extent to which the newer GDM diagnostic criteria of the International Association of Diabetes and Pregnancy Study Groups will affect demand for diabetes prevention services in not yet known [ 59 ], but our finding that the majority of our cohort were at low risk using the previous, higher GDM diagnostic cut-offs suggests that the relative benefit and cost associated with offering an early postnatal period DPP to all women with a previous GDM pregnancy does not make it a sensible use of scarce health resources.
A better health service approach might be to improve the currently recommended annual diabetes screening within family medicine practice for women with previous GDM, so more women with prediabetes, who are at high risk, can be identified [ 50 ].
This health service approach could be supported by a reminder system within a national GDM registry, the NGDR being the current Australian example, and women with prediabetes could be more selectively targeted for recruitment into an appropriate DPP. Our results show that a low intensity, group-delivered DPP was superior to usual care in preventing postnatal weight gain in a cohort of women with previous GDM.
However, the level of engagement was low, and DPPs may need to be offered at other time points after pregnancy. Further research on engagement is required, including participant input into the design of interventions, and a more effective option may be to follow up women with previous GDM until they show IGT or HbA1c levels in the prediabetes range before offering entry to a DPP.
Minimum to moderate engagement was defined as attending the individual session and 1—4 group sessions; full engagement was attending all sessions. We sincerely thank all MAGDA-DPP participants and organisations who participated in the trial; the MAGDA-DPP Manual Training Committee and the MAGDA-DPP RCT Working Group for supporting the intervention delivery; Dino Asproloupos for senior project management; Jessica Bucholc for field data collection; and all the additional staff who delivered the intervention and collected data for this complex trial.
The views expressed in this publication do not necessarily reflect the policies of the State of Victoria, the Victorian Government, the Victorian Department of Health, the Victorian Minister for Health or the South Australian Government.
Conceived and designed the experiments: JAD JDB EJ RC JJNO MA PAP. Analyzed the data: VV JR TS STFS. Wrote the first draft of the manuscript: SLOR.
Contributed to the writing of the manuscript: JAD VV EJ JDB. Enrolled patients: CW. Designed the intervention program materials: TS VH CW SLOR. Trained the facilitators to deliver the program: TS CW. Responsible for evaluation planning: STFS. Guarantor and general supervisor of the study: JAD.
All authors have read, and confirm that they meet, ICMJE criteria for authorship. Article Authors Metrics Comments Media Coverage Reader Comments Figures. Abstract Background Gestational diabetes mellitus GDM is an increasingly prevalent risk factor for type 2 diabetes.
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.
Trial Registration Australian New Zealand Clinical Trials Registry ACTRN Author Summary Why Was This Study Done? Women who have had gestational diabetes are much more likely to develop type 2 diabetes. Although many diabetes prevention programs for people over the age of 50 exist, few are tailored to the needs of young mothers who have had gestational diabetes.
On the assumption that offering prevention earlier is beneficial, researchers developed and tested a diabetes prevention program for women who had gestational diabetes; women participated in the program during their first year after giving birth.
What Did the Researchers Do and Find? The researchers enrolled women in a one-year study: women were assigned to the diabetes prevention program one individual session and five group sessions over a three-month period, followed by telephone calls at six and nine months , and were assigned to the control group usual postnatal care.
After one year, the average changes for women in the diabetes prevention program were a 0. The between-group difference in weight change was 0. What Do These Findings Mean? These findings suggest that although a diabetes prevention program designed for women who have had gestational diabetes can prevent weight gain over 12 months, getting women to engage with the program was challenging, so it would not be sustainable in routine health services.
The women who participated in the study had low diabetes risk profiles only one in ten had impaired glucose tolerance , and most diabetes prevention guidelines would not categorise them as being at sufficiently high risk for participation in a diabetes prevention program. For diabetes prevention programs in women who have had gestational diabetes, further research is required on the process of engagement and lifestyle interventions at other time points, including participant involvement in the design of interventions.
Australian clinical guidelines stipulate that women who have had gestational diabetes should be screened annually for diabetes. One option for management would be to wait until they develop prediabetes before offering a diabetes prevention program, which may prove more effective because their children will be older and women may be easier to engage in improving their health.
Introduction Gestational diabetes mellitus GDM and type 2 diabetes mellitus T2DM rates are rising worldwide [ 1 ], posing an increasing burden on the health and economic welfare of nations [ 2 ].
Methods Study Design MAGDA-DPP was a multicentre, prospective, open randomised controlled trial RCT to assess the effectiveness of a structured DPP for women with previous GDM. Recruitment MADGA-DPP used multiple recruitment strategies, prospective and retrospective, which are described in full within our methodology publications [ 29 , 30 ].
Randomisation The trial was registered with the Australian New Zealand Clinical Trials Registry on 28 April , and the first participant was randomised on 1 August Diabetes Prevention Program After randomisation, the active intervention consisted of one individual and five group sessions delivered by specially trained healthcare professionals, with two additional follow-up maintenance telephone calls for each participant, as shown in S1 Fig.
Box 1. Group session 1 community venue within 1 mo of individual session Understanding diabetes and diabetes risk factors, knowledge and skill building on the topic of saturated fat, family-focused activities on reducing saturated fat content in diet, review of personalised goals and group goal setting for next 2 wk.
Group session 4 community venue 2 wk after group session 3 Knowledge and skill building on healthier meal planning, learning activities focused on negotiating stressful situations around food choice with family members and mindful eating, knowledge and skill building on good sleep hygiene, review of personalised goals and group goal setting for next 2 wk.
Group session 5 community venue 2 wk after group session 4 Knowledge and skill building on postnatal depression awareness and stress management, discussion on lifestyle modification relapse prevention and change maintenance, review of personalised goals and group longer-term goal setting.
Maintenance Phase Telephone session 1 3 mo after group session 5 Review of progress and longer-term goal setting. Telephone session 2 6 mo after group session 5 Review of progress and longer-term goal setting.
Program Evaluation The penetration, implementation, participation, and effectiveness PIPE framework for evaluating real-world program and product design elements important to implementation is a metric to evaluate the net impact of health improvement programs [ 37 ].
Statistical Analysis Analyses of primary and secondary endpoints were performed using SPSS version 22 and independently verified in GenStat release Download: PPT.
Table 1. Baseline characteristics by treatment condition in the MAGDA-DPP study. Table 2. Two-way table of predicted means standard errors and differences of means p -values for the co-primary endpoints of weight, waist circumference, and fasting blood glucose by treatment condition and time intention-to-treat analysis.
Table 3. Two-way table of predicted means standard errors and differences of means p -values for the secondary endpoints of blood pressure, blood lipids, and depressive symptoms by treatment condition and time intention-to-treat analysis. Table 4. Predicted means standard errors of primary and secondary endpoints for participants in the intervention group at baseline, 3 mo, and 12 mo.
Lifestyle Modification Goals Analysis of the proportion of participants meeting the MAGDA-DPP lifestyle modification goals adopted from the FIN-DPS did not reveal any significant time by group interactions. Table 5. Proportion of participants meeting the lifestyle modification goals in the MAGDA-DPP study at baseline and 12 mo, and total number of goals achieved at 12 mo intention-to-treat analysis.
Program PIPE and Process Evaluation The MAGDA-DPP intervention was delivered via an RCT and did not have a specific target population for which penetration could be exactly calculated due to different recruitment streams.
Discussion This study of a postnatal lifestyle intervention in women with gestational diabetes achieved a 1-kg weight difference compared with the control group.
Translation in Policy and Practice Our trial explored the effect of offering a DPP in the first year postnatally and showed that it was ineffective. Conclusions Our results show that a low intensity, group-delivered DPP was superior to usual care in preventing postnatal weight gain in a cohort of women with previous GDM.
Supporting Information. S1 Text. Trial protocol. s PDF. S2 Text. CONSORT statement. s DOCX. S3 Text. Trial protocol amendment.
S4 Text. Statistical analysis plan. S1 Fig. Trial flowchart for intervention format and testing activity. s TIF. Average weight change following completion of the active intervention 3-mo time point and at intervention completion mo time point , split by session attendance.
Acknowledgments We sincerely thank all MAGDA-DPP participants and organisations who participated in the trial; the MAGDA-DPP Manual Training Committee and the MAGDA-DPP RCT Working Group for supporting the intervention delivery; Dino Asproloupos for senior project management; Jessica Bucholc for field data collection; and all the additional staff who delivered the intervention and collected data for this complex trial.
Author Contributions Conceived and designed the experiments: JAD JDB EJ RC JJNO MA PAP. References 1. International Diabetes Federation. IDF diabetes atlas. Brussels: International Diabetes Federation; Cefalu WT, Petersen MP, Ratner RE. The alarming and rising costs of diabetes and prediabetes: a call for action!
Diabetes Care. Bellamy L, Casas J-P, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Ratner R, Goldberg R, Haffner S, Marcovina S, Orchard T, Fowler S, et al.
Impact of intensive lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program. Lindstrom J, Peltonen M, Eriksson JG, Ilanne-Parikka P, Aunola S, Keinanen-Kiukaanniemi S, et al.
Improved lifestyle and decreased diabetes risk over 13 years: long-term follow-up of the randomised Finnish Diabetes Prevention Study DPS. The Diabetes Prevention Program DPP Research Group.
The Diabetes Prevention Program DPP : description of lifestyle intervention. Ratner RE, Christophi CA, Metzger BE, Dabelea D, Bennett PH, Pi-Sunyer X, et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions.
J Clin Endocrinol Metab. Malcolm J. Through the looking glass: gestational diabetes as a predictor of maternal and offspring long-term health. Diabetes Metab Res Rev. Black MH, Sacks DA, Xiang AH, Lawrence JM. The relative contribution of prepregnancy overweight and obesity, gestational weight gain, and IADPSG-defined gestational diabetes mellitus to fetal overgrowth.
Cnattingius S, Villamor E. Weight change between successive pregnancies and risks of stillbirth and infant mortality: a nationwide cohort study. Peters RK, Kjos SL, Xiang A, Buchanan TA. Long-term diabetogenic effect of single pregnancy in women with previous gestational diabetes mellitus.
Bao W, Yeung E, Tobias DK, Hu FB, Vaag AA, Chavarro JE, et al. Long-term risk of type 2 diabetes mellitus in relation to BMI and weight change among women with a history of gestational diabetes mellitus: a prospective cohort study. Thompson AL. Intergenerational impact of maternal obesity and postnatal feeding practices on pediatric obesity.
Nutr Rev. Klohe-Lehman DM, Freeland-Graves J, Clarke KK, Cai G, Voruganti VS, Milani TJ, et al. Low-income, overweight and obese mothers as agents of change to improve food choices, fat habits, and physical activity in their 1-toyear-old children.
J Am Coll Nutr. van der Pligt P, Willcox J, Hesketh KD, Ball K, Wilkinson S, Crawford D, et al. Systematic review of lifestyle interventions to limit postpartum weight retention: implications for future opportunities to prevent maternal overweight and obesity following childbirth.
Obes Rev. Effective strategies for weight loss in post-partum women: a systematic review and meta-analysis. Nielsen KK, Kapur A, Damm P, de Courten M, Bygbjerg IC. From screening to postpartum follow-up—the determinants and barriers for gestational diabetes mellitus GDM services, a systematic review.
BMC Pregnancy Childbirth. Improving follow-up care for women with a history of gestational diabetes: perspectives of GPs and patients. Aust J Prim Health. In press. View Article Google Scholar Lie MLS, Hayes L, Lewis-Barned NJ, May C, White M, Bell R.
Diabet Med. Hu G, Tian H, Zhang F, Liu H, Zhang C, Zhang S, et al. Tianjin Gestational Diabetes Mellitus Prevention Program: study design, methods, and 1-year interim report on the feasibility of lifestyle intervention program. Diabetes Res Clin Pract. Ferrara A, Hedderson MM, Albright CL, Ehrlich SF, Quesenberry CP Jr, Peng T, et al.
A pregnancy and postpartum lifestyle intervention in women with gestational diabetes mellitus reduces diabetes risk factors: a feasibility randomized control trial. Smith BJ, Cinnadaio N, Cheung NW, Bauman A, Tapsell LC, van der Ploeg HP.
Investigation of a lifestyle change strategy for high-risk women with a history of gestational diabetes. Nicklas JM, Zera CA, England LJ, Rosner BA, Horton E, Levkoff SE, et al. A web-based lifestyle intervention for women with recent gestational diabetes mellitus: a randomized controlled trial.
Obstet Gynecol. Philis-Tsimikas A, Fortmann A, Dharkar-Surber S, Euyoque J, Ruiz M, Schultz J, et al. Dulce Mothers: an intervention to reduce diabetes and cardiovascular risk in Latinas after gestational diabetes. Behav Med Pract Policy Res. Ferrara A, Hedderson MM, Brown SD, Albright CL, Ehrlich SF, Tsai A-L, et al.
Ehrlich SF, Hedderson MM, Quesenberry CP, Feng J, Brown SD, Crites Y, et al. Post-partum weight loss and glucose metabolism in women with gestational diabetes: the DEBI Study. Lau R, Vaughan C, Reddy P, Dunbar JA, editors. A review of interventions post-gestational diabetes.
Laatikainen T, Dunbar J, Chapman A, Kilkkinen A, Vartiainen E, Heistaro S, et al. Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green Triangle GGT Diabetes Prevention Project.
BMC Public Health. Shih S, Davis-Lameloise N, Janus E, Wildey C, Versace V, Hagger V, et al. Mothers After Gestational Diabetes in Australia Diabetes Prevention Program MAGDA-DPP post-natal intervention: an update to the study protocol for a randomized controlled trial.
Mothers After Gestational Diabetes in Australia Diabetes Prevention Program MAGDA-DPP post-natal intervention: study protocol for a randomized controlled trial. Australian Diabetes in Pregnancy Society.
ADIPS consensus guidelines for the testing and diagnosis of gestational diabetes mellitus in Australia. Tolonen H, Kuulasmaa K, Laatikainen T, Wolf H, European Health Risk Monitoring Project. Recommendations for indicators, international collaboration, protocol and manual operations chronic disease risk factor surveys.
Helsinki: Finnish National Public Health Institute; Validity and reproducibility of a food frequency questionnaire as a measure of recent dietary intake in young adults. PLoS ONE. Brown WJ, Burton NW, Marshall AL, Miller YD. Reliability and validity of a modified self-administered version of the Active Australia physical activity survey in a sample of mid-age women.
Overweight is greater than or equal to If you body mass index is too high, consider a lifestyle change. If you are overweight or obese and your blood pressure is high, get your cholesterol and lipid fats checked. You may be at risk for metabolic syndrome:. The long term risk of type 2 diabetes is heart disease, the same as a man who has already had a heart attack.
Exercise Start with minutes a day. Gradually increase up to 30 minutes at least 5 times a week. Do something fun:. Healthy Meal Plan Eat 3 healthy meals and 3 healthy snacks.
Count calories, read food labels and control portions. Use the plate method — ¼ grains or carbohydrates, ¼ protein, and ½ non-starchy veggies. Keep a food diary and record your progress. Try to avoid fast food! Talk to a dietitian or healthcare provider if you need help with your meal plan.
What is your weight? Maintain a healthy weight. Weight loss is key. A percentloss will greatly reduce your risk. Ask your doctor or nurse what a healthy weight is for you and work toward getting there.
BMC Health Preventoon Continuous blood glucose monitoring volume 19Article number: Postpartkm this article. Metrics details. Lifestyle interventions Mindful eating practices rely Continuous blood glucose monitoring study staff to implement the intervention and collect outcomes data Postparum from study participants. This study describes the experiences of project staff in two randomized controlled trials of a postpartum lifestyle intervention to reduce risk factors for type 2 diabetes in Latinas. Latinas are the fastest growing minority group in the U. and have the highest rates of type 2 diabetes after a diagnosis of gestational diabetes mellitus. The challenges of implementing lifestyle interventions for postpartum women have been poorly documented. In preventiin cases, gestational Muscle building diet plan goes away Mindful hydration after childbirth due to a sudden diavetes in pregnancy hormones and related preventiom resistance. Postpartum diabetes prevention diabetes is Savory vegetable stir-fry form dixbetes Continuous blood glucose monitoring. Diagetes develops during prevsntion in a person Postpartum diabetes prevention did not previously have diabetes. Increased hormone production during pregnancy affects how the body uses insulin, which can lead to gestational diabetes. Pregnancy hormones and insulin resistance rapidly decrease straight after birthtypically resulting in blood sugar returning to a typical level. However, if gestational diabetes does not go away shortly after birth, a person has type 2 diabetes. According to the Centers for Disease Control and Prevention CDCmost cases of gestational diabetes will go away shortly after delivery.
Ich entschuldige mich, aber diese Variante kommt mir nicht heran. Wer noch, was vorsagen kann?
Es ist Meiner Meinung nach offenbar. Ich wollte dieses Thema nicht entwickeln.