Personalized Letter Aids Those With Gestational Diabetes

Troy Brown, RN

April 20, 2018

Women with gestational diabetes who received a customized letter with recommendations upon diagnosis were significantly more likely to meet national guidelines for total gestational weight gain or rate of weekly weight gain than women who did not receive the letter, a new study has found.

Monique M Hedderson, PhD, from the Division of Research, Kaiser Permanente Northern California, Oakland, and colleagues reported their findings April 18 in Diabetes Care.

"The tailored letter was a simple, scalable intervention. This low-intensity approach — which efficiently leveraged clinical data to send personalized advice directly to patients on behalf of the health care system — could have beneficial effects at the population level," second author Susan D Brown, PhD, also of Kaiser Permanente Northern California, said in a news release.

The study randomly assigned women at the facility level to receive usual care or the intervention, which comprised the tailored letter during pregnancy, and 13 postpartum telephone sessions with a lifestyle coach.

Women Who Received Letter More Likely to Meet IOM Guidelines

The study included 2014 women at 44 medical facilities from the Gestational Diabetes' Effects on Moms (GEM) cluster-randomized controlled trial: 1047 women at 22 facilities randomly assigned to receive usual obstetric care and 967 women at 22 facilities who received the personalized letter and follow-up (multicomponent intervention).

Women with gestational diabetes in the usual care group received a packet of health educational materials soon after their diagnosis, and a nurse called them once or twice each week to review self-monitored glucose data and provide advice about nutrition and physical activity. The women had telephone access to nurses 7 days/week and dieticians 5 days/week. Recommendations on gestational weight gain were not provided in the health educational materials or during telephone calls, however.

Women in the intervention group received a separate personalized letter, written at below eighth-grade reading level, after the packet of educational materials.

Letters included six tailored messages regarding:

  1. Weight history (the woman's prepregnancy weight, prepregnancy body mass index (BMI), and current weight at time of gestational diabetes diagnosis);

  2. A recommendation for total gestational weight gain specific to the woman's prepregnancy BMI;

  3. A corresponding end-of-pregnancy weight goal;

  4. A recommendation for weight management based on the woman's gestational weight trajectory;

  5. Lifestyle tips to help meet the end-of-pregnancy weight goal; and

  6. Information regarding the impact of gestational weight gain on pregnancy and postpartum health.

Hedderson and colleagues used Institute of Medicine (IOM) recommendations for gestational weight gain, which are based on BMI categorized as underweight (15.9–18.4 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obese (30.0–59.7 kg/m2) (J Midwifery Womens Health. 2010;55:512-519).

The researchers previously reported the main trial results of GEM, showing that women randomized to the multicomponent intervention (with the letter) had significantly less postpartum weight retention than women randomized to usual care.

In this new analysis, they wanted to drill down into the influence of distinct components of the intervention. And so they first evaluated whether the tailored letter improved gestational weight gain, and then whether gestational weight gain mediated the effect of the multicomponent intervention on the trial's main outcome, postpartum weight retention.

Women who received the letter were significantly more likely to meet the IOM guidelines for rate of weight gain compared with women in the usual care group (72.6% vs 67.1%; relative risk [RR], 1.08). Results were similar among those who were underweight or of normal weight (RR, 1.07), and those who were overweight or obese (RR, 1.08).

More women (36%) in the intervention group met the gestational weight gain goal compared with those in the usual care (33%) group (RR, 1.08), a difference that was significant among underweight and normal-weight women (RR, 1.28), but not among overweight and obese women (RR, 0.99).

"Most women gain more weight than recommended in pregnancy. Clinicians want counseling tips and actions that can help their patients meet the weight-gain guidelines — especially high-risk patients, such as those with gestational diabetes," explained Tracy Flanagan, MD, director of women's health for the Permanente Medical Group of Kaiser Permanente Northern California, in the press release. "Effective communication, with reminders, tips, and coaching, supports patients in achieving that goal."

Fewer LGA Infants Born to Moms Who Received Personalized Letter

Women in the intervention group were also significantly less likely to give birth to a large-for-gestational-age (LGA) infant compared with usual care (9.7% vs 12.8%; P = .04).

The researchers found no significant differences between the two groups in the proportions of preterm birth (9.8% vs 11.2%; P = .36), cesarean delivery (30.2% vs 33.1%; P = .19), neonatal intensive care unit admissions (13.9% vs 16.5%; P = .07), or small-for-gestational-age infants (8.7% vs 7.8%; P = .83).

And meeting the IOM recommendation for appropriate weekly rate of weight gain from gestational diabetes diagnosis to delivery mediated the intervention's effect on postpartum weight retention by 24.6%.

"This finding demonstrates the importance of gestational weight gain in impacting postpartum weight retention in this population," the authors observe.

"Thus, for women with gestational diabetes, pregnancy may offer a unique window of opportunity to intervene to reduce postpartum weight retention when women are motivated to change lifestyle behaviors," and using the electronic health record enables tailored advice to be provided to large patient populations, they add.

"Our study provides strong evidence that managing weight during pregnancy can have lasting benefits for mom's weight after the baby is born," concluded senior author Assiamira Ferrara, MD, PhD, Associate Director of Women's and Children's Health, Kaiser Permanente Division of Research.

The authors have reported no relevant financial relationships.

Diabetes Care. Published online April 18, 2018. Abstract

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