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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

The systematic review and meta-analysis is an important reminder of the need for early and long term support of women who have been diagnosed with gestational diabetes. Gestational diabetes mellitus (GDM) has been well documented as a risk factor for the development of type 2 diabetes mellitus (T2DM) with cumulative incidences markedly increasing in the first 5 years post-delivery (Kim, Newton, & Knopp, 2002). The call for programmes to prevent or delay the progression from GDM to T2DM is a timely one and should positively impact the prevalence of T2DM.

During the gestational period the immediate need for the woman is a healthy child and the return of blood sugar to a normal range in the postpartum period. Post-delivery however, the demands of motherhood and shifting priorities could result in the mother’s neglect of her own health. Though mothers with GDM are often aware of the long term dangers and have intent to make lifestyle changes, the barriers are multiple and complex (Nielsen, Kapur, Damm, de Courten & Bygbjerg, 2014). The question is how does one ensure screening and the necessary uninterrupted follow up post-partum in the first 5 years and beyond?

A diagnosis is usually made based on recommended criteria and the aim is to control blood sugar to ensure a healthy baby and prevent potential difficulties during childbirth such as macrosomia and shoulder dystocia (World Health Organization [WHO], 2018). Nurses and in particular those trained as diabetes educators play a pivotal role in the provision of education especially to the mother and by extension family in the area of insulin self-administration and nutritional therapy.
There is no doubt that post-delivery, the recommendation having the best chance of improving outcomes in the mother with GDM is ‘intensive lifestyle interventions and /or Metformin to prevent diabetes” (American Diabetes Association, 2020). A structured programme or approach at all levels would become necessary to facilitate lifestyle changes to delay or prevent the progression to T2DM. Additional recommendations are postnatal checks and three-yearly screening for pre-diabetes and or diabetes. Four of every five adults with undiagnosed diabetes live in low – and middle income countries (LMICs) (IDF Diabetes Atlas, 2019). Developing national databases of all mothers with GDM is therefore important to generate new evidence especially in the LIMCs.. Prevention or delay in the development of diabetes in the LMIC would certainly improve productivity and reduce physical disabilities and health care costs. Emotional aspects, in particular, diabetes distress and depression impacting on productivity are also of concern. The study protocol for the Face-it study which is an intervention study will utilize health visitors; that is, nurses with specialized training in maternal, postnatal and child care in the health promotion to reduce the risk of T2DM in patients who have had GDM (Nielsen, 2020).

Emerging evidence links diabetes to other health issues, therefore early identification and treatment of women with GDM would be strategic in keeping with the Sustainable Development Goals (UN, 2019). Further research regarding health-system and patient-related barriers to post-partum follow up for GDM women in LMICs is needed to inform policy and programme decisions (Muhwava, Murphy, Zarowsky, & Levitt, 2018). Investment in nurses as diabetes educators, dedicated to support postpartum follow up of women with GDM, could make a significant difference in reducing the high burden of type 2 diabetes in LMICs.

Publication bias was insignificant for the studies included in the analysis. However, there was no indication that unpublished data was used and once valid could be significant for the research. Future research should solicit resources to exclude language bias as diabetes affects all ethnic groups and could provide invaluable data. Inability to compute ethnic risk, lack of incidence rate data and absence of individual patient level data (IPD) are areas that need to be addressed. Meta-analyses of IPD, if resources allow, would yield patient level characteristics.

Andrea Norman McPherson

American Diabetes Association (2020). Classification and diagnosis of diabetes: Standards of medical care in diabetes. Diabetes Care, 43(Suppl. 1):S14–S31
International Diabetes Federation (2019). IDF Diabetes Atlas 9th ed. Brussels, Belgium. Available at:

Kim C., Newton K.M. & Knopp R.H. (2002). Gestational diabetes and the incidence of
type 2 diabetes: A systematic review. Diabetes Care, 25(10):1862–8.

Muhwava, L. S., Murphy, K., Zarowsky, C., & Levitt, N. (2018). Policies and clinical practices relating to the management of gestational diabetes mellitus in the public health sector, South Africa - a qualitative study. BMC Health Services Research, 18(1), 349.

Nielsen, K. K., Kapur, A., Damm, P., de Courten, M., & Bygbjerg, I. C. (2014). From screening to postpartum follow-up - the determinants and barriers for gestational diabetes mellitus (GDM) services, a systematic review. BMC Pregnancy and Childbirth, 14, 41.

Nielsen, K.K., Dahl-Petersen, I.K., Jensen, D.M., Ovesen, P., Damm, P., Jensen, N.H., Thøgersen, M., Timm, A., Hillersdal, L., Kampmann, U., Vinter, C. A., Mathiesen, E. R., Maindal, H.T. (2020). Protocol for a randomized controlled trial of a co-produced, complex, health promotional intervention for women with prior gestational diabetes and their families: The Face-it study.Trials 21, 146 (2020).

UN (2019). The Sustainable Development Goals Report 2019. UN, New York,

World Health Organization (2018). The WHO Reproductive Health Library. Geneva: WHO. Available from:

Competing interests: No competing interests

16 July 2020
Andrea Marie Norman-McPherson
The UWI School of Nursing, Mona
9 Gibraltar Camp Way, The University of the West Indies, Kingston, Jamaica