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Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States

Cora Peterson, PhD; Scott D. Grosse, PhD; Rui Li, PhD; Andrea J. Sharma, PhD; Hilda Razzaghi, PhD; William H. Herman, MD, MPH; Suzanne M. Gilboa, PhD.  Am J Obstet Gynecol 2015;212:74.e1-9.


OBJECTIVE: Preconception care for women with diabetes can reduce the occurrence of adverse birth outcomes. We aimed to estimate the preconception care (PCC) - preventable health and cost burden of adverse birth outcomes associated with diagnosed and undiagnosed pregestational diabetes mellitus (PGDM) in the United States.


STUDY DESIGN: Among women of reproductive age (15-44 years), we estimated age- and race/ethnicity-specific prevalence of diagnosed and undiagnosed diabetes. We applied age and race/ethnicity-specific pregnancy rates, estimates of the risk reduction from PCC for 3 adverse birth outcomes (preterm birth, major birth defects, and perinatal mortality), and lifetime medical and lost productivity costs for children with those outcomes. Using a probabilistic model, we estimated the reduction in adverse birth outcomes and costs associated with universal PCC compared with no PCC among women with PGDM. We did not assess maternal outcomes and associated costs.


RESULTS: We estimated 2.2% of US births are to women with PGDM. Among women with diagnosed diabetes, universal PCC might avert 8397 (90% prediction interval [PI], 5252-11,449) preterm deliveries, 3725 (90% PI, 3259-4126) birth defects, and 1872 (90% PI, 1239-2415) perinatal deaths annually. Associated discounted lifetime costs averted for the affected cohort of children could be as high as $4.3 billion (90% PI, 3.4-5.1 billion) (2012 US dollars). PCC among women with undiagnosed diabetes could yield an additional $1.2 billion (90% PI, 951 million-1.4 billion) in averted cost.


CONCLUSION: Results suggest a substantial health and cost burden associated with PGDM that could be prevented by universal PCC, which might offset the cost of providing such care.


An Early Pregnancy HbA1c $5.9% (41 mmol/mol) Is Optimal for Detecting Diabetes and Identifies Women at Increased Risk of Adverse Pregnancy Outcomes 

Ruth C.E. Hughes, M. Peter Moore, Joanna E. Gullam, Khadeeja Mohamed, Janet Rowan. Diabetes Care Published Ahead of Print, published online September 4, 2014

Pregnant women with undiagnosed diabetes are a high-risk group that may benefit from early intervention. Extrapolating from nonpregnancy data, HbA1c ‡6.5% (48 mmol/mol) is recommended to define diabetes in pregnancy. Our aims were to determine the optimal HbA1c threshold for detecting diabetes in early pregnancy as defined by an early oral glucose tolerance test (OGTT) at <20 weeks’ gestation and to examine pregnancy outcomes relating to this threshold.

During 2008–2010 in Christchurch, New Zealand, women were offered an HbA1c measurement with their first antenatal bloods. Pregnancy outcome data were collected. A subset completed an early OGTT, and HbA1c performance was assessed using World Health Organization criteria.

HbA1c was measured at a median 47 days’ gestation in 16,122 women. Of those invited, 974/4,201 (23%) undertook an early OGTT. In this subset, HbA1c ‡5.9% (41 mmol/mol) captured all 15 cases of diabetes, 7with HbA1c <6.5% (<48mmol/mol). This HbA1c threshold was also 98.4% (95% CI 97–99.9%) specific for gestational diabetes mellitus (GDM) before 20 weeks (positive predictive value = 52.9%). In the total cohort, excluding women referred for GDM management, women with HbA1c of 5.9–6.4% (41–46 mmol/mol; n = 200) had poorer pregnancy outcomes than those with HbA1c <5.9% (<41 mmol/mol; n = 8,174): relative risk (95% CI) of major congenital anomaly was 2.67 (1.28–5.53), preeclampsia was 2.42 (1.34–4.38), shoulder dystocia was 2.47 (1.05–5.85), and perinatal death was 3.96 (1.54–10.16). 

HbA1c measurements were readily performed in contrast to the low uptake of early OGTTs. HbA1c ‡5.9% (‡41 mmol/mol) identified all women with diabetes and a group at significantly increased risk of adverse pregnancy outcomes.

Lack of Peri-conceptional Vitamins or Supplements Containing Folic Acid and Diabetes-associated Birth Defects

Accepted manuscript: Correa, A., Gilboa, S.M., Botto, L.D., Moore, C.A., Hobbs, C.A., Cleves, M.A., Riehle-Colarusso, T.J., Waller, D.K., Reece, E.A., National Birth Defects Prevention Study. American Journal of Obstetrics and Gynecology 2011).

OBJECTIVE: To examine the risk of birth defects in relation to lack of use of

Peri-conceptional vitamins or supplements containing folic acid and diabetes.

STUDY DESIGN: The National Birth Defects Prevention Study (1997–2004), a multicenter, population-based case-control study of birth defects (14,721 case and 5,437 control infants). Cases were categorized into 18 types of heart defects and 26 non-cardiac birth defects. We estimated odds ratios for independent and joint effects of pre-existing diabetes and lack of Peri-conceptional use of vitamins or supplements containing folic acid.

RESULTS: The pattern of odds ratios suggested an increased risk of defects associated with diabetes in the absence versus the presence of Peri-conceptional use of vitamins or supplements containing folic acid.

CONCLUSIONS: Lack of Peri-conceptional use of vitamins or supplements containing folic acid may be associated with an excess risk for birth defects due to diabetes.

Preventing Type 2 DM: Public Health Implications For Women With a History of Gestational Diabetes Mellitus

Lucinda J. England, MD, MSPH; Patricia M. Dietz, DrPH, MPH; Terry Njoroge, MPH; William M. Callaghan, MD, MPH; Carol Bruce, BSN, MPH; Rebecca M. Buus, PhD; David F. Williamson, PhD. American Journal of Obstetrics & Gynecology, 2008.

There is now strong evidence that lifestyle modification can prevent or delay the development of type 2 diabetes mellitus in high-risk individuals. Women with gestational diabetes mellitus are at increased risk for type 2 diabetes and so are candidates for prevention programs. We review literature on type 2 diabetes risk in women with gestational diabetes, examine current recommendations for postpartum and long-term follow-up, and summarize findings from a 2007 expert-panel meeting. We found data to support that women with gestational diabetes have an increase in risk of type 2 diabetes comparable in magnitude with that of individuals with impaired glucose tolerance and/or impaired fasting glucose and that prevention interventions likely are effective in this population. Current recommendations from leading organizations on follow-up of women after delivery are conflicting and compliance is poor. Clinicians and public health workers face numerous challenges in developing intervention strategies for this population. Translation research will be critical in addressing this important public health issue.

Do Postal Reminders Increase Postpartum Screening of Diabetes in Women with Gestational Diabetes? A Randomized Controlled Trial

Heather D. Clark, MD, MSc; Ian D. Graham, PhD; Alan Karovitch, MD, MEd; Erin J. Keely, MD.  American Journal of Obstetrics & Gynecology, June 2009.

OBJECTIVE: Women with previous gestational diabetes mellitus rarely receive the recommended 2-hour oral glucose tolerance test (OGTT) after delivery. We sought to determine whether postal reminders to be sent after delivery to a patient, her physician, or both would increase screening rates.

STUDY DESIGN: Patients were assigned randomly to 4 groups: reminders sent to both physician and patient, to physician but not patient, or to patient but not physician or no reminders were sent. The primary outcome was the proportion of patients who underwent an OGTT within 1 year after delivery. The secondary outcome was the performance of other postpartum screening tests.

RESULTS: OGTT rates were significantly increased in the physician/patient reminder group (49/81 women; 60.5%), in the patient-only reminder group (42/76 women; 55.3%), and in the physician-only reminder group (16/31 women; 51.6%) compared with the no reminder group (5/35 women; 14.3%; P.05).

CONCLUSION: Postpartum reminders greatly increased screening rates for women with gestational diabetes mellitus.

Modifiable Risk Factors for Developing Diabetes Among Women With Previous GDM

Shumei Yun, MD, PhD, Nisreen H. Kabeer, MPH, Bao-Ping Zhu, MD, MS, Ross C. Brownson, PhD.  Prev Chronic Dis 2007 Jan.

Introduction-Gestational diabetes mellitus (GDM) affects approximately 2% to 4% of all pregnant women in the United States each year. Women who have had GDM are at high risk for developing nongestational diabetes. The objective of this study was to assess the prevalence of modifiable risk factors for developing diabetes among women with previous GDM only.

Methods-Cross-sectional data for nonpregnant women from the 2003 Behavioral Risk Factor Surveillance System were used to estimate and compare the prevalence of modifiable risk factors among three groups: nonpregnant women with previous GDM only, nonpregnant women with current diabetes, and nonpregnant women without diabetes.

Results-In 2003, 7.6% of nonpregnant women aged 18 years and older in the United States had current self-reported physician-diagnosed diabetes, and 1.5% had previous GDM only. Compared with women without diabetes, women with previous GDM only had higher prevalence of no leisure-time physical activity (32.0% vs 25.7%), overweight (62.2% vs 49.0%), and obesity (29.4% vs 20.0%).

After adjusting for sociodemographic variables, women with previous GDM only were more likely to have no leisure-time physical activity (prevalence odds ratio [POR], 1.4; 95% confidence interval [CI], 1.2–1.7) and more likely to be overweight (POR, 1.8; 95% CI, 1.6–2.2) or obese (POR, 1.7; 95% CI, 1.4–2.1), compared with women with no diabetes.

Conclusion-Women with previous GDM are more likely to have modifiable risk factors for developing diabetes than women without diabetes. More attention to this issue is needed from health care providers and public health officials to encourage the promotion of healthy lifestyles during and after pregnancy.


New Study on Healthy Maternal Diet and Reduced Risks of Birth Defects

October 3, 2011 online publication of the Archives of Pediatrics and Adolescent Medicine.   The WIC Wire, May 2012, Volume 6, Issue 5, Utah Department of Health WIC Program

This new study from the Stanford University School of Medicine has shown that women who ate better before and during their pregnancy gave birth to fewer infants who had anomalies of the brain and spinal cord, or orofacial clefts, such as cleft lip and cleft palate. Previous research has focused on one nutrient at a time. For example folic acid has been shown to protect against brain or spinal cord anomalies (examples are anencephaly and spina bifida). However, after fortification of the U.S. food supply with folic acid, these types of birth defects did not disappear completely. Thus, other single nutrient studies were conducted to assess possible diet - defect associations or connections.



Risk Perception for Diabetes Among Women With Histories of Gestational Diabetes Mellitus


Catherine Kim, MD, MPH; Laura N. McEwen, PhD; John D. Piette, PhD; Jennifer Goewey, MHA; Assiamira Ferrara, MD, PhD; Elizabeth A. Walker PhD, RN. Diabetes Care, Volume 30, Number 9, September 2007.

OBJECTIVE — To examine risk perception for diabetes among women with histories of gestational diabetes mellitus (GDM).

RESULTS — Ninety percent of women recognized that GDM was a risk factor for future diabetes, but only 16% believed that they themselves had a high chance of developing diabetes; perceived risk increased to 39% when women were asked to estimate their risk assuming they maintained their current lifestyle. Women who consumed three or more but less than five servings a day of fruits and vegetables reported lower odds of moderate/high risk perception (adjusted odds ratio [OR] 0.39 [95% CI 0.16 – 0.92]) than women who consumed less than three servings a day, although this association was not significant after further adjustment for income. Women who perceived themselves to be at moderate/high risk more often planned to modify their future lifestyle behaviors (9.1 [0.16 – 0.92]).

CONCLUSIONS — Despite understanding the association between GDM and postpartum diabetes, women with histories of GDM usually do not perceive themselves to be at elevated risk.


Preventive Services for Women: New and Important Changes in Covered Services

Rebekah E. Gee, MD, MPH. CME/CE Released: 11/15/2012; valid for credit through 11/15/2013.

Under the Patient Protection and Affordable Care Act of 2010 (ACA), coverage for a variety of important preventive health care services is required by new (non-grandfathered) health plans with no cost sharing as of September 23, 2010, when services are rendered by an in-network provider. However, although women's healthcare needs are widely recognized as different from those of men, no single body of recommendations specific to women's preventive services existed at the time the ACA was signed into law. As such, the law required coverage of: "with respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by [The Health Resources and Services Administration] (not otherwise addressed by the recommendations of the [U.S. Preventive Services] Task Force)."

A simple scoring method using cardiometabolic risk measurements in pregnancy to determine 10-year risk of type 2 diabetes in women with gestational diabetes.


A. Barden, R. Singh, B. Walters, M. Phillips, and LJ Beili.  Nutrition & Diabetes (2013) 3, e72. 


OBJECTIVE: To examine if clustering of cardiometabolic risk factors in pregnancy predicts type 2 diabetes and cardiovascular disease (CVD) risk at 10 years in women with gestational diabetes mellitus (GDM).

STUDY DESIGN AND SUBJECTS: A prospective case–control study in 150 GDM and 72 overweight women with normal glucose tolerance (NGT) measured cardio-metabolic risk factors (body mass index (BMI), systolic blood pressure (SBP), fasting glucose, insulin, and triglycerides and high-density lipoprotein (HDL) cholesterol) at 28 weeks gestation and 6 months and 10 years after pregnancy. Cluster analysis of cardiometabolic risk factors in pregnancy was used to stratify GDM as ‘high’ and ‘low risk’ for diabetes and CVD risk at 10 years. The data in pregnancy were used to determine a simple method for assessing risk of future diabetes. RESULTS: BMI in the 150 GDM at study entry was similar to NGT, but 35% of GDM fell into a ‘high-risk cluster’ with elevated BMI, SBP, glucose, insulin and triglycerides and lower HDL levels. At 10 years, type 2 diabetes was sixfold higher in ‘high-risk’ GDM (odds ratio (OR) = 6.75, confidence interval (CI) = 2.0, 22.7, P=0.002) compared with ‘low-risk’ GDM and was not reported in NGT. The ‘high-risk’ cluster predicted type 2 diabetes better than BMI > 30 (OR= 2.13, CI= 0.71, 6.4, P= 0.179) or fasting glucose > 5.5 mmoll –1, (OR= 4.56, CI= 1.50, 3.85, P= 0.007). We determined that GDM with any four of the cardiometabolic risk factors (BMI > 30kgm –2, fasting glucose > 5.0mmoll –1 , insulin > 7.8 mUl –1 , triglycerides > 2.4mmoll –1 , HDL < 1.6 mmoll –1  or SBP > 105 mmHg) in pregnancy would be in a ‘high-risk’ cluster.

CONCLUSIONS: A metabolic syndrome-like cluster in pregnant GDM identifies risk for type 2 diabetes providing an opportunity to focus on rigorous lifestyle interventions after delivery to reduce the burden of disease attributed to this condition.



Follow-Up of Gestational Diabetes Mellitus in an Urban Safety Net Hospital: Missed Opportunities to Launch Preventive Care for Women


Lois McCloskey, DrPH, Judith Bernstein, PHD, Michael winter, MPH, Ronald Iverson, MD, and Aviva Lee-Parritz, MD. Journal of Women’s Health, Volume 23, Number 4, 2014, Mary Ann Liebert, Inc.                        
Background: Our study assessed the follow-up of gestational diabetes mellitus (GDM) in the postpartum period among a racially and ethnically diverse group of women receiving care in a major urban medical center.

Methods: We conducted cross-sectional analysis of clinical and administrative data on women aged 18–44 years who gave birth at Boston Medical Center (BMC) between 2003 and 2009, had GDM, and used BMC for regular care. We calculated the rate of glucose testing by 70 days and by 180 days after delivery and used logistic regression to assess the predictors of testing.

Results: By 6 months postpartum, only 23.4% of GDM-affected women received any kind of glucose test. Among these, over half had been completed by 10 weeks but only 29% were the recommended oral glucose tolerance test (OGTT). After accounting for sociodemographic and health service factors, women aged ≤ 35

years of age and women with a family practice provider were significantly less likely to be tested than their counterparts (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.32, 0.83 and OR 0.36; 95% CI 0.19, 0.71 respectively). Women who attended a primary care visit within 180 days after birth had three times higher odds of being tested than those without such a visit (OR 3.10; 95% CI 1.97, 4.87).

Conclusions: Despite widely disseminated clinical guidelines, postpartum glucose testing rates are exceedingly low, marking a critical missed opportunity to launch preventive care for women at high risk of type 2 DM. Failed follow-up of GDM by providers of prenatal and postpartum care also reflects a broader systems failure: the absence of a well-supported transition from pregnancy care to ongoing primary care for women.

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