Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122

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Best Practice & Research Clinical

Obstetrics and Gynaecology
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11

Lifestyle interventions to reduce risk of diabetes

among women with prior gestational diabetes
mellitus
Lisa Chasan-Taber, ScD, Professor of Epidemiology *
Division of Biostatistics & Epidemiology, Department of Public Health, School of Public Health &
Health Sciences, University of Massachusetts, Amherst, MA, USA

Keywords:
While lifestyle interventions involving exercise and a healthy diet
lifestyle intervention in high-risk adults have been found to reduce progression to type 2
type 2 diabetes diabetes by >50%, little attention has been given to the potential
prevention benefits of such strategies in women with a history of gestational
physical activity diabetes mellitus (GDM). We conducted a literature search of
pregnancy PubMed for English language studies of randomized controlled
gestational diabetes mellitus trials of lifestyle interventions among women with a history of
GDM. In total, nine studies were identified which fulfilled the
eligibility criteria. The majority of randomized trials of lifestyle
interventions in women with GDM have been limited to pilot or
feasibility studies. However, preliminary findings suggest that such
interventions can improve diabetes risk factors in women with a
history of GDM. Larger, well-designed controlled randomized trials
are needed to assess the effects of lifestyle interventions on pre-
venting subsequent progression to type 2 diabetes among women
with GDM.
© 2014 Elsevier Ltd. All rights reserved.

Background

Type 2 diabetes is a global epidemic. Worldwide, the total number of people with diabetes is
projected to rise from 171 million in 2000 to 366 million in 2030 [1]. At the same time, the age at onset

* Division of Biostatistics & Epidemiology, School of Public Health and Health Sciences, 405 Arnold House, University of
Massachusetts, 715 North Pleasant Street, Amherst, MA 01003-9304, USA. Tel.: þ1 413 545 1664; Fax:þ1 413 545 1645.
E-mail address: LCT@schoolph.umass.edu.

http://dx.doi.org/10.1016/j.bpobgyn.2014.04.019
1521-6934/© 2014 Elsevier Ltd. All rights reserved.
 L. Chasan-Taber / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122 111

for type 2 diabetes is decreasing [2] highlighting the importance of identifying high-risk groups early,
in order to implement prevention efforts. One such high-risk group is women who develop glucose
intolerance during pregnancy. Both gestational diabetes mellitus (GDM) and milder glucose intoler-
ance in pregnancy identify women who are at a high risk of subsequent glucose intolerance and type 2
diabetes. [3,4]
GDM is one of the most common complications of pregnancy with a prevalence rate varying from
1% to 20% depending on the population studied and diagnostic criteria applied [2,5]. With the recent
adoption of the International Association of Diabetes and Pregnancy Study Groups Consensus Panel
(IADPSG) diagnostic criteria, it is estimated that 18% of pregnant women will be diagnosed with GDM
[5]. Obesity is strongly associated with the risk of GDM [6], and it is expected that the incidence of GDM
among women of reproductive age will further increase as the prevalence of obesity continues to rise
among this age group.
GDM is related to short- and long-term adverse health outcomes for the mother. Compared with
women with healthy pregnancies, women with histories of GDM have elevated cardiovascular disease
(CVD) risk factors including higher blood pressure, triglyceride levels, and lower high-density lipo-
protein (HDL) [7]. Consistent with these findings, a meta-analysis found that GDM confers a sevenfold
risk of future type 2 diabetes [8] and up to one-third of women with type 2 diabetes have previously
been diagnosed with GDM [9].
According to a systematic review, the highest risk period for the development of type 2 diabetes is
within the first 5 years after a GDM pregnancy [3] with 50% of Hispanic women developing type 2
diabetes within 5 years [10]. Furthermore, a growing body of evidence shows a rapid postpartum
change in CVD risk factors [11]. For example, Retnakaran et al. found that by 12 months post partum,
17.1% of those with recent GDM and 10% of women with milder degrees of gestational glucose intol-
erance had progressed to prediabetes or diabetes [12].
Therefore, pregnancy can unveil a preexisting susceptibility for type 2 diabetes and offers the op-
portunity to implement interventions to decrease such a risk. However, while lifestyle interventions
involving exercise and a healthy diet in high-risk adults have been found to reduce progression to type
2 diabetes by >50% [13e16], little attention has been given to the potential benefits of such strategies in
women with a history of GDM. Indeed, studies of diabetes prevention among such high-risk pregnant
and postpartum women are sparse. Collectively, the prior body of evidence suggests that such lifestyle
interventions, if delivered to women with a history of GDM, would have the potential to delay or
prevent one-sixth of type 2 diabetes cases in the female population [17].
Therefore, the goal of this review is to provide researchers and practitioners with a comprehensive
overview of the randomized controlled trials of lifestyle interventions designed to reduce the risk of
diabetes or diabetes risk factors among women with a history of GDM. To this end, the review first
describes the impact of the lifestyle interventions on the incidence of type 2 diabetes and biomarkers of
insulin resistance, weight change, and healthy behaviors such as physical activity, diet, and breast-
feeding. The review then goes on to describe the study design and methods of new randomized tri-
als which have been recently launched. The review concludes with a summary and recommendations
for future research and practice.

Methods

We conducted a literature search of PubMed for English language studies of randomized controlled
trials of lifestyle interventions among women with a history of GDM. Only published peer-reviewed
journal articles of original research in the English language were included. Keyword searches
included the following: lifestyle intervention, randomized controlled trial, type 2 diabetes, prevention,
diet, physical activity, postpartum, pregnancy, weight retention, GDM, and health behaviors. Additional
relevant articles cited in the reference lists of identified papers were retrieved manually.
In total, nine randomized controlled trials of lifestyle interventions conducted among women with a
history of GDM were identified to fulfill the eligibility criteria (Tables 1 and 2) [18e24].
Of these studies, two examined the impact of the lifestyle intervention on the subsequent incidence
of diabetes [23,25], and four examined the impact on postpartum biomarkers of insulin resistance
[20e22,26].
112 L. Chasan-Taber / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122

In terms of other risk factors for diabetes, all with the exception of one study [25] examined the
impact of the lifestyle intervention on weight change and physical activity. Four of the trials examined
the impact on diet [19,20,24,26]. Only one study to date reported the impact on breast-feeding [19].

Impact on risk of type 2 diabetes and biomarkers of insulin resistance

Among the nine randomized controlled trials conducted among women with GDM, two evaluated
the impact of a lifestyle intervention on the subsequent incidence of diabetes [23,25] and four
examined the impact on postpartum biomarkers of insulin resistance (Table 2) [20e22,26]. The most
successful intervention to date in terms of impact on subsequent diabetes was observed by the Dia-
betes Prevention Program (DPP) [13], a multicenter randomized trial of an intensive lifestyle inter-
vention conducted among a population of adults who had elevated fasting and post-load plasma
glucose concentrations. The goals of the lifestyle intervention were at least a 7% reduction in enroll-
ment weight, a low-calorie and low-fat diet, and at least 150 min/week of moderate-intensity physical
activity. In a subset of this population limited to women with a self-reported history of GDM (n ¼ 350/
2190), Ratner et al. [23] found that the incidence of type 2 diabetes in those randomized to the lifestyle
intervention was 7.4 per 100 person-years, compared with 15.2 per 100 person years in the placebo
group, for a 53% reduction in incidence (p ¼ 0.002). However, this study involved an intensive inter-
vention not easily administered in a clinical setting and was conducted an average of 12 years after
GDM diagnosis such that intervening lifestyle factors and subsequent pregnancies may have modified
findings. For example, women with early postpartum conversion to diabetes, and therefore at the
highest risk, were not eligible.
In the second trial to evaluate the impact of the intervention on subsequent diabetes, Wein et al.
[25] randomized 200 women with previous GDM and subsequent impaired glucose tolerance during
the timer period of 1989e1991 to an intensive dietary intervention targeting healthy eating and regular
exercise (i.e., 30 min for three times per week) or to routine dietary advice. The follow-up continued for
a median of 51 months. Women randomized to the dietary intervention had an annual incidence rate of
type 2 diabetes of 6.1% as compared to 7.3% in the control arm, for an incident rate ratio of 0.83 (95% CI
0.47e1.48) which was not statistically significant. As with the study by Ratner et al., this trial was
conducted years after GDM diagnosis and therefore faced the same limitations described above.
Of the four studies that evaluated the impact of the lifestyle intervention on biomarkers of insulin
resistance [20e22,26], two observed a statistically significant positive impact on blood glucose mea-
sures [20,26]. For example, Hu et al. randomized 404 participants in the Tianjin Gestational Diabetes
Mellitus Prevention Program (TGDMPP) diagnosed with GDM from 2005 to 2009 to either a lifestyle
intervention or a control group [20]. The goals of the intervention included weight loss of 5e10% of
pregnancy weight if overweight through reduction of at least 10% of total calories, participation in
150 min per week of moderate-intensity activity or harder, and reduction of total fat to <30% of calories.
Interim 1-year results indicate that women in the intervention group had a greater reduction in plasma
insulin levels (11.8 ± 27.4 pmol/l) as compared to those in the control arm (3.2 ± 31.2 pmol/l,
p ¼ 0.004). The authors also observed the suggestion of a positive impact of the intervention on fasting
glucose levels.
Similar findings were observed by Shyam et al. who randomized 77 Asian women who had been
diagnosed with GDM in the prior 2 months to a low glycemic index dietary intervention or to a usual
care control [26]. The goals of the intervention were a 5e7% reduction in body weight if prepregnancy
BMI was >23 kg/m2 and moderate-intensity physical activity of 30 min at least five times per week. At 6
months of follow-up, the intervention group had significantly greater decreases in 2-h post-load blood
glucose after a 75-g oral glucose tolerance test (median (interquartile range, IQR): 0.2 (2.8) mmol/l) as
compared to the control arm (0.8 (2.0) mmol/l), p ¼ 0.025). The suggestion of a beneficial impact on
plasma insulin was not statistically significant.

Impact on weight

With the exception of one study [25], all of the intervention studies conducted among women with
prior GDM examined the impact on weight (Table 2). It is important to note here that four of these
Table 1
Randomized trials of lifestyle interventions to reduce risk of type 2 diabetes among women with gestational diabetes mellitus (GDM); study designs.

Author (year) Name Design Pilot Population Intervention Mode Goals

Cheung et al.; RCT; FU: Pilot 43 women with Exercise intervention vs. individualized PA: 150 min/week or 10,000 steps/day
2011 12 months previous GDM usual care control in-person; for 5 days/week.
<4 years previously; telephone;
Australia mailings
Ferrara et al.; DEBI (Diet, RCT; FU: Pilot 197 women with Lifestyle intervention individualized Weight: return to prepregnancy weight
2011 Exercise and 12 months current GDM; (diet, exercise, in-person; if normal, lose 5% of prepregnancy weight
Breastfeeding California breast-feeding) telephone if overweight; PA: 150 min/week of
Intervention) versus usual care moderate-intensity or harder; Diet: 25%
control calories from fat; Breast-feeding: exclusively
for 6 months
Hu et al.; Tianjin RCT; 1 year Preliminary 404 women with Lifestyle intervention individualized Weight: no weight loss if normal weight,
2012 Gestational results previous GDM from (diet and exercise) versus in-person lose 5e10% of prepregnancy weight if BMI
Diabetes 05 to 09; China usual care control 24 kg/m2 through reduction of
Mellitus 10% total calories; PA: 150 of
Prevention moderate-intensity or harder; Diet:
Program TF <30%; fiber 20e30 g/day; % calories
(TGDMPP) from fat
Kim et al.; RCT; FU: Pilot 49 women with previous Exercise intervention web based Steps: up to 10,000 steps/day
2012 13 weeks GDM within past 3 years; versus usual care control
Michigan
McIntyre et al.; RCT; FU: Pilot 28 women with Exercise intervention individualized PA: 150 min/week
2012 12 weeks previous GDM versus usual care control in-person;
6 weeks post telephone
partum; Australia
Ratner et al.; Diabetes RCT; FU: 350 women with Lifestyle intervention individualized Weight: Reduction 7% of initial body
2008 Prevention 2.8 years. previous GDM (diet and exercise) in person; weight; Diet: low-calorie, low-fat;
Project (DPP) and current versus placebo group sessions PA: moderate intensity 150 min/wk.
elevated glucose
levels from the
DPP; US
Reinhardt et al.; RCT; FU: Pilot 38 women following Lifestyle intervention telephone; Healthy eating and physical activity
2012 6 months GDM diagnosis; (diet and exercise) versus mailings
Australia usual care control
Shyam et al.; RCT; FU: 77 women with Low GI diet versus usual in-person; Weight: 5e7% reduction in body weight
2013 6 months previous GDM care control text messaging, if BMI >23 and maintain if normal; PA:
within 2 months; emails moderate intensity 30 min/day for 5
Malaysia times/week
Wein et al.; RCT; FU: 200 women with Diet intervention telephone; Diet: healthy eating; PA: exercise
1999 796 previous GDM from versus control mailings (30 min for 3 times/week)
person-years 89 to 91 and
(median 51 subsequent IGT
months)

RCT ¼ randomized clinical trial; FU ¼ follow-up; GDM ¼ gestational diabetes mellitus; IGT ¼ impaired glucose tolerance; PA¼physical activity; FG ¼ fasting glucose; GI ¼ glycemic index; PA ¼
physical activity, LTPA ¼ leisure time physical activity, BMI ¼ body mass index.
Table 2

114
Randomized trials of lifestyle interventions to reduce risk of type 2 diabetes among women with gestational diabetes mellitus (GDM); findings.

Author (year) Name Impact on type 2 Impact on Impact on weight Impact on PA Impact on diet Impact on breast-
diabetes biomarkers of feeding
insulin resistance

Cheung et al.; 2011 NA NA BMI (kg/m2): 28 Steps (% achieving NA

L. Chasan-Taber / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122
(95% CI: 23.9, 34.3) goal): 30.8 versus
versus 25.5 (95% CI: 17.6 p ¼ 0.34; PA
22.5, 28.7), p ¼ 0.14 (% achieving goal):
70.0 versus 57.9,
p ¼ 0.51
Ferrara et al.; 2011 DEBI (Diet, Exercise NA NA Weight (% achieving PA (difference in Fat (% difference in Breastfeeding
and Breastfeeding goal): 37.5% versus mean change in mean change) 3.6, (difference in %
Intervention) 21.4%, p ¼ 0.07 min/week): 25.3, p ¼ 0.002 partially or
p ¼ 0.91 exclusively breast-
feeding): 15%,
p ¼ 0.09
Hu et al.; 2012 Tianjin Gestational NA FG (change in mmol/ Weight change: LTPA (% increased): Fat (% decrease): NA
Diabetes Mellitus l): 0.09 ± 0.52 1.4 ± 3.44 kg 59.4% versus 26.9%, 77.1 versus 68.9,
Prevention Program versus 0.09 ± 0.6, versus p < 0.001 p ¼ 0.064; Fiber
(TGDMPP) p ¼ 0.97; Insulin 0.21 ± 3.52 kg (% increase) 59.5
(change in pmol/l): (0.3%), p ¼ 0.001; versus 47.4,
11.8 ± 27.4 versus BMI change: p ¼ 0.012
3.2 ± 31.2, 0.50 ± 1.41 kg/m2
p ¼ 0.004 versus
0.09 ± 1.37 kg/m2,
p ¼ 0.004
Kim et al.; 2012 NA FG (change in Weight (change in PA (% moderate- NA NA
mmol/l): 0.046 kg): -0.14 kg versus intensity): 58 versus
versus 0.038, 1.5 kg, p ¼ 0.13 47, p ¼ 0.51
p ¼ 0.65; 2-h
glucose on 75-g
OGTT (change in
mmol/l): 0.48
versus 0.42,
p ¼ 0.91
McIntyre et al.; 2012 NA FG (change in mmol/ Change in weight PA (median (range) NA NA
L): 0.25 þ 0.56 (kg): 0.97 þ 3.7 increase in planned
versus 0.12 þ 0.42, versus 0.22 þ 4.2 NS PA min/week): 60
NS; Insulin (change (0540) versus
in mU/mL): 0 (0580);
1.49 þ 4.23 versus p ¼ 0.234; walking:
0.06 þ 3.89, NS NS
 Ratner et al.,; 2008 Diabetes Prevention Diabetes: 53% risk NA Weight (change in PA (change in h/ NA NA
Project (DPP) reduction versus kg): 5.13 ± 0.43 week): 1.5 h/week
placebo, p ¼ 0.002 versus approx. 0 in versus NA in year 1;
placebo at 6 <0.5 versus NA in
months; 1.6 ± 0.80 year 3.
versus approx. 0 in

L. Chasan-Taber / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122
placebo at 3 years
Reinhardt et al.; NA NA BMI (difference in LTPA (change in Total fat (change in NA
2012 change in kg/m2): min/day): 11 (95% g/day): 19 (95%CI:
1.5 (95% CI: 2.8, CI: 1, 22) 37, 1); GL (unit
0.1); Weight change) 26 (95% CI
(difference in 48, 4)
change in kg): 4.0
(95% CI: 7.6, 0.5)
Shyam et al.; 2013 NA Glucose: 2-h post Weight (% achieving PA (median MET- Fat (g): 58 ± 18
75 g OGTT (median goal): 33% versus 8%, min/week, IQR): 933 versus 53 ± 16,
mmol/l, IQR): 0.2 p ¼ 0.01 (1403) versus 965 p ¼ 0.695 for
(2.8) versus 0.8 (2.0), (857), p ¼ 0.908 difference in
p ¼ 0.025; Insulin change; Fiber (g):
(<2 mU/L): 61.5% 17 ± 4 versus 13 ± 4,
versus 52.6%, p ¼ 0.02 for
p ¼ 0.228 difference in
change; GI: 57 ± 5
versus 64 ± 6,
p ¼ 0.033 for
difference in change
Wein et al.; 1999 Diabetes (annual NA NA NA NA
IR): 6.1% versus 7.3%
(IRR ¼ 0.83, 95% CI:
0.47, 1.48)

RCT ¼ randomized clinical trial; FU ¼ follow-up; GDM ¼ gestational diabetes mellitus; IGT ¼ impaired glucose tolerance; PA ¼ physical activity; FG ¼ fasting glucose; GI ¼ glycemic index;
PA ¼ physical activity, LTPA ¼ leisure-time physical activity.

115
116 L. Chasan-Taber / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122

studies [20e22,26] were conducted among women with current GDM or very recent (e.g., within the
past 2 months) GDM and, therefore, were focused on postpartum weight loss and return to prepreg-
nancy weight. The majority observed a statistically significant positive impact of the intervention
[20,23,24,26].
In a feasibility study, Ferrara et al. randomized women with a current diagnosis of GDM in late
pregnancy to a lifestyle intervention which continued for 12 months post partum or to a usual care
control arm [19]. The goals of the intervention were to return to prepregnancy weight, if it was normal,
or achieve a 5% reduction from prepregnancy weight if overweight. The proportion of women who
reached the postpartum weight goal was higher, although not statistically significantly so, in the
lifestyle intervention arm as compared to the usual care arm (37.5 vs. 21.4%, absolute difference 16.1%,
p ¼ 0.07). However, in the subgroup of women not exceeding gestational weight gain guidelines, the
lifestyle intervention was more effective (difference in the proportion of women meeting the weight
goals: 22.5%, p ¼ 0.04).
Findings of similar magnitude were observed by Hu et al. in the TGDMPP [20]. Specifically, the
authors found a 1.4-kg (2.1%) weight loss in the intervention arm at 1 year of follow-up compared to a
0.21-kg (0.3%) weight loss in the control arm (p ¼ 0.001), as well as a positive impact on BMI, body fat,
and waist circumference. Ratner et al. in the DPP observed a weight loss of 5.13 ± 0.43 kg in the
lifestyle arm after 6 months which decreased to a weight loss of 1.6 ± 0.80 kg at year 3 of follow-up
[23]. Shyam et al. found that 33% of women in the intervention arm achieved the prespecified weight
loss goal as compared to 8% in the control arm (p ¼ 0.01) [26].

Impact on physical activity

All of the trials, with the exception of one [25], examined the impact of a lifestyle intervention on
physical activity among women diagnosed with GDM (Table 2). Of these, three [20,23,24] observed a
statistically significant impact on one or more measures of activity, while the others tended to observe
the suggestion of a beneficial effect. For example, Reinhardt et al. randomized 38 women in rural
Australia following their diagnosis of GDM into an exercise intervention or a control arm [24]. At the 6-
month follow-up, the intervention group increased leisure physical activity compared to the control
group by 11 min per day (95% CI: 1, 22); however, changes in total physical activity levels were not
statistically significantly different between groups.
Hu et al. in the TGDMPP observed a similar positive impact on leisure-time physical activity, with a
percent increase of 59.4% in the intervention arm as compared to a 26.9% increase (p < 0.001) in the
control arm, but no significant impact on walking [20]. Ratner et al. in the DPP observed an increase of
approximately 1.5 h per week in moderate-intensity physical activity after 1 year, which diminished to
an increase of <30 min of physical activity by year 3 [23].

Impact on diet

Four of the trials examined the impact of the lifestyle intervention on diet [19,20,24,26] and all
observed a statistically significant beneficial impact on one or more dietary components. For example,
in the pilot feasibility study by Ferrara et al., the authors observe a percent difference in mean change in
fat of 3.55% between the lifestyle arm and the control arm (p ¼ 0.002) [19]. Hu et al. in the TGDMPP
observed that the lifestyle arm had 77.1% decrease in energy from fat as compared to a 68.9% decrease
in the control arm (p ¼ 0.064) [20]. Reinhardt et al. [24] in their 6-month pilot in Australian women
observed a change in total fat between the arms of 19 g/day (95% CI: 37, 1). A beneficial impact of
the lifestyle intervention on fiber was observed by Hu et al. and Shyam et al.

Impact on breast-feeding

Only one study to date examined the impact of the lifestyle intervention on breast-feeding among
women with prior GDM [19]. Specifically, Ferrara et al. found that the difference in the percentage of
women partially or exclusively breast-feeding between the intervention and control arms was 15%
(p ¼ 0.09).
 L. Chasan-Taber / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122 117

Newly launched randomized trials of lifestyle interventions to prevent diabetes among women
with gdm

The following section provides an overview of the recently launched lifestyle intervention studies
among women with GDM. Five trials are currently ongoing (Table 3) [27e29].
Berry et al. [27] are conducting a randomized controlled trial among 100 African American, non-
Hispanic white, and bilingual Hispanic women between 22 and 36 weeks of pregnancy who are
diagnosed with GDM in North Carolina. Women are randomized in late pregnancy (22e36 weeks of
gestation) to a 14-week lifestyle intervention including diet and physical activity or to a wait-listed
control group. Follow-up will continue to 10 months post partum. The primary outcomes will
include fasting blood glucose and BMI from baseline to 10 months post partum. The secondary
maternal outcomes will include clinical, adiposity, health behaviors, and self-efficacy outcomes.
Chasan-Taber et al. are conducting Estudio Parto (Project Aiming to Reduce Type 2 diabetes), a
randomized controlled trial in western Massachusetts [28]. A total of 300 Hispanic prenatal care pa-
tients who screen positive for GDM at 24e28 weeks of gestation are randomized to a culturally and
linguistically modified, individually tailored lifestyle intervention or to a health and wellness com-
parison control group. Follow-up will continue to 12 months post partum. The intervention is delivered
via three in-person sessions, telephone booster calls, and mailed materials. The targets of the inter-
vention are: (1) postpartum weight reduction to prepregnancy weight if prepregnancy BMI was in the
normal range, or a 5% reduction from prepregnancy weight if prepregnancy BMI was overweight/
obese; (2) at least 150 min per week of moderate-intensity physical activity; and (3) reduction in
postpartum total caloric intake via reduced consumption of popular calorie dense foods, reduced
portion size, modifications in ethnic recipes, and higher fruit and vegetable intake. Primary outcomes
will include postpartum weight loss, biomarkers associated with insulin resistance, other cardiovas-
cular risk factors, and the adoption and maintenance of healthy physical activity and dietary behaviors.
Ferrara et al. are conducting the Gestational Diabetes' Effects on Moms (GEM) study [29], a cluster-
randomized clinical trial of 44 medical facilities at Kaiser Permanente Northern California. A total of
2320 women with a GDM diagnosis between March 2011 and March 2012 are randomized to either the
intervention or usual care conditions. Follow-up will continue to 12 months post partum. The inter-
vention is a DPP-derived print/telephone lifestyle intervention. Primary outcomes will include the
achievement of postpartum weight goals and total weight change. Secondary outcomes include
postpartum glycemia, blood pressure, depression, percent of calories from fat, total caloric intake, and
physical activity levels.
Infanti et al. [30] are conducting Croi MyAction, a two-group, parallel randomized controlled trial
for women with prior GDM. A total of 54 women with a history of GDM and persistent postpartum
glucose dysfunction are randomly assigned to an intervention group or to a control arm. Follow-up will
continue to 1 year post intervention. The lifestyle intervention is delivered via in-person sessions
including one-on-one sessions, group exercise, and education programs. Primary outcomes include
fasting plasma glucose levels on a 75-g oral glucose tolerance test.
Shih et al. are conducting the Mothers After Gestational Diabetes in Australia Diabetes Prevention
Program (MAGDA-DPP), a randomized controlled trial among 574 women with a diagnosis of GDM in
their most recent pregnancy [31]. Women are randomized to a 12-month diabetes prevention program
or to a usual care control group. The intervention is delivered via in-person and group sessions, and
telephone. Follow-up continues for 12 months. Primary outcomes include incidence of diabetes, and
secondary outcomes include cardiovascular risk factors and psychosocial and quality of life factors.

Discussion

Postpartum lifestyle interventions are critical in light of recent findings from long-term follow-up
studies that a significant proportion of women with GDM go on to develop type 2 diabetes, especially
during the first decade after the index pregnancy [8]. With the growing rates of diabetes and obesity in
US women, evidence regarding the effectiveness of lifestyle modification for the prevention of diabetes
in women with GDM is critical. Therefore, GDM offers an important opportunity for the development,
testing, and implementation of clinical strategies for prevention of subsequent type 2 diabetes [32].
Table 3

118
Newly launched randomized trials of lifestyle interventions to reduce risk of type 2 diabetes among women with gestational diabetes mellitus (GDM).

Author (year) Name Design Population Intervention Mode Goals Outcomes

Berry et al.; 2013 RCT; FU: 10 months 100 ethnically/ Lifestyle individualized Healthy behaviors Primary: FPG, BMI;
racially diverse intervention in-person; group Secondary: clinical,
women with current (diet and exercise) sessions; text adiposity, behaviors,

L. Chasan-Taber / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122
GDM; North Carolina versus control messaging. self-efficacy
Chasan-Taber et al.; Estudio Parto RCT; FU: 12 months 300 Hispanic women Lifestyle individualized Weight: return to Primary: postpartum
2014 with current GDM; intervention in-person; prepregnancy weight retention,
Massachusetts (diet and exercise) telephone; mailings weight if normal biomarkers of
versus health and weight, lose 5% of insulin resistance
wellness control prepregnancy and CVD; Secondary:
weight if exercise, diet
overweight; PA:
150 min/week of
moderate-intensity
or harder; Diet:
25% calories from
fat
Ferrara et al.; 2014 Gestational Diabetes' RCT; FU 12 months 2320 women with a Lifestyle telephone; mailings Weight: return to Primary: postpartum
Effects on Moms GDM diagnosis (diet, exercise) prepregnancy weight; Secondary:
(GEM) study between March versus usual care weight if normal postpartum
2011 and March control weight, lose 5% of glycemia, blood
2012; California prepregnancy pressure, depression,
weight if overweight % calories from fat,
or obese PA and Diet: total caloric intake,
individualized goals PA levels.
Infanti et al.; 2013 Croi MyAction RCT; FU: 12 months 54 women with Lifestyle individualized Healthy lifestyle Primary: FPG;
previous GDM and intervention in-person; group Secondary: insulin
persistent (diet and exercise) resistance, diet
postpartum glucose vs. control adherence, weight
dysfunction; Ireland and BMI, PA and
fitness, lipid profile,
psychological factors
Shih et al.; 2013 Mothers After RCT; FU: 12 months 574 women with Lifestyle individualized Weight: Reduce Primary: diabetes
Gestational Diabetes GDM in most recent intervention in-person; group >5%; PA 30 min/ risk; Secondary:
in Australia Diabetes pregnancy; Australia (diet and exercise) sessions; telephone day moderate- psychosocial, QOL,
Prevention Program versus control intensity; Diet: Fat CVD risk factors
(MAGDA-DPP) intake <30%; fiber
>15 g per 1000 kcal

RCT ¼ randomized clinical trial; FU ¼ follow-up; GDM ¼ gestational diabetes mellitus; IGT ¼ impaired glucose tolerance; PA¼physical activity; FG¼fasting glucose; GI ¼ glycemic index; PA
¼ physical activity, LTPA ¼ leisure time physical activity, BMI ¼ body mass index; kcal ¼ kilocalories; QOL ¼ quality of life; CVD ¼ cardiovascular disease.
 L. Chasan-Taber / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122 119

Such protocols can capitalize on the teachable moment of pregnancy [33] and empower women to
make postpartum lifestyle changes.
To date, the majority of randomized controlled trials of lifestyle interventions in women with GDM
designed to prevent type 2 diabetes have been limited to pilot or feasibility studies. However, pre-
liminary findings suggest that such interventions can improve postpartum biomarkers of insulin
resistance and other diabetes risk factors in women with a history of GDM. Specifically, the trials
conducted to date have observed favorable impacts on fasting glucose, insulin, postpartum weight,
leisure time physical activity, and intake of total fat, fiber, and glycemic load. Only one study to date
examined the impact on breast-feeding and found the suggestion of a beneficial impact [19].

Recommendations for future research

While evidence is rapidly accumulating that behavior in the postpartum period may be critical in
the prevention of longer-term progression towards diabetes, lifestyle changes can be difficult to
implement in these critical years after delivery. Postpartum women may be faced with the pressures of
caring for a new baby in addition to their existing household and caregiving responsibilities. Recent
qualitative data show that having young children is a major barrier to an active lifestyle in the first 12
months post partum [34]. Other qualitative and quantitative studies indicate a number of barriers to
physical activity during postpartum, including physical discomfort, parenting duties, too tired, lack of
time, not prioritizing their health over other competing responsibilities, and lack of spousal/partner
support [6].
A second challenge to implementing behavior change in the postpartum period is the relatively low
perceived risk of future diabetes among women with recent GDM. A review [35] of studies examined
the risk perceptions and health behaviors of women with previous GDM. The authors found low-risk
perceptions for future type 2 diabetes and suboptimal levels of physical activity and fruit and vegetable
intake. The majority of studies reveal a distinct knowledgeebehavior gap among this population as
well as a lack of knowledge regarding necessary lifestyle modifications [35].
Promising strategies to address these challenges can be found in recent studies which have found a
number of enablers to postpartum lifestyle changes including social support [36]. Dasgupta et al. [37]
conducted focus groups among women within 5 years of a GDM diagnosis. Participants stated that
their participation in a diabetes prevention program would be enhanced by face-to-face interactions
with professionals and peers, provision of childcare support, and inclusion of spouses/partners.
Therefore, interventions that integrate the entire family and influence family members, along with the
participant, to adopt health-promoting behaviors may be particularly successful.
In this vein, and to address transportation barriers, home-based interventions conducted via mail,
telephone, Internet/e-mail, and text messaging or involving home visits by health educators may be
more feasible and acceptable to women in the postpartum period. For example, several recent trials
that relied largely on the Internet, mail, or telephone have observed promising results. Furthermore,
there is evidence that Internet-based lifestyle interventions can increase exercise in a general post-
partum population [38]. However, at the same time Internet access may be a barrier as women with
GDM tend to have lower socioeconomic status than women without GDM [39].
Weight loss interventions that begin during pregnancy may be more effective than those initiated
only in the postpartum period given the strong association between GWG and postpartum weight
retention, and the fact that it may be difficult to reduce postpartum weight retention without first
preventing excessive gestational weight gain during pregnancy [40]. Two of the published trials began
in late pregnancy [19,24] and suggest that such protocols can have a beneficial impact on gestational
weight gain as well as prepare women for postpartum changes. Consideration should also be given to
translating such programs to clinical care. In their newly launched study [29], Ferrara et al. are eval-
uating whether delivering a diabetes prevention program at the health system level is able to suc-
cessfully reach women with prior GDM.
Breast-feeding has been associated with reduced blood glucose levels and a reduced incidence of
type 2 diabetes among women with a history of GDM [41]. However, only one of the nine published
trials included breast-feeding as one of their goals [19]. Future trials should focus on promoting a
combination of breast-feeding, diet, and physical activity.
120 L. Chasan-Taber / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 110e122

Finally, the rates of progression to type 2 diabetes vary by ethnicity, with, for example, Asian and
Hispanic women having higher rates of progression than non-Hispanic white women [42]. At the same
time, Hispanic women have higher rates of overweight/obesity when entering pregnancy and are more
likely to be sedentary than non-Hispanic white women [42]. Future studies should focus on these high-
risk groups. One newly launched study [28] is being conducted in Hispanic women only and will
evaluate whether a culturally modified intervention will be effective in reducing diabetes risk in La-
tinas with GDM.

Summary

Larger, well-designed controlled randomized trials are needed to assess the effects of lifestyle in-
terventions on preventing subsequent progression to type 2 diabetes among women with GDM. Such
interventions that focus on the acquisition of healthy lifestyle skills in late pregnancy and post partum
have a high potential for preventing the intergenerational cycle of diabetes in this high-risk population.

Practice points

 Preliminary findings suggest that lifestyle interventions can improve diabetes risk factors in
women with a history of GDM.

Research agenda

 Larger, well-designed controlled randomized trials are needed to assess the effects of life-
style interventions on preventing subsequent progression to type 2 diabetes among women
with GDM.

Conflict of interest

Author declares that there is no conflict of interest.

Acknowledgments

This work was funded by NIH/NIDDK 2R01DK064902 and DK097011.

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