OBJECTIVETo pilot, among women with gestational diabetes mellitus (GDM), the feasibility of a prenatal/postpartum intervention to modify diet and physical activity similar to the Diabetes Prevention Program. The intervention was delivered by telephone, and support for breastfeeding was addressed.RESEARCH DESIGN AND METHODSThe goal was to help women return to their prepregnancy weight, if it was normal, or achieve a 5% reduction from prepregnancy weight if overweight. Eligible participants were identified shortly after a GDM diagnosis; 83.8% consented to be randomly assigned to intervention or usual medical care (96 and 101 women, respectively). The retention was 85.2% at 12 months postpartum.RESULTSThe proportion of women who reached the postpartum weight goal was higher, although not statistically significant, in the intervention condition than among usual care (37.5 vs. 21.4%, absolute difference 16.1%, P = 0.07). The intervention was more effective among women who did not exceed the recommended gestational weight gain (difference in the proportion of women meeting the weight goals: 22.5%, P = 0.04). The intervention condition decreased dietary fat intake more than the usual care (condition difference in the mean change in percent of calories from fat: −3.6%, P = 0.002) and increased breastfeeding, although not significantly (condition difference in proportion: 15.0%, P = 0.09). No differences in postpartum physical activity were observed between conditions.CONCLUSIONSThis study suggests that a lifestyle intervention that starts during pregnancy and continues postpartum is feasible and may prevent pregnancy weight retention and help overweight women lose weight. Strategies to help postpartum women overcome barriers to increasing physical activity are needed.

OBJECTIVETo compare the effectiveness of diabetes prevention strategies addressing postpartum weight retention for women with gestational diabetes mellitus (GDM) delivered at the health system level: mailed recommendations (usual care) versus usual care plus a Diabetes Prevention Program (DPP)–derived lifestyle intervention.RESEARCH DESIGN AND METHODSThis study was a cluster randomized controlled trial of 44 medical facilities (including 2,280 women with GDM) randomized to intervention or usual care. The intervention included mailed gestational weight gain recommendations plus 13 telephone sessions between 6 weeks and 6 months postpartum. Primary outcomes included the following: proportion meeting the postpartum goals of 1) reaching pregravid weight if pregravid BMI <25.0 kg/m2 or 2) losing 5% of pregravid weight if BMI ≥25.0 kg/m2; and pregravid to postpartum weight change.RESULTSOn average, over the 12-month postpartum period, women in the intervention had significantly higher odds of meeting weight goals than women in usual care (odds ratio [OR] 1.28 [95% CI 1.10, 1.47]). The proportion meeting weight goals was significantly higher in the intervention than usual care at 6 weeks (25.5 vs. 22.4%; OR 1.17 [1.01, 1.36]) and 6 months (30.6 vs. 23.9%; OR 1.45 [1.14, 1.83]). Condition differences were reduced at 12 months (33.0 vs. 28.0%; OR 1.25 [0.96, 1.62]). At 6 months, women in the intervention retained significantly less weight than women in usual care (mean 0.39 kg [SD 5.5] vs. 0.95 kg [5.5]; mean condition difference −0.64 kg [95% CI −1.13, −0.14]) and had greater increases in vigorous-intensity physical activity (mean condition difference 15.4 min/week [4.9, 25.8]).CONCLUSIONSA DPP-derived lifestyle intervention modestly reduced postpartum weight retention and increased vigorous-intensity physical activity.

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BackgroundWomen with gestational diabetes (GDM) are at high risk of developing diabetes later in life. After a GDM diagnosis, women receive prenatal care to control their blood glucose levels via diet, physical activity and medications. Continuing such lifestyle skills into early motherhood may reduce the risk of diabetes in this high risk population. In the Gestational Diabetes’ Effects on Moms (GEM) study, we are evaluating the comparative effectiveness of diabetes prevention strategies for weight management designed for pregnant/postpartum women with GDM and delivered at the health system level.Methods/DesignThe GEM study is a pragmatic cluster randomized clinical trial of 44 medical facilities at Kaiser Permanente Northern California randomly assigned to either the intervention or usual care conditions, that includes 2,320 women with a GDM diagnosis between March 27, 2011 and March 30, 2012. A Diabetes Prevention Program-derived print/telephone lifestyle intervention of 13 telephonic sessions tailored to pregnant/postpartum women was developed. The effectiveness of this intervention added to usual care is to be compared to usual care practices alone, which includes two pages of printed lifestyle recommendations sent to postpartum women via mail. Primary outcomes include the proportion of women who reach a postpartum weight goal and total weight change. Secondary outcomes include postpartum glycemia, blood pressure, depression, percent of calories from fat, total caloric intake and physical activity levels. Data were collected through electronic medical records and surveys at baseline (soon after GDM diagnosis), 6 weeks (range 2 to 11 weeks), 6 months (range 12 to 34 weeks) and 12 months postpartum (range 35 to 64 weeks).DiscussionThere is a need for evidence regarding the effectiveness of lifestyle modification for the prevention of diabetes in women with GDM, as well as confirmation that a diabetes prevention program delivered at the health system level is able to successfully reach this population. Given the use of a telephonic case management model, our Diabetes Prevention Program-derived print/telephone intervention has the potential to be adopted in other settings and to inform policies to promote the prevention of diabetes among women with GDM.Trial registrationClinical Trials.gov number, NCT01344278.

Objective: To compare the effectiveness of glyburide and insulin for the treatment of Gestational diabetes mellitus (GDM) in women who had OGCT X200 mg/dl and fasting hyperglycemia.Study design: A retrospective study was performed among a subset of women treated with glyburide or insulin for GDM from 1999 to 2002 with an OGCT X200 mg/dl and pretreatment fasting plasma glucose X105 mg/dl. Exclusion criteria included pretreatment fasting X140 mg/dl, gestational age X34 weeks and multiple gestation. Maternal and neonatal outcomes were assessed. Statistical methods included bivariate and multivariable logistic regression analyses.Results: In 1999 to 2000, 78 women were treated with insulin; in 2001 to 2002, 44 of 69 (64%) received glyburide. There were no statistically significant differences between the two groups with regards to mean OGCT (230±25 vs 223±23 mg/dl, P ¼ 0.07) and mean pretreatment fasting (120±10 vs 119±11 mg/dl, P ¼ 0.45). Seven women (16%) failed glyburide. Women in the insulin group were younger (31.5±5.8 vs 35.2±4.7 years, P<0.001) and had a higher mean BMI (32.4±6.4 vs 29.1±5.8 kg/m 2 , P ¼ 0.003) compared to glyburide group. There were no significant differences in birth weight (3524±548 vs 3420±786 g, P ¼ 0.65), macrosomia (19 vs 23%, P ¼ 0.65), pre-eclampsia (12 vs 11%, P ¼ 0.98) or cesarean delivery (39 vs 46%, P ¼ 0.45). Neonates in the glyburide group were diagnosed more frequently with hypoglycemia (34 vs 14%, P ¼ 0.01). When controlled for confounders, macrosomia was found to be associated with glyburide treatment (OR 3.5, 95% CI 1.1 to 11.4). Conclusion:In women with GDM who had a markedly elevated OGCT and fasting hyperglycemia, glyburide achieved similar birth weights and delivery outcomes but was associated with an increased risk of macrosomia. The possible increased risk of neonatal hypoglycemia in the glyburide group warrants further investigation.

Objective-To determine whether, among women with gestational diabetes (GDM), referral to a telephonic nurse management program was associated with lower risk of macrosomia and increased postpartum glucose testing.Study Design-There was medical center-level variation in the percent of patients referred to a telephonic nurse management program at 12 Kaiser Permanente medical centers, allowing to examine in a quasi-experimental design the associations between referral and outcomes.Results-Compared with women from centers where the annual proportion of referral nurse management was <30%, women who delivered from centers with an annual referral proportion >70% were less likely to have a macrosomic infant and more likely to have postpartum glucose testing [multiple-adjusted OR (95%CI): 0.75 (0.57-0.98) and 22.96 (2.56-3.42), respectively].Conclusion-Receiving care at the centers with higher referral frequency to a telephonic nurse management for GDM was associated with decreased risk of macrosomic infant and increased postpartum glucose testing.

Objective To determine whether, among women with gestational diabetes (GDM), referral to a telephonic nurse management program was associated with lower risk of macrosomia and increased postpartum glucose testing. Study Design There was medical center-level variation in the percent of patients referred to a telephonic nurse management program at 12 Kaiser Permanente medical centers, allowing to examine in a quasi-experimental design the associations between referral and outcomes. Results Compared with women from centers where the annual proportion of referral nurse management was <30%, women who delivered from centers with an annual referral proportion >70% were less likely to have a macrosomic infant and more likely to have postpartum glucose testing [multiple-adjusted OR (95%CI): 0.75 (0.57–0.98) and 22.96 (2.56–3.42), respectively]. Conclusion Receiving care at the centers with higher referral frequency to a telephonic nurse management for GDM was associated with decreased risk of macrosomic infant and increased postpartum glucose testing.

Aim To assess the association of regular, unsupervised sports and exercise during pregnancy, by intensity level, with glycemic control in women with gestational diabetes (GDM). Methods Prospective cohort study of 971 women who, shortly after being diagnosed with GDM, completed a Pregnancy Physical Activity Questionnaire assessing moderate and vigorous intensity sports and exercise in the past 3 months. Self-monitored capillary glucose values were obtained for the 6 week period following the questionnaire, with optimal glycemic control defined ≥80% values meeting the targets <5.3 mmol/l for fasting and <7.8 mmol/l 1-hour after meals. Logistic regression estimated the odds of achieving optimal control; linear regression estimated activity level-specific least square mean glucose, as well as between-level mean glucose differences. Results For volume of moderate intensity sports and exercise [(MET · hours)/week], the highest quartile, compared to the lowest, had significantly increased odds of optimal control [OR= 1.82 (95% CI 1.06–3.14) P= 0.03]. There were significant trends for decreasing mean 1-hour post breakfast, lunch and dinner glycemia with increasing quartile of moderate activity (all P < 0.05). Any participation in vigorous intensity sports and exercise was associated with decreased mean 1-hour post breakfast and lunch glycemia (both P < 0.05). No associations were observed for fasting. Conclusion Higher volumes of moderate intensity sports and exercise, reported shortly after GDM diagnosis, were significantly associated with increased odds of achieving glycemic control. Clinicians should be aware that unsupervised moderate intensity sports and exercise performed in mid-pregnancy aids in subsequent glycemic control among women with GDM.