For many women who experience gestational diabetes, the metabolic issues don't disappear after childbirth. In Denmark, 40-50% of these women develop type 2 diabetes within 10 years. From 2019 to 2022, a pilot program in Denmark offered extra support to pregnant women with gestational diabetes, including dietitian meetings and extensive blood tests. Despite this, 20% of participants developed prediabetes or type 2 diabetes within a year postpartum. The study highlights the importance of continued monitoring and early intervention for these women to prevent long-term complications.
For many women who experience gestational diabetes, their metabolic problems do not vanish forever once the baby is born. Previous studies indicate that 40–50% of women in Denmark who have gestational diabetes go on to develop type 2 diabetes within the next 10 years.
What can healthcare providers do to help reduce this risk?
From 2019 to 2022, a pilot programme led by Steno Diabetes Center Aarhus in Denmark offered additional resources to expectant mothers with gestational diabetes, from the last trimester of their pregnancy through the first year after birth. Women could choose to participate in meetings with dietitians and get more extensive blood tests, including one to assess how well their body processes glucose, before and after giving birth.
The researchers behind the programme were surprised to find that 20% of even the most motivated mothers who took advantage of all the extra offerings had developed prediabetes or type 2 diabetes within just 12 months of giving birth.
The authors say that their findings, published in March in the Journal of the Endocrine Society, are the first to document long-term glucose dysregulation so soon after birth among women in Denmark.
“It’s quite worrying that even women who attended extra visits in pregnancy and learned more about how they should prevent diabetes later on have such a high rate of prediabetes and diabetes after just a year,” says co-author Ulla Kampmann, Associate Professor at Steno Diabetes Center Aarhus.
Cellular fuel and a metabolic crystal ball
Growing a new person from scratch is an unparalleled stress test for the human body and requires a tremendous investment of cellular fuel in the form of glucose.
During pregnancy, tissues all over the woman’s body become more insulin resistant – meaning that they are less responsive to insulin’s cue to take up glucose from the bloodstream for use or storage – so that more energy can be rerouted to the growing fetus.
“Most women are able to increase insulin production enough to maintain normal blood glucose” during pregnancy, Kampmann says. But for some people, pregnancy reveals that their glucose regulation may have been struggling all along, just barely meeting their own body’s needs without showing symptoms.
That makes pregnancy something like a “crystal ball,” says co-author Sine Knorr, an endocrinologist-in-training and postdoctoral fellow at Steno Diabetes Center Aarhus. The stress test of pregnancy gives expectant mothers a glimpse of whether they are likely to develop diabetes in the future, Knorr explains.
“This is really a window of opportunity to see whether these women will develop diabetes eventually” while they are still quite young, Kampmann adds. “Men do not have this type of stress test.”
“Star patients” and additional resources
The researchers designed a new clinical offering to be extended to women with gestational diabetes in the Central Denmark Region from April 2019 to December 2022. Five hospitals participated, including Aarhus University Hospital, the home institution of Steno Diabetes Center Aarhus.
Outside the new clinical offering, women diagnosed with gestational diabetes across Denmark are advised to attend their general practitioner for a doctor’s consultation and blood tests three and 12 months postpartum. The pilot programme of Steno Diabetes Center Aarhus added some optional elements, including a dietitian consultation and more extensive blood tests late in pregnancy; extensive blood tests, including an oral glucose tolerance test to determine how well the body handles a blood glucose spike three months after birth; and extensive blood tests and a dietitian consultation 12 months after birth.
“The women could pick and choose themselves what they wanted to participate in,” Knorr says.
The rate of participation ended up lower than they had hoped, the researchers say – just 44% of eligible women participated in the three-month postpartum visit and glucose tolerance test, while 49% attended the 12-month visit. Only 26% attended both. The COVID-19 pandemic undoubtedly contributed to the low participation rate, since official guidance while the clinical offering was available urged pregnant women to avoid hospitals as much as possible.
Regardless, Kampmann and Knorr say that they were particularly interested to determine the demographics of the women who took advantage of the additional offerings.
The women who did opt in to the extras were more likely to be ethnically European, more likely to be slightly older and more likely to have high educational attainment, the researchers found. In short, the “women with the most resources,” Kampmann says.
The women who completed the full programme are “star patients,” she explains – the mothers who are the most motivated and have the most resources to devote to reducing their risk of developing diabetes. Kampmann and Knorr were surprised that, even among this select group, 20% had already developed prediabetes or type 2 diabetes within their first year postpartum.
“We were surprised at the number that were already diagnosed this early after pregnancy,” Knorr says.
Kampmann describes that high figure as “puzzling” and “quite worrying”. And the rates of prediabetes and diabetes are almost certainly higher for the women who did not attend the extra offerings, the authors agree. Those who missed the clinical offering are those with whom healthcare providers are most eager to connect, Kampmann adds – younger women with lower educational attainment from non-European ethnic backgrounds have a greater risk of diabetes complications.
What’s next?
For now, the pilot programme has been suspended. “I do not think we can implement a visit with a dietitian one year after birth” realistically across Denmark, Kampmann says.
Kampmann and Knorr say that they hope that this programme will raise awareness among both patients and healthcare providers of how gestational diabetes is connected to future blood glucose dysregulation.
Some healthcare professionals still tell women “Just don’t mind the diabetes, you will be over it when you have given birth to your child. Don’t ever think about it again,” Kampmann says. Unfortunately, that is not true for everyone – and Kampmann considers this a missed chance for intervention. “Hopefully, both groups can be more alert about this.”
The researchers emphasise the importance of yearly monitoring for women who have experienced gestational diabetes. “The sooner you find out you have diabetes or prediabetes, the sooner you can be treated,” Kampmann says. “If you are treated very early in the disease trajectory, you can postpone or even avoid complications.”
