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Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis

BMJ 2020; 369 doi: (Published 13 May 2020) Cite this as: BMJ 2020;369:m1361

Linked Opinion

Gestational diabetes—missed opportunities in post-partum follow-up

Rapid Response:

Re: Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis

Dear Editor,

Vounzoulaki and colleagues’ finding that women with a history of GDM are almost ten times more likely to develop T2DM, starkly underscores the importance of providing ongoing postnatal support for this high-risk group. However, postnatal and annual HbA1c screening alone is unlikely to achieve reduction in the risk of incident T2DM without access to interventions which support sustained lifestyle change in this population. There is currently a dearth of evidence regarding optimal timing, content, intensity and effectiveness of lifestyle change interventions in women who have had GDM.

Our patient and public engagement [1], and qualitative research [2] has found that while women with GDM are generally satisfied with their antenatal secondary care, they feel abandoned postnatally. They are uncertain what to expect from their GP in terms of follow-up, and experience significant barriers to optimising their diet and activity levels in the postnatal period [1].

These women feel postnatal care could be enhanced by peer support, multidisciplinary professional input, and subsidised exercise activities and facilities. Technology has the potential to act as an adjunct to this by providing access to tailored advice, enabling flexible and personalised self-management, and facilitating social support. Such interventions need to be based on sound behaviour change theory. Our more recent work has demonstrated the utility of the COM-B framework to code and the socio-ecological model to contextualise participant responses [3]. This has highlighted that a multi-level approach needs to be taken in the development of interventions for women with GDM. A top-down intervention approach is likely to be less effective than one which involves collaboration at the family and community level to ensure sustained
behaviour change [3].

One in twenty pregnant women in the UK develop GDM, and prevalence is increasing. The reduction of associated T2DM postnatally is an urgent public and primary healthcare priority. It is critical to intervene at both the antenatal and postnatal stage to reduce the likelihood that those with GDM will then go on to develop T2DM.

Brian McMillan, Jen Boyd, Caroline Mitchell

1. McMillan, B., Easton, K., Goyder, E., Delaney, B., Madhuvrata, P., Abdelgalil, R., & Mitchell, C., (2018). Reducing risk of type 2 diabetes after gestational diabetes: a qualitative study to explore the potential of technology in primary care British Journal of General Practice, 68 (669): e260-e267. DOI:

2. McMillan B, Easton K, Delaney B, Mitchell C. Patient and public involvement research report. Reducing the risk of progression from Gestational Diabetes to Type 2 Diabetes Mellitus: women’s perspectives on the content, research development and evaluation of a mobile health technology lifestyle intervention to support postnatal dietary and activity lifestyle change.

3. Mitchell, C., Boyd, J., McMillan, B., Easton, K., Delaney, B. What is the utility of the COM-B model in identifying facilitators and barriers to maintaining a healthy postnatal lifestyle following a diagnosis of gestational diabetes: a qualitative study. Proceedings of the SAPC Annual Scientific Conference, 15-17 July 2020

Competing interests: No competing interests

19 May 2020
Brian McMillan
NIHR Clinical Lecturer and GP
Jen Boyd, Caroline Mitchell
University of Manchester
Centre for Primary Care and Health Services Research, The University of Manchester, Oxford Road, Manchester, M13 9PL