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Published online June 15, 2007
Diabetes Care 30:2293-2295, 2007
DOI: 10.2337/dc07-0290
© 2007 by the American Diabetes Association
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Epidemiology/Health Services Research
Original Article

Self-Reported Past Gestational Diabetes Mellitus as a Risk Factor for Abnormal Glucose Tolerance Among Australian Women

David Simmons, FRACP1,2, Simon Eaton, MRCP3, Jonathan Shaw, FRACP4 and Paul Zimmet, FRACP4

1 School of Rural Health, University of Melbourne, Shepparton, Australia
2 Addenbrooke's Hospital, Cambridge, U.K
3 Northumbria Healthcare NHS Trust, North Shields, U.K
4 International Diabetes Institute, Melbourne, Australia

Address correspondence and reprint requests to Professor David Simmons, Dept. of Diabetes, Addenbrooke's Hospital, Box 49, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, U.K. CB2 2QQ. E-mail: dsworkster{at}gmail.com

Abbreviations: AGT, abnormal glucose tolerance • GDM, gestational diabetes mellitus • IFG, impaired fasting glucose • IGT impaired glucose tolerance


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 
At least 50% of women who have a pregnancy complicated by gestational diabetes mellitus (GDM) progress to permanent type 2 diabetes (1). While few long-term studies have been undertaken (2), progression from GDM to abnormal glucose tolerance (AGT) may not occur in all women. We hypothesized that if AGT occurs, then progression to diabetes would be more likely and that a greater excess of diabetes rather than impaired glucose tolerance (IGT)/impaired fasting glucose (IFG) would occur over time. We used two cohorts of Australian women who participated in either AusDiab (Australian Diabetes, Obesity and Lifestyle Study) (3,4) or CUDS (Crossroads Undiagnosed Disease Study) (5) to investigate the relationship between current glucose tolerance status and self-reported history of diagnosis of GDM.


   RESEARCH DESIGN AND METHODS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
RESULTS
 CONCLUSIONS
 References
 
AusDiab (May 1999 though December 2000) involved 42 randomly selected areas across Australia, and CUDS (June 2001 through March 2003) randomly selected households across six small towns and a regional center in rural Victoria, Australia (3–5). Both studies included residents aged ≥25 years within a household who responded to an initial census and used identical questionnaires and laboratories (and much of the same staff) for sample analysis. Attendance rates for women were 58% (n = 6,198) and 69% (n = 819), respectively, among whom 174 had incomplete data, 991 were nulliparous, and 13 had type 1 diabetes on clinical criteria. Among the remaining 5,839 parous women, those without known diabetes had a 75-g oral glucose tolerance test (6) and height, weight, and blood pressure measurements. Plasma glucose and serum lipid concentrations were determined enzymatically. Adult Treatment Panel-III criteria were used for the metabolic syndrome (7). Questions regarding women's health included the following. 1) "When you were pregnant, were you ever tested for diabetes? That is a blood or urine sugar test. This may have involved drinking a very sugary drink." 2) "Were you ever told that you had gestational diabetes or pregnancy-related diabetes?" 3) "Were you ever tested again for diabetes after pregnancy?"

All tests are two tailed, with P < 0.05 taken as significant. Discrete variables were compared using the {chi}2 test and adjusted for age-group using the Mantel-Haenszel test. Odds ratios are shown with 95% CIs. Continuous variables are compared using ANOVA or ANCOVA. The studies were approved by the relevant ethics committees and signed individual consent obtained.


   RESULTS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
CONCLUSIONS
 References
 
Past GDM was reported in 4.1%. In comparison with other women, those with past GDM were younger (44 ± 12 vs. 53 ± 14 years, P < 0.001), with a higher BMI (28.0 ± 6.5 vs. 27.0 ± 5.6 kg/m2, P = 0.006), and were more likely to be of non-European descent (10.0 vs. 5.8%, P = 0.008). Parity and age at first pregnancy were comparable. Current diabetes was more likely among those with past GDM (12.5 vs. 7.0%, P < 0.05), but the prevalence of IGT/IFG was similar in the two groups (16.7 vs. 16.2%). Metabolic syndrome prevalence was not significantly different (25.4 vs. 21.9%).

The prevalence of self-reported GDM screening decreased progressively with increasing age, as did the proportion with self-reported past GDM (Table 1). Current diabetes and IGT/IFG prevalence was similar among women, regardless of whether they remembered being screened. Among the former, the proportion with past GDM remained similar across all age-groups.


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  		Table 1— Prevalence of diabetes, penetration of screening by recall, and proportion with self-reported GDM and AGT

 
The excess of current diabetes among women with past GDM commenced from 35 to 44 years. A statistically significant excess of IGT/IFG was apparent in those aged 25–44 years but not in older age-groups. A significant excess of any AGT among those with past GDM was seen up to age 54 years but not beyond.


   CONCLUSIONS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
References
 
Attempting to interpret longitudinal patterns across cross-sectional data is fraught with difficulty (8,9). Notwithstanding this, and the unreliability of self-reports of past GDM testing and diagnosis, data validity here is supported by the relative risk of diabetes among women with past GDM, as compared with the sixfold excess shown by Cheung and Byth (2). Furthermore, with increasing age, the proportion of "screened" women with current diabetes after self-reported past GDM increased to a proportion slightly less than the original O'Sullivan cohort follow-up (in spite of the different diagnostic criteria) (10).

Among women with past GDM, the excess of current diabetes was seen at all ages, while no excess of current IGT/IFG was shown after age 55 years. If our observations are not a product of the various confounders, the proportion of older women with any AGT is comparable with and without past GDM. This suggests an excess loss of women with past GDM (through, e.g., death or nonparticipation) or that there is only a proportion of women with GDM who will actually progress to AGT. In those with AGT, however, a higher proportion of older women with past GDM had diabetes rather than IGT/IFG, suggesting that an additional process (e.g., reduced insulin secretory capacity) (11,12) has led to a greater transition to diabetes. Whether this is genetically determined due to the experience of GDM itself (13), excess obesity, or some other reason is unclear.

Interestingly, the prevalences of diabetes and IGT/IFG here were comparable regardless of whether women had been screened for GDM. The high risk of developing future diabetes among women with GDM, found in this study, supports recommendations for screening all pregnant women for diabetes. Furthermore, it emphasizes the need for interventions to reduce the risk of progression to type 2 diabetes in this group and for regular postpartum screening for diabetes.


   Acknowledgments
 
We thank all those who supported, funded, and took part in the AusDiab and Crossroads studies.


   Footnotes
 
Published ahead of print at http://care.diabetesjournals.org on 15 June 2007. DOI: 10.2337/dc07-0290.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C Section 1734 solely to indicate this fact.

Received for publication February 11, 2007. Accepted for publication June 6, 2007.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 

  1. Kim C, Newton KM, Knopp RH: Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 25: 1862–1868, 2002[Abstract/Free Full Text]
  2. Cheung NW, Byth K: The population health significance of gestational diabetes. Diabetes Care 26:2005–2009, 2003[Abstract/Free Full Text]
  3. Dunstan DW, Zimmet PZ, Welborn TA, Shaw J, de Courten M, Cameron A, Sicree RA, Dwyer T, Colagiuri S, Jolley D, Knuiman M, Atkins R, Shaw JE: The rising prevalence of diabetes and impaired glucose tolerance: the Australian Diabetes, Obesity and Lifestyle Study. Diabetes Care 25:829–834, 2002[Abstract/Free Full Text]
  4. Dunstan D, Zimmet P, Welborn T, Cameron A, Shaw J, de Courten M: The Australian Diabetes, Obesity and Lifestyle Study (AusDiab): methods and response rates. Diabetes Res Clin Pract 57:119–129, 2002
  5. Simmons D, McKenzie A, Eaton A, Shaw J, Zimmet P: Prevalence of diabetes in rural Victoria. Diabetes Res Clin Pract 70:287–290, 2005[Medline]
  6. World Health Organization: Definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO consultation. Part 1. Diagnosis and classification of diabetes mellitus. Geneva, World Health Org., 1999
  7. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).JAMA 285:2486–2497, 2001[Free Full Text]
  8. Cutchie W, Simmons D, Cheung NW: Comparison of international and New Zealand guidelines for the care of pregnant women with diabetes. Diabet Med 23:460–468, 2006[Medline]
  9. Rumbold AR, Crowther CA: Guideline use for gestational diabetes mellitus and current screening, diagnostic and management practices in Australian hospitals. Aust N Z J Obstet Gynaecol 41:86–90, 2001[Medline]
  10. O'Sullivan JB: Diabetes Mellitus after GDM. Diabetes 40:131–135, 1991[Medline]
  11. Ryan EA, Imes S, Liu D, McManus R, Finegood DT, Polonsky KS, Sturis J: Defects in insulin secretion and action in women with a history of gestational diabetes. Diabetes 44:506–512, 1995[Abstract]
  12. Homko C, Sivan E, Chen X, Reece EA, Boden G: Insulin secretion during and after pregnancy in patients with gestational diabetes mellitus. J Clin Endocrinol metab 86:568–573, 2001[Abstract/Free Full Text]
  13. Peters RK, Kjos SL, Xiang A, Buchanan TA: Long term diabetogenic effect of single pregnancy in women with previous gestational diabetes. Lancet 347:227–230, 1996[Medline]

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This Article
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