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Meta-Analysis
. 2017 May 4;5(5):CD011970.
doi: 10.1002/14651858.CD011970.pub2.

Lifestyle interventions for the treatment of women with gestational diabetes

Julie Brown  1 , Nisreen A Alwan  2 , Jane West  3 , Stephen Brown  4 , Christopher Jd McKinlay  1 , Diane Farrar  5 , Caroline A Crowther  1
Affiliations
Meta-Analysis

Lifestyle interventions for the treatment of women with gestational diabetes

Julie Brown et al. Cochrane Database Syst Rev. .

Abstract

Background: Gestational diabetes (GDM) is glucose intolerance, first recognised in pregnancy and usually resolving after birth. GDM is associated with both short- and long-term adverse effects for the mother and her infant. Lifestyle interventions are the primary therapeutic strategy for many women with GDM.

Objectives: To evaluate the effects of combined lifestyle interventions with or without pharmacotherapy in treating women with gestational diabetes.

Search methods: We searched the Pregnancy and Childbirth Group's Trials Register (14 May 2016), ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) (14th May 2016) and reference lists of retrieved studies.

Selection criteria: We included only randomised controlled trials comparing a lifestyle intervention with usual care or another intervention for the treatment of pregnant women with GDM. Quasi-randomised trials were excluded. Cross-over trials were not eligible for inclusion. Women with pre-existing type 1 or type 2 diabetes were excluded.

Data collection and analysis: We used standard methodological procedures expected by the Cochrane Collaboration. All selection of studies, data extraction was conducted independently by two review authors.

Main results: Fifteen trials (in 45 reports) are included in this review (4501 women, 3768 infants). None of the trials were funded by a conditional grant from a pharmaceutical company. The lifestyle interventions included a wide variety of components such as education, diet, exercise and self-monitoring of blood glucose. The control group included usual antenatal care or diet alone. Using GRADE methodology, the quality of the evidence ranged from high to very low quality. The main reasons for downgrading evidence were inconsistency and risk of bias. We summarised the following data from the important outcomes of this review. Lifestyle intervention versus control groupFor the mother:There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of hypertensive disorders of pregnancy (pre-eclampsia) (average risk ratio (RR) 0.70; 95% confidence interval (CI) 0.40 to 1.22; four trials, 2796 women; I2 = 79%, Tau2 = 0.23; low-quality evidence); caesarean section (average RR 0.90; 95% CI 0.78 to 1.05; 10 trials, 3545 women; I2 = 48%, Tau2 = 0.02; low-quality evidence); development of type 2 diabetes (up to a maximum of 10 years follow-up) (RR 0.98, 95% CI 0.54 to 1.76; two trials, 486 women; I2 = 16%; low-quality evidence); perineal trauma/tearing (RR 1.04, 95% CI 0.93 to 1.18; one trial, n = 1000 women; moderate-quality evidence) or induction of labour (average RR 1.20, 95% CI 0.99 to 1.46; four trials, n = 2699 women; I2 = 37%; high-quality evidence).More women in the lifestyle intervention group had met postpartum weight goals one year after birth than in the control group (RR 1.75, 95% CI 1.05 to 2.90; 156 women; one trial, low-quality evidence). Lifestyle interventions were associated with a decrease in the risk of postnatal depression compared with the control group (RR 0.49, 95% CI 0.31 to 0.78; one trial, n = 573 women; low-quality evidence).For the infant/child/adult:Lifestyle interventions were associated with a reduction in the risk of being born large-for-gestational age (LGA) (RR 0.60, 95% CI 0.50 to 0.71; six trials, 2994 infants; I2 = 4%; moderate-quality evidence). Birthweight and the incidence of macrosomia were lower in the lifestyle intervention group.Exposure to the lifestyle intervention was associated with decreased neonatal fat mass compared with the control group (mean difference (MD) -37.30 g, 95% CI -63.97 to -10.63; one trial, 958 infants; low-quality evidence). In childhood, there was no clear evidence of a difference between groups for body mass index (BMI) ≥ 85th percentile (RR 0.91, 95% CI 0.75 to 1.11; three trials, 767 children; I2 = 4%; moderate-quality evidence).There was no clear evidence of a difference between lifestyle intervention and control groups for the risk of perinatal death (RR 0.09, 95% CI 0.01 to 1.70; two trials, 1988 infants; low-quality evidence). Of 1988 infants, only five events were reported in total in the control group and there were no events in the lifestyle group. There was no clear evidence of a difference between lifestyle intervention and control groups for a composite of serious infant outcome/s (average RR 0.57, 95% CI 0.21 to 1.55; two trials, 1930 infants; I2 = 82%, Tau2 = 0.44; very low-quality evidence) or neonatal hypoglycaemia (average RR 0.99, 95% CI 0.65 to 1.52; six trials, 3000 infants; I2 = 48%, Tau2 = 0.12; moderate-quality evidence). Diabetes and adiposity in adulthood and neurosensory disability in later childhoodwere not prespecified or reported as outcomes for any of the trials included in this review.

Authors' conclusions: Lifestyle interventions are the primary therapeutic strategy for women with GDM. Women receiving lifestyle interventions were less likely to have postnatal depression and were more likely to achieve postpartum weight goals. Exposure to lifestyle interventions was associated with a decreased risk of the baby being born LGA and decreased neonatal adiposity. Long-term maternal and childhood/adulthood outcomes were poorly reported.The value of lifestyle interventions in low-and middle-income countries or for different ethnicities remains unclear. The longer-term benefits or harms of lifestyle interventions remains unclear due to limited reporting.The contribution of individual components of lifestyle interventions could not be assessed. Ten per cent of participants also received some form of pharmacological therapy. Lifestyle interventions are useful as the primary therapeutic strategy and most commonly include healthy eating, physical activity and self-monitoring of blood glucose concentrations.Future research could focus on which specific interventions are most useful (as the sole intervention without pharmacological treatment), which health professionals should give them and the optimal format for providing the information. Evaluation of long-term outcomes for the mother and her child should be a priority when planning future trials. There has been no in-depth exploration of the costs 'saved' from reduction in risk of LGA/macrosomia and potential longer-term risks for the infants.

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Conflict of interest statement

Julie Brown: none known.

Nisreen A Alwan: received funding from the Wellcome Trust between Sep 2009‐May 2014 for a Research Training Fellowship entitled: "The effect of maternal iron status and intake during pregnancy on cardiovascular disease risk in the offspring".

Jane West: none known.

Stephen Brown: none known.

Christopher JD McKinlay: none known.

Diane Farrar: none known.

Caroline A Crowther is the lead investigator for the ACHOIS trial that assessed treatment for women with mild gestational diabetes. This will be considered for inclusion in this review. However, Professor Crowther will not be involved in the decisions about inclusion of data or any data extraction from that trial.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Funnel plot of comparison: 1 Lifestyle intervention versus usual care/control, outcome: 1.2 Caesarean section.
1.1
1.1. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 1 Hypertensive disorders of pregnancy (including pre‐eclampsia, pregnancy‐induced hypertension, eclampsia).
1.2
1.2. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 2 Caesarean section.
1.3
1.3. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 3 Development of type 2 diabetes.
1.4
1.4. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 4 Perinatal (fetal and neonatal death) and later infant mortality.
1.5
1.5. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 5 Large‐for‐gestational age.
1.6
1.6. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 6 Death or serious morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy).
1.7
1.7. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 7 Use of additional pharmacotherapy.
1.8
1.8. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 8 Maternal hypoglycaemia.
1.9
1.9. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 9 Glycaemic control during/end treatment.
1.10
1.10. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 10 Weight gain in pregnancy (kg).
1.11
1.11. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 11 Induction of labour.
1.12
1.12. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 12 Postpartum haemorrhage.
1.13
1.13. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 13 Postnatal infection/pyrexia.
1.14
1.14. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 14 Perineal trauma/tear.
1.15
1.15. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 15 Breastfeeding at discharge, six weeks postpartum, six months or longer.
1.16
1.16. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 16 Sense of well‐being and quality of lifeduring treatment.
1.17
1.17. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 17 Sense of well‐being and quality of life three months postpartum.
1.18
1.18. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 18 Postnatal depression.
1.19
1.19. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 19 Postnatal weight retention or return to pre‐pregnancy weight.
1.20
1.20. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 20 Fasting plasma glucose 3 months postpartum mmol/L.
1.21
1.21. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 21 Maternal postnatal impaired glucose tolerance.
1.22
1.22. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 22 Maternal metabolic syndrome (follow‐up).
1.23
1.23. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 23 Stillbirth.
1.24
1.24. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 24 Neonatal death.
1.25
1.25. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 25 Macrosomia.
1.26
1.26. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 26 Small‐for‐gestational age.
1.27
1.27. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 27 Birth trauma (shoulder dystocia, bone fracture, nerve palsy).
1.28
1.28. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 28 Gestational age at birth (weeks).
1.29
1.29. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 29 Preterm birth (< 37 weeks’ gestation; and < 32 weeks' gestation).
1.30
1.30. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 30 Five‐minute Apgar less than seven.
1.31
1.31. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 31 Birthweight (grams).
1.32
1.32. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 32 Length (cm).
1.33
1.33. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 33 Adiposity (Neonatal fat mass (g)).
1.34
1.34. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 34 Neonatal hypoglycaemia.
1.35
1.35. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 35 Respiratory distress syndrome.
1.36
1.36. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 36 Neonatal jaundice (hyperbilirubinaemia).
1.37
1.37. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 37 Hypocalcaemia.
1.38
1.38. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 38 Polycythemia.
1.39
1.39. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 39 Childhood weight (kg).
1.40
1.40. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 40 Childhood height (cm).
1.41
1.41. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 41 Adiposity (Childhood BMI > 85th percentile).
1.42
1.42. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 42 Adiposity (BMI Z score childhood).
1.43
1.43. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 43 Childhood glycaemic control (mmol/L).
1.44
1.44. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 44 Dyslipidaemia or metabolic syndrome (Childhood cholesterol (mg/dL)).
1.45
1.45. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 45 Number of antenatal visits or admissions.
1.46
1.46. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 46 Number of hospital or health professional visits (including midwife, obstetrician, physician, dietician, diabetic nurse).
1.47
1.47. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 47 Number of hospital or health professional visits (including midwife, obstetrician, physician, dietician, diabetic nurse)l.
1.48
1.48. Analysis
Comparison 1 Lifestyle intervention versus usual care/control, Outcome 48 Admission to neonatal intensive care unit/nursery.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD011970

References

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Abirami 2014 {published data only}
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Grant 2011 {published data only}
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Langer 1989 {published data only}
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References to studies awaiting assessment

Cao 2012 {published data only}
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Kaveh 2012 {published data only}
    1. Kaveh M, Kiani A, Salehi M, Amouei S. Impact of education on nutrition and exercise on the level of knowledge and metabolic control indicators (FBS & PPBS) of gestational diabetes mellitus (GDM) patients. Iranian Journal of Endocrinology and Metabolism 2012;13(5):541‐8.
Zhang 2012 {published data only}
    1. Zhang LX. Evaluation of the effect of health education on self‐management of patients with gestational diabetes mellitus. Maternal and Child Health Care of China 2012; Vol. 27, issue 31:4850‐1.

References to ongoing studies

Durnwald NCT01858233 {published data only}
    1. NCT01858233. The IBEP Study: an intervention for lifestyle modification in women with gestational diabetes. clinicaltrials.gov/show/NCT01858233 Date first received: 8 May 2013.
Ferrara NCT01489163 {unpublished data only}
    1. NCT01489163. Lifestyle interventions program for women with gestational diabetes or gestational impaired glucose tolerance (APPLES). clinicaltrials.gov/show/NCT01489163 Date first received: 7 December 2011.
Hoseinzadeh IRCT2014080418682N1 {published data only}
    1. IRCT2014080418682N1. The effects of an educational intervention based on the theory of planned behavior on self‐care behavior and blood glucose levels in pregnant women with gestational diabetes treated with insulin. en.search.irct.ir/view/IRCT2014080418682N1 Date first received: 13 March 2015.
Mirfeizi IRCT201406022892N3 {published data only}
    1. IRCT201406022892N3. The effect of self care education on quality of life in women with gestational diabetes. en.search.irct.ir/view/IRCT201406022892N3 Date first received: 26 June 2014.
Roeder NCT01926457 {published data only}
    1. NCT01926457. Treating prediabetes in the first trimester. clinicaltrials.gov/show/NCT01926457 Date first received: 15 August 2013.
Sahnaz IRCT2014042017346N1 {published data only}
    1. IRCT2014042017346N1. Effectiveness of stress management with cognitive behavioural method on blood sugar levels and stress among patient with gestational diabetes. en.search.irct.ir/view/17875 Date first received: 27 April 2014.
Ziegler DRKS00000465 {published data only}
    1. DRKS00000465. MuKiS‐ Mother‐child sports ‐ a study to evaluate the impact of exercise on maternal metabolism and fetal development in women with gestational diabetes. drks‐neu.uniklinik‐freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DR... Date first received: 30 June 2010.

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References to other published versions of this review

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