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Brown SD, Garcia BL, Ritchie JL, Tsai AL, Millman A, Greenberg M, Quesenberry CP, Ferrara A. Digital health outreach to promote postpartum screening after gestational diabetes: A randomized factorial pilot study. PEC INNOVATION 2024; 4:100256. [PMID: 38282680 PMCID: PMC10818066 DOI: 10.1016/j.pecinn.2024.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 12/18/2023] [Accepted: 01/17/2024] [Indexed: 01/30/2024]
Abstract
Objective We examined the acceptability and feasibility of a multi-component digital health outreach intervention to promote uptake of guideline-recommended postpartum screening for type 2 diabetes among patients with gestational diabetes (GDM). Methods We conducted a 24 randomized factorial experiment as part of the Multiphase Optimization Strategy (MOST) preparation phase for developing behavioral interventions. Participants with current or recent GDM in an integrated healthcare system were randomized to receive an outreach message with up to four intervention components, designed to be self-administered in about 10 min and efficiently delivered online via REDCap: a streamlined values affirmation, personalized information on diabetes risk, an interactive motivational interviewing-based component, and an interactive action planning component. Patient-reported acceptability and feasibility outcomes were assessed via survey. Results Among 162 participants, 72% self-identified with a racial/ethnic minority group. Across components, acceptability scores averaged 3.9/5; ≥91% of participants read most or all of the outreach message; ≥89% perceived the amount of information as "about right"; and ≥ 87% completed ≥1 interactive prompt. Conclusion Each intervention component was acceptable to diverse patients and feasible to deliver in a brief, self-directed, online format. Innovation These novel components target unaddressed barriers to patient engagement in guideline-recommended postpartum diabetes screening and adapt theory-based behavior change techniques for large-scale use.
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Affiliation(s)
- Susan D. Brown
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Brittany L. Garcia
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA
| | - Jenna L. Ritchie
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Ai-Lin Tsai
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Andrea Millman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Mara Greenberg
- Regional Perinatal Service Center, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Ioannou E, Humphreys H, Homer C, Purvis A. Preventing Type 2 Diabetes after Gestational Diabetes: A Systematic Review Mapping Physical Activity Components using the Socio-Ecological Model. Matern Child Health J 2024; 28:1354-1379. [PMID: 38829517 PMCID: PMC11269493 DOI: 10.1007/s10995-024-03948-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES Gestational diabetes commonly occurs during pregnancy and increases lifetime risk of type 2 diabetes following pregnancy. Engaging in physical activity postnatally can reduce this subsequent risk. Interventions aiming to increase physical activity after gestational diabetes may not address the wide range of post-pregnancy barriers. A socio-ecological approach highlights the need to include multi-level factors such as social, community and organisational factors. The aim of the review was to map intervention components to prevent type 2 diabetes after gestational diabetes using the socio-ecological model as a framework and investigate how physical activity changes align with different intervention components utilised. METHODS Eligible studies included any study type within 5 years of a gestational diabetes diagnosis and targeted physical activity. A systematic search of MEDLINE, Cochrane Library, Web of Science, CINAHL Complete, and Scopus was conducted in October 2022. Results were categorised based on whether findings demonstrated no increases, non-statistically significant increases or statistically significant increases in physical activity. RESULTS Forty-eight studies were included (37 different interventions). Thirty-eight studies were assessed as "adequate" quality, only two studies were "good" quality, and the remaining were limited quality. Mixed physical activity outcomes were observed across components used at the intrapersonal level, with components across other levels of the socio-ecological model showing more increases in physical activity. Intervention components within the social and organisational levels, for example childcare provision, providing group-based sessions and offering remote delivery, were more often present in interventions with physical activity increases. CONCLUSIONS FOR PRACTICE Future interventions targeting physical activity after gestational diabetes should aim to include social and organisational-level components in their intervention design. This systematic review was registered in PROSPERO (ID: CRD42021272044).
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Affiliation(s)
- Elysa Ioannou
- Sport and Physical Activity Research Centre, Sheffield Hallam University, Sheffield, UK.
| | - Helen Humphreys
- Centre for Behavioural Science and Applied Psychology (CeBSAP), Sheffield Hallam University, Sheffield, UK
| | - Catherine Homer
- Sport and Physical Activity Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Alison Purvis
- Sport and Physical Activity Research Centre, Sheffield Hallam University, Sheffield, UK
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Fortmann AL, Soriano EC, Gallo LC, Clark TL, Spierling Bagsic SR, Sandoval H, Jones JA, Roesch S, Gilmer T, Schultz J, Bodenheimer T, Philis-Tsimikas A. Medical Assistant Health Coaching for Type 2 Diabetes in Primary Care: Results From a Pragmatic Cluster Randomized Controlled Trial. Diabetes Care 2024; 47:1171-1180. [PMID: 38752923 PMCID: PMC11208755 DOI: 10.2337/dc23-2487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/07/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE This cluster (clinic-level) randomized controlled trial (RCT) compared medical assistant (MA) health coaching (MAC) with usual care (UC) among at-risk adults with type 2 diabetes in two diverse real-world primary care environments: a federally qualified health center (FQHC; Neighborhood Healthcare) and a large nonprofit private insurance-based health system (Scripps Health). RESEARCH DESIGN AND METHODS A total of 600 adults with type 2 diabetes who met one or more of the following criteria in the last 90 days were enrolled: HbA1c ≥8% and/or LDL cholesterol ≥100 mg/dL and/or systolic blood pressure (SBP) ≥140 mmHg. Participants at MAC clinics received in-person and telephone self-management support from a specially trained MA health coach for 12 months. Electronic medical records were used to examine clinical outcomes in the overall sample. Behavioral and psychosocial outcomes were evaluated in a subsample (n = 300). RESULTS All clinical outcomes improved significantly over 1 year in the overall sample (P < 0.001). The reduction in HbA1c was significantly greater in the MAC versus UC group (unstandardized Binteraction = -0.06; P = 0.002). A significant time by group by site interaction also showed that MAC resulted in greater improvements in LDL cholesterol than UC at Neighborhood Healthcare relative to Scripps Health (Binteraction = -1.78 vs. 1.49; P < 0.05). No other statistically significant effects were observed. CONCLUSIONS This was the first large-scale pragmatic RCT supporting the real-world effectiveness of MAC for type 2 diabetes in U.S. primary care settings. Findings suggest that this team-based approach may be particularly effective in improving diabetes outcomes in FQHC settings.
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Affiliation(s)
| | | | - Linda C. Gallo
- Department of Psychology, San Diego State University, San Diego, CA
| | - Taylor L. Clark
- San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, CA
| | | | | | | | - Scott Roesch
- Department of Psychology, San Diego State University, San Diego, CA
| | - Todd Gilmer
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA
| | | | - Thomas Bodenheimer
- Department of Family and Community Medicine, University of California San Francisco School of Medicine, San Francisco, CA
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Basirat Z, Ramaezani F, Sepidarkish M, Kashifard M, Faramarzi M. Psychiatric Symptoms in Women with High-risk Pregnancy in the Postpartum Period: A Case-control Study. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:186-191. [PMID: 37224840 PMCID: PMC10208729 DOI: 10.1055/s-0043-1768997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE Psychiatric symptoms are common mental issues in pregnancy and the postpartum period. There is limited information regarding the psychiatric symptoms of women with high-risk pregnancy in the postpartum period. This study aimed to compare the severity of psychiatric symptoms and psychological distress in women with high-risk and low-risk pregnancies in the postpartum period. METHODS This case-control study examined 250 women in the postpartum period in two groups with low-risk (n = 112) and high-risk (n = 138) pregnancies. Women completed the Brief Symptom Inventory-53 (BSI-53) and the Risk Postnatal Psychosocial Depression Risk Questionnaire (PPDRQ). RESULTS The mean severity of psychiatric symptoms in women with high-risk pregnancies was significantly higher than that in women with low-risk pregnancies (39.34 ± 17.51 vs. 30.26 ± 17.08). Additionally, the frequency of psychological distress in women with high-risk pregnancies was approximately twice higher than that in women with low-risk pregnancies (30.3% vs. 15.2%). Furthermore, the risk factors for depression in women with high-risk pregnancies were almost 1.5 times (59.8% vs. 39.8%) higher than the factors in women with low-risk pregnancies. The results of the logistic analysis indicated that high-risk pregnancies could be twice the odds ratio of developing postpartum psychological distress (ß = 2.14, 95% CI 1.4-6.3, p= 0.036). CONCLUSION Psychiatric symptoms and the psychological distress index are higher in postpartum women with high-risk pregnancies than in postpartum women with low-risk pregnancies. The study suggests that obstetricians and pregnant women's health care providers should strongly consider screening of psychiatric symptoms in women with high-risk pregnancies both during pregnancy and after delivery as the women's routine care priorities.
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Markers of Cardiovascular Risk Associated with Pregnancy. Curr Cardiol Rep 2023; 25:77-87. [PMID: 36745273 DOI: 10.1007/s11886-022-01830-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of the review is to summarize the unique cardiovascular disease (CVD) risk factors encountered during pregnancy and to provide the reader with a framework for acquiring a comprehensive obstetric history during the cardiovascular (CV) assessment of women. RECENT FINDINGS Individuals with a history of pregnancies complicated by hypertensive disorders of pregnancy (HDP), gestational diabetes (GDM), preterm delivery, low birth weight, and fetal growth restriction during pregnancy are at a higher risk of developing short- and long-term CV complications compared to those without adverse pregnancy outcomes (APOs). Women with a history of APOs can be at increased risk of CVD even after achieving normoglycemia and normal blood pressure control postpartum. Risk assessment and stratification in women must account for these APOs as recommended by the 2019 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the primary prevention of CVD. Early recognition, monitoring, and treatment of APOs are key to limiting CVD complications late in maternal life. Recognition of APOs as female-specific cardiovascular risk factors is critical for risk stratification for women and birthing persons. Further research is needed to understand the complex interplay between genetics, environmental, behavioral, and maternal vascular health, and the association between APOs and CVD risk.
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Choi E, Kazzi B, Varma B, Ortengren AR, Minhas AS, Vaught AJ, Bennett WL, Lewey J, Michos ED. The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care. CURRENT CARDIOVASCULAR RISK REPORTS 2022; 16:219-229. [PMID: 36159207 PMCID: PMC9490714 DOI: 10.1007/s12170-022-00706-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 01/26/2023]
Abstract
Purpose of Review The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester. Recent Findings A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness. Summary Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.
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Affiliation(s)
- Eunjung Choi
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Brigitte Kazzi
- Department of Medicine, Johns Hopkins University School of Medicine, MD 21287 Baltimore, USA
| | - Bhavya Varma
- Department of Medicine, Johns Hopkins University School of Medicine, MD 21287 Baltimore, USA
| | | | - Anum S. Minhas
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Arthur Jason Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Wendy L. Bennett
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287 USA
| | - Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
- Division of Cardiology, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524-B, Baltimore, MD 21287 USA
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Brown SD, Hedderson MM, Gordon N, Albright CL, Tsai AL, Quesenberry CP, Ferrara A. Reach, acceptability, and perceived success of a telehealth diabetes prevention program among racially and ethnically diverse patients with gestational diabetes: the GEM cluster-randomized trial. Transl Behav Med 2022; 12:793-799. [PMID: 35849139 DOI: 10.1093/tbm/ibac019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Patients with gestational diabetes mellitus and from racial/ethnic minority groups face disproportionate risk for type 2 diabetes. Lifestyle interventions, if accessible and acceptable to diverse patients, could advance diabetes prevention and mitigate racial/ethnic disparities. Here we describe overall and race/ethnicity-specific reach, acceptability, and perceived success from an effective telehealth diabetes prevention lifestyle program for patients with gestational diabetes mellitus, implemented in the Gestational Diabetes Effects on Moms (GEM) cluster-randomized controlled trial. GEM tested a program of 13 telephone sessions and behavior change techniques (BCTs, e.g., goal setting) in a healthcare system. We evaluated participation (completing ≥1 session), acceptability of BCTs, and perceived success reaching program goals. Among 1,087 patients (75.2% from minority groups), 50.3% participated. Participation rates were 61.7% among Black, 56.4% among Hispanic, 55.6% among multiracial/other, 53.0% among White, and 43.7% among Asian/Pacific Islander patients. Evaluation survey respondents (n = 433/547; 79.2%) largely rated BCTs as very helpful (range 40.9%-58.4%) or moderately helpful (27.3%-34.9%). Respondents from minority groups largely rated goal setting for weight management as very or moderately helpful, with fewer minority respondents rating it as only a little/not at all helpful than White respondents (p = .02). Black and White respondents reported more limited success reaching a healthy weight than Asian/Pacific Islander, Hispanic, and multiracial/other women (p = .005). A telehealth diabetes prevention lifestyle program demonstrated reach and acceptability across racial/ethnic groups. While perceived success can be improved among Black and White participants, such programs could promote access to preventive care and help mitigate disparities in diabetes risk.
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Affiliation(s)
- Susan D Brown
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Monique M Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Nancy Gordon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Cheryl L Albright
- Nancy Atmospera-Walch School of Nursing, University of Hawai'i at Manoa, Honolulu, HI, USA
| | - Ai-Lin Tsai
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Glaser K, Ferrara A, Ritchie JL, Tsai AL, Greenberg M, Quesenberry CP, Brown SD. Perspectives on postpartum diabetes screening among patients with gestational diabetes in an integrated healthcare system. Am J Obstet Gynecol 2022; 226:857-859.e1. [PMID: 35167814 DOI: 10.1016/j.ajog.2022.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 11/24/2022]
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Brown SD, Hedderson MM, Zhu Y, Tsai AL, Feng J, Quesenberry CP, Ferrara A. Uptake of guideline-recommended postpartum diabetes screening among diverse women with gestational diabetes: associations with patient factors in an integrated health system in USA. BMJ Open Diabetes Res Care 2022; 10:10/3/e002726. [PMID: 35725017 PMCID: PMC9214412 DOI: 10.1136/bmjdrc-2021-002726] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/20/2022] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Clinical guidelines urge timely postpartum screening for diabetes among women with gestational diabetes mellitus (GDM), yet patient factors associated with screening uptake remain unclear. We aimed to identify patient factors associated with completed postpartum diabetes screening (2-hour oral glucose tolerance test within 4-12 weeks postpartum), as recommended by the American Diabetes Association (ADA). RESEARCH DESIGN AND METHODS Within the context of Gestational Diabetes' Effects on Moms (GEM), a pragmatic cluster randomized trial (2011-2012), we examined survey and electronic health record data to assess clinical and sociodemographic factors associated with uptake of ADA-recommended postpartum screening. Participants included 1642 women (76% racial/ethnic minorities) identified with GDM according to the Carpenter and Coustan criteria in a health system that deploys population-level strategies to promote screening. To contextualize these analyses, screening rates derived from the GEM trial were compared with those in the health system overall using registry data from a concurrent 10-year period (2007-2016, n=21 974). RESULTS Overall 52% (n=857) completed recommended postpartum screening in the analytic sample, comparable to 45.7% (n=10 040) in the registry. Screening in the analytic sample was less likely among women at elevated risk for type 2 diabetes, assessed using items from an ADA risk test (vs non-elevated; adjusted rate ratio (aRR)=0.86 (95% CI 0.75 to 0.98)); perinatal depression (0.88 (0.79 to 0.98)); preterm delivery (0.84 (0.72 to 0.98)); parity ≥2 children (vs 0; 0.80 (0.69 to 0.93)); or less than college education (0.79 (0.72 to 0.86)). Screening was more likely among Chinese Americans (vs White; 1.31 (1.15 to 1.49)); women who attended a routine postpartum visit (5.28 (2.99 to 9.32)); or women who recalled receiving healthcare provider advice about screening (1.31 (1.03 to 1.67)). CONCLUSIONS Guideline-recommended postpartum diabetes screening varied by patient clinical and sociodemographic factors. Findings have implications for developing future strategies to improve postpartum care.
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Affiliation(s)
- Susan D Brown
- Department of Internal Medicine, University of California, Davis, Sacramento, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Monique M Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Yeyi Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Ai-Lin Tsai
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Juanran Feng
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Charles P Quesenberry
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Huang S, Magny-Normilus C, McMahon E, Whittemore R. Systematic Review of Lifestyle Interventions for Gestational Diabetes Mellitus in Pregnancy and the Postpartum Period. J Obstet Gynecol Neonatal Nurs 2021; 51:115-125. [PMID: 34843670 DOI: 10.1016/j.jogn.2021.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To examine the characteristics and effectiveness of lifestyle interventions for gestational diabetes mellitus (GDM) in pregnancy and the postpartum period to prevent Type 2 diabetes. DATA SOURCES We conducted searches in seven databases, including Ovid MEDLINE, CINAHL, Ovid Embase, Cochrane Central, Web of Science, Ovid PsycInfo, and ProQuest Dissertations and Theses for articles published from inception to January 2021. STUDY SELECTION We included articles on controlled intervention studies in which researchers evaluated a lifestyle intervention provided during pregnancy and the postpartum period for women with or at risk for GDM that were published in English. DATA EXTRACTION Twelve articles that were reports of seven studies met the inclusion criteria. In some cases, more than one article was selected from the same study. For example, articles reported different outcomes from the same study. We extracted data with the use of a data collection form and compared and synthesized data on study design, purpose, sample, intervention characteristics, recruitment and retention, and outcomes. DATA SYNTHESIS All seven studies focused on weight management and/or healthy lifestyle behaviors (diet and physical activity). Outcomes included glucose regulation, weight, lifestyle behaviors, and knowledge. The interventions varied in duration/dosage, strategies, and modes of delivery. In four studies, researchers reported interventions that had significant effects on improving glucose regulation and/or weight change. Some characteristics from the four effective interventions included goal setting, individualized care, and good retention rates. In the other three studies, limitations included low rates of participant retention, lack of personalized interventions, and limited population diversity or lack of culturally sensitive care. CONCLUSION Lifestyle interventions provided during and after pregnancy to reduce the risk associated with GDM have the potential to improve outcomes. Health care counseling to promote healthy lifestyle behaviors related to the prevention of Type 2 diabetes is needed at different stages of maternity care for women with GDM. Additional high-quality studies are needed to address the limitations of current studies.
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Phelan S, Jelalian E, Coustan D, Caughey AB, Castorino K, Hagobian T, Muñoz-Christian K, Schaffner A, Shields L, Heaney C, McHugh A, Wing RR. Protocol for a randomized controlled trial of pre-pregnancy lifestyle intervention to reduce recurrence of gestational diabetes: Gestational Diabetes Prevention/Prevención de la Diabetes Gestacional. Trials 2021; 22:256. [PMID: 33827659 PMCID: PMC8024941 DOI: 10.1186/s13063-021-05204-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/17/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is associated with several maternal complications in pregnancy, including preeclampsia, preterm labor, need for induction of labor, and cesarean delivery as well as increased long-term risks of type 2 diabetes, metabolic syndrome, and cardiovascular disease. Intrauterine exposure to GDM raises the risk for complications in offspring as well, including stillbirth, macrosomia, and birth trauma, and long-term risk of metabolic disease. One of the strongest risk factors for GDM is the occurrence of GDM in a prior pregnancy. Preliminary data from epidemiologic and bariatric surgery studies suggest that reducing body weight before pregnancy can prevent the development of GDM, but no adequately powered trial has tested the effects of a maternal lifestyle intervention before pregnancy to reduce body weight and prevent GDM recurrence. METHODS The principal aim of the Gestational Diabetes Prevention/Prevención de la Diabetes Gestacional is to determine whether a lifestyle intervention to reduce body weight before pregnancy can reduce GDM recurrence. This two-site trial targets recruitment of 252 women with overweight and obesity who have previous histories of GDM and who plan to have another pregnancy in the next 1-3 years. Women are randomized within site to a comprehensive pre-pregnancy lifestyle intervention to promote weight loss with ongoing treatment until conception or an educational control group. Participants are assessed preconceptionally (at study entry, after 4 months, and at brief quarterly visits until conception), during pregnancy (at 26 weeks' gestation), and at 6 weeks postpartum. The primary outcome is GDM recurrence, and secondary outcomes include fasting glucose, biomarkers of cardiometabolic disease, prenatal and perinatal complications, and changes over time in weight, diet, physical activity, and psychosocial measures. DISCUSSION The Gestational Diabetes Prevention /Prevención de la Diabetes Gestacional is the first randomized controlled trial to evaluate the effects of a lifestyle intervention delivered before pregnancy to prevent GDM recurrence. If found effective, the proposed lifestyle intervention could lay the groundwork for shifting current treatment practices towards the interconception period and provide evidence-based preconception counseling to optimize reproductive outcomes and prevent GDM and associated health risks. TRIAL REGISTRATION ClinicalTrials.gov NCT02763150 . Registered on May 5, 2016.
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Affiliation(s)
- Suzanne Phelan
- Department of Kinesiology & Public Health, Center for Health Research, California Polytechnic State University, San Luis Obispo, CA USA
| | - Elissa Jelalian
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI USA
| | - Donald Coustan
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI USA
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
| | | | - Todd Hagobian
- Department of Kinesiology & Public Health, Center for Health Research, California Polytechnic State University, San Luis Obispo, CA USA
| | - Karen Muñoz-Christian
- Department of World Languages and Cultures, California Polytechnic State University, San Luis Obispo, CA USA
| | - Andrew Schaffner
- Statistics Department, California Polytechnic State University, San Luis Obispo, CA USA
| | - Laurence Shields
- Dignity Health, Marian Regional Medical Center, Santa Maria, CA USA
| | - Casey Heaney
- Department of Kinesiology & Public Health, Center for Health Research, California Polytechnic State University, San Luis Obispo, CA USA
| | - Angelica McHugh
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, USA
| | - Rena R. Wing
- Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, USA
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Lin LY, Jochym N, Merz JF. Refusal rates and waivers of informed consent in pragmatic and comparative effectiveness RCTs: A systematic review. Contemp Clin Trials 2021; 104:106361. [PMID: 33737197 DOI: 10.1016/j.cct.2021.106361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pragmatic and comparative effectiveness randomized controlled trials (RCTs) aim to be highly generalizable studies, with broad applicability and flexibility in methods. These trials also address recruitment issues by minimizing exclusions. The trials may also appeal to potential subjects because of lower risk and lower burdens of participation. We sought to examine rates of refusal and uses of waivers of informed consent in pragmatic and comparative effectiveness RCTs. METHODS A systematic review of pragmatic and comparative effectiveness RCTs performed wholely or in part in the United States and first published in 2014 and 2017. RESULTS 103 studies involving 105 discrete populations were included for review. Refusal data was collected for 71 RCTs. Overall, studies reported an average rate of 31.9% of potential subjects refused participation; on an individual basis, 38.4% of people asked to take part refused at some point during recruitment. 23 trials (22%) were performed, at least in part, with a waiver of informed consent, 7 (30%) of which provided any form of notice to subjects. CONCLUSIONS Overall refusal rates for pragmatic and comparative effectiveness RCTs appear roughly the same as other types of research, with studies reporting about a third of people solicited for participation refuse. Moreover, informed consent was waived in 22% (95% Binomial exact Confidence Interval 13.9-30.5%) of the trials, and further study is needed to understand when waivers are justified and when notice should be provided.
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Affiliation(s)
- Lisa Y Lin
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States of America.
| | - Nicole Jochym
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ 08103, United States of America
| | - Jon F Merz
- Department of Medical Ethics & Health Policy, Perelman School of Medicine at the University of Pennsylvania, Blockley Hall 1427, 423 Guardian Drive, Philadelphia, PA 19104-4884, United States of America.
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13
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Ferrara A. Translating Research on Diabetes and Obesity in Pregnancy Into Prevention: The 2019 Norbert Freinkel Award Lecture. Diabetes Care 2020; 43:2635-2642. [PMID: 33082243 PMCID: PMC7576424 DOI: 10.2337/dci19-0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland CA
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14
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Fortmann AL, Philis-Tsimikas A, Euyoque JA, Clark TL, Vital DG, Sandoval H, Bravin JI, Savin KL, Jones JA, Roesch S, Gilmer T, Bodenheimer T, Schultz J, Gallo LC. Medical assistant health coaching ("MAC") for type 2 diabetes in diverse primary care settings: A pragmatic, cluster-randomized controlled trial protocol. Contemp Clin Trials 2020; 100:106164. [PMID: 33053431 DOI: 10.1016/j.cct.2020.106164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/28/2020] [Accepted: 08/06/2020] [Indexed: 01/30/2023]
Abstract
In the US, nearly 11% of adults were living with diagnosed diabetes in 2017, and significant type 2 diabetes (T2D) disparities are experienced by socioeconomically disadvantaged, racial/ethnic minority populations, including Hispanics. The standard 15-min primary care visit does not allow for the ongoing self-management support that is needed to meet the complex needs of individuals with diabetes. "Team-based" chronic care delivery is an alternative approach that supplements physician care with contact from allied health personnel in the primary care setting (e.g., medical assistants; MAs) who are specially trained to provide ongoing self-management support or "health coaching." While rigorous trials have shown MA health coaching to improve diabetes outcomes, less is known about if and how such a model can be integrated within real world, primary care clinic workflows. Medical Assistant Health Coaching for Type 2 Diabetes in Diverse Primary Care Settings - A Pragmatic, Cluster-Randomized Controlled Trial will address this gap. Specifically, this study compares MA health coaching versus usual care in improving diabetes clinical control among N = 600 at-risk adults with T2D, and is being conducted at four primary care clinics that are part of two health systems that serve large, ethnically/racially, and socioeconomically diverse populations in Southern California. Electronic medical records are used to identify eligible patients at both health systems, and to examine change in clinical control over one year in the overall sample. Changes in behavioral and psychosocial outcomes are being evaluated by telephone assessment in a subset (n = 300) of participants, and rigorous process and cost evaluations will assess potential for sustainability and scalability.
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Affiliation(s)
- Addie L Fortmann
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Athena Philis-Tsimikas
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Johanna A Euyoque
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Taylor L Clark
- San Diego State University/ University of California, San Diego Joint Doctoral Program in Clinical Psychology, 5500 Campanile Dr, San Diego, CA 92182 / 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Daniela G Vital
- San Diego State University Research Foundation, 5500 Campanile Dr, San Diego, CA 92182, USA.
| | - Haley Sandoval
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Julia I Bravin
- San Diego State University/ University of California, San Diego Joint Doctoral Program in Clinical Psychology, 5500 Campanile Dr, San Diego, CA 92182 / 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Kimberly L Savin
- San Diego State University/ University of California, San Diego Joint Doctoral Program in Clinical Psychology, 5500 Campanile Dr, San Diego, CA 92182 / 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Jennifer A Jones
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Scott Roesch
- Department of Psychology, San Diego State University, 5500 Campanile Dr, San Diego, CA 92182, USA.
| | - Todd Gilmer
- Department of Family Medicine and Public Health, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Thomas Bodenheimer
- Department of Family and Community Medicine, University of California at San Francisco School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - James Schultz
- Neighborhood Healthcare, 460 N Elm St, Escondido, CA 92025, USA.
| | - Linda C Gallo
- Department of Psychology, San Diego State University, 5500 Campanile Dr, San Diego, CA 92182, USA.
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15
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Physical Activity Programs during Pregnancy Are Effective for the Control of Gestational Diabetes Mellitus. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176151. [PMID: 32847106 PMCID: PMC7503359 DOI: 10.3390/ijerph17176151] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/19/2020] [Accepted: 08/21/2020] [Indexed: 12/12/2022]
Abstract
Gestational diabetes mellitus has an incidence of 14% worldwide and nursing is responsible for its monitoring during pregnancy. Excessive weight gain during pregnancy is directly related to gestational diabetes mellitus development. Gestational diabetes mellitus (GDM) has negative repercussions on the evolution of the pregnancy and the fetus. The objective of this systematic review is to establish how physical activity influences pregnant women with gestational diabetes mellitus and to analyze what benefits physical activity has in the control of gestational diabetes mellitus. A systematic search was carried out in different databases (Cochrane, Superior Council of Scientific Investigations (CSIC), EBSCOhost, Pubmed, Scopus, Web os Science, and Proquest) for papers published within the last 12 years, taking into account different inclusion and exclusion criteria. Six randomized controlled studies and one observational case-control study of a high quality were selected. Fasting, postprandial glucose and HbcA1 were assessed, as well as the requirement and amount of insulin used. Thus, there is a positive relationship between the performance of physical activity and the control of gestational diabetes mellitus. Resistance, aerobic exercise, or a combination of both are effective for the control of glucose, HbcA1, and insulin. Due to the variability of the exercises of the analyzed studies and the variability of the shape of the different pregnant women, it does not permit the recommendation of a particular type of exercise. However, any type of physical activity of sufficient intensity and duration can have benefits for pregnant women with GDM. Pregnant women with gestational diabetes mellitus should exercise for at least 20–50 min a minimum of 2 times a week with at a least moderate intensity.
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16
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Heisler M, Kullgren J, Richardson C, Stoll S, Alvarado Nieves C, Wiley D, Sedgwick T, Adams A, Hedderson M, Kim E, Rao M, Schmittdiel JA. Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART). Contemp Clin Trials 2020; 95:106048. [PMID: 32497783 PMCID: PMC8059966 DOI: 10.1016/j.cct.2020.106048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Michele Heisler
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America.
| | - Jeffrey Kullgren
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America; Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, United States of America; University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States of America.
| | - Caroline Richardson
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America.
| | - Shelley Stoll
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America.
| | - Cristina Alvarado Nieves
- University of Michigan, Department of Internal Medicine- Metabolism, Endocrinology and Diabetes, United States of America.
| | - Deanne Wiley
- Kaiser Permanente Northern California, United States of America.
| | - Tali Sedgwick
- Kaiser Permanente Northern California Division of Research, United States of America.
| | - Alyce Adams
- Kaiser Permanente Northern California, United States of America.
| | | | - Eileen Kim
- The Permanente Medical Group (Kaiser Permanente, Northern California), United States of America.
| | - Megan Rao
- The Permanente Medical Group (Kaiser Permanente, Northern California), United States of America.
| | - Julie A Schmittdiel
- Kaiser Permanente Northern California Division of Research, United States of America.
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17
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Kivelä J, Wikström K, Virtanen E, Georgoulis M, Cardon G, Civeira F, Iotova V, Karuranga E, Ko W, Liatis S, Makrilakis K, Manios Y, Mateo-Gallego R, Nanasi A, Rurik I, Tankova T, Tsochev K, Van Stappen V, Lindström J. Obtaining evidence base for the development of Feel4Diabetes intervention to prevent type 2 diabetes - a narrative literature review. BMC Endocr Disord 2020; 20:140. [PMID: 32164690 PMCID: PMC7066732 DOI: 10.1186/s12902-019-0468-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/04/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Feel4Diabetes was a school and community based intervention aiming to promote healthy lifestyle and tackle obesity for the prevention of type 2 diabetes among families in 6 European countries. We conducted this literature review in order to guide the development of evidence-based implementation of the Feel4Diabetes intervention. We focused on type 2 diabetes prevention strategies, including all the phases from risk identification to implementation and maintenance. Special focus was given to prevention among vulnerable groups and people under 45 years. METHODS Scientific and grey literature published between January 2000 and January 2015 was searched for relevant studies using electronic databases. To present the literature review findings in a systematic way, we used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. A complementary literature search from February 2015 to December 2018 was also conducted. RESULTS The initial review included 27 studies with a follow-up ≥12 months and 9 studies with a follow-up ≥6 months and with a participant mean age < 45 years. We found out that interventions should be targeted at people at risk to improve recruiting and intervention effectiveness. Screening questionnaires (primarily Finnish Diabetes Risk Score FINDRISC) and blood glucose measurement can both be used for screening; the method does not appear to affect intervention effectiveness. Screening and recruitment is time-consuming, especially when targeting lower socioeconomic status and age under 45 years. The intervention intensity is more important for effectiveness than the mode of delivery. Moderate changes in several lifestyle habits lead to good intervention results. A minimum of 3-year follow-up seemed to be required to show a reduction in diabetes risk in high-risk individuals. In participants < 45 years, the achieved results in outcomes were less pronounced. The complementary review included 12 studies, with similar results regarding intervention targets and delivery modes, as well as clinical significance. CONCLUSION This narrative review highlighted several important aspects that subsequently guided the development of the Feel4Diabetes high-risk intervention. Research on diabetes prevention interventions targeted at younger adults or vulnerable population groups is still relatively scarce. Feel4Diabetes is a good example of a project aiming to fill this research gap. TRIAL REGISTRATION clinicaltrials.gov NCT02393872, registered 20th March 2015.
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Affiliation(s)
- Jemina Kivelä
- Department of Public Health Solutions, National Institute for Health and Welfare, PO BOX 27, 00300 Helsinki, Finland
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Katja Wikström
- Department of Public Health Solutions, National Institute for Health and Welfare, PO BOX 27, 00300 Helsinki, Finland
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Eeva Virtanen
- Department of Public Health Solutions, National Institute for Health and Welfare, PO BOX 27, 00300 Helsinki, Finland
| | - Michael Georgoulis
- Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
| | - Greet Cardon
- Department of Movement and Sports Sciences, Ghent University, Ghent, Belgium
| | - Fernando Civeira
- GENUD (Growth, Exercise, Nutrition and Development) Research Group, University of Zaragoza, Zaragoza, Spain
| | - Violeta Iotova
- Department of Paediatrics, Medical University Varna, Varna, Bulgaria
| | | | - Winne Ko
- International Diabetes Federation, Brussels, Belgium
| | - Stavros Liatis
- National and Kapodistrian University of Athens, Athens, Greece
| | | | - Yannis Manios
- Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
| | - Rocío Mateo-Gallego
- GENUD (Growth, Exercise, Nutrition and Development) Research Group, University of Zaragoza, Zaragoza, Spain
| | - Anna Nanasi
- Department of Family and Occupational Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Imre Rurik
- Department of Family and Occupational Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Tsvetalina Tankova
- Department of Diabetology, Clinical Center of Endocrinology, Medical University Sofia, Sofia, Bulgaria
| | - Kaloyan Tsochev
- Department of Paediatrics, Medical University Varna, Varna, Bulgaria
| | - Vicky Van Stappen
- Department of Movement and Sports Sciences, Ghent University, Ghent, Belgium
| | - Jaana Lindström
- Department of Public Health Solutions, National Institute for Health and Welfare, PO BOX 27, 00300 Helsinki, Finland
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18
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Zhu Y, Hedderson MM, Sridhar S, Xu F, Feng J, Ferrara A. Poor diet quality in pregnancy is associated with increased risk of excess fetal growth: a prospective multi-racial/ethnic cohort study. Int J Epidemiol 2020; 48:423-432. [PMID: 30590563 DOI: 10.1093/ije/dyy285] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Nutritional perturbations during pregnancy may impact fetal and long-term childhood growth, although there are limited data on overall diet quality. We investigated whether diet quality, measured by the Healthy Eating Index-2010 (HEI-2010), during pregnancy was related to birthweight z-score (BWZ) and the clinically relevant birth outcomes of large- and small-for-gestational age (LGA and SGA). METHODS In a prospective cohort of 2269 multi-racial/ethnic women from the Pregnancy Environment and Lifestyle Study (2014-2017), dietary intake was assessed by a food frequency questionnaire during early pregnancy. Offspring BWZ and LGA or SGA were derived based on gestational age-, sex-, and racial/ethnic-specific birthweight distributions. Multivariable linear and Poisson regression with robust standard errors were used. RESULTS About 80% of women did not achieve good diet quality (HEI-2010 < 80). After adjusting for covariates, infants born to women in the lowest vs highest quartile of HEI-2010 (37.5-64.4 vs 78.7-94.2) had a 0.12 standard-deviation [95% confidence interval (CI) 0.01-0.23, P-for-trend = 0.023] greater BWZ and 1.76-fold (1.08-2.87, P-for-trend = 0.037) increased risk of LGA. No association was observed between HEI-2010 and SGA. Per-5-point substitution of the reversely coded empty calories component score with the whole grains component score in the HEI-2010 was related to a 25% (95% CI 0.66-0.86) lower risk of LGA. CONCLUSIONS Poor diet quality in pregnancy was associated with higher birthweight and increased risk of LGA independent of maternal obesity and other covariates. Substitution of empty calories with whole grains may mitigate the risk of excess fetal growth. Our findings may inform potential prevention strategies and dietary guidelines for pregnant women.
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Affiliation(s)
- Yeyi Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Monique M Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Sneha Sridhar
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Fei Xu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Juanran Feng
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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19
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O'Reilly SL, Leonard Y, Dasgupta K, Terkildsen Maindal H. Diabetes after pregnancy prevention trials: Systematic review for core outcome set development. MATERNAL AND CHILD NUTRITION 2020; 16:e12947. [PMID: 31943785 PMCID: PMC7296791 DOI: 10.1111/mcn.12947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 12/04/2019] [Accepted: 12/15/2019] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Sharleen L O'Reilly
- UCD Institute of Food and Health, School of Agriculture and Food Science, University College Dublin, Ireland.,School of Agriculture and Food Science, University College Dublin, Ireland
| | - Yvonne Leonard
- School of Agriculture and Food Science, University College Dublin, Ireland
| | - Kaberi Dasgupta
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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20
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Fadl H, Saeedi M, Montgomery S, Magnuson A, Schwarcz E, Berntorp K, Sengpiel V, Storck-Lindholm E, Strevens H, Wikström AK, Brismar-Wendel S, Persson M, Jansson S, Ahlsson F, Ursing C, Ryen L, Petersson K, Wennerholm UB, Hildén K, Simmons D. Changing diagnostic criteria for gestational diabetes in Sweden - a stepped wedge national cluster randomised controlled trial - the CDC4G study protocol. BMC Pregnancy Childbirth 2019; 19:398. [PMID: 31675922 PMCID: PMC6823965 DOI: 10.1186/s12884-019-2547-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/09/2019] [Indexed: 01/19/2023] Open
Abstract
Background The optimal criteria to diagnose gestational diabetes mellitus (GDM) remain contested. The Swedish National Board of Health introduced the 2013 WHO criteria in 2015 as a recommendation for initiation of treatment for hyperglycaemia during pregnancy. With variation in GDM screening and diagnostic practice across the country, it was agreed that the shift to new guidelines should be in a scientific and structured way. The aim of the Changing Diagnostic Criteria for Gestational Diabetes (CDC4G) in Sweden (www.cdc4g.se/en) is to evaluate the clinical and health economic impacts of changing diagnostic criteria for GDM in Sweden and to create a prospective cohort to compare the many long-term outcomes in mother and baby under the old and new diagnostic approaches. Methods This is a stepped wedge cluster randomised controlled trial, comparing pregnancy outcomes before and after the switch in GDM criteria across 11 centres in a randomised manner. The trial includes all pregnant women screened for GDM across the participating centres during January–December 2018, approximately two thirds of all pregnancies in Sweden in a year. Women with pre-existing diabetes will be excluded. Data will be collected through the national Swedish Pregnancy register and for follow up studies other health registers will be included. Discussion The stepped wedge RCT was chosen to be the best study design for evaluating the shift from old to new diagnostic criteria of GDM in Sweden. The national quality registers provide data on the whole pregnant population and gives a possibility for follow up studies of both mother and child. The health economic analysis from the study will give a solid evidence base for future changes in order to improve immediate pregnancy, as well as long term, outcomes for mother and child. Trial registration CDC4G is listed on the ISRCTN registry with study ID ISRCTN41918550 (15/12/2017)
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Affiliation(s)
- Helena Fadl
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Maryam Saeedi
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Epidemiology and Public Health, University College London, London, UK
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, University Hospital Örebro, Örebro, Sweden
| | - Erik Schwarcz
- Department of Internal Medicine, School of medical health and sciences, Örebro University Hospital, Örebro, Sweden
| | - Kerstin Berntorp
- Department of Endocrinology, Skåne University Hospital, Clinical Research Center Malmö, Lund University, Lund, Sweden
| | - Verena Sengpiel
- Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Helena Strevens
- Department of Obstetrics and Gynaecology, Skåne University Hospital, Clinical Research Center Lund, Lund University, Lund, Sweden
| | | | - Sophia Brismar-Wendel
- Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden
| | - Martina Persson
- Department of Paediatrics, Sachsska Children's and Youth hospital and Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
| | - Stefan Jansson
- School of Medical Sciences, University Health Care Research Center, Örebro University, Örebro, Sweden
| | - Fredrik Ahlsson
- Department of Women's and Children's health, Uppsala University, Uppsala, Sweden
| | - Carina Ursing
- Department of Endocrinology, Södersjukhuset, Stockholm, Sweden
| | - Linda Ryen
- Center for Health Care Science, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kerstin Petersson
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden
| | - Ulla-Britt Wennerholm
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karin Hildén
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - David Simmons
- Macarthur Clinical School, Western Sydney University, Campbell town, Australia.,Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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21
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Exploring the effectiveness of physical activity interventions in women with previous gestational diabetes: A systematic review of quantitative and qualitative studies. Prev Med Rep 2019; 14:100877. [PMID: 31110933 PMCID: PMC6510702 DOI: 10.1016/j.pmedr.2019.100877] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/28/2019] [Accepted: 04/22/2019] [Indexed: 12/17/2022] Open
Abstract
Women with previous Gestational Diabetes Mellitus (GDM) have seven times the risk of Type 2 diabetes later in life compared to women without GDM. Physical activity can reduce this risk and most women with previous GDM are not physically active. Aims To explore: (1) effectiveness of physical activity interventions for women with previous GDM; (2) factors that women with previous GDM perceive influence their physical activity; (3) how these factors are addressed by the interventions. Methods A systematic review of quantitative (aim 1) and qualitative (aim 2) studies with a mixed-methods synthesis (aim 3) was conducted in October 2017 following Cochrane methodology. Of 8101 articles identified, twenty-eight studies were included in total: 18 in Review 1 and 10 in Review 2. Results Four interventions significantly increased physical activity and 14 had either mixed effectiveness or no changes in physical activity. Reporting of intervention components and study quality varied greatly. Relevant qualitative factors included accounting for childcare issues, social support and cultural sensitivities. Interventions that incorporated these factors were associated with effectiveness. Education about how to reduce future risk of Type 2 diabetes and using pedometers in interventions were not associated with intervention effectiveness. Other factors that future interventions should address consist of ‘putting others before yourself’; ‘putting off lifestyle change’; ‘lack of support from healthcare professionals’ and ‘being a healthy role model for families’. Conclusion Combining the results of qualitative and quantitative studies can provide a nuanced understanding of the effectiveness of physical activity and lifestyle interventions. Women with previous gestational diabetes are at high risk for type 2 diabetes. Interventions to increase physical activity have not worked for this group. Mixed-methods reviews allow us to identify effective intervention components. Childcare, social support and cultural relevance are part of successful interventions. Interventions should incorporate this review's results to improve effectiveness.
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Brown SD, Hedderson MM, Ehrlich SF, Galarce MN, Tsai AL, Quesenberry CP, Ferrara A. Gestational weight gain and optimal wellness (GLOW): rationale and methods for a randomized controlled trial of a lifestyle intervention among pregnant women with overweight or obesity. BMC Pregnancy Childbirth 2019; 19:145. [PMID: 31039753 PMCID: PMC6492416 DOI: 10.1186/s12884-019-2293-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/12/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Excess gestational weight gain (GWG) is common among women with overweight or obesity, increasing their risks for pregnancy complications, delivering a large infant, and postpartum weight retention. To date, only intensive interventions have had success and few interventions have been designed for implementation in healthcare settings. METHODS We describe the development, rationale, and methods of GLOW (GestationaL Weight Gain and Optimal Wellness), a randomized controlled trial evaluating the efficacy of a lifestyle intervention to prevent excess GWG among racially/ethnically diverse women with overweight or obesity in an integrated healthcare delivery system. Participants in Kaiser Permanente Northern California will be randomized, within 2 weeks of completing a study baseline clinic visit at 10 weeks' gestation, to either usual medical care or a multi-component pregnancy lifestyle intervention adapted from the Diabetes Prevention Program (target N = 400). Informed by focus groups with patients and designed to be feasible in a clinical setting, the intervention will include 13 weekly individual sessions (11 delivered by telephone) focused on behavior change for weight management, healthy eating, physical activity, and stress management. Outcomes will be assessed in women and their infants from randomization to 12 months postpartum. The primary outcome is GWG. Secondary outcomes include changes in diet and physical activity during pregnancy and infant birthweight. Exploratory outcomes include cardiometabolic profile assessed via pregnancy blood samples and cord blood samples; and postpartum weight retention and infant anthropometrics up to 12 months of age. The trial includes systematic approaches to enhance intervention fidelity, intervention adherence, and participant retention in trial assessments. DISCUSSION GLOW is among few trials targeting excess GWG among diverse women with overweight or obesity in a healthcare setting, with long-term maternal and infant outcomes assessed up to 12 months after delivery. This evaluation of a multi-component intervention is designed to produce generalizable results to inform potential adoption of the intervention in clinical settings. TRIAL REGISTRATION ClinicalTrials.gov ( NCT02130232 ): submitted April 30, 2014; posted May 5, 2014.
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Affiliation(s)
- Susan D. Brown
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612 USA
| | - Monique M. Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612 USA
| | - Samantha F. Ehrlich
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612 USA
- The University of Tennessee, Knoxville, TN USA
| | - Maren N. Galarce
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612 USA
| | - Ai-Lin Tsai
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612 USA
| | | | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612 USA
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Gadgil MD, Ehrlich SF, Zhu Y, Brown SD, Hedderson MM, Crites Y, Ferrara A. Dietary Quality and Glycemic Control Among Women with Gestational Diabetes Mellitus. J Womens Health (Larchmt) 2019; 28:178-184. [PMID: 30376391 PMCID: PMC6390645 DOI: 10.1089/jwh.2017.6788] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND/OBJECTIVE Poor dietary quality, measured by the Healthy Eating Index 2010 (HEI-2010), is associated with risk of gestational diabetes mellitus (GDM) and type 2 diabetes. The aim was to investigate the association between dietary quality and glycemic control in women with GDM. MATERIALS AND METHODS The study included 1220 women with GDM. Dietary quality was calculated by HEI-2010 score from a Food Frequency Questionnaire administered shortly after GDM diagnosis; higher scores indicate higher dietary quality. Subsequent glycemic control was defined as ≥80% of all capillary glucose measurements meeting recommended clinical targets below 95 mg/dL for fasting, and below 140 mg/dL 1-hour glucose after meals. RESULTS As compared with Quartile 1 of HEI-2010 score, Quartiles 2, 3, and 4 showed increased adjusted odds of overall optimal glycemic control (odds ratio [95% confidence interval] 1.90 [1.34-2.70], 1.77 [1.25-2.52], and 1.55 [1.09-2.20], respectively). Increased odds of glycemic control were observed in Quartiles 2, 3, and 4 as compared with Quartile 1 of HEI-2010 score for 1-hour postbreakfast and 1-hour postdinner. Mean capillary glucose was lower in Quartiles 2, 3, and 4 of HEI-2010 score when compared with Quartile 1 for 1-hour postdinner (p = 0.03). CONCLUSIONS Clinicians should be aware that even a small improvement in diet quality may be beneficial for the achievement of improved glycemic control in women with GDM. TRIAL REGISTRATION Clinical Trials.gov number, NCT01344278.
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Affiliation(s)
- Meghana D. Gadgil
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California
| | - Samantha F. Ehrlich
- Department of Public Health, University of Tennessee Knoxville, Knoxville, Tennessee
| | - Yeyi Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Susan D. Brown
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Monique M. Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Yvonne Crites
- Division of Perinatology, Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Santa Clara, California
| | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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Hedderson MM, Brown SD, Ehrlich SF, Tsai AL, Zhu Y, Quesenberry CP, Crites Y, Ferrara A. A Tailored Letter Based on Electronic Health Record Data Improves Gestational Weight Gain Among Women With Gestational Diabetes Mellitus: The Gestational Diabetes' Effects on Moms (GEM) Cluster-Randomized Controlled Trial. Diabetes Care 2018; 41:1370-1377. [PMID: 29669736 PMCID: PMC6463614 DOI: 10.2337/dc17-1133] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 02/15/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Evaluate whether a tailored letter improved gestational weight gain (GWG) and whether GWG mediated a multicomponent intervention's effect on postpartum weight retention among women with gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS A cluster-randomized controlled trial of 44 medical facilities (n = 2,014 women) randomized to usual care or a multicomponent lifestyle intervention delivered during pregnancy (tailored letter) and postpartum (13 telephone sessions) to reduce postpartum weight retention. The tailored letter, using electronic health record (EHR) data, recommended an end-of-pregnancy weight goal tailored to prepregnancy BMI and GWG trajectory at GDM diagnosis: total GWG at the lower limit of the IOM range if BMI ≥18.5 kg/m2 or the midpoint if <18.5 kg/m2 and weight maintenance if women had exceeded this. The outcomes for this study were the proportion of women meeting the Institute of Medicine (IOM) guidelines for weekly rate of GWG from GDM diagnosis to delivery and meeting the end-of-pregnancy weight goal. RESULTS The tailored letter significantly increased the proportion of women meeting the IOM guidelines (72.6% vs. 67.1%; relative risk 1.08 [95% CI 1.01-1.17]); results were similar among women with BMI <25.0 kg/m2 (1.07 [1.00-1.15]) and ≥25.0 kg/m2 (1.08 [0.98-1.18]). Thirty-six percent in the intervention vs. 33.0% in usual care met the end-of-pregnancy weight goal (1.08 [0.99-1.18]); the difference was statistically significant among women with BMI <25.0 kg/m2 (1.28 [1.05-1.57]) but not ≥25.0 kg/m2 (0.99 [0.87-1.13]). Meeting the IOM guidelines mediated the effect of the multicomponent intervention in reducing postpartum weight retention by 24.6% (11.3-37.8%). CONCLUSIONS A tailored EHR-based letter improved GWG, which mediated the effect of a multicomponent intervention in reducing postpartum weight retention.
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Affiliation(s)
| | - Susan D Brown
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Samantha F Ehrlich
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
- Department of Public Health, The University of Tennessee, Knoxville, Knoxville, TN
| | - Ai-Lin Tsai
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Yeyi Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Yvonne Crites
- Division of Perinatology, Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Santa Clara, CA
| | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Jones EJ, Fraley HE, Mazzawi J. Appreciating Recent Motherhood and Culture: A Systematic Review of Multimodal Postpartum Lifestyle Interventions to Reduce Diabetes Risk in Women with Prior Gestational Diabetes. Matern Child Health J 2018; 21:45-57. [PMID: 27435732 DOI: 10.1007/s10995-016-2092-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objectives Gestational diabetes mellitus (GDM) substantially increases a woman's lifetime risk of developing type 2 diabetes mellitus (DM). Lifestyle modification interventions have been effective in preventing DM in high-risk populations but present challenges in diverse, postpartum women. We systematically reviewed the literature to synthesize current knowledge and practices around tailoring multimodal, primarily home-based interventions for situational and cultural relevance to reduce DM risk in women with prior GDM. Methods We identified original research articles published from January 2000 through July 2015 describing randomized controlled trials testing multimodal interventions to reduce DM risk in women with prior GDM. We compared articles by study objective, delivery modes, intervention components, degree of individualization, theoretical basis, design, population, outcome variables, and findings. Results Ten studies met the inclusion criteria. Telephone and mailings (n = 7) and websites (n = 3) were the primary modes of participant contact in these primarily home-based interventions. These studies demonstrate that individualizing interventions may contribute to increased postpartum weight loss and improved dietary behaviors; however, researchers remain challenged to improve physical activity in this population. Additionally, even when testing primarily home-based interventions, recruitment rates were very low, underscoring challenges of engaging this population in lifestyle changes. Conclusions Postpartum interventions addressing the broader social-ecological dimensions of health behaviors should be tested in women with prior GDM. Researchers and clinicians must continue to explore ways to engage women, including women's families and communities, in interventions to adequately address the sociocultural determinants that affect women's lifestyle behaviors impacting their DM risk.
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Affiliation(s)
- Emily J Jones
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA, 02125, USA.
| | - Hannah E Fraley
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA, 02125, USA
| | - Julianne Mazzawi
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA, 02125, USA
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Horsch A, Gilbert L, Lanzi S, Gross J, Kayser B, Vial Y, Simeoni U, Hans D, Berney A, Scholz U, Barakat R, Puder JJ. Improving cardiometabolic and mental health in women with gestational diabetes mellitus and their offspring: study protocol for MySweetHeart Trial, a randomised controlled trial. BMJ Open 2018; 8:e020462. [PMID: 29487077 PMCID: PMC5855393 DOI: 10.1136/bmjopen-2017-020462] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/10/2017] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Gestational diabetes mellitus (GDM) carries prenatal and perinatal risk for the mother and her offspring as well as longer-term risks for both the mother (obesity, diabetes, cardiovascular disease) and her child (obesity, type 2 diabetes). Compared with women without GDM, women with GDM are twice as likely to develop perinatal or postpartum depression. Lifestyle interventions for GDM are generally limited to physical activity and/or nutrition, often focus separately on the mother or the child and take place either during or after pregnancy, while their results are inconsistent. To increase efficacy of intervention, the multifactorial origins of GDM and the tight link between mental and metabolic as well as maternal and child health need to be heeded. This calls for an interdisciplinary transgenerational approach starting in, but continuing beyond pregnancy. METHODS AND ANALYSIS This randomised controlled trial will assess the effect of a multidimensional interdisciplinary lifestyle and psychosocial intervention aimed at improving the metabolic and mental health of 200 women with GDM and their offspring. Women with GDM at 24-32 weeks gestational age who understand French or English, and their offspring and partners can participate. The intervention components will be delivered on top of usual care during pregnancy and the first year postpartum. Metabolic and mental health outcomes will be measured at 24-32 weeks of pregnancy, shortly after birth and at 6-8 weeks and 1 year after childbirth. Data will be analysed using intention-to-treat analyses. The MySweetHeart Trial is linked to the MySweetHeart Cohort (clinicaltrials.gov/ct2/show/NCT02872974). ETHICS AND DISSEMINATION We will disseminate the findings through regional, national and international conferences and through peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02890693; Pre-results.
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Affiliation(s)
- Antje Horsch
- Woman-Mother-Child Department, Lausanne University Hospital, Lausanne, Switzerland
- Institute of Higher Education and Research in Healthcare (IUFRS), University of Lausanne, Lausanne, Switzerland
| | - Leah Gilbert
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
| | - Stefano Lanzi
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
- Service of Angiology, Heart and Vessel Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Justine Gross
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
| | - Bengt Kayser
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Yvan Vial
- Woman-Mother-Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Umberto Simeoni
- DOHad Laboratory, Pediatrics Division, Woman-Mother-Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Didier Hans
- Center of Bone Diseases, Rheumatology Service, Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Alexandre Berney
- Consultation Liaison Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Urte Scholz
- Applied Social and Health Psychology, Department of Psychology, University Research Priority Program Dynamics of Healthy Aging, University of Zurich, Lausanne, Switzerland
| | - Ruben Barakat
- Facultad de Ciencias de la Actividad Física y del Deporte-INEF, Universidad Politécnica de Madrid, Madrid, Spain
| | - Jardena J Puder
- Institute of Higher Education and Research in Healthcare (IUFRS), University of Lausanne, Lausanne, Switzerland
- Service of Pediatric Endocrinology, Diabetology and Obesity, Lausanne University Hospital, Lausanne, Switzerland
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27
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Psychosocial predictors of gestational weight gain and the role of mindfulness. Midwifery 2017; 56:86-93. [PMID: 29096284 DOI: 10.1016/j.midw.2017.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 09/17/2017] [Accepted: 10/14/2017] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To identify the psychosocial factors (i.e., stress, anxiety, depression, social support) that are associated with gestational weight gain (GWG) and the relationship of mindfulness with GWG during each trimester of pregnancy. DESIGN In this cross-sectional study, an online survey that assessed physical and mental health and wellness practices was administered to pregnant women. PARTICIPANTS Pregnant women ≥8 weeks gestation, ≥18 years old, and could read and write in English. MEASUREMENT AND FINDINGS Women who responded to the survey (N=1,073) were on average 28.7±4.6 years old. Findings from a regression analysis suggest that increased levels of depression may be predictive of increased GWG in the second trimester and decreased levels of mindfulness may be predictive of increased GWG in the first trimester. Anxiety, stress, and overall social support were not associated with GWG in any trimester. KEY CONCLUSIONS Mindfulness-based strategies (e.g., yoga) may have the potential to manage both depression and excessive GWG and may beneficial for and preferred by pregnant women. More research is warranted to determine clear relationships between psychosocial health, mindfulness, and GWG. IMPLICATIONS FOR PRACTICE Health care providers are encouraged to screen for depression in early pregnancy (i.e., first or second trimester) and provide resources to manage symptoms of depression and GWG to promote optimal birth outcomes. Health care providers may want to counsel patients on how to manage depression and/or GWG by suggesting mindfulness-based approaches.
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Brown SD, Grijalva CS, Ferrara A. Leveraging EHRs for patient engagement: perspectives on tailored program outreach. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:e223-e230. [PMID: 28850790 PMCID: PMC6163036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Electronic health records (EHRs) present healthcare delivery systems with scalable, cost-effective opportunities to promote lifestyle programs among patients at high risk for type 2 diabetes, yet little consensus exists on strategies to enhance patient engagement. We explored patient perspectives on program outreach messages containing content tailored to EHR-derived diabetes risk factors-a theory-driven strategy to increase the persuasiveness of health communications. STUDY DESIGN Convergent mixed methods. METHODS Within an integrated healthcare delivery system, women with a history of gestational diabetes participated in 1 of 6 ethnic-specific focus groups to elicit diverse perspectives and a survey yielding quantitative data to contextualize qualitative responses. RESULTS The sample included 35 participants (80% racial/ethnic minorities; mean age = 36 years). Themes regarding tailored messages centered on diabetes risk communication (opposing attitudes about whether to feature diabetes risk factors), privacy (how and whether patient data should be accessed), authenticity (perceiving messages as personalized vs generically computer generated), and preferences for messages sent by one's personal physician. Trust in the medical profession and perceived risk for diabetes were similar to levels reported in comparable samples. CONCLUSIONS Patient reactions highlight the challenges of leveraging EHRs for tailored messages. Some viewed messages as caring reminders to take preventive action and others raised concerns over intrusiveness. Optimal lifestyle program outreach to improve quality of care for women at high risk for diabetes may require communication from personal physicians, careful development to mitigate concerns over privacy and authenticity, and techniques to counteract the threatening nature of personalized risk communication.
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Affiliation(s)
- Susan D Brown
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612. E-mail:
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Meltzer-Brody S, Maegbaek ML, Medland SE, Miller WC, Sullivan P, Munk-Olsen T. Obstetrical, pregnancy and socio-economic predictors for new-onset severe postpartum psychiatric disorders in primiparous women. Psychol Med 2017; 47:1427-1441. [PMID: 28112056 PMCID: PMC5429203 DOI: 10.1017/s0033291716003020] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Childbirth is a potent trigger for the onset of psychiatric illness in women including postpartum depression (PPD) and postpartum psychosis (PP). Medical complications occurring during pregnancy and/or childbirth have been linked to postpartum psychiatric illness and sociodemographic factors. We evaluated if pregnancy and obstetrical predictors have similar effects on different types of postpartum psychiatric disorders. METHOD A population-based cohort study using Danish registers was conducted in 392 458 primiparous women with a singleton delivery between 1995 and 2012 and no previous psychiatric history. The main outcome was first-onset postpartum psychiatric episodes. Incidence rate ratios (IRRs) were calculated for any psychiatric contact in four quarters for the first year postpartum. RESULTS PPD and postpartum acute stress reactions were associated with pregnancy and obstetrical complications. For PPD, hyperemesis gravidarum [IRR 2.69, 95% confidence interval (CI) 1.93-3.73], gestational hypertension (IRR 1.84, 95% CI 1.33-2.55), pre-eclampsia (IRR 1.45, 95% CI 1.14-1.84) and Cesarean section (C-section) (IRR 1.32, 95% CI 1.13-1.53) were associated with increased risk. For postpartum acute stress, hyperemesis gravidarum (IRR 1.93, 95% CI 1.38-2.71), preterm birth (IRR 1.51, 95% CI 1.30-1.75), gestational diabetes (IRR 1.42, 95% CI 1.03-1.97) and C-section (IRR 1.36, 95% CI 1.20-1.55) were associated with increased risk. In contrast, risk of PP was not associated with pregnancy or obstetrical complications. CONCLUSIONS Pregnancy and obstetrical complications can increase the risk for PPD and acute stress reactions but not PP. Identification of postpartum women requiring secondary care is needed to develop targeted approaches for screening and treatment. Future work should focus on understanding the contributions of psychological stressors and underlying biology on the development of postpartum psychiatric illness.
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Affiliation(s)
- S. Meltzer-Brody
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M. L. Maegbaek
- National Center for Register-based Research, Aarhus University, Aarhus, Denmark
| | - S. E. Medland
- Quantitative Genetics, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - W. C. Miller
- Department of Epidemiology, The Ohio State University, Columbus, OH, USA
| | - P. Sullivan
- Departments of Genetics and Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - T. Munk-Olsen
- National Center for Register-based Research, Aarhus University, Aarhus, Denmark
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Kubo A, Ferrara A, Brown SD, Ehrlich SF, Tsai AL, Quesenberry CP, Crites Y, Hedderson MM. Perceived psychosocial stress and gestational weight gain among women with gestational diabetes. PLoS One 2017; 12:e0174290. [PMID: 28350836 PMCID: PMC5369756 DOI: 10.1371/journal.pone.0174290] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 03/06/2017] [Indexed: 12/03/2022] Open
Abstract
Growing evidence links perceived stress-a potentially modifiable psychosocial risk factor-with health behaviors and obesity. Yet little is known about the relationship between stress during pregnancy and gestational weight gain, particularly among women with pregnancy complications. We conducted a cross-sectional analysis to examine associations between psychosocial stress during pregnancy and gestational weight gain among women with gestational diabetes. We used baseline data from the Gestational Diabetes's Effects on Moms (GEM) study: 1,353 women with gestational diabetes who delivered a term singleton within Kaiser Permanente Northern California were included. Perceived stress near the time of gestational diabetes diagnosis was measured using the validated Perceived Stress Scale (PSS10). Gestational weight gain was categorized according to the 2009 Institute of Medicine recommendations. Binomial regression analyses adjusted for gestational age and maternal age at the time of gestational diabetes diagnosis, and race/ethnicity and estimated rate ratios (RR) and their 95% confidence interval (CI). Among women with a normal pregravid Body Mass Index (BMI 18.5-24.9 kg/m2), there was a significant association between high (Q4) PSS score and risk of both exceeding and gaining below the Institute of Medicine recommendations compared to those with lower stress (Q1) [adjusted RR = 2.16 95% CI 1.45-3.21; RR = 1.39 95% CI 1.01-1.91, respectively.] Among women with pregravid overweight/obesity (BMI≥25 kg/m2), there was no association. Although the temporal relationship could not be established from this study, there may be a complex interplay between psychosocial stress and gestational weight gain among women with gestational diabetes. Further studies examining stress earlier in pregnancy, risk of developing gestational diabetes and excess/inadequate gestational weight gain are warranted to clarify these complex relationships.
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Affiliation(s)
- Ai Kubo
- Kaiser Permanente Division of Research, Oakland, California, United States of America
| | - Assiamira Ferrara
- Kaiser Permanente Division of Research, Oakland, California, United States of America
| | - Susan D. Brown
- Kaiser Permanente Division of Research, Oakland, California, United States of America
| | - Samantha F. Ehrlich
- Kaiser Permanente Division of Research, Oakland, California, United States of America
- Department of Public Health, University of Tennessee Knoxville, Knoxville, Tennessee, United States of America
| | - Ai-Lin Tsai
- Kaiser Permanente Division of Research, Oakland, California, United States of America
| | | | - Yvonne Crites
- Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Santa Clara, California, United States of America
| | - Monique M. Hedderson
- Kaiser Permanente Division of Research, Oakland, California, United States of America
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Sousa AMDS, Fiuza D, Mikami FCF, Abrão KC, Francisco RPV, Zugaib M. Evaluation of information retention and adherence to treatment in patients with gestational diabetes mellitus after multidisciplinary group. Rev Assoc Med Bras (1992) 2017; 62:212-7. [PMID: 27310543 DOI: 10.1590/1806-9282.62.03.212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 08/24/2014] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the retention of information after participation in multidisciplinary group in patients with gestational diabetes mellitus (GDM) through a phone contact. METHOD 122 pregnant women diagnosed with gestational diabetes were included. After diagnosis of gestational diabetes, the patients were referred to the multidisciplinary group where they received medical, nutrition and nursing guidelines related to the disease. After three days these patients received one telephone call from a nurse, who made the same questions regarding the information received. In the statistical analysis, results were presented as absolute and relative frequencies. RESULTS Most patients 119/122 patients (97.5%) were managing to do self glucose monitoring. Twenty-one patients (17.2%) reported having difficulty performing the blood glucose, especially finger pricking. When questioning whether the woman was following the proposed diet, 24/122 (19.7%) patients said they did not; the meal frequency was not reached by 23/122 (18.9%) of the women, and forty-seven (38.5%) of the women reported having ingested sugar in the days following the guidance in multidisciplinary group. CONCLUSION Regarding the proposed treatment, there was good adherence of patients, especially in relation to blood glucose monitoring. As for nutritional control, we observed greater difficulty in following the guidelines demonstrating the need for long-term monitoring, as well as further clarification to the patients about the importance of nutrition in diabetes management.
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Affiliation(s)
- Ana Maria da Silva Sousa
- Universidade de São Paulo, Universidade de São Paulo, Faculdade de Medicina, Department of Gynecology and Obstetrics, São Paulo SP , Brazil, MSc in Science and Health, Department of Gynecology and Obstetrics, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Daine Fiuza
- Universidade Anhembi Morumbi, Universidade Anhembi Morumbi, São Paulo SP , Brazil, Medical Student, Universidade Anhembi Morumbi, São Paulo, SP, Brazil
| | - Fernanda Cristina Ferreira Mikami
- Universidade de São Paulo, FMUSP, Hospital das Clínicas, Fetal Medicine Division, São Paulo SP , Brazil, Assistant Physician at the Fetal Medicine Division of Hospital das Clínicas, FMUSP, São Paulo, SP, Brazil
| | - Karen Cristine Abrão
- Universidade Anhembi Morumbi, Universidade Anhembi Morumbi, Escola de Ciências da Saúde, São Paulo SP , Brazil, PhD from FMUSP - Academic Director, Escola de Ciências da Saúde and Escola de Medicina da Universidade Anhembi Morumbi, São Paulo, SP, Brazil
| | - Rossana Pulcineli Vieira Francisco
- Universidade de São Paulo, FMUSP, Department of Gynecology and Obstetrics, São Paulo SP , Brazil, Habilitation (BR: Livre-docência) from FMUSP - Associate Professor of Obstetrics, Department of Gynecology and Obstetrics, FMUSP, São Paulo, SP, Brazil
| | - Marcelo Zugaib
- Universidade de São Paulo, FMUSP, Department of Gynecology and Obstetrics, São Paulo SP , Brazil, Full Professor of Obstetrics, Department of Gynecology and Obstetrics, FMUSP, São Paulo, SP, Brazil
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Magee M, Bardsley JK, Wallia A, Smith KM. Transitioning the Adult with Type 2 Diabetes From the Acute to Chronic Care Setting: Strategies to Support Pragmatic Implementation Success. Curr Diab Rep 2017; 17:6. [PMID: 28138821 DOI: 10.1007/s11892-017-0830-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Michelle Magee
- MedStar Diabetes Institute, 100 Irving St, NW, #4114, Washington, DC, USA.
- MedStar Health Research Institute, 6525 Belcrest Rd., Ste. 700, Hyattsville, MD, 20782, USA.
- Georgetown University School of Medicine and Healthcare Sciences, Washington, DC, USA.
| | - Joan K Bardsley
- MedStar Health Research Institute, 6525 Belcrest Rd., Ste. 700, Hyattsville, MD, 20782, USA
- MedStar Health Corporate Nursing, 6525 Belcrest Rd., Ste. 700, Hyattsville, MD, 20782, USA
| | - Amisha Wallia
- Northwestern University Feinberg School of Medicine, Suite 530 645N, Michigan Avenue, Chicago, IL, 60611, USA
| | - Kelly M Smith
- MedStar Health Research Institute, 6525 Belcrest Rd., Ste. 700, Hyattsville, MD, 20782, USA
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Abstract
Gestational diabetes mellitus (GDM) is linked with several acute maternal health risks and long-term development of type 2 diabetes, metabolic syndrome, and cardiovascular disease. Intrauterine exposure to GDM similarly increases offspring risk of early-life health complications and later disease. GDM recurrence is common, affecting 40 to 73% of women, and augments associated maternal/fetal/child health risks. Modifiable and independent risk factors for GDM include maternal excessive gestational weight gain and prepregnancy overweight and obesity. Lifestyle interventions that target diet, activity, and behavioral strategies can effectively modify body weight. Randomized clinical trials testing the effects of lifestyle interventions during pregnancy to reduce excessive gestational weight gain have generally shown mixed effects on reducing GDM incidence. Trials testing the effects of postpartum lifestyle interventions among women with a history of GDM have shown reduced incidence of diabetes and improved cardiovascular disease risk factors. However, the long-term effects of interpregnancy or prepregnancy lifestyle interventions on subsequent GDM remain unknown. Future adequately powered and well-controlled clinical trials are needed to determine the effects of lifestyle interventions to prevent GDM and identify pathways to effectively reach reproductive-aged women across all levels of society, before, during, and after pregnancy.
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Affiliation(s)
- Suzanne Phelan
- Department of Kinesiology, California Polytechnic State University
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Brown SD, Ehrlich SF, Kubo A, Tsai AL, Hedderson MM, Quesenberry CP, Ferrara A. Lifestyle behaviors and ethnic identity among diverse women at high risk for type 2 diabetes. Soc Sci Med 2016; 160:87-93. [PMID: 27214712 PMCID: PMC4912226 DOI: 10.1016/j.socscimed.2016.05.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 05/09/2016] [Accepted: 05/13/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Diet and physical activity lifestyle behaviors are modifiable risk factors for type 2 diabetes and are shaped by culture, potentially influencing diabetes health disparities. OBJECTIVES We examined whether ethnic identity-the strength of attachment to one's ethnic group, and a long-standing focus of psychological research-could help account for variations in lifestyle behaviors within a diverse population at high risk for chronic disease. METHODS Using data from the Gestational Diabetes' Effects on Moms trial, this US-based cross-sectional study included 1463 pregnant women (74% from minority ethnic/racial groups; 46% born outside the US) with gestational diabetes (GDM), a common pregnancy complication conferring high risk for type 2 diabetes after delivery. Mixed linear regression models examined whether ethnic identity is associated with lifestyle behaviors after adjusting for demographic, clinical, and acculturative characteristics (e.g., nativity and length of residence in the US). RESULTS In the overall sample, a one-unit increase in ethnic identity score was significantly associated with 3% greater fiber intake, 4% greater fruit/vegetable intake, 11% greater total activity, and 11% greater walking (p values < 0.01). Within ethnic/racial groups, a one-unit increase in ethnic identity score was significantly associated with 17% greater fiber intake among Filipina women; 5% lower total caloric intake among non-Hispanic White women; and 40% greater total activity, 35% greater walking, and 8% greater total caloric intake among Latina women (p values ≤ 0.03). CONCLUSION Results from this large study suggest that ethnic group attachment is associated with some lifestyle behaviors, independent of acculturation indicators, among young women with GDM who are at high risk for type 2 diabetes. Stronger ethnic identity may promote certain choices known to be associated with reduced risk of type 2 diabetes. Prospective research is needed to clarify the temporal nature of associations between ethnic identity and modifiable diabetes risk factors.
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Affiliation(s)
- Susan D Brown
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States.
| | - Samantha F Ehrlich
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Ai Kubo
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Ai-Lin Tsai
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Monique M Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Charles P Quesenberry
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
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Ehrlich SF, Sternfeld B, Krefman AE, Hedderson MM, Brown SD, Mevi A, Chasan-Taber L, Quesenberry CP, Ferrara A. Moderate and Vigorous Intensity Exercise During Pregnancy and Gestational Weight Gain in Women with Gestational Diabetes. Matern Child Health J 2016; 20:1247-57. [PMID: 26955997 PMCID: PMC5019099 DOI: 10.1007/s10995-016-1926-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objectives To estimate the associations of moderate and vigorous intensity exercise during pregnancy with the rate of gestational weight gain (GWG) from gestational diabetes (GDM) diagnosis to delivery, overall and stratified by prepregnancy overweight/obesity. Methods Prospective cohort study with physical activity reported shortly after the GDM diagnosis and prepregnancy weight and post-diagnosis GWG obtained from electronic health records (n = 1055). Multinomial logistic regression models in the full cohort and stratified by prepregnancy overweight/obesity estimated associations of moderate and vigorous intensity exercise with GWG below and above the Institute of Medicine's (IOM) prepregnancy BMI-specific recommended ranges for weekly rate of GWG in the second and third trimesters. Results In the full cohort, any participation in vigorous intensity exercise was associated with decreased odds of GWG above recommended ranges as compared to no participation [odds ratio (95 % confidence interval): 0.63 (0.40, 0.99)], with a significant trend for decreasing odds of excess GWG with increasing level of vigorous intensity exercise. Upon stratification by prepregnancy overweight/obesity, significant associations were only observed for BMI ≥ 25.0 kg/m(2): any vigorous intensity exercise, as compared to none, was associated with 54 % decreased odds of excess GWG [0.46 (0.27, 0.79)] and significant trends were detected for decreasing odds of GWG both below and above the IOM's recommended ranges with increasing level of vigorous exercise (both P ≤ 0.03). No associations were observed for moderate intensity exercise. Conclusions for Practice In women with GDM, particularly overweight and obese women, vigorous intensity exercise during pregnancy may reduce the odds of excess GWG.
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Affiliation(s)
- Samantha F Ehrlich
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- Department of Public Health, College of Education, Health and Human Sciences, University of Tennessee, Knoxville, TN, USA.
| | - Barbara Sternfeld
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Amy E Krefman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Monique M Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Susan D Brown
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Ashley Mevi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Lisa Chasan-Taber
- Division of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | | | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Handley MA, Harleman E, Gonzalez-Mendez E, Stotland NE, Althavale P, Fisher L, Martinez D, Ko J, Sausjord I, Rios C. Applying the COM-B model to creation of an IT-enabled health coaching and resource linkage program for low-income Latina moms with recent gestational diabetes: the STAR MAMA program. Implement Sci 2016; 11:73. [PMID: 27193580 PMCID: PMC4870786 DOI: 10.1186/s13012-016-0426-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 04/24/2016] [Indexed: 11/10/2022] Open
Abstract
Background One of the fastest growing risk groups for early onset of diabetes is women with a recent pregnancy complicated by gestational diabetes, and for this group, Latinas are the largest at-risk group in the USA. Although evidence-based interventions, such as the Diabetes Prevention Program (DPP), which focuses on low-cost changes in eating, physical activity and weight management can lower diabetes risk and delay onset, these programs have yet to be tailored to postpartum Latina women. This study aims to tailor a IT-enabled health communication program to promote DPP-concordant behavior change among postpartum Latina women with recent gestational diabetes. The COM-B model (incorporating Capability, Opportunity, and Motivational behavioral barriers and enablers) and the Behavior Change Wheel (BCW) framework, convey a theoretically based approach for intervention development. We combined a health literacy-tailored health IT tool for reaching ethnic minority patients with diabetes with a BCW-based approach to develop a health coaching intervention targeted to postpartum Latina women with recent gestational diabetes. Current evidence, four focus groups (n = 22 participants), and input from a Regional Consortium of health care providers, diabetes experts, and health literacy practitioners informed the intervention development. Thematic analysis of focus group data used the COM-B model to determine content. Relevant cultural, theoretical, and technological components that underpin the design and development of the intervention were selected using the BCW framework. Results STAR MAMA delivers DPP content in Spanish and English using health communication strategies to: (1) validate the emotions and experiences postpartum women struggle with; (2) encourage integration of prevention strategies into family life through mothers becoming intergenerational custodians of health; and (3) increase social and material supports through referral to social networks, health coaches, and community resources. Feasibility, acceptability, and health-related outcomes (weight loss, physical activity, consumption of healthy foods, breastfeeding, and glucose screening) will be evaluated at 9 months postpartum using a randomized controlled trial design. Conclusions STAR MAMA provides a DPP-based intervention that integrates theory-based design steps. Through systematic use of behavioral theory to inform intervention development, STAR MAMA may represent a strategy to develop health IT intervention tools to meet the needs of diverse populations. Trial registration ClinicalTrials.gov NCT02240420 Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0426-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Margaret A Handley
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA. .,Division of General Internal Medicine, UCSF/Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA. .,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, 94110, USA.
| | - Elizabeth Harleman
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, USA.,Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Enrique Gonzalez-Mendez
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, USA.,Vista Family Health Center, Santa Rosa, USA
| | - Naomi E Stotland
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, USA.,Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Priyanka Althavale
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, 94110, USA
| | - Lawrence Fisher
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, USA
| | - Diana Martinez
- Division of General Internal Medicine, UCSF/Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, 94110, USA
| | - Jocelyn Ko
- University of California San Francisco, San Francisco, USA
| | - Isabel Sausjord
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, 94110, USA
| | - Christina Rios
- Division of General Internal Medicine, UCSF/Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, 94110, USA
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Van Ryswyk EM, Middleton PF, Hague WM, Crowther CA. Women's views on postpartum testing for type 2 diabetes after gestational diabetes: Six month follow-up to the DIAMIND randomised controlled trial. Prim Care Diabetes 2016; 10:91-102. [PMID: 26320407 DOI: 10.1016/j.pcd.2015.07.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 05/26/2015] [Accepted: 07/24/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND This study assessed the views of the women who participated in the DIAMIND randomised trial of postpartum SMS reminders to test for type 2 diabetes after gestational diabetes (GDM) on their preferred type of postpartum reminder system and barriers and facilitators to completion of postpartum diabetes testing. METHOD A written questionnaire was sent to women with recent GDM who participated in the DIAMIND trial (n=276) via post or email at six months after the birth of their baby. RESULTS 208 women (75%) returned the study questionnaires. Preferred postpartum reminder types were: SMS (67%), email (17%), postal (12%) and voice call (1%). Women who had not yet completed an OGTT indicated that they planned to undertake one in the future (61%). Common barriers to postpartum OGTT completion included: not having enough time (73%), inadequate childcare (30%), and a need to focus on the health of the baby (30%). The most common facilitator was having a shorter test (33%). CONCLUSIONS Improved childcare quality and access as well as more research into a shorter, more convenient test procedure for type 2 diabetes screening are needed. Reminder systems for postpartum diabetes screening should be electronic where possible.
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Affiliation(s)
- E M Van Ryswyk
- Robinson Research Institute, The University of Adelaide, Adelaide, Australia.
| | - P F Middleton
- Robinson Research Institute, The University of Adelaide, Adelaide, Australia.
| | - W M Hague
- Robinson Research Institute, The University of Adelaide, Adelaide, Australia.
| | - C A Crowther
- Robinson Research Institute, The University of Adelaide, Adelaide, Australia; Liggins Institute, The University of Auckland, Auckland, New Zealand.
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Schmidt MI, Duncan BB, Castilhos C, Wendland EM, Hallal PC, Schaan BD, Drehmer M, Costa E Forti A, Façanha C, Nunes MA. Lifestyle INtervention for Diabetes prevention After pregnancy (LINDA-Brasil): study protocol for a multicenter randomized controlled trial. BMC Pregnancy Childbirth 2016; 16:68. [PMID: 27029489 PMCID: PMC4812654 DOI: 10.1186/s12884-016-0851-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 03/17/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Gestational diabetes mellitus (GDM), a hyperglycemic state detected during pregnancy, is an established risk factor for diabetes. However, treatment during pregnancy in and of itself is not able to eliminate this risk, and a considerable fraction of women with GDM will develop frank diabetes in the decade following pregnancy. Our aim is to conduct a multicenter randomized controlled trial to investigate the effectiveness of a lifestyle intervention program implemented after a pregnancy complicated by GDM in delaying or preventing the development of type 2 diabetes. METHODS Women aged 18 or older identified as having recent GDM are recruited and followed by telephone to assess eligibility for the trial. To be eligible, women must have used insulin during pregnancy or present intermediate hyperglycemia postpartum. Women are encouraged to enter the trial as early as 10 weeks, and are permitted to do so up to 2 years after a pregnancy with GDM. An estimated 740 women will be randomized to either conventional care or to coach-based interventions focused on breastfeeding, weight loss, healthy eating, and increased physical activity, and predominantly delivered by telephone. Women are followed annually to detect new onset diabetes, the primary outcome, and additional secondary outcomes which include reversion to normoglycemia, weight loss, physical activity and fitness, and insulin resistance. DISCUSSION Though previous studies have demonstrated that type 2 diabetes can be delayed or prevented, no study has yet demonstrated the feasibility and effectiveness of similar interventions implemented in the postpartum period for women with recent GDM. If shown to be successful, this approach could become an important means of preventing diabetes in primary care settings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02327286; Registered 23 December 2014.
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Affiliation(s)
- Maria Inês Schmidt
- Postgraduate Program in Epidemiology, School of Medicine, Federal University of Rio Grande do Sul, R. Ramiro Barcelos, 2600, Sala 414, Porto Alegre, RS, 90035-003, Brazil. .,Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
| | - Bruce B Duncan
- Postgraduate Program in Epidemiology, School of Medicine, Federal University of Rio Grande do Sul, R. Ramiro Barcelos, 2600, Sala 414, Porto Alegre, RS, 90035-003, Brazil.,Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Eliana Márcia Wendland
- Postgraduate Program in Epidemiology, School of Medicine, Federal University of Rio Grande do Sul, R. Ramiro Barcelos, 2600, Sala 414, Porto Alegre, RS, 90035-003, Brazil.,Department of Collective Health, Federal University of Health Sciences, Porto Alegre, RS, Brazil
| | - Pedro C Hallal
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil
| | - Beatriz D'Agord Schaan
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.,Postgraduate Studies Program in Endocrinology, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Michele Drehmer
- Postgraduate Program in Epidemiology, School of Medicine, Federal University of Rio Grande do Sul, R. Ramiro Barcelos, 2600, Sala 414, Porto Alegre, RS, 90035-003, Brazil.,Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Adriana Costa E Forti
- Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil.,Integrated Center for Diabetes and Hypertension, Ceará State Health Department, Fortaleza, Ceará, Brazil
| | - Cristina Façanha
- Integrated Center for Diabetes and Hypertension, Ceará State Health Department, Fortaleza, Ceará, Brazil.,School of Medicine, Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Maria Angélica Nunes
- Postgraduate Program in Epidemiology, School of Medicine, Federal University of Rio Grande do Sul, R. Ramiro Barcelos, 2600, Sala 414, Porto Alegre, RS, 90035-003, Brazil
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Ferrara A, Hedderson MM, Brown SD, Albright CL, Ehrlich SF, Tsai AL, Caan BJ, Sternfeld B, Gordon NP, Schmittdiel JA, Gunderson EP, Mevi AA, Herman WH, Ching J, Crites Y, Quesenberry CP. The Comparative Effectiveness of Diabetes Prevention Strategies to Reduce Postpartum Weight Retention in Women With Gestational Diabetes Mellitus: The Gestational Diabetes' Effects on Moms (GEM) Cluster Randomized Controlled Trial. Diabetes Care 2016; 39:65-74. [PMID: 26657945 PMCID: PMC4686847 DOI: 10.2337/dc15-1254] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/01/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the effectiveness of diabetes prevention strategies addressing postpartum weight retention for women with gestational diabetes mellitus (GDM) delivered at the health system level: mailed recommendations (usual care) versus usual care plus a Diabetes Prevention Program (DPP)-derived lifestyle intervention. RESEARCH DESIGN AND METHODS This study was a cluster randomized controlled trial of 44 medical facilities (including 2,280 women with GDM) randomized to intervention or usual care. The intervention included mailed gestational weight gain recommendations plus 13 telephone sessions between 6 weeks and 6 months postpartum. Primary outcomes included the following: proportion meeting the postpartum goals of 1) reaching pregravid weight if pregravid BMI <25.0 kg/m(2) or 2) losing 5% of pregravid weight if BMI ≥25.0 kg/m(2); and pregravid to postpartum weight change. RESULTS On average, over the 12-month postpartum period, women in the intervention had significantly higher odds of meeting weight goals than women in usual care (odds ratio [OR] 1.28 [95% CI 1.10, 1.47]). The proportion meeting weight goals was significantly higher in the intervention than usual care at 6 weeks (25.5 vs. 22.4%; OR 1.17 [1.01, 1.36]) and 6 months (30.6 vs. 23.9%; OR 1.45 [1.14, 1.83]). Condition differences were reduced at 12 months (33.0 vs. 28.0%; OR 1.25 [0.96, 1.62]). At 6 months, women in the intervention retained significantly less weight than women in usual care (mean 0.39 kg [SD 5.5] vs. 0.95 kg [5.5]; mean condition difference -0.64 kg [95% CI -1.13, -0.14]) and had greater increases in vigorous-intensity physical activity (mean condition difference 15.4 min/week [4.9, 25.8]). CONCLUSIONS A DPP-derived lifestyle intervention modestly reduced postpartum weight retention and increased vigorous-intensity physical activity.
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Affiliation(s)
- Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Susan D Brown
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Cheryl L Albright
- School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu, HI
| | - Samantha F Ehrlich
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Ai-Lin Tsai
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Bette J Caan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Barbara Sternfeld
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Nancy P Gordon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Erica P Gunderson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Ashley A Mevi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - William H Herman
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Jenny Ching
- Division of Perinatology, Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Santa Clara, CA
| | - Yvonne Crites
- Division of Perinatology, Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Santa Clara, CA
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Bernstein JA, McCloskey L, Gebel CM, Iverson RE, Lee-Parritz A. Lost opportunities to prevent early onset type 2 diabetes mellitus after a pregnancy complicated by gestational diabetes. BMJ Open Diabetes Res Care 2016; 4:e000250. [PMID: 27347422 PMCID: PMC4916637 DOI: 10.1136/bmjdrc-2016-000250] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/13/2016] [Accepted: 05/26/2016] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Gestational diabetes mellitus (GDM) greatly increases the risk of developing diabetes in the decade after delivery, but few women receive appropriately timed postpartum glucose testing (PPGT) or a referral to primary care (PC) for continued monitoring. This qualitative study was designed to identify barriers and facilitators to testing and referral from patient and providers' perspectives. METHODS We interviewed patients and clinicians in depth about knowledge, values, priorities, challenges, and recommendations for increasing PPGT rates and PC linkage. Interviews were coded with NVIVO data analysis software, and analyzed using an implementation science framework. RESULTS Women reported motivation to address GDM for the health of the fetus. Most women did not anticipate future diabetes for themselves, and focused on delivery outcomes rather than future health risks. Patients sought and received reassurance from clinicians, and were unlikely to discuss early onset following GDM or preventive measures. PPGT barriers described by patients included provider not mentioning the test or setting it up, transportation difficulties, work responsibilities, fatigue, concerns about fasting while breastfeeding, and timing of the test after discharge from obstetrics, and no referral to PC for follow-up. Practitioners described limited communication among multiple care providers during pregnancy and delivery, systems issues, and separation of obstetrics from PC. CONCLUSIONS Patients' barriers to PPGT included low motivation for self-care, structural obstacles, and competing priorities. Providers reported the need to balance risk with reassurance, and identified systems failures related to test timing, limitations of electronic medical record systems (EMR), lack of referrals to PC, and inadequate communication between specialties. Prevention of early onset has great potential for medical cost savings and improvements in quality of life.
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Affiliation(s)
- Judith A Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lois McCloskey
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Christina M Gebel
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Ronald E Iverson
- Boston University School of Medicine, Boston, Massachusetts, USA
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Baptiste-Roberts K, Bronner Y, Nicholson WK. Adoption of a Healthy Lifestyle Following Gestational Diabetes Mellitus. Curr Nutr Rep 2015. [DOI: 10.1007/s13668-015-0135-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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42
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Maintaining older brain functionality: A targeted review. Neurosci Biobehav Rev 2015; 55:453-77. [DOI: 10.1016/j.neubiorev.2015.06.008] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 06/01/2015] [Accepted: 06/03/2015] [Indexed: 12/20/2022]
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Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excessive weight gain in pregnancy. Cochrane Database Syst Rev 2015; 2015:CD007145. [PMID: 26068707 PMCID: PMC9428894 DOI: 10.1002/14651858.cd007145.pub3] [Citation(s) in RCA: 275] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This is an update of a Cochrane review first published in 2012, Issue 4. Excessive weight gain during pregnancy is associated with poor maternal and neonatal outcomes including gestational diabetes, hypertension, caesarean section, macrosomia, and stillbirth. Diet or exercise interventions, or both, may reduce excessive gestational weight gain (GWG) and associated poor outcomes; however, evidence from the original review was inconclusive. OBJECTIVES To evaluate the effectiveness of diet or exercise, or both, interventions for preventing excessive weight gain during pregnancy and associated pregnancy complications. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (5 November 2014), contacted investigators of the previously identified ongoing studies and scanned reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) of diet or exercise, or both, interventions for preventing excessive weight gain in pregnancy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We organised RCTs according to the type of interventions and pooled data using the random-effects model in the Review Manager software. We also performed subgroup analyses according to the initial risk of adverse effects related to poor weight control. We performed sensitivity analysis to assess the robustness of the findings. MAIN RESULTS We included 65 RCTs, out of which 49 RCTs involving 11,444 women contributed data to quantitative meta-analysis. Twenty studies were at moderate-to-high risk of bias. Study interventions involved mainly diet only, exercise only, and combined diet and exercise interventions, usually compared with standard care. Study methods varied widely; therefore, we estimated the average effect across studies and performed sensitivity analysis, where appropriate, by excluding outliers and studies at high risk of bias.Diet or exercise, or both, interventions reduced the risk of excessive GWG on average by 20% overall (average risk ratio (RR) 0.80, 95% confidence interval (CI) 0.73 to 0.87; participants = 7096; studies = 24; I² = 52%). This estimate was robust to sensitivity analysis, which reduced heterogeneity, therefore we graded this evidence as high-quality. Interventions involving low glycaemic load diets, supervised or unsupervised exercise only, or diet and exercise combined all led to similar reductions in the number of women gaining excessive weight in pregnancy.Women receiving diet or exercise, or both interventions were more likely to experience low GWG than those in control groups (average RR 1.14, 95% CI 1.02 to 1.27; participants = 4422; studies = 11; I² = 3%; moderate-quality evidence). We found no difference between intervention and control groups with regard to pre-eclampsia (RR 0.95, 95% CI 0.77 to 1.16; participants = 5330; studies = 15; I² = 0%; high-quality evidence); however, maternal hypertension (not a pre-specified outcome) was reduced in the intervention group compared with the control group overall (average RR 0.70, 95% CI 0.51 to 0.96; participants = 5162; studies = 11; I² = 43%; low-quality evidence).There was no clear difference between groups with regard to caesarean delivery overall (RR 0.95, 95% CI 0.88 to 1.03; participants = 7534; studies = 28; I² = 9%; high-quality evidence); although the effect estimate suggested a small difference (5%) in favour of the interventions. In addition, for combined diet and exercise counselling interventions there was a 13% (-1% to 25%) reduction in this outcome (borderline statistical significance).We found no difference between groups with regard to preterm birth overall (average RR 0.91, 95% CI 0.68 to 1.22; participants = 5923; studies = 16; I² = 16%; moderate-quality evidence); however limited evidence suggested that these effect estimates may differ according to the types of interventions, with a trend towards an increased risk for exercise-only interventions.We found no clear difference between intervention and control groups with regard to infant macrosomia (average RR 0.93, 95% CI 0.86 to 1.02; participants = 8598; studies = 27; I² = 0%; high-quality evidence), although the effect estimate suggested a small difference (7% reduction) in favour of the intervention group. The largest effect size occurred in the supervised exercise-only intervention group (RR 0.81, 95% CI 0.64 to 1.02; participants = 2445; studies = 7; I² = 0%), which approached statistical significance (P = 0.07). Furthermore, in subgroup analysis by risk, high-risk women (overweight or obese women, or women with or at risk of gestational diabetes) receiving combined diet and exercise counselling interventions experienced a 15% reduced risk of infant macrosomia (average RR 0.85, 95% CI 0.73 to 1.00; participants = 3252; studies = nine; I² = 0; P = 0.05; moderate-quality evidence)There were no differences in the risk of poor neonatal outcomes including shoulder dystocia, neonatal hypoglycaemia, hyperbilirubinaemia, or birth trauma (all moderate-quality evidence) between intervention and control groups; however, infants of high-risk women had a reduced risk of respiratory distress syndrome if their mothers were in the intervention group (RR 0.47, 95% CI 0.26 to 0.85; participants = 2256; studies = two; I² = 0%; moderate-quality evidence). AUTHORS' CONCLUSIONS High-quality evidence indicates that diet or exercise, or both, during pregnancy can reduce the risk of excessive GWG. Other benefits may include a lower risk of caesarean delivery, macrosomia, and neonatal respiratory morbidity, particularly for high-risk women receiving combined diet and exercise interventions. Maternal hypertension may also be reduced. Exercise appears to be an important part of controlling weight gain in pregnancy and more research is needed to establish safe guidelines. Most included studies were carried out in developed countries and it is not clear whether these results are widely applicable to lower income settings.
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Affiliation(s)
- Benja Muktabhant
- Faculty of Public Health, Khon Kaen UniversityDepartment of Nutrition123 Friendship HighwayKhon KaenKhon KaenThailand40002
| | - Theresa A Lawrie
- World Health OrganizationDepartment of Reproductive Health and ResearchAvenue Appia 20GenevaSwitzerland1201
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Malinee Laopaiboon
- Khon Kaen UniversityDepartment of Biostatistics and Demography, Faculty of Public Health123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
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Gilinsky AS, Kirk AF, Hughes AR, Lindsay RS. Lifestyle interventions for type 2 diabetes prevention in women with prior gestational diabetes: A systematic review and meta-analysis of behavioural, anthropometric and metabolic outcomes. Prev Med Rep 2015; 2:448-61. [PMID: 26844102 PMCID: PMC4721374 DOI: 10.1016/j.pmedr.2015.05.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Purpose To systematically review lifestyle interventions for women with prior Gestational Diabetes Mellitus (GDM) to report study characteristics, intervention design and study quality and explore changes in 1) diet, physical activity and sedentary behaviour; 2) anthropometric outcomes and; 3) glycaemic control and diabetes risk. Methods Databases (Web of Science, CCRCT, EMBASE and Science DIRECT) were searched (1980 to April 2014) using keywords for controlled or pre–post design trials of lifestyle intervention targeting women with previous GDM reporting at least one behavioural, anthropometric or diabetes outcome. Selected studies were narratively synthesized with anthropometric and glycaemic outcomes synthesized using meta-analysis. Results Three of 13 included studies were rated as low bias risk. Recruitment rates were poor but study retention good. Six of 11 studies reporting on physical activity reported favourable intervention effects. All six studies reporting on diet reported favourable intervention effects. In meta-analysis, significant weight-loss was attributable to one Chinese population study (WMD = − 1.06 kg (95% CI = − 1.68, − 0.44)). Lifestyle interventions did not change fasting blood glucose (WMD = − 0.05 mmol/L, 95% CI = − 0.21, 0.11) or type 2 diabetes risk. Conclusions Lack of methodologically robust trials gives limited evidence for the success of lifestyle interventions in women with prior GDM. Recruitment into trials is challenging. There is good evidence for diet change after lifestyle intervention in GDM. Limited evidence of PA, anthropometric or glycaemic change with lifestyle in GDM More methodologically robust trials of lifestyle intervention in GDM are required. Recruitment to lifestyle intervention trials for women with GDM is challenging.
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Affiliation(s)
- A S Gilinsky
- School of Psychological & Health Sciences, University of Strathclyde, Glasgow, Scotland, G1 1QE, United Kingdom
| | - A F Kirk
- School of Psychological & Health Sciences, University of Strathclyde, Glasgow, Scotland, G1 1QE, United Kingdom
| | - A R Hughes
- School of Psychological & Health Sciences, University of Strathclyde, Glasgow, Scotland, G1 1QE, United Kingdom
| | - R S Lindsay
- British Heart Foundation Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow G11 8TA, United Kingdom
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O'Reilly SL. Prevention of Diabetes after Gestational Diabetes: Better Translation of Nutrition and Lifestyle Messages Needed. Healthcare (Basel) 2014; 2:468-91. [PMID: 27429288 PMCID: PMC4934570 DOI: 10.3390/healthcare2040468] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 10/14/2014] [Accepted: 11/10/2014] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Sharleen L O'Reilly
- Centre for Physical Activity and Nutrition Research, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia.
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Chasan-Taber L. Lifestyle interventions to reduce risk of diabetes among women with prior gestational diabetes mellitus. Best Pract Res Clin Obstet Gynaecol 2014; 29:110-22. [PMID: 25220104 DOI: 10.1016/j.bpobgyn.2014.04.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/13/2014] [Indexed: 11/19/2022]
Abstract
While lifestyle interventions involving exercise and a healthy diet in high-risk adults have been found to reduce progression to type 2 diabetes by >50%, little attention has been given to the potential benefits of such strategies in women with a history of gestational diabetes mellitus (GDM). We conducted a literature search of PubMed for English language studies of randomized controlled trials of lifestyle interventions among women with a history of GDM. In total, nine studies were identified which fulfilled the eligibility criteria. The majority of randomized trials of lifestyle interventions in women with GDM have been limited to pilot or feasibility studies. However, preliminary findings suggest that such interventions can improve diabetes risk factors in women with a history of GDM. Larger, well-designed controlled randomized trials are needed to assess the effects of lifestyle interventions on preventing subsequent progression to type 2 diabetes among women with GDM.
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Affiliation(s)
- Lisa Chasan-Taber
- Division of Biostatistics & Epidemiology, Department of Public Health, School of Public Health & Health Sciences, University of Massachusetts, Amherst, MA, USA.
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