Breastfeeding Associated with Lower Prevalence of Metabolic Syndrome in Women with Gestational Diabetes in the Very Early Postpartum Period

OBJECTIVE

 The aim of this study is to examine the association of breastfeeding with metabolic syndrome (MetS) in women with recent gestational diabetes mellitus (GDM) in the very early postpartum (PP) period.

STUDY DESIGN

 We performed a secondary analysis of the Balance After Baby Intervention (BABI) study which enrolled women with recent GDM. Data collected during an early (~8 weeks) PP visit were used in this analysis. At this visit, weight, height, waist circumference (WC), blood pressure (BP), fasting plasma glucose (FPG), and lipids were obtained. MetS was classified per National Cholesterol Education Program Adult Treatment Program III (NCEP-ATP III) criteria. We defined breastfeeding as currently breastfeeding or not currently breastfeeding for the main analysis.

RESULTS

 Of 181 women enrolled in BABI, 178 were included in this analysis (3 excluded for missing lipids). Thirty-four percent were Hispanic. Of non-Hispanics, 31.5% were White, 18.5% Asian, and 12.9% Black/African American. The prevalence of MetS was 42.9% in women not breastfeeding versus 17.1% in women breastfeeding (p < 0.001; adjusted odds ratio [aOR] = 0.16 [95% confidence interval (CI): 0.06-0.41]). Breastfeeding women had significantly lower odds of FPG ≥100 mg/dL (aOR = 0.36 [95% CI: 0.14-0.95], p = 0.039), HDL < 50 mg/dL (aOR = 0.19 [95% CI: 0.08-0.46], p < 0.001), and triglycerides (TG) ≥ 150 mg/dL (aOR = 0.26 [95% CI: 0.10-0.66], p = 0.005). When evaluated as continuous variables, WC, FPG, and TG were significantly lower and HDL significantly higher in women breastfeeding in the very early PP period (vs. not breastfeeding).

CONCLUSION

 In a diverse population of women with recent GDM, there was lower prevalence of MetS in women breastfeeding compared with those not breastfeeding in the very early PP period. This study extends the findings of an association of breastfeeding with MetS previously reported at time points more remote from pregnancy to the very early PP period and to an ethnically and racially diverse population.

KEY POINTS

· MetS prevalence in women with recent GDM was lower in breastfeeding than not breastfeeding women.. · FPG, HDL, WC, and TG were improved in the breastfeeding group.. · This study extends prior findings to the very early PP period and to a diverse population..

Smooth Muscle Mineralocorticoid Receptor Promotes Hypertension After Preeclampsia

BACKGROUND

Preeclampsia is a syndrome of high blood pressure (BP) with end organ damage in late pregnancy that is associated with high circulating soluble VEGF receptor (sFlt1 [soluble Fms-like tyrosine kinase 1]). Women exposed to preeclampsia have a substantially increased risk of hypertension after pregnancy, but the mechanism remains unknown, leaving a missed interventional opportunity. After preeclampsia, women have enhanced sensitivity to hypertensive stress. Since smooth muscle cell mineralocorticoid receptors (SMC-MR) are activated by hypertensive stimuli, we hypothesized that high sFlt1 exposure in pregnancy induces a postpartum state of enhanced SMC-MR responsiveness.

METHODS

Postpartum BP response to high salt intake was studied in women with prior preeclampsia. MR transcriptional activity was assessed in vitro in sFlt1-treated SMC by reporter assays and PCR. Preeclampsia was modeled by transient sFlt1 expression in pregnant mice. Two months post-partum, mice were exposed to high salt and then to AngII (angiotensin II) and BP and vasoconstriction were measured.

RESULTS

Women exposed to preeclampsia had significantly enhanced salt sensitivity of BP verses those with a normotensive pregnancy. sFlt1 overexpression during pregnancy in mice induced elevated BP and glomerular endotheliosis, which resolved post-partum. The sFlt1 exposed post-partum mice had significantly increased BP response to 4% salt diet and to AngII infusion. In vitro, SMC-MR transcriptional activity in response to aldosterone or AngII was significantly increased after transient exposure to sFlt1 as was aldosterone-induced expression of AngII type 1 receptor. Post-partum, SMC-MR-KO mice were protected from the enhanced response to hypertensive stimuli after preeclampsia. Mechanistically, preeclampsia mice exposed to postpartum hypertensive stimuli develop enhanced aortic stiffness, microvascular myogenic tone, AngII constriction, and AngII type 1 receptor expression, all of which were prevented in SMC-MR-KO littermates.

CONCLUSIONS

These data support that sFlt1-induced vascular injury during preeclampsia produces a persistent state of enhanced sensitivity of SMC-MR to activation. This contributes to postpartum hypertension in response to common stresses and supports testing of MR antagonism to mitigate the increased cardiovascular risk in women after PE.

Self-Efficacy and Readiness to Change Among Women with Recent Gestational Diabetes Engaging in a Web-Based Lifestyle Intervention: The Balance After Baby Intervention Trial

Few evidence-based programs exist to help women with a history of gestational diabetes reduce their risk of developing type 2 diabetes. In secondary analyses from a randomized clinical trial of a web-based lifestyle intervention program for postpartum women with recent gestational diabetes, we studied changes in self-efficacy for diet and physical activity and readiness to change health behaviors. Women were randomized at ∼6 weeks postpartum and completed questionnaires at 6 weeks and 6, 12, 18, and 24 months. Our study included 181 women (mean age 32.4 ± 5.2 years; 48% White, 19% Asian, 14% Black or African American, 17% other/mixed race; 34% Hispanic). In a linear mixed effects model, women in the intervention had significantly greater improvement in overall self-efficacy scores for physical activity compared with the control group at 24 months (difference in change scores between groups .35, 95% CI: .03 to .67, P = .03). The intervention group also demonstrated significantly greater improvement in self-efficacy scores for both physical activity subdomains, specifically “sticking to it” at 24 months and “making time” at 12 months. Participants in the intervention did not experience a significant difference in change in self-efficacy for diet or readiness to change compared with those in the control arm.

Breastfeeding Is Associated With Lower Prevalence of Metabolic Syndrome in Women With Recent Gestational Diabetes in the Early Postpartum Period

Introduction: Women with gestational diabetes (GD) are at increased risk of future cardiovascular disease. The identification of factors that reduce metabolic syndrome (MetS) is important to improve cardiovascular outcomes. MetS has been shown to be associated with breastfeeding in women remote from pregnancy. We examined the association of breastfeeding with MetS in women with recent GD in the very early postpartum (pp) period. Methods: We performed a secondary analysis of the Balance After Baby (BAB) program which enrolled women with recent GD. GD was defined by Carpenter-Coustan criteria, a 50 gram glucose load test &gt;200 mg/dL or by clinician diagnosis. Data collected during an early (~6 weeks) pp visit was used in this analysis. At this visit, weight, height, waist circumference (WC), blood pressure (BP), fasting plasma glucose (FPG) and lipid panel were obtained. MetS was classified per NCEP III. We defined breastfeeding as currently breastfeeding or not currently breastfeeding. We performed Student’s t-tests and Wilcoxon rank-sum tests as appropriate, and fit logistic and linear regression models. Models were adjusted for age, race/ethnicity, low household income, pre-pregnancy BMI, and weeks since delivery. An exploratory model further adjusted for postpartum weight retention. Results: Of 181 women enrolled in BAB, 178 were included in this analysis (3 excluded for missing lipid panels). The mean (± SD) age of participants was 33 ± 5 years and were 8.0 ± 1.8 weeks since delivery. Thirty-four % were Hispanic. Of non-Hispanics, 31.5% were White, 18.5% Asian and 12.9% Black/African American. The prevalence of MetS was 42.9% in women not breastfeeding versus 17.1% in women breastfeeding (P &lt; 0.001; adjusted odds ratio [aOR] 0.16 [95% CI 0.06–0.41]). Breastfeeding women had significantly lower odds of FPG ≥100 mg/dL (aOR 0.36 [95% CI 0.14–0.95], p=0.039), HDL &lt;50 mg/dL (aOR 0.19 [95% CI 0.08–0.46], p&lt;0.001), and triglycerides (TG) ≥150 mg/dL (aOR 0.26 [95% CI 0.10–0.66], p=0.005). There was no significant difference in WC or BP between groups. All ORs remained significant after adjusting for weight retention. When evaluated as continuous variables, WC, FPG, and TG were significantly lower and HDL significantly higher in women breastfeeding in the early pp period (vs not breastfeeding). Conclusion: In a diverse population of women with recent GD, there was a lower prevalence of MetS in women breastfeeding compared to those not breastfeeding in the early postpartum period. This study extends the findings of an association of breastfeeding with MetS previously reported at times remote from pregnancy. Further studies are needed to determine if there is a protective role of breastfeeding on the risk of MetS.

OR08-03 Association of Hemoglobin A1c with Early Postpartum Metabolic Syndrome in Women with Gestational Diabetes

Background: Women with gestational diabetes (GDM) are at increased risk of metabolic syndrome (MetS), an important risk factor for development of type 2 diabetes (T2DM) and cardiovascular disease. Elevated hemoglobin A1c (HbA1c) is associated with MetS outside of pregnancy and may enhance detection of MetS. It is not known whether HbA1c is associated with MetS in the early postpartum period in women with recent GDM.

Objective: We aimed to characterize the prevalence of MetS 4-12 weeks postpartum in women with recent GDM and to determine whether there was an association between HbA1c and MetS.

Methods: Women with GDM as defined by Carpenter-Coustan criteria or clinician diagnosis were enrolled into the Balance After Baby Intervention trial of a web-based intervention to prevent T2DM. They underwent a baseline study visit at 4-12 weeks postpartum. Waist circumference and blood pressure were obtained and a fasting lipid panel, HbA1c and a 75-g, 2 hr OGTT was performed. We defined MetS by NCEP ATP III criteria. We fit a logistic regression model adjusted for age, race/ethnicity, and number of weeks postpartum.

Results: 181 women with GDM were enrolled in the study. Three women were excluded because they did not have fasting lipid measurements. Women were a mean of 8.0 ± 1.8 weeks postpartum at their baseline study visit. 24.2% (n=43) of women had MetS (at least 3 of 5 NCEP ATP III criteria). Of these, 77% met the waist circumference criterion, 37.6% met the HDL criterion, 23.6% met the triglycerides criterion, 16.9% met the fasting glucose criterion and 14.6% met the blood pressure criterion. HbA1c as a continuous variable was not significantly associated with MS (OR for each 0.5% increase: 1.60, 95% CI 0.88-2.91). Elevated HbA1c (prediabetes range ≥5.7 to <6.5%) was also not associated with MetS (OR 0.98, 95% CI 0.46-2.12). A 2 hr blood glucose value of ≥140 mg/dL on OGTT testing was significantly associated with MetS (OR 5.28, 95% CI 2.11-13.22).

Conclusion: Nearly 1 in 4 women with recent GDM had MetS in the early postpartum period. There was no significant association between HbA1c and presence of MetS. However, an elevated 2 hr value on OGTT was significantly associated with MetS, suggesting that women with elevated 2 hr values may require additional monitoring for MetS and may have elevated cardiometabolic risk beyond the risk of development of T2DM.

OR21-4 Heart Health 4 Moms: A Randomized Trial to Reduce Cardiovascular Risk in Women with Recent Preeclampsia

BACKGROUND: Preeclampsia is associated with a 2 to 3-fold increased risk for future maternal cardiovascular disease (CVD).To reduce CVD risk and overcome participation barriers, we tested an online intervention to promote a healthy lifestyle among women with recent preeclampsia. METHODS: We conducted a 9-month randomized controlled trial among 151 US women with preeclampsia within the prior 5 years. Preeclampsia history was validated by medical record review for new-onset hypertension (systolic blood pressure ≥140 and/or diastolic blood pressure ≥90 mm Hg) with proteinuria (≥ 300 mg/24hr, or urine protein/urine creatinine ratio ≥ 0.3 or urine dipstick ≥ 1+) after 20 weeks gestation. The intervention group received a patient-centered program, Heart Health 4 Moms (HH4M), created with input from preeclampsia survivors and the Preeclampsia Foundation. The program, available in English and Spanish, included online educational modules, a community forum, heart healthy resources (e.g., meal plans), and communication with a lifestyle coach including 6 scheduled phone calls. The control group received access to a website with links to CVD risk reduction websites accessible to the general public. Primary outcomes were self-efficacy for healthy eating and increasing physical activity; change in physical activity/inactivity; adherence to the Dietary Approaches to Stop Hypertension diet; and knowledge of and personal control over CVD risk. Secondary outcomes were weight and blood pressure. We used the Hochberg method to adjust the p value for multiple comparisons. RESULTS: Participants were, on average, 31 years of age, 1.3 years removed from their preeclampsia pregnancy, predominantly non-Hispanic white and resided in 41 US states. Retention rates were high (control 93%; intervention 91%). During the 9 months of follow-up, 69% of control participants and 99% of intervention participants visited the study website (p<0.00001). In the intervention arm, 84% of participants accessed at least one online educational module and 89% completed at least three scheduled calls with the coach. At the end of follow-up, intervention participants reported increased self-efficacy for healthy eating (p=0.03), greater knowledge of CVD risk factors (p=0.01), and less physical inactivity (p=0.0006) than individuals in the control arm. The groups did not differ in personal control over CVD risk, self-efficacy for physical activity, or reported physical activity levels. There were no differences in secondary outcomes between groups. CONCLUSIONS: The on-line HH4M program was used by women with recent preeclampsia across the US, improved their self-efficacy to achieve a healthy diet and their knowledge of CVD risk and reduced their physical inactivity. HH4M provides a model for an on-line, easily-accessible lifestyle program to reduce CVD risk in women with recent preeclampsia. (Funded by PCORI).

Early or late pregnancy loss and development of clinical cardiovascular disease risk factors: a prospective cohort study

OBJECTIVE

To assess the association between the outcome of a woman's first pregnancy and risk of clinical cardiovascular disease risk factors.

DESIGN

Prospective cohort study.

SETTING AND POPULATION

Nurses' Health Study II.

METHODS

Multivariable-adjusted Cox proportional hazards models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between first pregnancy outcome and hypertension, type 2 diabetes, and hypercholesterolemia.

MAIN OUTCOME MEASURES

Hypertension, type 2 diabetes, and hypercholesterolemia.

RESULTS

Compared to women who reported a singleton live first birth, women with early spontaneous abortion (<12 weeks) had a greater rate of type 2 diabetes (HR: 1.20; 95% CI: 1.07-1.34) and hypercholesterolemia (HR: 1.06; 95% CI: 1.02-1.10), and a marginally increased rate of hypertension (HR: 1.05, 95% CI: 1.00-1.11). Late spontaneous abortion (12-19 weeks) was associated with an increased rate of type 2 diabetes (HR: 1.38; 95% CI: 1.14-1.65), hypercholesterolemia (HR: 1.11; 95% CI: 1.03-1.19), and hypertension (HR: 1.15; 95% CI: 1.05-1.25). The rates of type 2 diabetes (HR: 1.45; 95% CI: 1.13-1.87) and hypertension (HR: 1.15; 95% CI: 1.01-1.30) were higher in women who delivered stillbirth. In contrast, women whose first pregnancy ended in an induced abortion had lower rates of hypertension (HR: 0.87; 95% CI: 0.84-0.91) and type 2 diabetes (HR: 0.89; 95% CI: 0.79-0.99) than women with a singleton live birth.

CONCLUSIONS

Several types of pregnancy loss were associated with an increased rate of hypertension, type 2 diabetes, and hypercholesterolemia, which may provide novel insight into the pathways through which pregnancy outcomes and CVD are linked.

TWEETABLE ABSTRACT

Pregnancy loss is associated with later maternal risk of hypertension, type 2 diabetes, and hypercholesterolemia.

Employing a Multi-level Approach to Recruit a Representative Sample of Women with Recent Gestational Diabetes Mellitus into a Randomized Lifestyle Intervention Trial

OBJECTIVE

The postpartum period is a window of opportunity for diabetes prevention in women with recent gestational diabetes (GDM), but recruitment for clinical trials during this period of life is a major challenge.

METHODS

We adapted a social-ecologic model to develop a multi-level recruitment strategy at the macro (high or institutional level), meso (mid or provider level), and micro (individual) levels. Our goal was to recruit 100 women with recent GDM into the Balance after Baby randomized controlled trial over a 17-month period. Participants were asked to attend three in-person study visits at 6 weeks, 6, and 12 months postpartum. They were randomized into a control arm or a web-based intervention arm at the end of the baseline visit at six weeks postpartum. At the end of the recruitment period, we compared population characteristics of our enrolled subjects to the entire population of women with GDM delivering at Brigham and Women's Hospital (BWH).

RESULTS

We successfully recruited 107 of 156 (69 %) women assessed for eligibility, with the majority (92) recruited during pregnancy at a mean 30 (SD ± 5) weeks of gestation, and 15 recruited postpartum, at a mean 2 (SD ± 3) weeks postpartum. 78 subjects attended the initial baseline visit, and 75 subjects were randomized into the trial at a mean 7 (SD ± 2) weeks postpartum. The recruited subjects were similar in age and race/ethnicity to the total population of 538 GDM deliveries at BWH over the 17-month recruitment period.

CONCLUSIONS

Our multilevel approach allowed us to successfully meet our recruitment goal and recruit a representative sample of women with recent GDM. We believe that our most successful strategies included using a dedicated in-person recruiter, integrating recruitment into clinical flow, allowing for flexibility in recruitment, minimizing barriers to participation, and using an opt-out strategy with providers. Although the majority of women were recruited while pregnant, women recruited in the early postpartum period were more likely to present for the first study visit. Given the increased challenges of recruiting postpartum women with GDM into research studies, we believe our findings will be useful to other investigators seeking to study this population.

Improving the postpartum care of women with a recent history of preeclampsia: a focus group study

OBJECTIVE

Women with prior preeclampsia are at increased risk of cardiovascular disease (CVD). This study investigated barriers and facilitators toward learning about this link and engaging in lifestyle modifications to reduce this risk.

METHODS

Four focus groups were held with 14 women within 6 months of a preeclamptic pregnancy.

RESULTS

Participants were unaware of the link between preeclampsia and CVD, suggested improvements to provider-patient communication, and discussed the benefits of social support and online tracking (weight, blood pressure) in making lifestyle modifications.

CONCLUSIONS

Solutions offered may improve efforts to modify lifestyle and communication between providers and women about this link.

Treatment for 2 mo with n 3 polyunsaturated fatty acids reduces adiposity and some atherogenic factors but does not improve insulin sensitivity in women with type 2 diabetes: a randomized controlled study

BACKGROUND

Information is lacking on the potential effect of n-3 polyunsaturated fatty acids (PUFAs) on the adipose tissue of patients with type 2 diabetes.

OBJECTIVE

We evaluated whether n-3 PUFAs have additional effects on adiposity, insulin sensitivity, adipose tissue function (production of adipokines and inflammatory and atherogenic factors), and gene expression in type 2 diabetes.

DESIGN

Twenty-seven women with type 2 diabetes without hypertriglyceridemia were randomly allocated in a double-blind parallel design to 2 mo of 3 g/d of either fish oil (1.8 g n-3 PUFAs) or placebo (paraffin oil).

RESULTS

Although body weight and energy intake measured by use of a food diary were unchanged, total fat mass (P < 0.019) and subcutaneous adipocyte diameter (P < 0.0018) were lower in the fish oil group than in the placebo group. Insulin sensitivity was not significantly different between the 2 groups (measured by homeostasis model assessment in all patients and by euglycemic-hyperinsulinemic clamp in a subgroup of 5 patients per group). By contrast, atherogenic risk factors, including plasma triacylglycerol (P < 0.03), the ratio of triacylglycerol to HDL cholesterol (atherogenic index, P < 0.03), and plasma plasminogen activator inhibitor-1 (P < 0.01), were lower in the fish oil group than in the placebo group. In addition, a subset of inflammation-related genes was reduced in subcutaneous adipose tissue after the fish oil, but not the placebo, treatment.

CONCLUSIONS

A moderate dose of n-3 PUFAs for 2 mo reduced adiposity and atherogenic markers without deterioration of insulin sensitivity in subjects with type 2 diabetes. Some adipose tissue inflammation-related genes were also reduced. These beneficial effects could be linked to morphologic and inflammatory changes in adipose tissue. This trial was registered at clinicaltrials.gov as NCT0037.