Screening low-income women of reproductive age for cardiovascular disease risk factors

Maternal cardiovascular disorders before and during pregnancy and offspring cardiovascular risk across the life course

Obesity, hypertension, type 2 diabetes mellitus and dyslipidaemia are highly prevalent among women of reproductive age and contribute to complications in >30% of pregnancies in Western countries. An accumulating body of evidence suggests that these cardiovascular disorders in women, occurring before and during their pregnancy, can affect the development of the structure, physiology and function of cardiovascular organ systems at different stages during embryonic and fetal development. These developmental adaptations might, in addition to genetics and sociodemographic and lifestyle factors, increase the susceptibility of the offspring to cardiovascular disease throughout the life course. In this Review, we discuss current knowledge of the influence of maternal cardiovascular disorders, occurring before and during pregnancy, on offspring cardiovascular development, dysfunction and disease from embryonic life until adulthood. We discuss findings from contemporary, large-scale, observational studies that provide insights into specific critical periods, evidence for causality and potential underlying mechanisms. Furthermore, we focus on priorities for future research, including defining optimal cardiovascular and reproductive health in women and men before their pregnancy and identifying specific embryonic, placental and fetal molecular developmental adaptations from early pregnancy onwards. Together, these approaches will help stop the intergenerational cycle of cardiovascular disease.

Diabetes risk in women with gestational diabetes mellitus and a history of polycystic ovary syndrome: a retrospective cohort study

AIMS

To investigate whether polycystic ovary syndrome further increases postpartum diabetes risk in women with gestational diabetes mellitus and to explore relationships between polycystic ovary syndrome and incident diabetes in women who do not develop gestational diabetes.

METHODS

This retrospective cohort study (Quebec Physician Services Claims; Hospitalization Discharge Databases; Birth and Death registries) included 34 686 women with gestational diabetes during pregnancy (live birth), matched 1:1 to women without gestational diabetes by age group, year of delivery and health region. Diagnostic codes were used to define polycystic ovary syndrome and incident diabetes. Cox regression models were used to examine associations between polycystic ovary syndrome and incident diabetes.

RESULTS

Polycystic ovary syndrome was present in 1.5% of women with gestational diabetes and 1.2% of women without gestational diabetes. There were more younger mothers and mothers who were not of white European ancestry among those with polycystic ovary syndrome. Those with polycystic ovary syndrome more often had a comorbidity and a lower proportion had a previous pregnancy. Polycystic ovary syndrome was associated with incident diabetes (hazard ratio 1.52; 95% CI 1.27, 1.82) among women with gestational diabetes. No conclusive associations between polycystic ovary syndrome and diabetes were identified (hazard ratio 0.94; 95% CI 0.39, 2.27) in women without gestational diabetes.

CONCLUSION

In women with gestational diabetes, polycystic ovary syndrome confers additional risk for incident diabetes postpartum. In women without gestational diabetes, an association between PCOS and incident diabetes was not observed. Given the already elevated risk of diabetes in women with a history of gestational diabetes, a history of both polycystic ovary syndrome and gestational diabetes signal a critical need for diabetes surveillance and prevention.

Opportunities to Reduce Diabetes Risk in Women of Reproductive Age: Assessment and Treatment of Prediabetes within a Large Integrated Delivery System

BACKGROUND

Preventing diabetes before pregnancy may be important to improve maternal and infant outcomes. Although the preconception period is a crucial time to focus on chronic disease prevention, little is known about preventive services for reproductive-aged women at risk of developing diabetes.

METHODS

Using electronic health record data from patients at Kaiser Permanente Northern California, we identified 21,965 nonpregnant women aged 18 to 44 with incident prediabetes (PDM; fasting plasma glucose [FPG] = 100-125 or glycated hemoglobin A1c = 5.7%-6.4%) between 2007 and 2010. We looked for evidence of a "clinical response" to PDM in the 6 months after laboratory testing, defined as retesting of blood glucose levels, referral or attendance to health education, diagnosis of PDM, metformin initiation, or a clinical note of discussion of PDM. Multilevel models were used to examine the relationship between patient characteristics and clinical response, and to assess provider-level variation.

RESULTS

Fewer than one-half of women had a documented clinical response to the PDM-range laboratory result. Women with higher FPG values and body mass indexes were more likely to have a PDM diagnosis (FPG 120-125 vs. 100-119: OR, 1.96; 95% CI, 1.78-2.17; body mass index, 30-34 kg/m² vs. <25 kg/m²: OR, 1.30; 95% CI, 1.13-1.48) and have 'PDM' recorded in the notes (FPG 120-125 vs. 100-119: OR, 1.15; 95% CI, 1.06-1.26; body mass index: 30-34 kg/m² vs. <25 kg/m²: OR, 1.58; 95% CI, 1.44-1.74). Provider-level variation was modest, except for metformin initiation (intraclass correlation coefficient, 0.8; p < .01).

CONCLUSIONS

Low clinical response to PDM among women of reproductive age suggests there are missed opportunities for diabetes prevention among this vulnerable population.

Impact of socioeconomic deprivation on screening for cardiovascular disease risk in a primary prevention population: a cross-sectional study

OBJECTIVES

Investigate the association between socioeconomic deprivation and completeness of cardiovascular disease (CVD) risk factor recording in primary care, uptake of screening in people with incomplete risk factor recording and with actual CVD risk within the screened subgroup.

DESIGN

Cross-sectional study.

SETTING

Nine UK general practices.

PARTICIPANTS

7987 people aged 50-74 years with no CVD diagnosis.

METHODS

CVD risk was estimated using the Framingham equation from data extracted from primary care electronic health records. Where there was insufficient information to calculate risk, patients were invited to attend a screening assessment.

ANALYSIS

Proportion of patients for whom clinical data were sufficiently complete to enable CVD risk to be calculated; proportion of patients invited to screening who attended; proportion of patients who attended screening whose 10-year risk of a cardiovascular event was high (>20%). For each outcome, a set of logistic regression models were run. Crude and adjusted ORs were estimated for person-level deprivation, age, gender and smoking status. We included practice-level deprivation as a continuous variable and practice as a random effect to account for clustering.

RESULTS

People who had lower Indices of Multiple Deprivation (IMD) scores (less deprived) had significantly worse routine CVD risk factor recording (adjusted OR 0.97 (0.95 to 1.00) per IMD decile; p=0.042). Screening attendance was poorer in those with more deprivation (adjusted OR 0.89 (0.86 to 0.91) per IMD decile; p<0.001). Among those who attended screening, the most deprived were more likely to have CVD risk >20% (OR 1.09 (1.03 to 1.15) per IMD decile; p=0.004).

CONCLUSIONS

Our data suggest that those who had the most to gain from screening were least likely to attend, potentially exacerbating existing health inequalities. Future research should focus on tailoring the delivery of CVD screening to ensure engagement of socioeconomically deprived groups.

Assessing the Feasibility of a Web-Based Weight Loss Intervention for Low-Income Women of Reproductive Age: A Pilot Study

Background

Low-income women of reproductive age are at increased risk for obesity and resulting increases in the risk of maternal/fetal complications and mortality and morbidity. Very few weight-loss interventions, however, have been targeted to this high-risk group. Based on the high prevalence of social media use among young and low-income individuals and previous successes using group formats for weight-loss interventions, the use of social media as a platform for weight-loss intervention delivery may benefit low-income women of reproductive age.

Objective

Examine the feasibility of delivering group-based weight-loss interventions to low-income women of reproductive age using face-to-face meetings and Web-based modalities including social media.

Methods

Participants attended a family planning clinic in eastern North Carolina and received a 5-month, group- and Web-based, face-to-face weight-loss intervention. Measures were assessed at baseline and 20 weeks.

Results

Forty participants enrolled, including 29 (73%) African American women. The mean body mass index of enrollees was 39 kg/m². Among the 12 women who completed follow-up, mean weight change was -1.3 kg. Participation in the intervention was modest and retention at 5 months was 30%. Returnees suggested sending reminders to improve participation and adding activities to increase familiarity among participants.

Conclusions

Engagement with the intervention was limited and attrition was high. Additional formative work on the barriers and facilitators to participation may improve the intervention’s feasibility with low-income women of reproductive age.

What barriers thwart postpartum women's physical activity goals during a 12-month intervention? A process evaluation of the Nā Mikimiki Project

Approximately 70% of new mothers do not meet national guidelines for moderate-to-vigorous physical activity (MVPA). The Nā Mikimiki ("the active ones") Project (2008-2011) was designed to increase MVPA among women with infants 2-12 months old. Participants' barriers to exercising and achievement of specific MVPA goals were discussed during telephone counseling calls over 12 months. Healthy, inactive women (n = 115, mean age = 31 ± 5 years, infants' mean age = 5.5 ± 3 months; 80% racial/ethnic minorities) received a total of 17 calls over 12 months in three phases. During Phase 1 weekly calls were made for a month, in Phase 2 biweekly calls were made for 2 months, and in Phase 3 monthly calls were made for 9 months. Across all phases, the most frequent barriers to achieving MVPA goals were: time/too busy (25%), sick child (11%), and illness (10%). Goals for MVPA minutes per week were achieved or surpassed 40.6% of the time during weekly calls, 39.9% during biweekly calls, and 42.0% during monthly calls. The least likely MVPA goals to be achieved (p < 0.04) were those which the woman encountered and for which she failed to overcome the barriers she had previously anticipated would impair her improvement of MVPA. This process evaluation demonstrated that telephone counseling somewhat facilitated the resolution of barriers and achievement of MVPA goals; thus, if clinical settings adopted such methods, chronic disease risks could be reduced in this vulnerable population of new mothers.

Outcomes of cardiovascular disease risk factor screening and referrals in a family planning clinic

BACKGROUND

Cardiovascular disease (CVD) screening in Title X settings can identify low-income women at risk of future chronic disease. This study examines follow-up related to newly identified CVD risk factors in a Title X setting.

METHODS

Female patients at a North Carolina Title X clinic were screened for CVD risk factors (n=462) and 167/462 (36.1%) were rescreened one year later. Clinical staff made protocol-driven referrals for women identified with newly diagnosed CVD risk factors. We used paired t-tests and chi square tests to compare screening and rescreening results (two-tailed, p<0.05).

RESULTS

Among 11 women in need of referrals for newly diagnosed hypertension or diabetes, 9 out of 11 (81.8%) were referred, and 2 of 11 (18.2%) completed referrals. Among hypertensive women who were rescreened (n=21), systolic blood pressure decreased (139 to 132 mmHg, p=0.001) and diastolic blood pressure decreased (90 to 83 mmHg, p=0.006). Hemoglobin A1c did not improve among rescreened diabetic women (n=5, p=0.640). Among women who reported smoking at enrollment, 129 of 148 (87.2%) received cessation counseling and 8 of 148 (5.4%) accepted tobacco quitline referrals. Among smokers, 53 out of 148 (35.8%) were rescreened and 11 of 53 (20.8%) reported nonsmoking at that time. Among 188 women identified as obese at enrollment, 22 (11.7%) scheduled nutrition appointments, but only one attended. Mean weight increased from 221 to 225 pounds (p 0<.05) among 70 out of 188 (37.2%) obese women who were rescreened.

CONCLUSIONS

The majority of women in need of referrals for CVD risk factors received them. Few women completed referrals. Future research should examine barriers and facilitators of referral care among low-income women.