COMMENTARY

Gestational Diabetes and Long-term Risk for Cardiovascular Disease

JoAnn E. Manson, MD, DrPH

Disclosures

November 08, 2017

Hello. I am Dr JoAnn Manson, professor of medicine at Harvard Medical School and Brigham and Women's Hospital in Boston, Massachusetts. I'd like to talk with you about a recent report in JAMA Internal Medicine[1] on gestational diabetes and the long-term risk for development of cardiovascular disease. Several clinicians have asked me to comment on this study, particularly its clinical implications. I'd like to acknowledge that I'm a coauthor of this report from the Harvard Nurses' Health Study II, which is a large-scale, prospective, cohort study. This analysis included more than 89,000 women who were age 24-44 at baseline and were followed for more than 20 years.

Disorders of pregnancy, including gestational diabetes mellitus (GDM) and pregnancy-induced hypertension/preeclampsia, can serve as a window into a woman's future risk for cardiovascular disease. The physiologic and metabolic demands of pregnancy in many ways serve as a stress test.

GDM affects about 5%-6% of women during pregnancy. Our cohort had approximately 5300 women with a history of GDM. The results of our study were that, overall, women with a history of GDM had a 43% higher risk of developing cardiovascular disease (which included myocardial infarction or stroke). The women who had an interim diagnosis of type 2 diabetes mellitus (T2DM) had a fourfold elevation in risk, and those without interim T2DM had only a marginally significant (30%) increased risk for cardiovascular events.

Also, the women who followed healthy lifestyle practices during the follow-up period (maintaining a healthy weight, regular physical activity, not smoking, following a heart-healthy diet) had no significant increased risk of developing cardiovascular disease. Women who did not follow these lifestyle practices, or who followed only one or two of them, had a substantial increase in risk.

Clinical Practice Implications

What are the implications of this study? In 2011, the American Heart Association added gestational diabetes to cardiovascular risk assessment in women.[2] It's important to inquire about a history of GDM, to look for it in the medical record, and to inform women that this is a marker for increased risk for cardiovascular disease as well as T2DM. Be particularly vigilant in recommending lifestyle modifications that can lower their risk.

The Diabetes Prevention Program was particularly successful in reducing the risk of developing T2DM. This program is available in communities and at YMCAs, and is covered by many health insurance policies.

It's important for women with a history of GDM to be screened within 1 to 3 months of delivery for persistent glucose intolerance and also regularly throughout mid- and later adulthood. There is some evidence that lactation and a longer duration of breastfeeding may be protective against future development of T2DM and cardiovascular disease, but the evidence is not yet conclusive. We need more research on that question.

We also need more research on the role of metformin and other pharmacologic agents, as well as on other lifestyle modifications that may reduce cardiovascular risk in this high-risk population. Thank you so much for your attention. This is JoAnn Manson.

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