Health EquityPriority Populations → Individuals with a Previous Gestational Diabetes Diagnosis

  

Individuals with a Previous Gestational Diabetes Diagnosis

 

Individuals with a previous gestational diabetes diagnosis have a much higher risk of developing type 2 diabetes, and participation in the National Diabetes Prevention Program (National DPP) lifestyle change program has been shown to decrease that risk. Children of gestational diabetes pregnancies also face an increased risk for obesity and type 2 diabetes. CDC’s eligibility criteria for the National DPP lifestyle change program includes persons with a previous diagnosis of gestational diabetes. Evidence supports that individuals who had gestational diabetes should be referred to the National DPP lifestyle change program as part of their regular postpartum care to decrease their future type 2 diabetes risk, potentially lower the risk of recurrent gestational diabetes, decrease cardiovascular disease risk, and teach healthy eating and physical activity behaviors that can benefit both them and their children. Given the current focus across the nation on improving maternal health outcomes, and the extension of Medicaid coverage to one-year postpartum, this is an especially opportune time to promote participation in the National DPP lifestyle change program for this population. Employers interested in supporting employees with gestational diabetes by covering the National DPP lifestyle change program can read case studies about both private and public employers covering the program on the Employer Coverage Landscape page of the Coverage Toolkit.

This page includes the following sections:

  1. What is Gestational Diabetes?
  2. Population-Specific Benefits of the Program
  3. Engaging Individuals with a Previous Gestational Diabetes Diagnosis
  4. Examples of Engaging Individuals with a Previous Gestational Diabetes Diagnosis

What is Gestational Diabetes?

Gestational diabetes is a form of diabetes that is diagnosed during pregnancy, which occurs in 2-10% of pregnancies annually in the United States. It occurs when a pregnant person’s pancreas cannot make enough insulin to process blood sugar efficiently. Gestational diabetes can lead to complications that affect both the mother and the baby. In a 2020 report, BlueCross BlueShield discussed rising rates of gestational diabetes that are driving an increase in pregnancy complication rates. In addition to pregnancy complications, studies indicate that about 50% of all people with gestational diabetes will go on to have type 2 diabetes, and that in the absence of intervention 70% of people with gestational diabetes will develop type 2 diabetes. Children of gestational diabetes pregnancies also face an increased risk for obesity and type 2 diabetes.


Population-Specific Benefits of the Program

Engaging individuals with a history of gestational diabetes represents an underutilized opportunity for diabetes prevention. It is currently estimated that only half of people with gestational diabetes are tested for diabetes or prediabetes postpartum, even though it is recommended for these individuals to have their blood sugar tested 6 to 12 weeks after the baby is born and then every 1 to 3 years to make sure their levels remain on target. This indicates an opportunity to improve postpartum care by focusing on prevention of type 2 diabetes for individuals who had gestational diabetes. There is an abundance of research supporting the benefit of the National DPP lifestyle change program for these individuals.

Summary of Evidence

As highlighted below, the National DPP lifestyle change program can benefit individuals with a history of gestational diabetes by greatly reducing the risk of developing type 2 diabetes. For maximum benefit, individuals with pregnancies affected by gestational diabetes should be referred to the program and participate during the postpartum period, defined as the first year following childbirth.

  • Participation reduces progression to diabetes. A ten-year randomized controlled clinical trial found that successful completion of the National DPP lifestyle change program reduced progression to diabetes by 35% among individuals with a previous gestational diabetes diagnosis.
  • The National DPP lifestyle change program is a beneficial but underutilized resource. A study on the effectiveness of the National DPP lifestyle change program delivered in a large network of Federally Qualified Health Centers (FQHCs) compared reach, retention, physical activity, and weight loss outcomes between a diverse group of women under 40 with previous gestational diabetes and other participants in the program. This group of women represented a smaller proportion of participants, but it was found that they attended more sessions and had greater weight loss than other participants, representing one third greater attendance and twice as much weight loss. Authors concluded that the National DPP lifestyle change program is a “beneficial but underutilized” resource for women with a previous gestational diabetes diagnosis.
  • Those with a previous gestational diabetes diagnosis can be highly successful in the program. An evaluation of National DPP lifestyle change program outcomes compared participation, self-monitoring behavior, weight loss, and cardiometabolic risk reduction among women with and without a previous gestational diabetes diagnosis. Authors concluded that individuals with a previous gestational diabetes diagnosis can be highly successful in the program and achieve significant weight loss.
  • Postpartum participation is recommended and may lower risk of recurrent gestational diabetes. Research published in 2023 recommends that individuals with a previous gestational diabetes diagnosis participate in the National DPP lifestyle change program postpartum to decrease and delay risk of developing type 2 diabetes. Authors suggest that participation in the program may also decrease participants’ risk of developing gestational diabetes in future pregnancies.
  • Participation can have a positive impact across generations. A study of diabetes prevention education programs for individuals with gestational diabetes found that participation in these programs can indirectly benefit the children of individuals participating in the program. Since children of gestational diabetes pregnancies face an increased risk for obesity and type 2 diabetes, parents developing healthy eating and physical activity behaviors through the program can have long-term benefits for their children as well.

Health Equity Implications

Focusing on coverage of the National DPP lifestyle change program for individuals with a previous gestational diabetes diagnosis has applicability to all payer types and aligns with efforts to reduce maternal mortality. This demonstrates an important opportunity, particularly for Medicaid beneficiaries, as Medicaid currently finances about 42% of all births in the U.S. With disparities evident in maternal mortality rates by race and ethnicity, coverage of the program for postpartum persons with a history of gestational diabetes could be one strategy used to address these inequities.

Populations that face health inequities related to diabetes, including the ones listed below, may benefit from prioritized and tailored outreach:

  • Non-white and Hispanic Women: Conversion rates from gestational diabetes to type 2 diabetes are higher among non-white and Hispanic women compared to other groups.
  • Women with Disabilities: Women with disabilities have a 25% higher risk for gestational diabetes than those without.
  • Rural Residents: Rates of gestational diabetes have been persistently higher in rural areas compared to urban areas.

For information on outreach strategies for the National DPP lifestyle change program, please visit the Recruitment and Referral page of the Coverage Toolkit. Additional content on health equity as it relates to the National DPP lifestyle change program can be found on the Health Equity suite of pages of the Coverage Toolkit.


Engaging Individuals with a Previous Gestational Diabetes Diagnosis

There are several key considerations when offering the National DPP lifestyle change program to individuals with a previous gestational diabetes diagnosis. This section will discuss several of these considerations including using the extended Medicaid postpartum coverage period, partnering with midwives and doulas, finding solutions to barriers to participation, and marketing about program eligibility.

Use the Extended Medicaid Postpartum Coverage

In response to the growing national focus on maternal health, the 2021 American Rescue Plan Act provided states with the unprecedented opportunity to extend Medicaid postpartum coverage from 60 days to 12 months postpartum. The vast majority of states have implemented this option which, while originally temporary, was made permanent in 2023 by the Consolidated Appropriations Act. For up-to-date information on which states have implemented this extension, please see KFF’s Medicaid Postpartum Coverage Extension Tracker or the National Academy for State Health Policy (NASHP)’s State Efforts to Extend Medicaid Postpartum Coverage Tracker.

This extension is one way that states have sought to address the maternal mortality crisis and provides a unique opportunity for postpartum Medicaid beneficiaries who had gestational diabetes to participate in the National DPP lifestyle change program in states where there is Medicaid coverage for the program. Prompt referrals and enrollment in the program could allow postpartum participants to complete the year-long program prior to losing Medicaid coverage. Given that many individuals will become eligible for Medicaid coverage again with subsequent pregnancies and the National DPP lifestyle change program likely would also decrease the risk of recurrent gestational diabetes, there are cost savings available to Medicaid by encouraging the use of this program during the postpartum period. To see which states currently have Medicaid coverage for the National DPP lifestyle change program, please see the Medicaid Coverage Landscape page on the Coverage Toolkit.

Partner with Midwives and Doulas

Health care provider referrals have consistently been shown to be one of the most effective ways to encourage participation in the National DPP lifestyle change program. In addition to primary care physicians and obstetricians, midwives and doulas could be used to connect the National DPP lifestyle change program as part of postpartum care. This concept is supported by national initiatives, such as the Centers for Medicare and Medicaid Services (CMS) Transforming Maternal Health (TMaH) Model, which, among other things, aims to increase access to midwives and doulas for prenatal and postpartum care. Midwives and doulas develop a relationship of trust with their patients throughout the course of pregnancy and delivery, and typically meet with their patients for longer visits. Midwives and doulas also often provide care with a prevention mindset and would likely be receptive to referring eligible postpartum participants to the program.

Another opportunity could be training midwives and doulas to participate directly in the program by becoming Lifestyle Coaches. Just as community health workers (CHWs) have been successful Lifestyle Coaches because of their understanding of the population they serve, the experience midwives and doulas have working with individuals during the postpartum period could make them well suited to adapting the program to meet the needs of this population.

Find Solutions to Barriers to Participation

Postpartum participants face unique barriers to participation in the National DPP lifestyle change program that should be considered. Common barriers faced by this population include:

The postpartum period can be a difficult, lonely time, and the National DPP lifestyle change program could have benefits beyond diabetes prevention by being a year-long support group and connection point to other services. While individuals with a previous gestational diabetes diagnosis could participate in any cohort of the National DPP lifestyle change program, CDC-recognized organizations and partners can tailor their outreach and program delivery to better resonate with this population and address these barriers to participation. For example, offering the program through online or distance learning delivery may make participation easier for some individuals. CDC-recognized organizations could also consider combining multiple participants who recently gave birth into a single cohort to help participants feel more supported. In cohorts comprised of postpartum individuals, CDC-recognized organizations may consider tailoring the program to include references to infant and postpartum care and providing program supports designed to meet the unique needs of this population, such as making childcare services available for participants or encouraging participants to bring their infants to the session with them. Lifestyle Coaches could also connect participants with other related resources, such as the Women, Infants, & Children (WIC) program, breastfeeding education and support, and programs on infant nutrition after breastfeeding. Additional information on meeting participants’ needs can be found on the Retention page of the Coverage Toolkit.

Additionally, systematic screening for health-related social needs (HRSN) could be incorporated into routine postpartum care in an effort to reduce barriers to participation in the program. Ensuring that the health care provider or organization has the capability to provide or direct individuals to needed resources would be essential to any postpartum HRSN screening initiative, as well as sharing with patients how their screening information will be used. Additional information on HRSN screening can be found on the Leveraging State and National Health Equity Initiatives page of the Coverage Toolkit.

Market Eligibility

As described earlier in the page, CDC’s eligibility criteria for the National DPP lifestyle change program includes persons with a previous diagnosis of gestational diabetes, and no additional testing is needed to refer individuals to the program. States and organizations can make it clear in their outreach and marketing materials that this population is eligible for the program. The following examples outline how this has been done in several states:

  • Virginia: The Virginia Department of Health’s diabetes prevention page and marketing materials (such as this provider resource) include mention of the National DPP lifestyle change program for persons with a previous gestational diabetes diagnosis.
  • Oregon: Oregon Health Authority specifies in their program materials, including in this Companion Guide, that people with a previous gestational diabetes diagnosis are eligible for the National DPP lifestyle change program.
  • Michigan: In Michigan, managed care organizations (MCOs) include individuals with a history of gestational diabetes in their initial outreach to eligible participants.

For additional information on eligibility for the National DPP lifestyle change program, please visit the Screening and Identification page of the Coverage Toolkit.

CDC-recognized organizations should note that while participants cannot be pregnant at the time of enrollment, organizations may allow participants who become pregnant during the program to continue participation at the discretion of their health care provider and the CDC-recognized organization. Since weight loss is not appropriate while pregnant, pregnant participants’ data, such as weight, should be excluded from the organizational analysis. In the case of a breastfeeding participant, the data should be collected and recorded as usual in accordance with the Diabetes Prevention Recognition Program (DPRP) Standards. Additional information on considerations for pregnant and breastfeeding participants can be found in CDC’s FAQ: Pregnant Participants.


Examples of Offering Diabetes Prevention Interventions to Individuals with a Previous Gestational Diabetes Diagnosis

The following table outlines several examples of states and organizations that have offered diabetes prevention interventions, including the National DPP lifestyle change program, to individuals with a previous gestational diabetes diagnosis.

Montana

Montana began by raising awareness among health care providers about the need for screening and referring individuals with a previous gestational diabetes diagnosis to the National DPP lifestyle change program. In the November 2013 Medicaid provider newsletter, they highlighted the low rates of postpartum screening for type 2 diabetes among Medicaid beneficiaries who had gestational diabetes. In 2017, Montana Department of Public Health and Human Services evaluated outcomes among women with and without a history of gestational diabetes enrolled in the National DPP lifestyle change program in Montana. The evaluation compared participation, self-monitoring behavior, weight loss, and cardiometabolic risk reduction and found that individuals with a previous gestational diabetes diagnosis can be highly successful in the program and achieve significant weight loss.

University of Kentucky

In 2015, the University of Kentucky began a National DPP lifestyle change program pilot for individuals with a history of gestational diabetes within the last five years. Recruitment for the pilot program included telephone outreach as well as in-person invitations to women attending pediatric, prenatal, or postpartum appointments. The evaluation of this pilot found in-person recruitment efforts to be more effective than telephone outreach. Due to the additional responsibilities faced postpartum and when parenting young children, the required time commitment of the program was cited as one of the main factors responsible for people not enrolling in the program and for program attrition. Lifestyle Coaches suggested that allowing participants to bring infants under one year old to the sessions or offering childcare for older children would have been beneficial for this population.

Balance After Baby

Balance After Baby was a web-based lifestyle intervention modified from the National DPP lifestyle change program for individuals with a previous gestational diabetes diagnosis. This program was developed through funding from CDC to address some of the common barriers (e.g., lack of time and energy, family demands, lack of childcare, etc.) faced by postpartum individuals through web-based delivery. Research from Brigham and Women’s Hospital in Boston, Massachusetts demonstrated the feasibility and efficacy of Balance After Baby to decrease postpartum weight retention in postpartum individuals with a previous gestational diabetes diagnosis.

Healthier You: NHS Diabetes Prevention Programme

In the United Kingdom, Healthier You: National Health Service (NHS) Diabetes Prevention Programme (DPP), a program similar to the National DPP lifestyle change program, expanded eligibility to include individuals with a previous gestational diabetes diagnosis.

The North London Integrated Care System shared a briefing and FAQ for providers that outlined the following key touchpoints to identify and refer individuals with a previous gestational diabetes diagnosis to the program:

  • During postnatal appointments, health care providers can
    • Review results of a postnatal glycemic check in women with gestational diabetes and refer those who meet eligibility criteria to the program
    • Make arrangements for yearly follow-ups with a glycemic check
  • Systematic searches of clinical systems for individuals with a history of gestational diabetes

Kaiser Permanente of Northern California

In 2011, Kaiser Permanente of Northern California examined the feasibility and potential value of a prenatal and postpartum diabetes prevention intervention, similar to the National DPP lifestyle change program. This pilot program was delivered by telephone to prenatal and postpartum women with a current or prior gestational diabetes diagnosis. The program was focused on modifying diet and physical activity, while also encouraging breastfeeding. The intervention was found to reduce type 2 diabetes and gestational diabetes risk factors among participants.

Content Updated: May 28, 2024