Modifiable risk factors and long term risk of type 2 diabetes among individuals with a history of gestational diabetes mellitus: prospective cohort study
Jiaxi Yang, Frank Qian, Jorge E Chavarro, Sylvia H Ley, Deirdre K Tobias, Edwina Yeung, Stefanie N Hinkle, Wei Bao, Mengying Li, Aiyi Liu, James L Mills, Qi Sun, Walter C Willett, Frank B Hu, Cuilin Zhang, Jiaxi Yang, Frank Qian, Jorge E Chavarro, Sylvia H Ley, Deirdre K Tobias, Edwina Yeung, Stefanie N Hinkle, Wei Bao, Mengying Li, Aiyi Liu, James L Mills, Qi Sun, Walter C Willett, Frank B Hu, Cuilin Zhang
Abstract
Objectives: To evaluate the individual and combined associations of five modifiable risk factors with risk of type 2 diabetes among women with a history of gestational diabetes mellitus and examine whether these associations differ by obesity and genetic predisposition to type 2 diabetes.
Design: Prospective cohort study.
Setting: Nurses' Health Study II, US.
Participants: 4275 women with a history of gestational diabetes mellitus, with repeated measurements of weight and lifestyle factors and followed up between 1991 and 2009.
Main outcome measure: Self-reported, clinically diagnosed type 2 diabetes. Five modifiable risk factors were assessed, including not being overweight or obese (body mass index <25.0), high quality diet (top two fifthsof the modified Alternate Healthy Eating Index), regular exercise (≥150 min/week of moderate intensity or ≥75 min/week of vigorous intensity), moderate alcohol consumption (5.0-14.9 g/day), and no current smoking. Genetic susceptibility for type 2 diabetes was characterised by a genetic risk score based on 59 single nucleotide polymorphisms associated with type 2 diabetes in a subset of participants (n=1372).
Results: Over a median 27.9 years of follow-up, 924 women developed type 2 diabetes. Compared with participants who did not have optimal levels of any of the risk factors for the development of type 2 diabetes, those who had optimal levels of all five factors had >90% lower risk of the disorder. Hazard ratios of type 2 diabetes for those with one, two, three, four, and five optimal levels of modifiable factors compared with none was 0.94 (95% confidence interval 0.59 to 1.49), 0.61 (0.38 to 0.96), 0.32 (0.20 to 0.51), 0.15 (0.09 to 0.26), and 0.08 (0.03 to 0.23), respectively (Ptrend<0.001). The inverse association of the number of optimal modifiable factors with risk of type 2 diabetes was seen even in participants who were overweight/obese or with higher genetic susceptibility (Ptrend<0.001). Among women with body mass index ≥25 (n=2227), the hazard ratio for achieving optimal levels of all the other four risk factors was 0.40 (95% confidence interval 0.18 to 0.91). Among women with higher genetic susceptibility, the hazard ratio of developing type 2 diabetes for having four optimal factors was 0.11 (0.04 to 0.29); in the group with optimal levels of all five factors, no type 2 diabetes events were observed.
Conclusions: Among women with a history of gestational diabetes mellitus, each additional optimal modifiable factor was associated with an incrementally lower risk of type 2 diabetes. These associations were seen even among individuals who were overweight/obese or were at greater genetic susceptibility.
Conflict of interest statement
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the NIH for the submitted work; DKT received grants from the American Diabetes Associations for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. No commercial re-use. See rights and permissions. Published by BMJ.
Figures
References
- Knowler WC, Barrett-Connor E, Fowler SE, et al. Diabetes Prevention Program Research Group . Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403. 10.1056/NEJMoa012512
- Pan X-R, Li GW, Hu Y-H, et al. . Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20:537-44. 10.2337/diacare.20.4.537
- Hu FB, Manson JE, Stampfer MJ, et al. . Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med 2001;345:790-7. 10.1056/NEJMoa010492.
- Zhang Y, Pan X-F, Chen J, et al. . Combined lifestyle factors and risk of incident type 2 diabetes and prognosis among individuals with type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies. Diabetologia 2020;63:21-33. 10.1007/s00125-019-04985-9
- Langenberg C, Sharp SJ, Franks PW, et al. . Gene-lifestyle interaction and type 2 diabetes: the EPIC interact case-cohort study. PLoS Med 2014;11:e1001647. 10.1371/journal.pmed.1001647
- Li H, Khor C-C, Fan J, et al. . Genetic risk, adherence to a healthy lifestyle, and type 2 diabetes risk among 550,000 Chinese adults: results from 2 independent Asian cohorts. Am J Clin Nutr 2020;111:698-707. 10.1093/ajcn/nqz310
- Said MA, Verweij N, van der Harst P. Associations of Combined Genetic and Lifestyle Risks With Incident Cardiovascular Disease and Diabetes in the UK Biobank Study. JAMA Cardiol 2018;3:693-702. 10.1001/jamacardio.2018.1717.
- Ward ZJ, Bleich SN, Cradock AL, et al. . Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity. N Engl J Med 2019;381:2440-50. 10.1056/NEJMsa1909301.
- Khan MAB, Hashim MJ, King JK, Govender RD, Mustafa H, Al Kaabi J. Epidemiology of type 2 diabetes–global burden of disease and forecasted trends. J Epidemiol Glob Health 2020;10:107-11. 10.2991/jegh.k.191028.001
- Lin J, Thompson TJ, Cheng YJ, et al. . Projection of the future diabetes burden in the United States through 2060. Popul Health Metr 2018;16:9. 10.1186/s12963-018-0166-4
- Control CfD . Prevention. National diabetes statistics report, 2020. Centers for Disease Control and Prevention, US Department of Health and Human Services, 2020: 12-5.
- Porta M, Curletto G, Cipullo D, et al. . Estimating the delay between onset and diagnosis of type 2 diabetes from the time course of retinopathy prevalence. Diabetes Care 2014;37:1668-74. 10.2337/dc13-2101
- Zheng Y, Ley SH, Hu FB. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nat Rev Endocrinol 2018;14:88-98. 10.1038/nrendo.2017.151.
- Tobias DK. Prediction and prevention of type 2 diabetes in women with a history of GDM. Curr Diab Rep 2018;18:78. 10.1007/s11892-018-1063-8
- Zhang F, Dong L, Zhang CP, et al. . Increasing prevalence of gestational diabetes mellitus in Chinese women from 1999 to 2008. Diabet Med 2011;28:652-7. 10.1111/j.1464-5491.2010.03205.x.
- Anna V, van der Ploeg HP, Cheung NW, Huxley RR, Bauman AE. Sociodemographic correlates of the increasing trend in prevalence of gestational diabetes mellitus in a large population of women between 1995 and 2005. Diabetes Care 2008;31:2288-93. 10.2337/dc08-1038.
- Vounzoulaki E, Khunti K, Abner SC, Tan BK, Davies MJ, Gillies CL. Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. BMJ 2020;369:m1361. 10.1136/bmj.m1361
- Zhang C, Olsen SF, Hinkle SN, et al. Diabetes & Women’s Health Study team . Diabetes & Women’s Health (DWH) Study: an observational study of long-term health consequences of gestational diabetes, their determinants and underlying mechanisms in the USA and Denmark. BMJ Open 2019;9:e025517. 10.1136/bmjopen-2018-025517.
- Zhu Y, Zhang C. Prevalence of Gestational Diabetes and Risk of Progression to Type 2 Diabetes: a Global Perspective. Curr Diab Rep 2016;16:7. 10.1007/s11892-015-0699-x.
- Tobias DK, Hu FB, Chavarro J, Rosner B, Mozaffarian D, Zhang C. Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus. Arch Intern Med 2012;172:1566-72. 10.1001/archinternmed.2012.3747.
- Bao W, Tobias DK, Bowers K, et al. . Physical activity and sedentary behaviors associated with risk of progression from gestational diabetes mellitus to type 2 diabetes mellitus: a prospective cohort study. JAMA Intern Med 2014;174:1047-55. 10.1001/jamainternmed.2014.1795.
- Hinkle SN, Bao W, Wu J, et al. . Association of Habitual Alcohol Consumption With Long-term Risk of Type 2 Diabetes Among Women With a History of Gestational Diabetes. JAMA Netw Open 2021;4:e2124669-69. 10.1001/jamanetworkopen.2021.24669
- Bao Y, Bertoia ML, Lenart EB, et al. . Origin, Methods, and Evolution of the Three Nurses’ Health Studies. Am J Public Health 2016;106:1573-81. 10.2105/AJPH.2016.303338.
- Solomon CG, Willett WC, Carey VJ, et al. . A prospective study of pregravid determinants of gestational diabetes mellitus. JAMA 1997;278:1078-83. 10.1001/jama.1997.03550130052036
- Rimm EB, Stampfer MJ, Colditz GA, Chute CG, Litin LB, Willett WC. Validity of self-reported waist and hip circumferences in men and women. Epidemiology 1990;1:466-73. 10.1097/00001648-199011000-00009.
- Hu FB, Satija A, Rimm EB, et al. . Diet assessment methods in the nurses’ health studies and contribution to evidence-based nutritional policies and guidelines. Am J Public Health 2016;106:1567-72. 10.2105/AJPH.2016.303348
- Chiuve SE, Fung TT, Rimm EB, et al. . Alternative dietary indices both strongly predict risk of chronic disease. J Nutr 2012;142:1009-18. 10.3945/jn.111.157222.
- Wannamethee SG, Camargo CA, Jr, Manson JE, Willett WC, Rimm EB. Alcohol drinking patterns and risk of type 2 diabetes mellitus among younger women. Arch Intern Med 2003;163:1329-36. 10.1001/archinte.163.11.1329
- National Diabetes Data Group . Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. Diabetes 1979;28:1039-57. 10.2337/diab.28.12.1039
- Expert Committee on the Diagnosis and Classification of Diabetes Mellitus . Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183-97. 10.2337/diacare.20.7.1183
- Pan A, Sun Q, Bernstein AM, Manson JE, Willett WC, Hu FB. Changes in red meat consumption and subsequent risk of type 2 diabetes mellitus: three cohorts of US men and women. JAMA Intern Med 2013;173:1328-35. 10.1001/jamainternmed.2013.6633
- Li M, Rahman ML, Wu J, et al. . Genetic factors and risk of type 2 diabetes among women with a history of gestational diabetes: findings from two independent populations. BMJ Open Diabetes Res Care 2020;8:e000850. 10.1136/bmjdrc-2019-000850
- Organization WH. Physical status: The use of and interpretation of anthropometry, Report of a WHO Expert Committee. World Health Organization, 1995.
- 2018 Physical Activity Guidelines Advisory Committee . 2018 Physical Activity Guidelines Advisory Committee Scientific Report. US Department of Health and Human Services, 2018.
- US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. .
- Hu Y, Ding M, Sampson L, et al. . Intake of whole grain foods and risk of type 2 diabetes: results from three prospective cohort studies. BMJ 2020;370:m2206. 10.1136/bmj.m2206
- Ratner RE, Christophi CA, Metzger BE, et al. Diabetes Prevention Program Research Group . Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab 2008;93:4774-9. 10.1210/jc.2008-0772.
- Diabetes Prevention Program Research Group . Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study. Lancet Diabetes Endocrinol 2015;3:866-75. 10.1016/S2213-8587(15)00291-0
- Paixão C, Dias CM, Jorge R, et al. . Successful weight loss maintenance: A systematic review of weight control registries. Obes Rev 2020;21:e13003. 10.1111/obr.13003
- Aune D, Norat T, Leitzmann M, Tonstad S, Vatten LJ. Physical activity and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis. Eur J Epidemiol 2015;30:529-42. 10.1007/s10654-015-0056-z.
- American Diabetes Association . 4. Prevention or Delay of Type 2 Diabetes. Diabetes Care 2016;39(Suppl 1):S36-8. 10.2337/dc16-S007.
- Pan A, Wang Y, Talaei M, Hu FB, Wu T. Relation of active, passive, and quitting smoking with incident type 2 diabetes: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2015;3:958-67. 10.1016/S2213-8587(15)00316-2.
- Knott C, Bell S, Britton A. Alcohol Consumption and the Risk of Type 2 Diabetes: A Systematic Review and Dose-Response Meta-analysis of More Than 1.9 Million Individuals From 38 Observational Studies. Diabetes Care 2015;38:1804-12. 10.2337/dc15-0710.
Source: PubMed