Jenny Ching

A Pregnancy and Postpartum Lifestyle Intervention in Women With Gestational Diabetes Mellitus Reduces Diabetes Risk Factors: A feasibility randomized control trial

OBJECTIVE To 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 METHODS The 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. RESULTS The 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. CONCLUSIONS This 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.

Comparison of glyburide and insulin for the management of gestational diabetics with markedly elevated oral glucose challenge test and fasting hyperglycemia

Objective:To compare the effectiveness of glyburide and insulin for the treatment of Gestational diabetes mellitus (GDM) in women who had OGCT ⩾200 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 ⩾200 mg/dl and pretreatment fasting plasma glucose ⩾105 mg/dl. Exclusion criteria included pretreatment fasting ⩾140 mg/dl, gestational age ⩾34 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=0.07) and mean pretreatment fasting (120±10 vs 119±11 mg/dl, P=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/m2, P=0.003) compared to glyburide group. There were no significant differences in birth weight (3524±548 vs 3420±786 g, P=0.65), macrosomia (19 vs 23%, P=0.65), pre-eclampsia (12 vs 11%, P=0.98) or cesarean delivery (39 vs 46%, P=0.45). Neonates in the glyburide group were diagnosed more frequently with hypoglycemia (34 vs 14%, P=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.

A pragmatic cluster randomized clinical trial of diabetes prevention strategies for women with gestational diabetes: design and rationale of the Gestational Diabetes’ Effects on Moms (GEM) study

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.

The Comparative Effectiveness of Diabetes Prevention Strategies to Reduce Postpartum Weight Retention in Women With Gestational Diabetes Mellitus: The Gestational Diabetes’ Effects on Moms (GEM) Cluster Randomized Controlled Trial

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

Managing High-Risk Obstetric Cases and Analyzing Neonatal Outcome: The KP Northern California Regional Perinatal Service Center

Located in Santa Clara, California, the Kaiser Permanente (KP) Northern California Regional Perinatal Service Center provides obstetric care to high-risk women throughout Northern California. Services designed to prevent preterm birth began in 1991, and the center has expanded to include home hypertension management, home diabetes management, hyperemesis support, and home nonstress testing programs. The goals of the center are to provide clinical services, to coordinate and maximize resources via telecommunications, to emphasize patient education, to empower patients in self-assessment and lifestyle change, and to support clinicians in the delivery of care. The center also conducts perinatal outcome studies and clinical trials.