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Gestational diabetes increases risk for long-term CVD

Women with a history of gestational diabetes had an elevated risk for experiencing major CVD events, such as myocardial infarction and stroke, later in life, according to findings published in JAMA Internal Medicine.

“Previous studies identify gestational diabetes as a risk factor for intermediate markers of CVD risk; however, few are prospective, evaluate hard CVD endpoints or account for shared risk factors including body weight and lifestyle,” Deirdre K. Tobias, ScD, from Brigham and Women’s Hospital and Harvard Medical School, and colleagues wrote.

Tobias and colleagues used data from the Nurses’ Health Study II to analyze the association between history of gestational diabetes and long-term CVD risk. Starting in 1989, participants completed questionnaires every 2 years to update their history of gestational diabetes, health outcomes and behavioral and lifestyle characteristics.

The researchers studied 89,479 women (mean age, 34.9 years) who were pregnant at least once and did not have CVD or cancer at baseline. Most participants (90%) completed follow-up through May 31, 2015.

Participants reported 612 MIs and 553 strokes, which were confirmed by medical records. Compared with women without gestational diabetes, those with a history of gestational diabetes demonstrated a 60% greater risk for subsequent CVD (HR = 1.60; 95% CI, 1.26-2.04); this association persisted after adjusting for age, prepregnancy BMI and other risk factors (HR = 1.43; 95% CI, 1.12-1.81). However, the association was moderately weakened after further adjustment for updated lifestyle and behavioral factors, including weight gain since pregnancy, current smoking status, diet quality score, alcohol intake, aspirin use and physical activity (HR = 1.29; 95% CI, 1.01-1.65).

The fully adjusted model revealed that CVD risk was increased more than threefold in women with both gestational diabetes and type 2 diabetes (HR = 3.71; 95% CI, 1.79-7.67) or type 2 diabetes only (HR = 3.74; 95% CI, 1.85-7.53) compared with those with no diabetes. After adjustment for weight gain and other lifestyle factors, history of gestational diabetes but without progression to type 2 diabetes was not associated with an increased risk for CVD (HR = 1.20; 95% CI, 0.91-1.58).

“These findings support the role of lifestyle for the prevention of CVD among high-risk women with a history of [gestational diabetes], although the small absolute rate increase of approximately 0.3 CVD events per 1,000 person-years observed for those with a history of [gestational diabetes] among these younger, predominantly white women may preclude widespread costly long-term interventions,” Tobias and colleagues concluded. “Future data with continuous follow-up of these women are warranted to evaluate longer-term health implications of [gestational diabetes] history.”

In an accompanying editorial, Erica P. Gunderson, PhD, MPH, MS, from Kaiser Permanente Northern California, Oakland, and Marc G. Jaffe, MD, from Kaiser Permanente South San Francisco Medical Center, wrote that the accumulating evidence that certain pregnancy complications can predict CVD risk later in life indicates that health care systems should consider implementing more surveillance and targeted interventions during the perinatal and reproductive periods, as well as the years that follow.

“These strategies include lifestyle behaviors (heart healthy diet, maintenance of a healthy weight, tobacco avoidance and physical activity) but also priorities for women’s postpartum health, including depression treatment, lactation support (in hospital and postdischarge), good sleep habits and social policies that support overall maternal health (extended paid maternity leave),” they wrote. “This effort will entail coordinated systems to identify, track, monitor, educate and treat these women before, during and after pregnancy. Effective interventions for risk reduction will also require increased awareness and engagement of primary care and specialty clinicians, as well as pragmatic research studies within integrated health care systems to evaluate and achieve optimal health for women decades after the diagnosis of [gestational diabetes].” – by Alaina Tedesco

Disclosures: Gunderson reports receiving funding from Janssen Pharmaceuticals. The other authors report no relevant financial disclosures.