Novel Program Cuts Weight Retention After Gestational Diabetes

Becky McCall

June 30, 2020

An online, lifestyle-based weight loss initiative known as the Balance After Baby (BAB) program is effective at reducing weight retention a year after birth among women with recent gestational diabetes.

Specifically, results of the study were positive in women of most ethnicities, bar those of a small group of Hispanic origin. 

Jacinda Nicklas, MD, from the University of Colorado School of Medicine, Aurora, presented findings of the BAB trial during the virtual American Diabetes Association (ADA) 80th Scientific Sessions. She was coprincipal investigator alongside Ellen Seely, MD, from Brigham and Women's Hospital, Boston, Massachusetts.

"Looking at the entire population of women on the BAB program, there was a trend in weight loss from 6 weeks postpartum to 12 months (P = .09), and significantly less postpartum weight retention at 12 months (P = .04)," Nicklas said.  

"Through this effect on postpartum weight retention, the BAB program has potential to delay or prevent development of type 2 diabetes in women with recent gestational diabetes, while the web-based, remote nature of the program is scalable and very relevant in current times," she added.

"However, the lack of efficacy in Hispanic women means it needs to be modified to be successful in this ethnic group."

Frank Qian, MD, who also presented during the same session, said the BAB program has potential as a viable way of preventing both future pregnancy complications as well as the progression to overt type 2 diabetes in this high risk population.

"Large-scale epidemiologic studies show us that weight gain from pregnancy is a major risk factor for long-term cardiometabolic risk, particularly for women with a history of gestational diabetes," he observed.

"In turn, it is critical to implement lifestyle interventions that can help women get as close to the weight they were before pregnancy as possible and keep that weight off."

Postpartum Weight Retention a Modifiable Risk Factor for Type 2 Diabetes

Current evidence shows that a large proportion of women who develop gestational diabetes go on to develop type 2 diabetes within 10 years and that women with a history of gestational diabetes are more likely to retain or gain weight postpartum.

Nicklas also pointed out that obesity and weight gain are the strongest modifiable risk factors for type 2 diabetes.

"We know from the Diabetes Prevention Program (DPP) that an intensive lifestyle program in women who had had gestational diabetes led to a 53% reduction in type 2 diabetes," Nicklas noted.

However, she added there were barriers to adhering to the intensive DPP program — which required 16 one-on-one meetings in the first 24 weeks — including travel, as some participants lived quite remotely, or family responsibilities

Consequently, Nicklas and colleagues developed the BAB pilot trial, which involved web-based delivery with remote coaching.

The trial involved women with a history of gestational diabetes who were, on average, 7 weeks postpartum. The key outcome was weight at 12 months compared with both 6-week postpartum weight and prepregnancy weight.

Based on encouraging results in the pilot trial — in which the intervention group showed significant weight loss from 6-week postpartum weight and in 12-month weight retention — a larger, two-site trial was initiated, the BAB Intervention randomized controlled trial.

Outcome measures were the same as for the pilot study. The 181 participants were 18-45 years of age, and had recent gestational diabetes and a mean prepregnancy body mass index of approximately 29 kg/m2. Around half were college educated, and 28% were from lower income households.

Overall, 48% were white, 22% Asian, 17% African American, and 13% were of other ethnicities, with just over a third being Hispanic. 

The initial study visit was at 6 weeks postpartum. Women were randomized to the behavioral intervention website plus a lifestyle coach group or to a control group that consisted of a website plus knowledge links.

The intervention website required women to complete some DPP-derived and bonus modules, and also featured action plans, tracked weight and steps, and had a direct link to contact their lifestyle coach. Follow-up visits were held at 6 and 12 months and A1c, waist circumference, and height/weight were measured. A total of 86% eligible women completed the 6- and 12-month visits.

Why Didn't the BAB Program Work in Hispanic Women?

"The overall result showed that weight change from 6 weeks postpartum to 12 months revealed a slight gain in the control group of 1.3 lb and a loss in the intervention group of 1.8 lb, resulting in a between-group difference of 3.1 lb (P = .09)," reported Nicklas. Adjustment for gestational weight gain and breastfeeding had no substantial effect.

When 12-month weight retention versus prepregnancy weight was assessed, the former was halved in participants in the BAB program.

The control group gained a mean of 10.1 lb, and those in the intervention group gained a mean of 5.3 lb, equivalent to a difference of 4.8 lb (P = .04).

A prespecified analysis was conducted of 120 non-Hispanic women. At 12 months, weight retention compared to prepregnancy weight showed an increase of 9 lb in the control group versus 1.8 lb in the intervention group (P value for difference = .01).

By comparison, in the small group of Hispanic women only, weight retention at 12 months compared to prepregnancy weight showed a 12.7 lb increase and a 13.3 lb increase in the control and intervention groups respectively, reported Nicklas.

Addressing the key question of why the BAB program was ineffective in Hispanic women, Nicklas said, "The literature tells us that low income Hispanic women are twice as likely to experience postpartum weight retention compared to white non-Hispanic women."

"But we also know that low income Hispanic women generally engage less with interventions, and there is a higher acceptance of overweight among this ethnic group."

The researchers hope to follow the women from their trial to determine who progresses to type 2 diabetes.

"Hispanic women are a high-risk population for gestational diabetes and type 2 diabetes, and we plan to identify the best options to help Hispanic women with a history of gestational diabetes prevent type 2 diabetes," Nicklas told Medscape Medical News.

Qian also remarked on the differences observed in the weight loss outcomes for non-Hispanic versus Hispanic women, noting that it highlights the importance of studying lifestyle interventions in diverse populations.

"Environmental and cultural factors that may differ across different racial or ethnic groups could impact the effectiveness of such interventions," he said.

Nicklas and Qian have reported no relevant financial relationships.

ADA 2020 Scientific Sessions. Presented June 14, 2020. Abstract 191-OR.

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