Implementation Components of Diabetes Prevention Programs after Gestational Diabetes Mellitus: A Scoping Review.

Pregnancy has long been recognized as a state of relative insulin resistance, and those women who cannot meet the increased demands for insulin during pregnancy have been labeled as having gestational diabetes mellitus (GDM). What threshold should be used in defining GDM (1) and the benefits of (2) and best methods for treating GDM (3, 4) continue to be matters of ongoing investigation and debate. There should be no debate, however, about the relationship between GDM and later diabetes mellitus (DM). Indeed the pioneering work by O’Sullivan and Mahan (5) in the 1960s focused on pregnancy as a stress test for the pancreas that identified women at significant risk for future DM. Results of the Diabetes Prevention Program (DPP) published in this issue of JCEM now argue that identifying GDM offers not just a warning for future DM but also an important opportunity to intervene and prevent incident cases (6). DPP randomized over 3000 individuals with impaired glucose tolerance (IGT), including women identified with IGT as a result of a history of GDM, to treatment with metformin, intensive lifestyle (ILS), or placebo and subsequently evaluated those enrolled semiannually to determine who developed DM. The DPP investigators have previously reported that in the overall cohort, both ILS and metformin reduced the incidence of diabetes by 58 and 31%, respectively, compared with placebo. Their current analysis focuses on women in DPP who reported a history of GDM and compares their outcomes to those of parous women who reported no such history. The results emphasize the risk GDM confers for future DM but, happily given this risk, also argue that women with GDM are more likely to benefit from pharmacological intervention. Among those in the placebo arm, 38% of women with a history of GDM developed DM in the 3 yr after randomization, an alarming rate of progression that echoes many past studies. Moreover, women with a history of GDM were at a 71% increased risk for developing DM compared with other parous subjects, an increase that is remarkable given that all, by definition, had demonstrated IGT and similar glucose levels at entry into DPP. Women with and without a history of GDM benefited similarly from ILS, demonstrating an approximately 50% reduction in risk of progression. Yet, whereas parous women without a history of GDM who were randomized to metformin treatment demonstrated a nonsignificant 14% reduction in progression, the benefits of metformin in the group with a history of GDM matched that of ILS: women with IGT and a history of GDM who were treated with medication were 50% less likely to progress to DM than those with an equivalent history in the placebo group. The investigators estimate that only five to six women with IGT and a history of GDM would need to be treated over 3 yr with either metformin or lifestyle changes to prevent one case of DM. In summary, this report emphasizes what previous DPP results argued: women with IGT after GDM should be encouraged to follow a plan of lifestyle modification or begin metformin treatment. In choosing between these alternatives, some may question whether pharmacological intervention truly prevents DM or simply restores euglycemia in those with preclinical disease. Further follow-up of those treated with metformin may be useful in answering this question, but, in the meantime, normalizing values on glucose testing seems a reasonable and reasonably important surrogate outcome. Because metformin is generally well tolerated, such therapy seems an appropriate alternative to use in treating women with IGT and a history of GDM. Given the time that had elapsed from the identification of GDM until enrollment in DPP, details about the diagnosis and management of GDM were not available. Accordingly, the investigators could not confirm the diagnosis or identify whether further variables—specific results from glucose tolerance testing in pregnancy, need for insulin, fetal macrosomia—could identify those cases at greatest risk. Nor for that matter, were they able to say whether similar variables in the parous controls might be similarly useful. One other important limitation is that because DPP required those enrolled to have identified IGT, the question

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BackgroundThe University of California’s Diabetes Prevention Program (UC DPP) Initiative was implemented across all 10 UC campuses in 2018. The COVID-19 pandemic and accompanying mandates required swift changes to program delivery, including pivoting from in-person to virtual delivery (i.e., Zoom). Our goal was to assess multilevel constituent perceptions of the use of a virtual platform to deliver UC DPP due to COVID-19 mandates.MethodsWe conducted qualitative interviews with 68 UC DPP participants, coordinators, and leaders to examine the use of virtual platform delivery on the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) of UC DPP. Transcripts were analyzed using rapid qualitative analysis and emergent themes were categorized using domains corresponding to RE-AIM framework.ResultsAmong UC DPP participants (n = 42), virtual delivery primarily impacted perceptions of UC DPP effectiveness and implementation. Some participants perceived program effectiveness to be negatively impacted, given their preference for in-person sessions, which they felt provided more engagement, peer support, and accountability. Implementation challenges included problems with virtual format (e.g., “Zoom fatigue”); however, several benefits were also noted (e.g., increased flexibility, maintenance of DPP connections during campus closures). UC DPP coordinators (n = 18) perceived virtual delivery as positively impacting UC DPP reach, since virtual platforms provided access for some who could not participate in-person, and negatively impacting effectiveness due to reduced engagement and lower peer support. UC leaders (n = 8) perceived that use of the virtual format had a positive impact on reach (e.g., increased availability, accessibility) and negatively impacted effectiveness (e.g., less intensive interactions on a virtual platform). Across constituent levels, the use of a virtual platform had little to no impact on perceptions of adoption and maintenance of UC DPP.ConclusionPerceptions of the reach, effectiveness, and implementation of UC DPP using a virtual platform varied across constituents, although all groups noted a potential negative impact on overall program effectiveness. Unanticipated program adaptations, including virtual delivery, present potential benefits as well as perceived drawbacks, primarily across the effectiveness domain. Understanding differential constituent perceptions of the impact of virtual delivery can help maximize RE-AIM and inform future UC DPP delivery strategies.

Objectives To evaluate lifestyle change outcomes among women with and without a history of gestational diabetes mellitus (GDM) enrolled in the Montana Diabetes Prevention Program (DPP). Methods Participation, self-monitoring behavior, weight loss, and cardiometabolic risk reduction were compared among 5091 women at high-risk for type 2 diabetes, with and without a history of GDM, enrolled in the Montana DPP between 2008 and 2015. Results Women with a history of GDM (6% of enrolled women, n = 283) were significantly younger than women without GDM. No significant differences in participation, self-monitoring fat intake, achievement of the physical activity goal, or weight loss were found among women with and without a history of GDM. Overall, women lost an average of 5.0kg (± 6.5), and 45 and 29% of women achieved 5 and 7% weight loss, respectively. Both groups lost significant and comparable amounts of weight. After adjusting for age and other factors, no differences were found in achievement of ≥ 5% weight loss (AOR 0.84; 95% CI 0.61-1.16) or the ≥ 7% weight loss goal (AOR 1.04; 95% CI 0.73-1.47) among women with and without a history of GDM. Conclusions for Practice Our findings suggest that women with and without a history of GDM successfully participate in and achieve significant weight loss in the DPP. Health care providers should identify and refer women with risk factors for type 2 diabetes, including a history of GDM, to a DPP within their community.

The Diabetes Prevention Program (DPP) helps people make lifestyle changes to lose weight. Women who have had gestational diabetes mellitus maintain a high risk of developing type 2 diabetes and may be reluctant to participate in DPP. Our study analyzed the preference for in-person vs. online DPP among these women. • Women who have had GDM vary in their perceived risk of type 2 diabetes. • Non-college graduates are more likely to prefer in-person versus on-line DPP. • Women who don't know whether GDM conveys risk are more likely to prefer in-person DPP.

The Effect of Virtual Versus In-Person Delivery on Behavior Changes Among Adults Enrolled in the Diabetes Prevention Program in the Rio Grande Valley, Texas: A Secondary Analysis

Co-Designing a postpartum diabetes prevention program after gestational diabetes mellitus: A MoSCoW prioritization workshop exercise.

Without treatment, prediabetic women with a history of gestational diabetes mellitus (GDM) are at greater risk for developing type 2 diabetes compared with women without a history of GDM. Both intensive lifestyle intervention and metformin can reduce risk. To predict risk and treatment response, we developed a risk prediction model specifically for women with prior GDM. The Diabetes Prevention Program was a randomized controlled trial to evaluate the effectiveness of intensive lifestyle intervention, metformin (850mg twice daily), and placebo in preventing diabetes. Data from the Diabetes Prevention Program (DPP) was used to conduct a secondary analysis to evaluate 11 baseline clinical variables of 317 women with prediabetes and a self-reported history of GDM to develop a 3-year diabetes risk prediction model using Cox proportional hazards regression. Reduced models were explored and compared with the main model. Within three years, 82 (25.9%) women developed diabetes. In our parsimonious model using 4 of 11 clinical variables, higher fasting glucose and hemoglobin A1C were each associated with greater risk for diabetes (each hazard ratio approximately 1.4), and there was an interaction between treatment arm and BMI suggesting that metformin was more effective relative to no treatment for BMI ≥ 35kg/m2 than BMI < 30kg/m2. The model had fair discrimination (bias corrected C index = 0.68) and was not significantly different from our main model using 11 clinical variables. The estimated incidence of diabetes without treatment was 37.4%, compared to 20.0% with intensive lifestyle intervention or metformin treatment for women with a prior GDM. A clinical prediction model was developed for individualized decision making for prediabetes treatment in women with prior GDM.

OBJECTIVEThe Diabetes Prevention Program (DPP) trial investigated rates of progression to diabetes among adults with prediabetes randomized to treatment with placebo, metformin, or intensive lifestyle intervention. Among women in the DPP, diabetes risk reduction with metformin was greater in women with prior gestational diabetes mellitus (GDM) compared with women without GDM but with one or more previous live births.RESEARCH DESIGN AND METHODSWe asked if genetic variability could account for these differences by comparing β-cell function and genetic risk scores (GRS), calculated from 34 diabetes-associated loci, between women with and without histories of GDM.RESULTSβ-Cell function was reduced in women with GDM. The GRS was positively associated with a history of GDM; however, the GRS did not predict progression to diabetes or modulate response to intervention.CONCLUSIONSThese data suggest that a diabetes-associated GRS is associated with development of GDM and may characterize women at risk for development of diabetes due to β-cell dysfunction.

Electronic Monitoring Of Mom's Schedule (eMOMS™): Protocol for a feasibility randomized controlled trial to improve postpartum weight, blood sugars, and breastfeeding among high BMI women

To identify the key elements that enabled the Greater Green Triangle Diabetes Prevention Project (GGT DPP) and the Montana Cardiovascular Disease and Diabetes Prevention (CDDP) programs successful establishment and implementation in rural areas, as well as identifying specific challenges or barriers for implementation in rural communities. Focus groups were held with the facilitators who delivered the GGT DPP in Australia and the Montana CDDP programs in the USA. Interview questions covered the facilitators' experiences with recruitment, establishing the program, the components and influence of rurality on the program, barriers and challenges to delivering the program, attributes of successful participants, and the influence of community resources and partnerships on the programs. Four main themes emerged from the focus groups: establishing and implementing the diabetes prevention program in the community; strategies for recruitment and retention of participants; what works in lifestyle intervention programs; and rural-centred issues. The results from this study have assisted in determining the factors that contribute to developing, establishing and implementing successful diabetes prevention programs in two rural areas. Recommendations to increase the likelihood of success of programs in rural communities include: securing funding early for the program; establishing support from community leaders and developing positive relationships with health care providers; creating a professional team with passion for the program; encouraging participants to celebrate their small and big successes; and developing procedures for providing post-intervention support to help participants maintain their success.

BackgroundType 2 diabetes can negatively impact long term health outcomes, healthcare costs and quality of life. However, intensive lifestyle interventions, including the Diabetes Prevention Program (DPP), can significantly lower risk of incident type 2 diabetes among overweight adults with prediabetes. Unfortunately, the majority of adults in the US who are at risk of developing diabetes do not engage in DPP-based lifestyle change programs. Increased adoption of evidence-based obesity and diabetes prevention interventions, such as the DPP, may help large employers reduce health risks and improve health outcomes among employees. In 2018, the University of California Office of thePresident (UCOP) implemented the UC DPP Initiative, a novel, multi-component program to address diabetes and obesity prevention across the UC system.MethodsThe goal of our study is to conduct a multifaceted evaluation of the UC DPP Initiative using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Our evaluation will integrate unique and diverse UC data sources, including electronic health record (EHR) data, administrative claims, campus-based DPP cohort data, qualitative interviews and site visits. Our primary outcome of interest is the mean percent weight change among three groups of overweight/obese UC beneficiaries at risk for diabetes at 12-month follow-up. Secondary outcomes include mean percent weight change at 24-month follow-up, barriers and facilitators associated with implementatio, as well as the degree of program adoption and maintenance.DiscussionOur study will help inform diabetes and obesity prevention efforts across the UC system. Findings from this evaluation will also be highly applicable to universities and large employers, as well as community organizers, healthcare organizations and insurers implementing the DPP and/or other health promotion interventions.

Implementation of a Diabetes Prevention Program (DPP) in both in-person and digital health-care settings has been increasing. The purpose of this article is to describe the protocol of a mixed-methods, natural experiment study designed to evaluate the implementation of DPP in a large, integrated health system. Kaiser Permanente Northwest patients who were 19 to 75 years with prediabetes (hemoglobin A1c or glycated hemoglobin, 5.7-6.4) and obesity (body mass index ≥ 30 kg/m2) were invited, via the Kaiser Permanente Northwest patient portal, to participate in the digital (n = 4124) and in-person (n = 2669) DPP during 2016 through 2018. Primary (weight) and secondary (hemoglobin A1c or glycated hemoglobin level) outcome data will be obtained from electronic health records. A cost-effectiveness analysis as well as qualitative interviews with patients (enrolled and not enrolled in the DPP) and stakeholders will be conducted to examine further implementation, acceptability, and sustainability. The mixed-methods, natural experiment design we will use to evaluate Kaiser Permanente Northwest's implementation of the digital and in-person DPP builds on existing evidence related to the effectiveness of these two DPP delivery modes and will contribute new knowledge related to best practices for implementing and sustaining the DPP within large health systems over the long term.

To investigate racial/ethnic disparities in diabetes risk after gestational diabetes mellitus (GDM). This is a retrospective cohort study of women enrolled in the Kaiser Permanente Southern California health plan from 1995 to 2009. GDM status was identified on the basis of plasma glucose levels during pregnancy. The incidence of diabetes after the first delivery complicated by GDM before 31 December 2009 (n = 12,998) was compared with the experience for women without GDM (n = 64,668) matched on maternal age at delivery, race/ethnicity and year of delivery (1:5 ratio). Matched Cox regression was used to compare the RRs of diabetes associated with GDM within and across racial/ethnic groups. Compared with the women without GDM, the HRs (95% CI) of diabetes for women after GDM were 6.5 (5.2, 8.0) in non-Hispanic white, 7.7 (6.8, 8.7) in Hispanic, 9.9 (7.5, 13.1) in black and 6.3 (5.0, 7.9) in Asian/Pacific Islanders after adjustment for parity, maternal education, comorbidity and number of outpatient visits before the index pregnancy. The HR of diabetes for black women was significantly higher than that for non-Hispanic white women (p = 0.032). Further adjustment for prepregnancy BMI reduced the diabetes risk association with GDM for each racial/ethnic group, but did not explain the risk differences across groups. Racial/ethnic disparities exist in risk of diabetes after GDM. Black women with GDM had the highest risk of developing diabetes. This highlights the importance of developing an effective diabetes screening and prevention programme in women with GDM, particularly black women with GDM.

Reducing the Risk of Developing Diabetes.