Postnatal Lifestyle Intervention for Overweight Women With Previous Gestational Diabetes: A Randomized Controlled Trial

Impact of a Women's Heart Clinic on Cardiovascular Disease Risk Awareness in Women with Past Pregnancy Complications: A Prospective Cohort Study

BACKGROUND

Gestational diabetes mellitus (GDM), hypertension during pregnancy (HDP) and/or having small-for-gestational-age (SGA) babies increase cardiovascular disease (CVD) risk. We investigated CVD risk awareness in women with past pregnancy complications and the impact of attending a Women's Heart Clinic (WHC) on this awareness.

METHOD

Women aged 30-55 years with past GDM, HDP and/or SGA babies were prospectively recruited into a 6-month WHC delivering education and management of CVD risk factors (Melbourne, Australia). A nine-item CVD risk Awareness Survey, consisting of six general/three female-specific questions, was administered at baseline and 6-month follow-up. The primary outcome was a change in overall CVD risk awareness before and after attending a WHC, analysed using a McNemar test. Logistic regression assessed for associations between CVD risk awareness and lifestyle behaviours.

RESULTS

A total of 156 women (mean age 41.0±4.2 years, 3.9±2.9 years postpartum) were recruited with 60.3% past GDM, 23.1% HDP, 13.5% both HDP/GDM and 3.2% SGA babies. The majority were White (68.6%), tertiary-educated (79.5%), and from higher income (84.6%). At baseline, 19.2% (95% confidence interval [CI] 13.0%-25.4%) of women had high overall CVD risk awareness, while 63.5% (95% CI 55.9%-71.0%) had high female-specific CVD risk awareness. At 6-month follow-up, overall CVD risk awareness (19.2%-76.1%, p<0.001) and female-specific CVD risk awareness (63.5%-94.8%; p<0.001) significantly increased. Improvement in CVD risk awareness was not associated with higher physical activity (adjusted odds ratio 0.49; 95% CI 0.04-3.21; p=0.51) or heart-healthy diet (adjusted odds ratio 2.49; 95% CI 0.88-6.93; p=0.08) at 6-month follow-up.

CONCLUSIONS

Attendance at a WHC significantly increased women's CVD risk awareness, however, this did not independently associate with lifestyle behaviours.

A Systematic Review and Meta-Analysis of Type 2 Diabetes Prevention Through Lifestyle Interventions in Women with a History of Gestational Diabetes-A Summary of Participant and Intervention Characteristics

Objectives: We aimed to review the effect of lifestyle interventions in women with a history of gestational diabetes mellitus (GDM) based on the participants and intervention characteristics. Methods: We systematically searched seven databases for RCTs of lifestyle interventions published up to 24 July 2024. We included 30 studies that reported the incidence of type 2 diabetes mellitus (T2DM) or body weight. A random effects model was used to calculate the relative risk and mean difference with a 95% confidence interval. Subgroup analyses were conducted for participants' characteristics (age, body mass index (BMI)) and intervention characteristics according to the Template for Intervention Description and Replication (TIDieR). Results: A greater T2DM risk reduction was seen in trials that started within one year postpartum, in participants with a mean baseline BMI of 30 kg/m2 or more, or based on behavioral change theory. For body weight reduction, studies on participants with a mean baseline BMI of 25 kg/m2 or more or ones that included electronic/mobile delivery (text message, web, phone call) were more effective. Conclusions: Diabetes prevention trials in women with a history of GDM are more effective when commencing within one year postpartum, underpinned by behavior change theory, and in participants with overweight or obesity.

Dietary Inflammatory Index Is Differentially Associated With Cardiometabolic Health After Pregnancy on the Basis of Adverse Pregnancy Outcome Exposure

BACKGROUND

Inflammatory diets may influence risk of cardiovascular disease. Subsequent cardiovascular disease is also influenced by adverse pregnancy outcomes (APOs) such as preterm birth, small-for-gestational-age birth, gestational diabetes, and hypertensive disorders of pregnancy. However, the associations between inflammatory diet, APOs, and cardiometabolic health remain unclear.

METHODS AND RESULTS

We used data from the nuMoM2b (Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-Be) HHS (Heart Health Study) to assess the relationship between dietary quality and cardiometabolic health. We calculated Energy-Adjusted Dietary Inflammatory Index scores representing the inflammatory burden in a person's diet. We used linear regression to determine the association between Energy-Adjusted Dietary Inflammatory Index score and cardiometabolic outcomes. We performed stratified analyses for outcomes with a significant interaction between Energy-Adjusted Dietary Inflammatory Index and APO. Data were available from 3249 participants at a median of 3.1 years after delivery. Higher Energy-Adjusted Dietary Inflammatory Index scores were associated with higher body mass index (B=0.29 kg/m2 [95% CI, 0.16-0.42]), waist circumference (0.66 cm [95% CI, 0.39-0.93]), diastolic blood pressure (0.26 mm Hg [95% CI, 0.09-0.44]), mean arterial pressure (0.23 mm Hg [95% CI, 0.06-0.40]), triglycerides (2.11 mg/dL [95% CI, 1.05-3.18]), creatinine (2.78 mg/dL [95% CI, 1.13-4.44]), insulin (exp[B]=1.04 [95% CI, 1.03-1.05]) and C-reactive protein (exp[B]=1.07 [95% CI, 1.04-1.10]), and lower high-density lipoprotein cholesterol (-0.41 mg/dL [95% CI, -0.66 to -0.37]) (all P<0.01). Significant interactions with APO (P<0.05) were identified for body mass index and waist circumference, with stratified analysis revealing stronger associations for individuals with APOs.

CONCLUSIONS

A more proinflammatory diet was associated with worse cardiometabolic health measures, and these relationships differed by a person's APO history. Further investigation should establish how dietary modifications after pregnancy may potentially mitigate cardiovascular disease risk.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

A Tool to Help Nurses Provide Health Education on Adverse Pregnancy Outcomes and Cardiovascular Health

Adverse pregnancy outcomes are associated with poor short- and long-term cardiovascular health. However, patients and their health care providers may not have knowledge of this risk or of the healthful practices that can reduce this risk. Childbirth care can be a pivotal time in the patient-clinician relationship to build awareness and spur prevention planning. As part of the American Heart Association-supported program entitled Providing an Optimized and Empowered Pregnancy for You (P3OPPY), our team collaborated with a community advisory board to create a teaching handout about adverse pregnancy outcomes for incorporation into hospital-based postpartum care. This handout can be used by pregnancy and maternity care providers, including postpartum nurses, to provide health education on how adverse pregnancy outcomes can influence risk for future cardiovascular disease and what can be done for prevention.

Impact of postpartum physical activity on cardiometabolic health, breastfeeding, injury and infant growth and development: a systematic review and meta-analysis

OBJECTIVE

To examine the relationship between postpartum physical activity and maternal postnatal cardiometabolic health, breastfeeding, injury, and infant growth and development.

DESIGN

Systematic review with random-effects meta-analysis and meta-regression.

DATA SOURCES

Eight online databases were searched up until 12 January 2024.

ELIGIBILITY CRITERIA

Studies of all designs in all languages were eligible (except case studies and reviews) if they contained information on the population (postpartum people), intervention (frequency, intensity, duration, volume, or type of exercise, alone ('exercise-only') or in combination with other intervention components (eg, dietary; 'exercise+co-intervention'), comparator (no or low volumes of physical activity), and outcomes: hypertension, diabetes, cardiometabolic risk factors (systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, high density lipoproteins, low density lipoproteins, and triglycerides, glycated hemoglobin (HbA1C), glucose and insulin concentration), breastfeeding (breast milk quality and volume), infant growth (length and weight) and development, or postpartum injury.

RESULTS

46 unique studies (n=8766 participants) from 20 countries were included. Moderate certainty of evidence showed exercise+co-interventions reduced the odds of developing diabetes by 28% (7 randomised controlled trials (RCTs), n=2496; OR 0.72 95% CI 0.54, 0.98, I2 12%), reduced SBP (10 RCTs, n=2753; mean difference (MD) -2.15 95% CI -3.89 to -0.40, I2 73%) and DBP (9 RCTs, n=2575; MD -1.38 95% CI -2.60 to -0.15, I2 66%) compared with controls. Infant growth and development, breast milk quality and quantity, and risk of injury were not different between exercise and control groups.

CONCLUSIONS

Physical activity improves cardiometabolic health without adversely impacting breast milk supply or quality, infant growth or maternal injury.

A Pregnancy and Postnatal RCT Among Women With Gestational Diabetes Mellitus and Overweight/Obesity: The PAIGE2 Study

Objective

This study examined the influence of a pregnancy and postnatal multicomponent lifestyle intervention for women with gestational diabetes mellitus (GDM) and overweight/obesity from 6 weeks to 12 months postnatal. The primary outcome was weight at 12 months. Secondary outcomes included change in body mass index (BMI), waist circumference (WC) and fasting plasma glucose (FPG).

Methods

The study involved 235 pregnant women with GDM and BMI ≥ 25 kg/m2 during pregnancy. Intervention components included an educational session, activity tracker (Fitbit), monthly phone calls, weekly motivational text messages, 12-week voucher for a commercial weight management organization and anthropometric, biochemical, and clinical measurements taken at 6 weeks, 6 months, and 12 months postnatal. The control group received routine local maternity care.

Results

A mean weight change of -2.0 (SD 7.1) kg was observed in the intervention group compared with -0.6 (SD 8.0) kg in the control group, difference -1.4 (95% CI -4.4, 1.5) kg from 6 weeks to 12 months postnatal, but this was not statistically significant (P = .34). Neither were significant differences obtained for any secondary outcomes: BMI -0.6 (-1.6, 0.5) kg/m2, WC -1.0 (-5.1, 3.2) cm and FPG 0.07 (-0.15, 0.29) mmol/L.

Conclusion

This lifestyle intervention among women with overweight/obesity and GDM resulted in a statistically nonsignificant 1.4 kg greater weight loss compared with routine care at 12 months postnatal. Further research is needed to understand how the different components of this lifestyle intervention might be better applied to elicit more successful results.

Postpartum life interventions to prevent type 2 diabetes in women with gestational diabetes: A systematic review and meta-analysis

AIMS/INTRODUCTION

Type 2 diabetes mellitus is a major metabolic disease that seriously endangers life and health, but women with gestational diabetes mellitus are at increased risk for developing type 2 diabetes mellitus. This study aimed to evaluate the effectiveness of postpartum lifestyle intervention on the prevention of type 2 diabetes mellitus, and the effect of lifestyle intervention on glycemic outcomes and anthropometric measures.

MATERIALS AND METHODS

We searched PubMed and other databases to retrieve articles published before May 21, 2023, on randomized controlled trials of postnatal lifestyle interventions (diet and/or physical activity) in women with gestational diabetes mellitus. We estimated the pooled odds ratios using fixed or random effects models and conducted a subgroup analysis of the different intervention methods to explore differences in the different lifestyle interventions.

RESULTS

The review included 17 randomized controlled trials. Overall, lifestyle changes started after a pregnancy complicated by gestational diabetes mellitus an 11% (RR = 0.89; 95% CI: 0.74-1.07) reduction in diabetes risk; significant differences were found for weight (MD = -1.33; 95% CI: [-1.76; -0.89], P < 0.00001) body mass index (MD = -0.53; 95% CI: [-0.74, -0.32], P < 0.00001), and waist circumference change (MD = -1.38; 95% CI: [-2.12; -0.64], P = 0.0002) but not for fasting glucose (MD = -0.06; 95% CI: [-0.19; 0.06], P = 0.32), 2 h glucose (MD = -0.12; 95% CI: [-0.30; 0.06], P = 0.19), and hemoglobin A1c (MD = -0.11; 95% CI: [-0.23; 0.02], P = 0.09). Subgroup analyses showed no significant differences in the effects of different lifestyle interventions on the incidence of type 2 diabetes, blood glucose levels, and anthropometric parameters.

CONCLUSION

Our comprehensive meta-analysis of lifestyle interventions can improve modifiable anthropometric measures in women with gestational diabetes. We need further research to provide more intensive lifestyle intervention, more scientific intervention methods, and to reduce the incidence of type 2 diabetes in patients with gestational diabetes.

Preventing Type 2 Diabetes after Gestational Diabetes: A Systematic Review Mapping Physical Activity Components using the Socio-Ecological Model

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).

The effectiveness of pharmacological and lifestyle interventions to reduce the risk of diabetes and hyperglycaemia following gestational diabetes: A systematic review and meta-analysis

AIMS

To synthesize the available evidence to better understand the effectiveness of interventions to prevent or delay hyperglycaemia and Type 2 diabetes mellitus (T2DM) postnatally in women with current or previous gestational diabetes mellitus (GDM).

METHODS

We searched five databases up to December 2020 for primary peer-reviewed articles reporting postpartum glycaemic outcomes in women with (previous) GDM following pharmacological or lifestyle intervention. Outcomes were relative risk of T2DM or continuous measures of glycaemia, change or at follow-up. A minimum of two studies evaluating the same intervention-outcome combination were needed to conduct meta-analyses, otherwise studies were described narratively. Meta-regression was used to evaluate whether associations varied by additional variables. We assessed risk of bias using the Critical Appraisal Skills Programme checklist. PROSPERO record CRD42018102380.

RESULTS

We included 31 studies in the review with a total sample size of 8624 participants, and 26 studies in meta-analyses. Two-thirds of studies followed up participants at 1 year or less. Pharmacological interventions were associated with reduced risk of T2DM (0.80 [95% CI 0.64-1.00], n = 6 studies), as were lifestyle interventions albeit with a smaller effect size (0.88 [95% CI 0.76-1.01], n = 12 studies). Dietary and physical activity interventions were associated with a small reduction in fasting plasma glucose, particularly in longer interventions, but inconsistent effects were seen for other continuous outcomes.

CONCLUSIONS

Although possibly due to chance, interventions to reduce hyperglycaemia after GDM may be effective. Future research should improve understanding of how interventions affect glucose control and how to optimise interventions for this population.

Effectiveness of a blended mobile-based lifestyle intervention in women with glucose intolerance after a recent history of gestational diabetes (MELINDA): a 1-year, prospective, multicentre, randomised controlled trial

Background

Women with glucose intolerance after gestational diabetes mellitus (GDM) are at high risk to develop type 2 diabetes. Traditional lifestyle interventions in early postpartum have limited impact. We investigated the efficacy of a blended mobile-based lifestyle intervention in women with glucose intolerance after a recent history of GDM.

Methods

Prospective, double-arm, non-masked, multicentre randomised controlled trial (RCT) in which women with glucose intolerance, diagnosed 6-16 weeks after a GDM-complicated pregnancy, were assigned 1:1 to a one-year blended-care, telephone- and mobile-based lifestyle program (intervention) or usual care (control). Primary endpoint was the proportion of women able to achieve their weight goal (≥5% weight loss if prepregnancy BMI ≥ 25 kg/m2 or return to prepregnancy weight if prepregnancy BMI < 25 kg/m2) in the intention-to-treat sample. Key secondary outcomes were frequency of glucose intolerance, diabetes and metabolic syndrome, and lifestyle-related outcomes assessed with self-administered questionnaires. The study was registered in ClinicalTrials.gov (NCT03559621).

Findings

Between April 10th 2019 and May 13th 2022, 240 participants were assigned to the intervention (n = 121) or control group (n = 119), of which 167 (n = 82 in intervention and n = 85 in control group) completed the study. Primary outcome was achieved by 46.3% (56) of intervention participants compared to 43.3% (52) in the control group [odds ratio (OR) 1.13, 95% confidence interval (CI) 0.63-2.03, p = 0.680; risk ratio 1.07, 95% CI (0.78-1.48)]. Women in the intervention group developed significantly less often metabolic syndrome compared to the control group [7.3% (6) vs. 16.5% (14), OR 0.40, CI (0.22-0.72), p = 0.002], reported less sedentary behaviour and higher motivation for continuing healthy behaviours. In the intervention group, 84.1% (69) attended at least eight telephone sessions and 70.7% (58) used the app at least once weekly.

Interpretation

A blended, mobile-based lifestyle intervention was not effective in achieving weight goals, but reduced the risk to develop metabolic syndrome.

Funding

Research fund of University Hospitals Leuven, Novo Nordisk, Sanofi, AstraZeneca, Boehringer-Ingelheim, Lilly.

Association between body mass index and chronic hypertension in patients with hypertension disorders of pregnancy one-year postpartum

OBJECTIVES

To determine the association between body mass index (BMI) and chronic hypertension (CHTN) one-year postpartum following pregnancies complicated by hypertensive disorders of pregnancy (HDP).

STUDY DESIGN

A retrospective cohort study of patients with HDP (gestational hypertension or preeclampsia) in a single Midwestern academic center from 2014 to 2018. The primary outcome was CHTN at one-year postpartum, defined as systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 80 mmHg or taking antihypertensive medication at one-year postpartum. The primary exposure variable was BMI at one-year postpartum, categorized as underweight (<18.5 kg/m2), normal (18.5-24.9 kg/m2), overweight (25-<30 kg/m2), and obese (≥30 kg/m2) and as continuous BMI variable. Descriptive statistics and adjusted logistic regression analysis were performed.

RESULTS

Out of 596 patients with HDP included in this analysis, 275 (46.1 %) had CHTN one-year postpartum. Mean one-year postpartum BMI was 27.9 ± 5.2 kg/m2. Prevalence of CHTN at one-year postpartum was higher in obese (38.1 %) and overweight (30.0 %) groups compared to the normal weight group (29.9 %), p < 0.001. In multivariate logistic regression, obesity at one-year postpartum, compared to normal, was associated with 73 % higher likelihood of CHTN following HDP (adjusted OR 1.73, 95 % CI 1.06-2.84). With BMI as a continuous variable, each unit increase in BMI one-year postpartum was associated with 6 % higher likelihood of CHTN (adjusted OR 1.06, 95 % CI 1.02-1.15).

CONCLUSIONS

Obesity at one-year postpartum following HDP was associated with a higher risk of CHTN compared with normal BMI. Weight is a modifiable risk factor that should be targeted in postpartum interventions to reduce cardiovascular disease following HDP.

Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association

Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.

Effect of a prepartum and postpartum, complex interdisciplinary lifestyle and psychosocial intervention on metabolic and mental health outcomes in women with gestational diabetes mellitus (the MySweetheart trial): randomised, single centred, blinded, controlled trial

Objective

To test the effect of a complex, interdisciplinary, lifestyle and psychosocial intervention on metabolic and mental health outcomes in women with gestational diabetes mellitus during pregnancy and in the post partum.

Design

Single centred, single blinded, randomised, controlled trial (the MySweetheart trial).

Setting

Lausanne University Hospital, Switzerland, from 2 September 2016 to 25 October 2021.

Participants

211 women aged at least 18 years with a diagnosis of gestational diabetes mellitus at 24-32 gestational weeks were randomly assigned (1:1) to the intervention (n=105) or to usual care (n=106).

Interventions

In addition to a comparator based on active guidelines for prepartum and postpartum usual care, the intervention consisted of four individual lifestyle visits during pregnancy and four interdisciplinary visits in the postpartum group, a peer support group workshop in pregnancy and post partum, and a bimonthly lifestyle coach support through telemedicine. The intervention focused on tailored behavioural and psychosocial strategies to improve diet, physical activity, mental health, social support, and adherence to gestational weight gain during pregnancy and weight retention recommendations.

Main outcome measures

Primary outcomes were between-group differences in the decrease in maternal weight and depression symptom scores between baseline and one year post partum. Secondary outcomes included changes in total and central body fat, anxiety, wellbeing, glycaemic parameters (homeostatic model assessment for insulin resistance (known as HOMA-IR) and Matsuda indices), aerobic fitness (maximal oxygen uptake), gestational weight gain, and weight retention. Assessors were blinded to primary and secondary outcomes.

Results

84 (80%) of 105 women in the intervention and 95 (90%) of 106 in the usual care completed the study. There was not enough evidence of a difference in the decrease in weight (mean difference -0.38 kg (95% confidence interval -2.08 to 1.30)) or depression scores (-0.67 (-1.84 to 0.49)). The intervention led to an increase in fat-free mass (0.02 kg (0.01 to 0.03)). The intervention also decreased gestational weight gain since the first gestational diabetes mellitus visit (-1.20 kg (-2.14 to -0.26)) and weekly weight gain throughout the entire pregnancy (-0.14 kg (-0.25 to -0.03)), and led to a higher proportion of women without weight retention at one year post partum (34.1% (28/82) v 20.8% (20/96), P=0.034).

Conclusions

Compared with active usual care based on guidelines, there was not enough evidence to conclude that the intervention led to decrease in weight or depression symptoms. However, the intervention decreased gestational weight gain and increased the proportion of women without weight retention.

Trial registration

Clinicaltrials.gov NCT02890693.

Mothers' experiences of a lifestyle intervention for weight reduction 12 months after gestational diabetes mellitus: Qualitative findings from the PAIGE2 study

The standardised pooled prevalence of gestational diabetes mellitus (GDM) globally is approximately 14 %, a reflection of increasing rates of obesity in women of childbearing age. Lifestyle interventions to reduce GDM and subsequent type 2 diabetes (T2D) have been deemed a research priority but are challenging to perform and have variable success rates. The PAIGE2 study was a pragmatic lifestyle randomised controlled trial for women with GDM and body mass index ≥25 kg/m2, which began during pregnancy and continued for one year postnatally. The primary outcome was weight loss 12 months postnatally compared with mothers receiving standard maternity care. Qualitative results are presented from end of study focus groups conducted amongst intervention mothers to gather feedback and determine acceptability of the PAIGE2 intervention. In total, 19 mothers participated in five virtual focus groups. Content analysis explored general study experience, longer term changes to lifestyle and suggested improvements of intervention components including monthly phone calls, motivational text messages, Fitbit experience, Slimming World, and study contact timings. Overall, most mothers found the individual PAIGE2 intervention components enjoyable, although opinions differed as to which were the most effective. Several mothers claimed the intervention helped them make long-term changes to their behaviours. A common suggested improvement was the establishment of a local group where mothers could share their experiences. In conclusion, most mothers deemed the intervention acceptable, and felt that with minor enhancements, it could be utilised as an effective tool to support weight loss after pregnancy and reduce future risk of obesity and T2D.

Lifestyle Interventions to Prevent Type 2 Diabetes in Women with a History of Gestational Diabetes: A Systematic Review and Meta-Analysis through the Lens of Health Equity

BACKGROUND

Type 2 diabetes mellites is one of the health problems disproportionally affecting people with low socioeconomic statuses. Gestational diabetes mellites increases the risk of type 2 diabetes by up to ten-fold for women. Lifestyle interventions prevent type 2 diabetes in women with prior gestational diabetes. However, it is unknown if similar effectiveness can be expected for all population subgroups.

OBJECTIVE

This study aims to assess the prevention of type 2 diabetes in women with prior gestational diabetes using population characteristics according to the PROGRESS (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital) criteria.

METHODS

MEDLINE, CINAHL, EMBASE, PubMed, PsycINFO, Web of Science, and EBM Reviews databases were searched for interventional studies of diet, physical activity, or behavioural interventions published up to 21 February 2023. Random effects subgroup meta-analysis was conducted to evaluate the association of population characteristics and intervention effects.

RESULTS

All studies were conducted in high-income countries or middle-income countries. Two-thirds of the studies reported on race/ethnicity and education level. Less than one-third reported on place (urban/rural), occupation, and socioeconomic status. None reported on religion or social capital. Studies from high-income countries (MD = -1.46; 95% CI: -2.27, -0.66, I2 = 70.46, p < 0.001) showed a greater reduction in bodyweight compared with the studies conducted in middle-income countries (MD = -0.11; 95% CI: -1.12, 0.89, I2 = 69.31, p < 0.001) (p for subgroup difference = 0.04).

CONCLUSION

There are significant equity gaps in the evidence for the prevention of type 2 diabetes in women with prior gestational diabetes due to reports on population characteristics being poor. Interventions may be less effective in reducing bodyweight in women from middle-income countries compared to high-income countries. Collecting and analysing data related to equity is needed to understand the effect of lifestyle interventions on type 2 diabetes for different population subgroups.

Gestational diabetes mellitus, follow-up of future maternal risk of cardiovascular disease and the use of eHealth technologies-a scoping review

BACKGROUND

Globally, gestational diabetes mellitus complicates 1 in 6 pregnancies and increases future risk of type 2 diabetes and cardiovascular disease in the affected women. There is a lack of consensus on the optimal follow-up of these women. eHealth is emerging as a health care tool, but its practical utility and advantages over standard care in the follow-up after pregnancy complications remains to be determined. Our aim was to systematically review the existing literature on cardiovascular follow-up after gestational diabetes, the utility of eHealth technology for this purpose, and to identify research gaps.

METHODS

We performed a systematic scoping review following a published protocol and the Joanna Briggs methodology for studies up until May 2022. Four databases were searched: Ovid MEDLINE, Embase, Maternity and Infant Care, and Cochrane Database of Systematic Reviews. Primary research articles and systematic reviews were included in the final analyses. Two reviewers independently screened abstracts and performed full text assessment. Data was extracted using a data charting form. In all stages of the process, if consensus was not reached, a third reviewer was consulted. The findings from the data charting process provided the basis for summarizing the findings from the included studies.

RESULTS

The search of the databases generated 2772 hits. After removing duplicates and manually adding a total of 19 studies, reviews, and guidelines, a total of 2769 titles and abstracts were screened, and 97 papers underwent full-text review. In the final analyses, 15 articles and 12 systematic reviews were included, whereas guidelines are presented as supplementary material. No studies were identified that examined follow-up regarding long-term overall cardiovascular risk after gestational diabetes. Various lifestyle interventions were tested for individual cardiovascular risk factors, with diverging effects. eHealth technologies were found acceptable by participants but had no consistent, statistically significant effect on relevant health outcomes.

CONCLUSIONS

This scoping review of the existing literature revealed neither an established systematic cardiovascular follow-up strategy for women after gestational diabetes nor evidence that eHealth technologies are superior to conventional follow-up. Further research into the utility of eHealth in cardiovascular follow-up after complicated pregnancies should include longer-term follow-up and core cardiovascular outcomes.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this scoping review was published at Open Science Framework (osf.io/p5hw6).

Effectiveness of the National Diabetes Prevention Program After Gestational Diabetes

INTRODUCTION

Women with previous gestational diabetes are at high risk of developing Type 2 diabetes. The National Diabetes Prevention Program (NDPP) is a widely disseminated lifestyle intervention to prevent Type 2 diabetes. Although NDPP programs are open to adults of any age, participants are usually older adults. Effectiveness among younger women with previous gestational diabetes is largely unknown.

METHODS

The NDPP was delivered by lifestyle coaches in a large network of Federally Qualified Health Centers. Reach, retention, physical activity, and weight loss outcomes were compared between women aged <40 years with previous gestational diabetes and all other participants. Data were collected from 2013 to 2019 and analyzed in 2022.

RESULTS

Among 2,865 enrollees who agreed to start the yearlong NDPP, 63.3% were Latinx, 18.8% were non-Latinx Black, and 16.4% were non-Latinx White. Younger women with previous gestational diabetes represented <4% (n=107) of participants. There was no significant difference in the frequency of attending ≥1 NDPP session between these women and all other participants (37.4% vs 44.6%; p=0.146). However, among those attending ≥1 session (n=1,265), younger women with previous gestational diabetes attended more (11.27 ± 1.27 vs 8.50 ± 0.22 sessions, p=0.021) and had greater weight loss (3.04% ± 0.59 vs. 1.49% ± 0.11, p=0.010) in covariate-adjusted models than other participants.

CONCLUSIONS

Diverse younger women with previous gestational diabetes attending the NDPP had one third greater attendance and twice as much weight loss as other NDPP participants but represented a much smaller proportion of enrollees. Thus, the NDPP appears to be a beneficial but underutilized resource for this high-risk population.

Postpartum home blood pressure monitoring and lifestyle intervention in overweight and obese individuals the first year after gestational hypertension or pre-eclampsia: A pilot feasibility trial

OBJECTIVE

To test the feasibility of a randomised trial of home blood pressure monitoring paired with a remote lifestyle intervention (Heart Health 4 New Moms) versus home blood pressure monitoring alone versus control in individuals with a hypertensive disorder of pregnancy in the first year postpartum.

DESIGN

Single-blinded three-arm randomised clinical trial.

SETTING

Two tertiary care hospitals and a community organisation.

POPULATION

Postpartum overweight and obese individuals with a hypertensive disorder of pregnancy and without pre-pregnancy hypertension or diabetes.

METHODS

We assessed the feasibility of recruitment and retention of 150 participants to study completion at 1-year postpartum with randomisation 1:1:1 into each arm. Secondary aims were to test effects of the interventions on weight, blood pressure and self-efficacy.

RESULTS

Over 23 months, we enrolled 148 of 400 eligible, screened individuals (37%); 28% black or other race and mean pre-pregnancy body mass index (BMI) of 33.4 ± 6.7 kg/m2 . In total, 129 (87%) participants completed the 1-year postpartum study visit. Overall, 22% of participants developed stage 2 hypertension (≥140/90 mmHg or on anti-hypertensive medications) by 1 year postpartum. There were no differences in weight or self-efficacy across the study arms.

CONCLUSION

In this pilot, randomised trial, we demonstrate feasibility of HBPM paired with a lifestyle intervention in the first year postpartum. We detected high rates of ongoing hypertension, emphasising the need for the development of effective interventions in this population.

Integration of nutrigenomics, melatonin, serotonin and inflammatory cytokines in the pathophysiology of pregnancy-specific urinary incontinence in women with gestational diabetes mellitus

Gestational diabetes mellitus is an important public health problem and has been associated with the development of pregnancy-specific urinary incontinence. The interaction is related to hyperglycemia, and inflammatory and hormonal patterns, which favor functional alterations in different organs and systems. Several genes associated with human diseases have been identified and partially characterized. Most of these genes are known to cause monogenic diseases. However, about 3 % of diseases do not fit the monogenic theory due to the complex interactions between multiple genes and environmental factors, as in chronic metabolic diseases such as diabetes. The nutritional, immunological, and hormonal patterns associated with changes in maternal metabolism may influence and contribute to greater susceptibility to urinary tract disorders. However, early systematic reviews have not yielded consistent findings for these associations. This literature review summarizes important new findings from integrating nutrigenomics, hormones, and cytokines in women with Gestational diabetes mellitus and pregnancy-specific urinary incontinence. Changes in maternal metabolism due to hyperglycemia can generate an inflammatory environment with increased inflammatory cytokines. This environment modulated by inflammation can alter tryptophan uptake through food and thus influence the production of serotonin and melatonin. As these hormones seem to have protective effects against smooth muscle dysfunction and to restore the impaired contractility of the detrusor muscle, it is assumed that these changes may favor the onset of urinary incontinence specific to pregnancy.

Telehealth interventions for physical activity and exercise participation in postpartum women: A quantitative systematic review

Postpartum women are one of the least physically active vulnerable populations globally and telehealth has been proposed as a potential method of delivering effective exercise interventions for this population. However, clinical practice guidelines are based upon the recommendations for the general population and therefore, the most efficacious exercise dose and the delivery method for this population is unclear. This quantitative systematic review will examine the implementation and outcomes of telehealth exercise interventions in the postpartum population to synthesise the degree to which these outcomes have been assessed and evaluated. Five databases were searched from January 2001 to March 2022. Studies implementing synchronous telehealth exercise interventions for postpartum women were included. Interventions were examined against the Template for Intervention Description and Replication (TIDieR) checklist that assesses intervention reporting completeness and replicability. Of the 1036 records identified, 16 studies progressed to data extraction. Six interventions provided individualised exercise prescription, and only four were delivered by university-level exercise practitioners. Physical activity participation was well reported, however health-related outcomes (i.e., muscular strength and aerobic capacity) were very minimally assessed. Only one intervention utilised modern video conferencing as the primary telehealth communication method. With the minimal assessment of health-related outcomes, there is limited scope to assess the effectiveness of these interventions for postpartum women. Future research interventions need to be reported according to a validated trial reporting system and focus on relevant health related outcomes including postpartum depressive symptoms, quality of life, cardiovascular fitness, muscular strength and body composition.

A pragmatic lifestyle intervention for overweight and obese women with gestational diabetes mellitus (PAIGE2): A parallel arm, multicenter randomized controlled trial study protocol

Background

The global epidemic of type 2 diabetes (T2D) and obesity has been translated into pregnancy, with approximately 18% of women being diagnosed worldwide with Gestational Diabetes Mellitus (GDM). Whilst preventive strategies have proven effective in the non-pregnant context, attrition rates are high and there is an urgent need to develop a customized, pragmatic lifestyle intervention for women both during and after pregnancy. Diet and exercise modification, behavioral support, and Commercial Weight Management Organizations have been strongly recommended to aid postpartum weight reduction for mothers with previous GDM, subsequently reducing their risk of developing obesity and T2D. This study, informed by a previous pilot study, aims to determine the effectiveness of a pragmatic pregnancy and postpartum lifestyle modification program for overweight women with previous GDM (PAIGE2) to reduce body weight at 12 months postpartum.

Methods/design

This paper summarizes the protocol for the PAIGE2 study, which has been developed based on results from a pilot study (PAIGE). A six center, two parallel arm, 12-month, randomized controlled trial will be conducted across Northern Ireland and the Republic of Ireland (3 centers each), involving 340 women with GDM and body mass index ≥25 kg/m² recruited during pregnancy. The lifestyle intervention involves a one-hour virtual educational program (to take place at 32-36 weeks gestation). Postpartum, the intervention will include monthly phone calls, weekly motivational text messages, weekly step counts, and referral for three months to a Commercial Weight Management Organization (Slimming World). The control arm will receive usual care as offered by the local maternity hospital. The primary outcome is weight loss at 12 months postpartum. Study visits for anthropometric and clinical measurements, fasting blood samples, questionnaires pertaining to health, wellbeing and physical activity will take place at 6 weeks, 6- and 12-months postpartum. Focus groups will be conducted with intervention mothers' post-intervention to determine the acceptability of the study design including utility of a Commercial Weight Management Organization, feasibility of remote patient contact, family involvement and patient satisfaction.

Discussion

The PAIGE2 study will address the gaps in previously conducted research and, if positive, has the potential to have major public health implications for the prevention of future GDM and subsequent T2D.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT04579016?term=NCT04579016&draw=2&rank=1, identifier NCT04579016.

Motivational interviewing to promote interconception health: A scoping review of evidence from clinical trials

BACKGROUND

Promoting interconception health can improve birth outcomes and long-term women's health. Motivational Interviewing (MI) is an evidence-based behavior change strategy that can address interconception health behaviors and health care engagement.

OBJECTIVE

This scoping review assessed the evidence for using MI to promote interconception health and assessed features of successful MI interventions.

METHODS

We searched PubMed, CHINAL, and Cochrane databases for clinical trials that involved an MI intervention and at least one comparison group published by 8/31/2021. Interventions occurred during pregnancy or within three months postpartum and outcomes were measured between birth and one year postpartum. We abstracted data on trial characteristics including outcome, population, interventionist training, MI fidelity monitoring, intervention dose, and comparison condition. We examined whether trials that demonstrated statistically significant improvement in outcomes had common features.

RESULTS

There were 37 included studies. Interventions addressed breastfeeding, teen contraception, tobacco, alcohol, or substance use, vaccine acceptance, nutrition, physical activity, and depression. No trials addressed more than one topic. Nineteen studies demonstrated improved outcomes. Interventions during the perinatal or postnatal periods were more likely to demonstrate improved interconception outcomes than interventions in the prenatal period. No other trial characteristics were consistently associated with demonstrating improved outcomes.

DISCUSSION

MI has been applied to a variety of interconception health behaviors, with some promising results, particularly for interventions in the perinatal or postpartum period. Outcomes were not clearly attributable to any other differences in intervention or study design. Further exploring context or implementation may help maximize the potential of MI in interconception health promotion.

PRACTICAL VALUE

MI may be implemented across a range of clinical settings, patient groups, and time points around pregnancy. Interventions on health topics relevant to the interconception period should incorporate perinatal or postpartum components.

The Effect of Health Education Combined with Personalized Psychological Nursing Intervention on Pregnancy Outcome of Pregnant Women with Gestational Diabetes Mellitus

Objective

To study the effect of health education combined with personalized psychological nursing intervention on pregnancy outcome of pregnant women with gestational diabetes mellitus (GDM).

Methods

170 patients with GDM admitted to Guangdong Women and Children Hospital from January 2018 to December 2018 were selected as study subjects and randomly divided into two groups. During the period from diagnosis of GDM to termination of pregnancy, both groups were given routine education and routine examination, and the intervention group adopted health education combined with personalized psychological nursing interventions during pregnancy. The pregnancy weight, blood glucose index, compliance, disease awareness, self-adjustment management ability, satisfaction, and pregnancy outcome were measured before and after the intervention.

Results

There were no statistically significant differences in pregnancy weight, fasting plasma glucose, and 2 h postprandial blood glucose between the two groups before intervention (P = 0.768, 0.605, and 0.762). After intervention, lower levels of the above indicators were obtained in the intervention group than in the control group (P < 0.001). The compliance and satisfaction with the intervention in the intervention group were significantly higher than those in the control group (P < 0.001). The intervention group had remarkably higher disease awareness rate and self-psychological adjustment and management ability than the control group (P < 0.001). Better pregnancy outcomes were observed in the intervention group compared with the control group (P < 0.001).

Conclusion

For patients with GDM, health education combined with personalized psychological nursing on the basis of the conventional nursing can effectively control patients' condition and ensure a better pregnancy outcome, which merits widespread promotion.

Effectiveness of physical activity monitors in adults: systematic review and meta-analysis

OBJECTIVE

To estimate the effectiveness of physical activity monitor (PAM) based interventions among adults and explore reasons for the heterogeneity.

DESIGN

Systematic review and meta-analysis.

STUDY SELECTION

The electronic databases MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched on 4 June 2021. Eligible randomised controlled trials compared interventions in which adults received feedback from PAMs with control interventions in which no feedback was provided. No restrictions on type of outcome measurement, publication date, or language were applied.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were used to synthesise the results. The certainty of evidence was rated by the Grading of Recommendations Assessment and Evaluation (GRADE) approach.

MAIN OUTCOME MEASURES

The three primary outcomes of interest were physical activity, moderate to vigorous physical activity, and sedentary time.

RESULTS

121 randomised controlled trials with 141 study comparisons, including 16 743 participants, were included. The PAM based interventions showed a moderate effect (standardised mean difference 0.42, 95% confidence interval 0.28 to 0.55) on physical activity, equivalent to 1235 daily steps; a small effect (0.23, 0.16 to 0.30) on moderate to vigorous physical activity, equivalent to 48.5 weekly minutes; and a small insignificant effect (-0.12, -0.25 to 0.01) on sedentary time, equal to 9.9 daily minutes. All outcomes favoured the PAM interventions.

CONCLUSIONS

The certainty of evidence was low for the effect of PAM based interventions on physical activity and moderate for moderate to vigorous physical activity and sedentary time. PAM based interventions are safe and effectively increase physical activity and moderate to vigorous physical activity. The effect on physical activity and moderate to vigorous physical activity is well established but might be overestimated owing to publication bias.

STUDY REGISTRATION

PROSPERO CRD42018102719.

Ethnic differences in response to lifestyle intervention for the prevention of type 2 diabetes in adults: A systematic review and meta-analysis

The risk of type 2 diabetes mellitus (T2DM) varies by ethnicity, but ethnic differences in response to diabetes prevention interventions remain unclear. This systematic review and meta-analysis assessed ethnic differences in the effects of lifestyle interventions on T2DM incidence, glycemic outcomes (fasting glucose, 2-h glucose, HbA_1c ), anthropometric measures (weight, BMI, waist circumference), and lifestyle behaviors (physical activity, energy intake, energy from fat, fiber intake). MEDLINE, EMBASE, and other databases were searched (to June 15, 2020) for randomized and non-randomized controlled trials on lifestyle interventions (diet and/or physical activity) in adults at risk of T2DM. Ethnicity was categorized into European, South Asian, East and Southeast Asian, Middle Eastern, Latin American, and African groups. Forty-four studies were included in meta-analyses. Overall, lifestyle interventions resulted in significant improvement in T2DM incidence, glycemic outcomes, anthropometric measures, physical activity, and energy intake (all P < 0.01). Significant subgroup differences by ethnicity were found for 2-h glucose, weight, BMI, and waist circumference (all P < 0.05) but not for T2DM incidence, fasting glucose, HbA_1c , and physical activity (all P > 0.05). Few studies in non-European groups reported dietary intake. Lifestyle interventions in different ethnic groups may have similar effects in reducing incidence of T2DM although this needs to be confirmed in further studies.

The Effect of Lifestyle Intervention on Diabetes Prevention by Ethnicity: A Systematic Review of Intervention Characteristics Using the TIDieR Framework

Lifestyle intervention is effective in preventing type 2 diabetes mellitus (T2DM), but the efficacy of intervention components across different ethnic groups is less clear. This systematic review examined the effects of intervention characteristics of lifestyle interventions on diabetes incidence and weight loss by ethnicity using the Template for Intervention Description and Replication (TIDieR) framework. MEDLINE, EMBASE and other databases were searched for randomized and non-randomized controlled trials on lifestyle interventions (diet and/or physical activity) in adults at risk of T2DM. Ethnicity was categorized into European, South Asian, East and Southeast Asian, Middle Eastern, Latin American and African groups. Forty-five studies (18,789 participants) were included in the systematic review and 41 studies in meta-analysis. Meta-analysis showed a high number of intervention sessions was significantly associated with a greater reduction in diabetes incidence (P = 0.043) and weight (P = 0.015), while other intervention characteristics including intervention provider and delivery format did not alter the outcomes (all P > 0.05). Additionally, narrative synthesis showed long-term interventions (≥12 months) were associated with significant diabetes risk reduction for all ethnic groups, while short-term interventions (<12 months) were more effective in weight loss in most ethnic groups. There may be ethnic preferences for the optimal number of intervention sessions.

Interventions to Mitigate Risk of Cardiovascular Disease After Adverse Pregnancy Outcomes: A Review

Importance

A growing body of evidence suggests that adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes (GD), preterm birth, and intrauterine growth restriction, are associated with increased risk of cardiometabolic disease and cardiovascular disease (CVD) later in life. Adverse pregnancy outcomes may therefore represent an opportunity to intervene to prevent or delay onset of CVD. The objective of this review was to summarize the current evidence for targeted postpartum interventions and strategies to reduce CVD risk in women with a history of APOs.

Observations

A search of PubMed and Ovid for English-language randomized clinical trials, cohort studies, descriptive studies, and guidelines published from January 1, 2000, to April 30, 2021, was performed. Four broad categories of interventions were identified: transitional clinics, lifestyle interventions, pharmacotherapy, and patient and clinician education. Observational studies suggest that postpartum transitional clinics identify women who are at elevated risk for CVD and may aid in the transition to longitudinal primary care. Lifestyle interventions to increase physical activity and improve diet quality may help reduce the incidence of type 2 diabetes in women with prior GD; less is known about women with other prior APOs. Metformin hydrochloride may prevent development of type 2 diabetes in women with prior GD. Evidence is lacking in regard to specific pharmacotherapies after other APOs. Cardiovascular guidelines endorse using a history of APOs to refine CVD risk assessment and guide statin prescription for primary prevention in women with intermediate calculated 10-year CVD risk. Research suggests a low level of awareness of the link between APOs and CVD among both patients and clinicians.

Conclusions and Relevance

These findings suggest that transitional clinics, lifestyle intervention, targeted pharmacotherapy, and clinician and patient education represent promising strategies for improving postpartum maternal cardiometabolic health in women with APOs; further research is needed to develop and rigorously evaluate these interventions. Future efforts should focus on strategies to increase maternal postpartum follow-up, improve accessibility to interventions across diverse racial and cultural groups, expand awareness of sex-specific CVD risk factors, and define evidence-based precision prevention strategies for this high-risk population.

The Impact of Lifestyle Intervention on Dietary Quality among Rural Women with Previous Gestational Diabetes Mellitus-A Randomized Controlled Study

Healthy diet is essential to type 2 diabetes mellitus (T2DM) prevention for women with previous gestational diabetes mellitus (GDM). To evaluate the effect of a lifestyle intervention program on diet quality for rural women who were previously diagnosed with GDM, we conducted a randomized controlled study in two counties located in south-central China. A total of 404 eligible women were allocated into an intervention group and control group. Participants in the intervention group received 6-month lifestyle intervention including six group seminars and eight telephone consultations. Dietary data were collected at baseline and 18 months via a 24 h dietary recall, and dietary quality was measured by two indicators, Chinese Healthy Eating Score (CHEI) and Minimum Dietary Diversity for Women (MDD-W). Baseline CHEI scores (54.4 vs. 53.5, p = 0.305) and the proportions of participants who met MDD-W (73.8% vs. 74.5%, p = 0.904) were comparable between the two groups. The intervention group achieved a higher CHEI score (62.2 vs. 58.9, p = 0.001) and higher MDD-W proportion (90.6% vs. 81.2%, p = 0.023) at 18 months. Lifestyle intervention was associated with the change of CHEI (p = 0.049) but not with MDD-W (p = 0.212). In conclusion, compared with usual care, lifestyle intervention resulted in greater improvement of dietary quality among rural women with previous GDM.

The Impact of a Lifestyle Intervention on Postpartum Weight Retention Among At-Risk Hispanic Women

INTRODUCTION

This study assesses the impact of a culturally modified, motivationally targeted, individually tailored intervention on postpartum weight retention among Hispanic women with abnormal glucose tolerance during pregnancy.

METHODS

Estudio Parto (Project Aiming to Reduce Type twO diabetes) was an RCT conducted in Western Massachusetts (collected 2013‒2017, analyzed 2018-2020). Hispanic women with blood glucose ≥140 mg/dL (7.77 mmol/L) on routine nonfasting oral glucose challenge test were randomized to a Lifestyle Intervention (n=100) focusing on healthy exercise and diet or to a comparison Health and Wellness Intervention (n=104) with no mention of exercise or diet behavior changes. The primary outcome was change in weight, calculated as the difference between prepregnancy weight and 6-week, 6-month, and 12-month postpartum weight. The secondary outcome was achievement of weight reduction to prepregnancy weight if prepregnancy BMI was normal, or a 5% reduction if prepregnancy BMI was overweight/obese.

RESULTS

In intent-to-treat analyses, there were no significant differences in weight change pattern between the intervention arms across all follow-up timepoints (β=0.03, 95% CI= -3.38, 3.45). However, at 12 months postpartum, women in the Lifestyle Intervention arm had a statistically significant 2.5-fold higher odds of meeting the secondary weight reduction outcome (OR=2.52, 95% CI=1.09, 5.82) than women in the Health and Wellness arm. Regardless of intervention arm, women who reported higher levels of postpartum sports/exercise had a greater decrease in weight (β= -2.39, 95% CI= -4.66, -0.13, p=0.04) than women reporting lower levels.

CONCLUSIONS

In this randomized trial among Hispanic women, no significant overall differences in weight change pattern between intervention arms were observed. Higher levels of self-reported physical activity were associated with greater weight loss in both arms.

Moms in motion: weight loss intervention for postpartum mothers after gestational diabetes: a randomized controlled trial

Background

Up to 50 % of women with gestational diabetes mellitus (GDM) will receive a diagnosis of type 2 diabetes mellitus (T2DM) within a decade after pregnancy. While excess postpartum weight retention exacerbates T2DM risk, lifestyle changes and behavior modifications can promote healthy postpartum weight loss and contribute to T2DM prevention efforts. However, some women have difficulty prioritizing self-care during this life stage. Efficacious interventions that women can balance with motherhood to reduce T2DM risk remain a goal. The objective of the Moms in Motion study is to evaluate the efficacy of a simple, novel, activity-boosting intervention using ankle weights worn with daily activities during a 6-month postpartum intervention among women with GDM. We hypothesize that women randomized to the 6-month intensity-modifying intervention will (1) demonstrate greater weight loss and (2) greater improvement in body composition and biomarker profile versus controls.

Methods

This study will be a parallel two-arm randomized controlled trial (n = 160). Women will be allocated 1:1 to an ankle weight intervention group or a standard-of-care control group. The intervention uses ankle weights (1.1 kg) worn on each ankle during routine daily activities (e.g., cleaning, childcare). Primary outcomes include pre- and post-assessments of weight from Visit 2 to Visit 3. Secondary outcomes include body composition, glycemia (2-h, 75 g oral glucose tolerance test), and fasting insulin. Exploratory outcomes include energy expenditure, diet, and psychosocial well-being.

Discussion

Beyond the expected significance of this study in its direct health impacts from weight loss, it will contribute to exploring (1) the mechanism(s) by which the intervention is successful (mediating effects of energy expenditure and diet on weight loss) and (2) the effects of the intervention on body composition and biomarkers associated with insulin resistance and metabolic health. Additionally, we expect the findings to be meaningful regarding the intervention’s effectiveness on engaging women with GDM in the postpartum period to reduce T2DM risk.

Trial registration

The ClinicalTrials.gov Identifier, is NCT03664089. The trial registration date is September 10, 2018. The trial sponsor is Dr. Sarah A. Keim.

Reducing weight and BMI following gestational diabetes: a systematic review and meta-analysis of digital and telemedicine interventions

Women with past gestational diabetes mellitus (GDM) are at risk of subsequent type 2 diabetes and adverse cardiovascular events. Digital and telemedicine interventions targeting weight loss and reductions in body mass index (BMI) may help reduce risk for women with GDM. The aim was to compare the effectiveness of digital or telemedicine intervention with usual care. Randomized controlled trials (RCTs) were identified in Embase, Medline, CINAHL, PsycINFO and the Cochrane Library. Included trials recruited women with prior GDM but without pre-existing diabetes, and tested a digital or telemedicine intervention with or without an in-person component. Data extraction was carried out independently by two authors. The search yielded 898 citations. Eighteen articles reporting 15 trials were included, of which 8 tested digital interventions. Reported outcomes included weight, BMI, fasting plasma glucose and waist circumference. None of the included trials reported type 2 diabetes incidence or cardiovascular risk. Data were pooled using a random-effects model. The point estimate favored the intervention but was non-significant for both BMI (-0.90 kg/m², 95% CI -1.89 to 0.09; p=0.08) and weight (-1.83 kg, 95% CI -4.08 to 0.42, p=0.11). Trials evaluating digital and telemedicine interventions identified clinically relevant, but non-significant improvements in BMI and weight compared with control. No trials assessed type 2 diabetes occurrence as an outcome. More well-designed RCTs with adequate power and long-term follow-up are needed to identify the impact of these interventions on type 2 diabetes occurrence.

Effects of lifestyle intervention on long-term risk of diabetes in women with prior gestational diabetes: A systematic review and meta-analysis of randomized controlled trials

We performed two meta-analyses to estimate the effects of lifestyle intervention during pregnancy and after delivery on the risk of postpartum diabetes among women with gestational diabetes mellitus (GDM). We searched the major databases to retrieve articles published in English or Chinese before 15 December 2019. The inclusion criteria were randomized controlled trials (RCTs) of diet, physical activity or both, conducted during or after pregnancy among women with GDM. The exclusion criteria were (1) having type 1 or type 2 diabetes before the intervention and (2) without postpartum diabetes documented. Fixed-effects model analysis was used to obtain the pooled relative risks (RRs) and 95% confidence intervals (CIs) of lifestyle intervention for diabetes in women with GDM. Four RCTs were identified to have implemented the intervention during pregnancy (n = 2883) and 10 to have conducted it within 3 years after delivery (n = 1733). Lifestyle intervention during pregnancy was not effective at reducing the risk of postpartum diabetes (RR: 0.91, 95%CI: 0.66-1.25). However, lifestyle intervention initiated within 3 years after delivery was highly effective in reducing the risk of postpartum diabetes (pooled RR: 0.57, 95% CI: 0.42-0.78). In conclusion, our findings support the early initiation of lifestyle intervention in women with GDM for the prevention of diabetes.

Feasibility and acceptability of a remotely-delivered behavioural health coaching intervention to limit gestational weight gain

INTRODUCTION

Gestational weight gain (GWG) and postpartum weight retention (PPWR) are significant, potentially modifiable, contributors to women's future weight and health trajectories. There is a need for feasible and patient-centered (i.e., convenient, remotely-delivered, technology-enhanced, and accessible through the prenatal care setting) behavioural interventions that limit GWG and PPWR. This study tests the feasibility and acceptability of a remotely-delivered behavioural health coaching intervention to limit gestational weight gain and postpartum weight retention.

METHODS

Pregnant women (11-16 weeks gestation) were recruited from two prenatal clinics and randomized to the active intervention or health education comparison group. Completion of the program was monitored and perceived helpfulness was rated (0-100).

RESULTS

Twenty-six women were randomized (n = 13 per arm; mean age = 31.6 years, SD = 3.6; mean BMI = 26.7 kg/m2, SD = 7.4). Participants completed a median of 18 coaching calls and 16/19 learning activities during pregnancy, and a median of 6 calls and 5/6 learning activities postpartum. They logged weights at least once/week for a median of 36/38 expected weeks and tracked daily calories and exercise for a median of 154/266 days and 72/266 days, respectively. Median (Q1, Q3) helpfulness ratings of the program during pregnancy were 80 (64, 91) and 62 (50, 81) postpartum; helpfulness ratings of coaching calls were 85 (58, 98). At 37 weeks gestation, 77% of participants achieved IOM weight gain recommendations compared to 54% in the comparison group.

CONCLUSIONS

This study provides evidence for the feasibility and acceptability of a remotely-delivered behavioural weight control intervention in pregnancy and postpartum.

The Role of Health Literacy in Postpartum Weight, Diet, and Physical Activity

Background: Postpartum weight retention is a significant contributor to obesity in women, adverse perinatal events in subsequent pregnancies, and chronic disease risk. Health literacy is known to impact health behaviors. The study aimed to identify the health literacy domains utilized in postpartum weight management interventions and to determine their impact on weight, diet and physical activity in postpartum women. Methods: We searched MEDLINE, CINAHL, EMBASE, PSYCINFO, and EBM databases. We included random control trials of lifestyle intervention in postpartum women (within two years post-delivery) published up to 3 May 2019. Subgroup analyses were performed to determine the effect of health literacy domains on outcomes. Results: Out of 5000 studies, 33 studies (n = 3905) were included in the systematic review and meta-analysis. The health literacy domain self-care (skills and knowledge) was associated with a significant reduction in body weight (mean difference (MD) −2.46 kg; 95% confidence interval (CI) from −3.65 to −1.27) and increase in physical activity (standardized mean difference (SMD) 0.61; 95% CI 0.20 to 1.02). No other health literacy domain was associated with significant outcomes in weight, energy intake, or physical activity. Conclusions: Health literacy skills such as knowledge of self-care are effective in improving weight and in increasing physical activity in postpartum women. The efficacy of other health domains was not supported.

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

Background

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

Objectives

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

Design

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

Setting

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

Participants

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

Main outcome measures

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

Results

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

Limitations

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

Conclusions

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

Trial registration

Current Controlled Trials ISRCTN39186148.

Funding

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

An evaluation of the impact of lifestyle interventions on body weight in postpartum women: A systematic review and meta-analysis

The established efficacy in postpartum lifestyle interventions has not been translated into better outcomes. This systematic review and meta-analysis assess the penetration (the proportion of women invited within the target population), implementation (fidelity), participation (the proportion of those invited who enrolled), and effect (weight loss compared to controls) (PIPE) of randomized controlled trials of lifestyle interventions in postpartum women (within two years after birth). MEDLINE, EMBASE, Pubmed, and other databases and clinical trial registries were searched up to the 3rd of May 2019. Data was extracted from published reports and missing data was obtained from study authors. The quality of the studies was appraised using the Cochrane Risk of Bias tool (2·0). Main outcomes were the PIPE impact metrics and changes in body weight. Thirty-six trials (49 publications) were included (n=5,315 women). One study provided sufficient information to calculate the population penetration rate (2·5%). All studies provided implementation (fidelity) information, but over half had low program fidelity. The participation rate was calculated for nine studies (0·94% to 86%). There was significant change in body weight (mean difference (MD) (95% confidence interval, CI) of -2·33 (-3·10 to -1·56). This highlights the inadequacy of conventional RCTs to inform implementation. Future research should broaden methods to pragmatic trials.

Systematic review of effectiveness and cost-effectiveness of lifestyle interventions to improve clinical diabetes outcome measures in women with a history of GDM

OBJECTIVE

Lifestyle interventions have been shown to be both effective and cost-effective in reducing diabetes and metabolic risk in high-risk populations. We systematically reviewed the effectiveness and cost-effectiveness of lifestyle interventions on anthropometric, glycemic and cardiovascular outcomes in women with previous gestational diabetes mellitus (GDM).

METHOD

Relevant randomized control trials (RCT) were identified by searching multiple electronic databases through 20th June 2018. Data were pooled using random-effects models. The review protocol was registered on the PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42018108870).

RESULTS

Twenty-one studies met the inclusion criteria and 16 studies with outcome data were analyzed in the meta-analysis. No RCT studies included cost-effectiveness data on lifestyle interventions. The pooled estimate for postpartum weight showed a significant mean reduction in the intervention arm (-1.8 kg [95% CI: -2.9, -0.6; p = 0.002; I² = 92.2%; p < 0.05]). Further, the effect of lifestyle intervention on weight change was significantly greater in studies of longer duration. Most of the other endpoints had modest improvements but only anthropometric endpoints were statistically significant. However, there was high heterogeneity between the studies.

CONCLUSIONS

Lifestyle interventions showed statistically and clinically significant improvements in anthropometric outcomes. However, more research is needed to explore lifestyle effects on glycemic and cardiovascular risk factors and to establish cost-effectiveness. Methodologically sound, large scale studies on diverse ethnicities and with longer follow-up would establish the real effect of lifestyle interventions to reduce diabetes risk in women with previous GDM.

A Pilot Randomised Controlled Trial of a Text Messaging Intervention with Customisation Using Linked Data from Wireless Wearable Activity Monitors to Improve Risk Factors Following Gestational Diabetes

Gestational diabetes (GDM) is a highly prevalent disorder of pregnancy which portends a high risk for future type 2 diabetes. Limited evidence indicates lifestyle intervention prevents the development of diabetes, but most previously studied interventions are resource-intensive. Intervention programs that utilise newer technologies may be scalable at lower cost. This 6-month pilot randomized controlled trial tested the delivery of text messages linked to an activity monitor, adaptive physical activity goal setting, and limited face-to-face counseling, as an intervention to improve rates of post-partum glucose tolerance testing and lifestyle behaviours amongst women following a GDM pregnancy. Sixty subjects were randomised 2:1 intervention vs. control. Compared to control subjects, there were trends for intervention subjects to improve diet, increase physical activity, and lose weight. There was no difference between the groups in the rate of glucose tolerance testing. Only 46 (77%) subjects completed some, and 19 subjects completed all the elements of the final evaluation. Feedback regarding the text messages and activity monitor was highly positive. Overall, results suggest that a text message and activity monitor intervention is feasible for a larger study or even as a potentially scalable population health intervention. However, low completion rates necessitate carefully considered modification of the protocol.

Prediction and Prevention of Type 2 Diabetes in Women with a History of GDM

PURPOSE OF THE REVIEW

Women with a history of gestational diabetes mellitus (GDM) have an alarmingly high risk of developing type 2 diabetes (T2D); yet, mechanisms underlying this progression are largely unknown.

RECENT FINDINGS

Clinical characteristics of a GDM pregnancy and postpartum metabolomics may contribute to risk prediction of T2D to identify those women at highest risk of progression and need for intervention. Evidence for effective postpartum lifestyle interventions from observational studies include adherence to a healthy dietary pattern, increasing physical activity, and maintaining a healthy body weight. Larger clinical trials with greater participant engagement are warranted to confirm the effectiveness of lifestyle interventions in women with recent GDM. Research is needed to refine prediction models of T2D after GDM, and to determine the most effective strategies to delay or prevent T2D onset. Incorporating novel biomarkers in the postpartum period, such as metabolomics, could offer a powerful approach.

Lifestyle Intervention for the Prevention of Diabetes in Women With Previous Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis

Background: Type 2 diabetes is increasing among the young, and gestational diabetes (GDM) offers a unique opportunity for diabetes prevention. We aimed to systematically review postpartum randomized trials to summarize the benefits of lifestyle interventions for women with previous GDM. Methods:We searched for RCTs involving women with previous GDM that compared lifestyle interventions-diet, physical activity or breastfeeding-at postpartum with usual care up to May 2018. Results:Of 1,895 abstracts identified, we selected 15 studies investigating incidence of diabetes or changes in glycemia. Most interventions focused on changes in diet and physical activity, only one also on incentive to breastfeeding. Meta-analysis of 8 studies investigating incidence of diabetes revealed a homogeneous (I² = 10%), reduction of 25% (RR = 0.75; 95%CI: 0.55-1.03) borderline statistically significant. Only trials offering intervention soon after delivery (< 6 months post-partum) were effective (RR = 0.61; 95%CI: 0.40-0.94; p for subgroup comparison = 0.11). Overall, no benefit was found regarding measures of glycemia. Although moderate reductions in weight (MD = -1.07 kg; -1.43-0.72 kg); BMI (MD = -0.94 kg/m²; -1.79 -0.09 kg/m²); and waist circumference (MD = -0.98 cm; -1.75 -0.21 cm) were observed, effects were larger with longer follow-up. Conclusions:Summary results of the available evidence support benefits of lifestyle interventions at postpartum for women with previous GDM. Benefits, although smaller than those of major trials based in older subjects receiving intensive interventions, appear clinically relevant for this young subset of woman. Further studies are needed to improve the quality of the evidence and to further tailor interventions to this specific setting.