Publications by authors named "Samantha F Ehrlich"

35 Publications

Exercise During the First Trimester of Pregnancy and the Risks of Abnormal Screening and Gestational Diabetes Mellitus.

Diabetes Care 2021 Feb 21;44(2):425-432. Epub 2020 Dec 21.

Division of Research, Kaiser Permanente Northern California, Oakland, CA.

Objective: To estimate the effects of exercise during the first trimester on the risks of abnormal screening and gestational diabetes mellitus (GDM).

Research Design And Methods: Data come from PETALS, a prospectively followed pregnancy cohort ( = 2,246, 79% minorities) receiving care at Kaiser Permanente Northern California. A Pregnancy Physical Activity Questionnaire was used to assess exercise. Glucose testing results for screening and diagnostic tests were obtained from electronic health records. Inverse probability of treatment weighting and targeted maximum likelihood with data-adaptive estimation (machine learning) of propensity scores and outcome regressions were used to obtain causal risk differences adjusted for potential confounders, including prepregnancy BMI, exercise before pregnancy, and gestational weight gain. Exercise was dichotomized at ) the cohort's 75th percentile for moderate- to vigorous-intensity exercise (≥13.2 MET-h per week or ≥264 min per week of moderate exercise), ) current recommendations (≥7.5 MET-h per week or ≥150 min per week of moderate exercise), and ) any vigorous exercise.

Results: Overall, 24.3% and 6.5% had abnormal screening and GDM, respectively. Exercise meeting or exceeding the 75th percentile decreased the risks of abnormal screening and GDM by 4.8 (95% CI 1.1, 8.5) and 2.1 (0.2, 4.1) fewer cases per 100, respectively, in adjusted analyses.

Conclusions: Exercise reduces the risks of abnormal screening and GDM, but the amount needed to achieve these risk reductions is likely higher than current recommendations. Future interventions may consider promoting ≥38 min per day of moderate-intensity exercise to prevent GDM.
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http://dx.doi.org/10.2337/dc20-1475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818322PMC
February 2021

Diabetes risk status and physical activity in pregnancy: U.S. BRFSS 2011, 2013, 2015, 2017.

BMC Pregnancy Childbirth 2020 Nov 30;20(1):743. Epub 2020 Nov 30.

University of North Florida, Jacksonville, FL, USA.

Background: Pregnant women without complications are advised to engage in physical activity (PA) to mitigate adverse outcomes. Differences may exist among pregnant women of diverging diabetes status in meeting national PA recommendations. We sought to examine differences in aerobic activity (AA) and muscle strengthening activity (MSA) by diabetes risk status (DRS) among pregnant women in the United States.

Methods: The sample (n = 9,597) included pregnant women, age 18-44 years, who participated in the 2011, 2013, 2015, and 2017 Behavioral Risk Factor Surveillance System. Levels of DRS include: no diabetes (ND), high risk for diabetes (HRD) due to self-reported gestational diabetes or pre-diabetes, and overt diabetes due to self-reported, clinically diagnosed diabetes (DM). Odds ratios (ORs) and 95% confidence intervals (CI) for meeting PA recommendations were obtained. Covariates included age, race, education, household child count, alcohol consumption, and smoking status.

Results: Findings revealed that on average, DM had 46.5 fewer minutes of weekly AA compared to ND. Furthermore, a significantly lower OR (0.39; CI 0.19-0.82) for meeting both recommendations was observed in DM as compared to ND after adjustment.

Conclusions: We observed that pregnant women with overt diabetes had a lower odds of engaging in PA, while those at high risk were similar in their PA engagement to ND. Future studies aimed at assessing determinants of PA behavior may help guide efforts to promote exercise in pregnant women with diabetes.
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http://dx.doi.org/10.1186/s12884-020-03434-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7708155PMC
November 2020

Leisure-time aerobic physical activity and the risk of diabetes-related mortality: An analysis of effect modification by race-ethnicity.

J Diabetes Complications 2021 Jan 15;35(1):107763. Epub 2020 Oct 15.

Department of Kinesiology, Recreation and Sports Studies, University of Tennessee Knoxville, 1914 Andy Holt Avenue, Knoxville, TN 37996, United States of America.

Aims: To examine the relationship between aerobic moderate-to-vigorous intensity leisure-time physical activity (LTPA) and the risk of diabetes-related mortality in the NHANES III (1988-1994) while considering potential effect modification by race-ethnicity.

Methods: The study sample (n = 14,006) included adults, 20-79 years of age, with Mobile Examination Center (MEC) data. An age-standardized physical activity score (PAS) was calculated from the self-reported frequency and intensity of 12 leisure-time aerobic activities. Three categories of PA were examined: inactive (PAS = 0), insufficiently active (PAS >0-<10), and active (PAS ≥10). Diabetes-related mortality was defined as death from diabetes mellitus. Cox Proportional Hazard models were used all analyses.

Results: A statistically significant reduction in risk was found for insufficiently active (HR 0.59, 95% CI 0.40-0.90) and active non-Hispanic black (NHB) (HR 0.54, 95% CI 0.34-0.88). Among active non-Hispanic white (NHW), a similar pattern of risk reduction was found, however, this relationship was borderline significance (HR 0.59, 95% CI 0.35-1.02, p = 0.06).

Conclusions: Any volume of aerobic LTPA is beneficial in terms of reducing the risk of diabetes-related mortality. However, these benefits may differ by racial-ethnic group, with further research on health disparities in the area of PA being warranted.
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http://dx.doi.org/10.1016/j.jdiacomp.2020.107763DOI Listing
January 2021

A telehealth lifestyle intervention to reduce excess gestational weight gain in pregnant women with overweight or obesity (GLOW): a randomised, parallel-group, controlled trial.

Lancet Diabetes Endocrinol 2020 06;8(6):490-500

Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.

Background: Excess gestational weight gain (GWG) among women with overweight or obesity synergistically increases their already elevated risk of having gestational diabetes, a caesarean delivery, a large for gestational age infant, and post-partum weight retention, and increases their child's risk of obesity. We investigated whether a primarily telehealth lifestyle intervention reduced excess GWG among women with overweight or obesity.

Methods: We did a randomised controlled trial in five antenatal clinics of Kaiser Permanente; Oakland, San Leandro, Walnut Creek, Fremont, and Santa Clara, CA, USA. Women at 8-15 weeks' gestation with singletons, pre-pregnancy BMI 25·0-40·0 kg/m, and aged 18 years or older were randomly assigned (1:1) to receive the telehealth lifestyle intervention or usual antenatal care. Randomisation was adaptively balanced for age, BMI, and race and ethnicity. Data collectors and investigators were masked to group assignments. The core lifestyle intervention consisted of two in-person and 11 telephone sessions on behavioural strategies to improve weight, diet, and physical activity, and stress management to help women meet a trial goal of gaining at the lower limit of the Institute of Medicine (IOM) guidelines range for total GWG: 7 kg for women with overweight and 5 kg for women with obesity. Usual antenatal care included an antenatal visit at 7-10 weeks' gestation, an additional seven antenatal visits, on average, and periodic health education newsletters, including the IOM GWG guidelines and information on healthy eating and physical activity in pregnancy. The primary outcome was weekly rate of GWG expressed as excess GWG, per Institute of Medicine guidelines and mean assessed in the intention-to-treat population. The trial is registered at ClinicalTrials.gov, NCT02130232.

Findings: Between March 24, 2014, and Sept 26, 2017, 5329 women were assessed for eligibility and 200 were randomly assigned to the lifestyle intervention group and 198 to the usual care group. Analyses included 199 women in the lifestyle intervention group (one lost to follow-up) and 195 in the usual care group (three lost to follow-up). 96 (48%) women in the lifestyle intervention group and 134 (69%) women in the usual care group exceeded Institute of Medicine guidelines for rate of GWG per week (relative risk 0·70, 95% CI 0·59 to 0·83). Compared with usual care, women in the lifestyle intervention had reduced weekly rate of GWG (mean 0·26 kg per week [SD 0·15] vs 0·32 kg per week [0·13]; mean between-group difference -0·07 kg per week, 95% CI -0·09 to -0·04). No between-group differences in perinatal complications were observed.

Interpretation: Our evidence-based programme showed that health-care delivery systems could further adapt to meet the needs of their clinical settings to prevent excess GWG and improve healthy behaviours and markers of insulin resistance among women with overweight or obesity by using telehealth lifestyle interventions.

Funding: US National Institutes of Health.
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http://dx.doi.org/10.1016/S2213-8587(20)30107-8DOI Listing
June 2020

Exercise During the First Trimester and Infant Size at Birth: Targeted Maximum Likelihood Estimation of the Causal Risk Difference.

Am J Epidemiol 2020 02;189(2):133-145

Division of Research, Kaiser Permanente Northern California, Oakland, California.

This cohort study sought to estimate the differences in risk of delivering infants who were small or large for gestational age (SGA or LGA, respectively) according to exercise during the first trimester of pregnancy (vs. no exercise) among 2,286 women receiving care at Kaiser Permanente Northern California in 2013-2017. Exercise was assessed by questionnaire. SGA and LGA were determined by the sex- and gestational-age-specific birthweight distributions of the 2017 US Natality file. Risk differences were estimated by targeted maximum likelihood estimation, with and without data-adaptive prediction (machine learning). Analyses were also stratified by prepregnancy weight status. Overall, exercise at the cohort-specific 75th percentile was associated with an increased risk of SGA of 4.5 (95% CI: 2.1, 6.8) per 100 births, and decreased risk of LGA of 2.8 (95% CI: 0.5, 5.1) per 100 births; similar findings were observed among the underweight and normal-weight women, but no associations were found among those with overweight or obesity. Meeting Physical Activity Guidelines was associated with increased risk of SGA and decreased risk of LGA but only among underweight and normal-weight women. Any vigorous exercise reduced the risk of LGA in underweight and normal-weight women only and was not associated with SGA risk.
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http://dx.doi.org/10.1093/aje/kwz213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156138PMC
February 2020

Diagnostic thresholds for pregnancy hyperglycemia, maternal weight status and the risk of childhood obesity in a diverse Northern California cohort using health care delivery system data.

PLoS One 2019 10;14(5):e0216897. Epub 2019 May 10.

Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America.

Objective: To estimate the risk of childhood obesity associated with the various criteria proposed for diagnosis of gestational diabetes (GDM), and the joint effects with maternal BMI.

Methods: Cohort study of 46,396 women delivering at the Kaiser Permanente Northern California health care delivery system in 1995-2004 and their offspring, followed through 5-7 years of age. Pregnancy hyperglycemia was categorized according to the screening and oral glucose tolerance test values proposed for the diagnosis of GDM by the International Association of the Diabetes and Pregnancy Study Group (IADPSG), Carpenter Coustan (CC), and the National Diabetes Data Group (NDDG). Childhood obesity was defined by the International Obesity Task Force's age and sex-specific BMI cut-offs. Poisson regression models estimated the risks of childhood obesity associated with each category of pregnancy glycemia compared to normal screening, and the joint effects of maternal BMI category and GDM by the CC and the IADPSG criteria.

Results: Compared with normal screening, increased risks of childhood obesity were observed for abnormal screening [RR (95% CI): 1.30 (1.22, 1.38)], 1+ abnormal values by the IADPSG or CC [1.47 (1.36, 1.59) and 1.48 (1.37, 1.59), respectively], and 2+ values by CC or NDDG [1.52 (1.39, 1.67) and 1.60 (1.43, 1.78), respectively]. Compared to obese women without GDM, obese women with GDM defined by the CC criteria had significantly increased risk of childhood obesity [1.20 (1.07, 1.34)], which was also observed for GDM by the IADSPG [1.18 (1.07, 1.30)], though GDM did not significantly increase the risk of childhood obesity among normal weight or overweight women.

Conclusions: The risk of childhood obesity starts to increase at levels of pregnancy glycemia below those used to diagnose GDM and the effect of GDM on childhood obesity risk appears more pronounced in women with obesity. Interventions to reduce obesity and pregnancy hyperglycemia are warranted.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0216897PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6510476PMC
January 2020

Gestational weight gain and optimal wellness (GLOW): rationale and methods for a randomized controlled trial of a lifestyle intervention among pregnant women with overweight or obesity.

BMC Pregnancy Childbirth 2019 Apr 30;19(1):145. Epub 2019 Apr 30.

Division of Research, Kaiser Permanente Northern California, Oakland, CA, 94612, USA.

Background: Excess gestational weight gain (GWG) is common among women with overweight or obesity, increasing their risks for pregnancy complications, delivering a large infant, and postpartum weight retention. To date, only intensive interventions have had success and few interventions have been designed for implementation in healthcare settings.

Methods: We describe the development, rationale, and methods of GLOW (GestationaL Weight Gain and Optimal Wellness), a randomized controlled trial evaluating the efficacy of a lifestyle intervention to prevent excess GWG among racially/ethnically diverse women with overweight or obesity in an integrated healthcare delivery system. Participants in Kaiser Permanente Northern California will be randomized, within 2 weeks of completing a study baseline clinic visit at 10 weeks' gestation, to either usual medical care or a multi-component pregnancy lifestyle intervention adapted from the Diabetes Prevention Program (target N = 400). Informed by focus groups with patients and designed to be feasible in a clinical setting, the intervention will include 13 weekly individual sessions (11 delivered by telephone) focused on behavior change for weight management, healthy eating, physical activity, and stress management. Outcomes will be assessed in women and their infants from randomization to 12 months postpartum. The primary outcome is GWG. Secondary outcomes include changes in diet and physical activity during pregnancy and infant birthweight. Exploratory outcomes include cardiometabolic profile assessed via pregnancy blood samples and cord blood samples; and postpartum weight retention and infant anthropometrics up to 12 months of age. The trial includes systematic approaches to enhance intervention fidelity, intervention adherence, and participant retention in trial assessments.

Discussion: GLOW is among few trials targeting excess GWG among diverse women with overweight or obesity in a healthcare setting, with long-term maternal and infant outcomes assessed up to 12 months after delivery. This evaluation of a multi-component intervention is designed to produce generalizable results to inform potential adoption of the intervention in clinical settings.

Trial Registration: ClinicalTrials.gov ( NCT02130232 ): submitted April 30, 2014; posted May 5, 2014.
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http://dx.doi.org/10.1186/s12884-019-2293-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492416PMC
April 2019

Dietary Quality and Glycemic Control Among Women with Gestational Diabetes Mellitus.

J Womens Health (Larchmt) 2019 02 30;28(2):178-184. Epub 2018 Oct 30.

3 Division of Research, Kaiser Permanente Northern California , Oakland, California.

Background/objective: Poor dietary quality, measured by the Healthy Eating Index 2010 (HEI-2010), is associated with risk of gestational diabetes mellitus (GDM) and type 2 diabetes. The aim was to investigate the association between dietary quality and glycemic control in women with GDM.

Materials And Methods: The study included 1220 women with GDM. Dietary quality was calculated by HEI-2010 score from a Food Frequency Questionnaire administered shortly after GDM diagnosis; higher scores indicate higher dietary quality. Subsequent glycemic control was defined as ≥80% of all capillary glucose measurements meeting recommended clinical targets below 95 mg/dL for fasting, and below 140 mg/dL 1-hour glucose after meals.

Results: As compared with Quartile 1 of HEI-2010 score, Quartiles 2, 3, and 4 showed increased adjusted odds of overall optimal glycemic control (odds ratio [95% confidence interval] 1.90 [1.34-2.70], 1.77 [1.25-2.52], and 1.55 [1.09-2.20], respectively). Increased odds of glycemic control were observed in Quartiles 2, 3, and 4 as compared with Quartile 1 of HEI-2010 score for 1-hour postbreakfast and 1-hour postdinner. Mean capillary glucose was lower in Quartiles 2, 3, and 4 of HEI-2010 score when compared with Quartile 1 for 1-hour postdinner (p = 0.03).

Conclusions: Clinicians should be aware that even a small improvement in diet quality may be beneficial for the achievement of improved glycemic control in women with GDM.

Trial Registration: Clinical Trials.gov number, NCT01344278.
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http://dx.doi.org/10.1089/jwh.2017.6788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6390645PMC
February 2019

A Pre-Pregnancy Biomarker Risk Score Improves Prediction of Future Gestational Diabetes.

J Endocr Soc 2018 Oct 13;2(10):1158-1169. Epub 2018 Sep 13.

Division of Research, Kaiser Permanente Northern California, Oakland, California.

Context: Previous studies have not examined the ability of multiple preconception biomarkers, considered together, to improve prediction of gestational diabetes mellitus (GDM).

Objective: To develop a preconception biomarker risk score and assess its association with subsequent GDM.

Design: A nested case-control study among a cohort of women with serum collected as part of a health examination (1984 to 1996) and subsequent pregnancy (1984 to 2009). Biomarkers associated with GDM were dichotomized into high/low risk.

Setting: Integrated health care system.

Participants: Two controls were matched to each GDM case (n = 256 cases) on year and age at examination, age at pregnancy, and number of pregnancies between examination and index pregnancy.

Main Outcome Measure: GDM.

Results: High-risk levels of sex hormone-binding globulin (SHBG; <44.2 nM), glucose (>90 mg/dL), total adiponectin (<7.2 μg/mL), and homeostasis model assessment-estimated insulin resistance (>3.9) were independently associated with 2.34 [95% confidence interval (CI): 1.50, 3.63], 2.03 (95% CI: 1.29, 3.19), 1.83 (95% CI: 1.16, 2.90), and 1.67 (95% CI: 1.07, 2.62) times the odds of GDM and included in the biomarker risk score. For each unit increase in the biomarker risk score, odds of GDM were 1.94 times greater (95% CI: 1.59, 2.36). A biomarker risk score including only SHBG and glucose was sufficient to improve prediction beyond established risk factors (age, race/ethnicity, body mass index, family history of diabetes, previous GDM; area under the curve = 0.73 vs 0.67, = 0.002).

Conclusions: The improved, predictive ability of the biomarker risk score beyond established risk factors suggests clinical use of the biomarker risk score in identifying women at risk for GDM before conception for targeted prevention strategies.
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http://dx.doi.org/10.1210/js.2018-00200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6169465PMC
October 2018

A Cohort Study of Metformin and Colorectal Cancer Risk among Patients with Diabetes Mellitus.

Cancer Epidemiol Biomarkers Prev 2018 05;27(5):525-530

Division of Research, Kaiser Permanente Northern California, Oakland, California.

Several epidemiologic studies have reported strong inverse associations between metformin use and risk of colorectal cancer, although time-related biases, such as immortal time bias, may in part explain these findings. We reexamined this association using methods to minimize these biases. A cohort study was conducted among 47,351 members of Kaiser Permanente Northern California with diabetes and no history of cancer or metformin use. Follow-up for incident colorectal cancer occurred from January 1, 1997, until June 30, 2012. Cox regression was used to calculate HRs and 95% confidence intervals (CIs) for colorectal cancer risk associated with metformin use (ever use, total duration, recency of use, and cumulative dose). No association was observed between ever use of metformin and colorectal cancer risk (HR, 0.90; 95% CI, 0.76-1.07) and there was no consistent pattern of decreasing risk with increasing total duration, dose, or recency of use. However, long-term use (≥5.0 years) appeared to be associated with reduced risk of colorectal cancer in the full population (HR, 0.78; 95% CI, 0.60-1.02), among current users (HR, 0.78; 95% CI, 0.59-1.04), and in men (HR, 0.65; 95% CI, 0.45-0.94) but not in women. Higher cumulative doses of metformin were associated with reduced risk. In initial users of sulfonylureas, switching to or adding metformin was also associated with decreased colorectal cancer risk. Our findings showed an inverse association between long-term use of metformin and colorectal cancer risk. Findings, especially the risk reduction among men, need to be confirmed in large, well-conducted studies. If our findings are confirmed, metformin may have a role in the chemoprevention of colorectal cancer. .
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http://dx.doi.org/10.1158/1055-9965.EPI-17-0424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935125PMC
May 2018

A Tailored Letter Based on Electronic Health Record Data Improves Gestational Weight Gain Among Women With Gestational Diabetes Mellitus: The Gestational Diabetes' Effects on Moms (GEM) Cluster-Randomized Controlled Trial.

Diabetes Care 2018 07 18;41(7):1370-1377. Epub 2018 Apr 18.

Division of Research, Kaiser Permanente Northern California, Oakland, CA.

Objective: Evaluate whether a tailored letter improved gestational weight gain (GWG) and whether GWG mediated a multicomponent intervention's effect on postpartum weight retention among women with gestational diabetes mellitus (GDM).

Research Design And Methods: A cluster-randomized controlled trial of 44 medical facilities ( = 2,014 women) randomized to usual care or a multicomponent lifestyle intervention delivered during pregnancy (tailored letter) and postpartum (13 telephone sessions) to reduce postpartum weight retention. The tailored letter, using electronic health record (EHR) data, recommended an end-of-pregnancy weight goal tailored to prepregnancy BMI and GWG trajectory at GDM diagnosis: total GWG at the lower limit of the IOM range if BMI ≥18.5 kg/m or the midpoint if <18.5 kg/m and weight maintenance if women had exceeded this. The outcomes for this study were the proportion of women meeting the Institute of Medicine (IOM) guidelines for weekly rate of GWG from GDM diagnosis to delivery and meeting the end-of-pregnancy weight goal.

Results: The tailored letter significantly increased the proportion of women meeting the IOM guidelines (72.6% vs. 67.1%; relative risk 1.08 [95% CI 1.01-1.17]); results were similar among women with BMI <25.0 kg/m (1.07 [1.00-1.15]) and ≥25.0 kg/m (1.08 [0.98-1.18]). Thirty-six percent in the intervention vs. 33.0% in usual care met the end-of-pregnancy weight goal (1.08 [0.99-1.18]); the difference was statistically significant among women with BMI <25.0 kg/m (1.28 [1.05-1.57]) but not ≥25.0 kg/m (0.99 [0.87-1.13]). Meeting the IOM guidelines mediated the effect of the multicomponent intervention in reducing postpartum weight retention by 24.6% (11.3-37.8%).

Conclusions: A tailored EHR-based letter improved GWG, which mediated the effect of a multicomponent intervention in reducing postpartum weight retention.
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http://dx.doi.org/10.2337/dc17-1133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6463614PMC
July 2018

Neonatal Abstinence Syndrome in East Tennessee: Characteristics and Risk Factors among Mothers and Infants in One Area of Appalachia.

J Health Care Poor Underserved 2017 ;28(4):1393-1408

Objective: To describe the epidemiology of neonatal abstinence syndrome (NAS) in a 16-county Appalachian area of eastern Tennessee.

Methods: The Tennessee Surveillance System for NAS provided data on maternal sources of opioids. Data linking hospital discharge diagnosis for NAS to birth certificate data allowed us to compare maternal, delivery, and infant characteristics for NAS births with those for non-NAS births.

Results: There were 339 cases of NAS in 2013 and 367 in 2014, for NAS rates of 25.5 and 28.5 per 1,000 live births, respectively. When compared with the state overall, mothers of NAS infants in eastern Tennessee were more likely to use opioids that had been prescribed to another person. There were numerous maternal, infant, and delivery characteristics that were significantly different for NAS births compared with non-NAS births.

Conclusion: Neonatal abstinence syndrome is epidemic in the eastern Tennessee area of Appalachia, with unique maternal and infant characteristics that have important implications for primary, secondary, and tertiary prevention.
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http://dx.doi.org/10.1353/hpu.2017.0122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5706557PMC
July 2018

Protective role of physical activity on type 2 diabetes: Analysis of effect modification by race-ethnicity.

J Diabetes 2018 Feb 4;10(2):166-178. Epub 2017 Jul 4.

Department of Kinesiology, Recreation and Sports Studies, University of Tennessee, Knoxville, Tennessee, USA.

Background: It is well known physical activity (PA) plays a role in the prevention of type 2 diabetes (T2D). However, the extent to which PA may affect T2D risk among different race-ethnic groups is unknown. Therefore, the aim of the present study was to systematically examine the effect modification of race-ethnicity on PA and T2D.

Methods: The PubMed and Embase databases were systematically searched through June 2016. Study assessment for inclusion was conducted in three phases: title review (n = 13 022), abstract review (n = 2200), and full text review (n = 265). In all, 27 studies met the inclusion criteria and were used in the analysis. Relative risks (RRs) and 95% confidence intervals (CIs) were extracted and analyzed using Comprehensive Meta-Analysis software. All analyses used a random-effects model.

Results: A significant protective summary RR, comparing the most active group with the least active PA group, was found for non-Hispanic White (RR 0.71, 95% CI 0.60-0.85), Asians (RR 0.76, 95% CI 0.67-0.85), Hispanics (RR 0.75, 95% CI 0.64-0.89), and American Indians (RR 0.73, 95% CI 0.60-0.88). The summary effect for non-Hispanic Blacks (RR 0.91, 95% CI 0.76-1.08) was not significant.

Conclusions: The results of the present study indicate that PA (comparing most to least active groups) provides significant protection from T2D, with the exception of non-Hispanic Blacks. The results also indicate a need for race-ethnicity-specific reporting of RRs in prospective cohort studies that incorporate multiethnic samples.
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http://dx.doi.org/10.1111/1753-0407.12574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701882PMC
February 2018

Perceived psychosocial stress and gestational weight gain among women with gestational diabetes.

PLoS One 2017 28;12(3):e0174290. Epub 2017 Mar 28.

Kaiser Permanente Division of Research, Oakland, California, United States of America.

Growing evidence links perceived stress-a potentially modifiable psychosocial risk factor-with health behaviors and obesity. Yet little is known about the relationship between stress during pregnancy and gestational weight gain, particularly among women with pregnancy complications. We conducted a cross-sectional analysis to examine associations between psychosocial stress during pregnancy and gestational weight gain among women with gestational diabetes. We used baseline data from the Gestational Diabetes's Effects on Moms (GEM) study: 1,353 women with gestational diabetes who delivered a term singleton within Kaiser Permanente Northern California were included. Perceived stress near the time of gestational diabetes diagnosis was measured using the validated Perceived Stress Scale (PSS10). Gestational weight gain was categorized according to the 2009 Institute of Medicine recommendations. Binomial regression analyses adjusted for gestational age and maternal age at the time of gestational diabetes diagnosis, and race/ethnicity and estimated rate ratios (RR) and their 95% confidence interval (CI). Among women with a normal pregravid Body Mass Index (BMI 18.5-24.9 kg/m2), there was a significant association between high (Q4) PSS score and risk of both exceeding and gaining below the Institute of Medicine recommendations compared to those with lower stress (Q1) [adjusted RR = 2.16 95% CI 1.45-3.21; RR = 1.39 95% CI 1.01-1.91, respectively.] Among women with pregravid overweight/obesity (BMI≥25 kg/m2), there was no association. Although the temporal relationship could not be established from this study, there may be a complex interplay between psychosocial stress and gestational weight gain among women with gestational diabetes. Further studies examining stress earlier in pregnancy, risk of developing gestational diabetes and excess/inadequate gestational weight gain are warranted to clarify these complex relationships.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0174290PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369756PMC
September 2017

A Population Health Driver Diagram to Address Neonatal Abstinence Syndrome.

J Public Health Manag Pract 2017 Nov/Dec;23(6):e21-e24

Department of Public Health, University of Tennessee, Knoxville, Tennessee (Drs Erwin, Meschke, and Ehrlich); and Public Health Foundation, Washington, District of Columbia (Dr Moran).

This article describes the process for developing a population health driver diagram to address a priority health issue in East Tennessee: neonatal abstinence syndrome (NAS). Population health driver diagrams are used in quality improvement processes for determining and aligning actions that a community can take to achieve a specified outcome. The Tennessee Department of Health contracted with the University of Tennessee's Department of Public Health to conduct a community participatory process to contribute to a statewide health improvement plan. Colleagues in local public health practice identified NAS as the leading perinatal health issue, and community engagement was achieved by involving community health councils. Qualitative and quantitative data were collected, analyzed, and provided to these councils. A region-wide stakeholders' meeting resulted in the development of a population health driver diagram to address NAS. We describe this process and provide lessons learned that can be valuable in other settings. Population health diagrams have important implications for practice because of their use as a framework for community action, especially in the context of a community health assessment.
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http://dx.doi.org/10.1097/PHH.0000000000000533DOI Listing
June 2018

Trends and racial and ethnic disparities in the prevalence of pregestational type 1 and type 2 diabetes in Northern California: 1996-2014.

Am J Obstet Gynecol 2017 Feb 15;216(2):177.e1-177.e8. Epub 2016 Oct 15.

Division of Research, Kaiser Permanente of Northern California, Oakland, CA. Electronic address:

Background: Despite concern for adverse perinatal outcomes in women with diabetes mellitus before pregnancy, recent data on the prevalence of pregestational type 1 and type 2 diabetes mellitus in the United States are lacking.

Objective: The purpose of this study was to estimate changes in the prevalence of overall pregestational diabetes mellitus (all types) and pregestational type 1 and type 2 diabetes mellitus and to estimate whether changes varied by race-ethnicity from 1996-2014.

Study Design: We conducted a cohort study among 655,428 pregnancies at a Northern California integrated health delivery system from 1996-2014. Logistic regression analyses provided estimates of prevalence and trends.

Results: The age-adjusted prevalence (per 100 deliveries) of overall pregestational diabetes mellitus increased from 1996-1999 to 2012-2014 (from 0.58 [95% confidence interval, 0.54-0.63] to 1.06 [95% confidence interval, 1.00-1.12]; P <.0001). Significant increases occurred in all racial-ethnic groups; the largest relative increase was among Hispanic women (121.8% [95% confidence interval, 84.4-166.7]); the smallest relative increase was among non-Hispanic white women (49.6% [95% confidence interval, 27.5-75.4]). The age-adjusted prevalence of pregestational type 1 and type 2 diabetes mellitus increased from 0.14 (95% confidence interval, 0.12-0.16) to 0.23 (95% confidence interval, 0.21-0.27; P <.0001) and from 0.42 (95% confidence interval, 0.38-0.46) to 0.78 (95% confidence interval, 0.73-0.83; P <.0001), respectively. The greatest relative increase in the prevalence of type 1 diabetes mellitus was in non-Hispanic white women (118.4% [95% confidence interval, 70.0-180.5]), who had the lowest increases in the prevalence of type 2 diabetes mellitus (13.6% [95% confidence interval, -8.0 to 40.1]). The greatest relative increase in the prevalence of type 2 diabetes mellitus was in Hispanic women (125.2% [95% confidence interval, 84.8-174.4]), followed by African American women (102.0% [95% confidence interval, 38.3-194.3]) and Asian women (93.3% [95% confidence interval, 48.9-150.9]).

Conclusions: The prevalence of overall pregestational diabetes mellitus and pregestational type 1 and type 2 diabetes mellitus increased from 1996-1999 to 2012-2014 and racial-ethnic disparities were observed, possibly because of differing prevalence of maternal obesity. Targeted prevention efforts, preconception care, and disease management strategies are needed to reduce the burden of diabetes mellitus and its sequelae.
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http://dx.doi.org/10.1016/j.ajog.2016.10.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5290002PMC
February 2017

Lifestyle behaviors and ethnic identity among diverse women at high risk for type 2 diabetes.

Soc Sci Med 2016 07 14;160:87-93. Epub 2016 May 14.

Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States.

Background: Diet and physical activity lifestyle behaviors are modifiable risk factors for type 2 diabetes and are shaped by culture, potentially influencing diabetes health disparities.

Objectives: We examined whether ethnic identity-the strength of attachment to one's ethnic group, and a long-standing focus of psychological research-could help account for variations in lifestyle behaviors within a diverse population at high risk for chronic disease.

Methods: Using data from the Gestational Diabetes' Effects on Moms trial, this US-based cross-sectional study included 1463 pregnant women (74% from minority ethnic/racial groups; 46% born outside the US) with gestational diabetes (GDM), a common pregnancy complication conferring high risk for type 2 diabetes after delivery. Mixed linear regression models examined whether ethnic identity is associated with lifestyle behaviors after adjusting for demographic, clinical, and acculturative characteristics (e.g., nativity and length of residence in the US).

Results: In the overall sample, a one-unit increase in ethnic identity score was significantly associated with 3% greater fiber intake, 4% greater fruit/vegetable intake, 11% greater total activity, and 11% greater walking (p values < 0.01). Within ethnic/racial groups, a one-unit increase in ethnic identity score was significantly associated with 17% greater fiber intake among Filipina women; 5% lower total caloric intake among non-Hispanic White women; and 40% greater total activity, 35% greater walking, and 8% greater total caloric intake among Latina women (p values ≤ 0.03).

Conclusion: Results from this large study suggest that ethnic group attachment is associated with some lifestyle behaviors, independent of acculturation indicators, among young women with GDM who are at high risk for type 2 diabetes. Stronger ethnic identity may promote certain choices known to be associated with reduced risk of type 2 diabetes. Prospective research is needed to clarify the temporal nature of associations between ethnic identity and modifiable diabetes risk factors.
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http://dx.doi.org/10.1016/j.socscimed.2016.05.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4912226PMC
July 2016

Moderate and Vigorous Intensity Exercise During Pregnancy and Gestational Weight Gain in Women with Gestational Diabetes.

Matern Child Health J 2016 06;20(6):1247-57

Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.

Objectives To estimate the associations of moderate and vigorous intensity exercise during pregnancy with the rate of gestational weight gain (GWG) from gestational diabetes (GDM) diagnosis to delivery, overall and stratified by prepregnancy overweight/obesity. Methods Prospective cohort study with physical activity reported shortly after the GDM diagnosis and prepregnancy weight and post-diagnosis GWG obtained from electronic health records (n = 1055). Multinomial logistic regression models in the full cohort and stratified by prepregnancy overweight/obesity estimated associations of moderate and vigorous intensity exercise with GWG below and above the Institute of Medicine's (IOM) prepregnancy BMI-specific recommended ranges for weekly rate of GWG in the second and third trimesters. Results In the full cohort, any participation in vigorous intensity exercise was associated with decreased odds of GWG above recommended ranges as compared to no participation [odds ratio (95 % confidence interval): 0.63 (0.40, 0.99)], with a significant trend for decreasing odds of excess GWG with increasing level of vigorous intensity exercise. Upon stratification by prepregnancy overweight/obesity, significant associations were only observed for BMI ≥ 25.0 kg/m(2): any vigorous intensity exercise, as compared to none, was associated with 54 % decreased odds of excess GWG [0.46 (0.27, 0.79)] and significant trends were detected for decreasing odds of GWG both below and above the IOM's recommended ranges with increasing level of vigorous exercise (both P ≤ 0.03). No associations were observed for moderate intensity exercise. Conclusions for Practice In women with GDM, particularly overweight and obese women, vigorous intensity exercise during pregnancy may reduce the odds of excess GWG.
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http://dx.doi.org/10.1007/s10995-016-1926-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5019099PMC
June 2016

The Comparative Effectiveness of Diabetes Prevention Strategies to Reduce Postpartum Weight Retention in Women With Gestational Diabetes Mellitus: The Gestational Diabetes' Effects on Moms (GEM) Cluster Randomized Controlled Trial.

Diabetes Care 2016 Jan 9;39(1):65-74. Epub 2015 Dec 9.

Division of Research, Kaiser Permanente Northern California, Oakland, CA.

Objective: To compare the effectiveness of diabetes prevention strategies addressing postpartum weight retention for women with gestational diabetes mellitus (GDM) delivered at the health system level: mailed recommendations (usual care) versus usual care plus a Diabetes Prevention Program (DPP)-derived lifestyle intervention.

Research Design And Methods: This study was a cluster randomized controlled trial of 44 medical facilities (including 2,280 women with GDM) randomized to intervention or usual care. The intervention included mailed gestational weight gain recommendations plus 13 telephone sessions between 6 weeks and 6 months postpartum. Primary outcomes included the following: proportion meeting the postpartum goals of 1) reaching pregravid weight if pregravid BMI <25.0 kg/m(2) or 2) losing 5% of pregravid weight if BMI ≥25.0 kg/m(2); and pregravid to postpartum weight change.

Results: On average, over the 12-month postpartum period, women in the intervention had significantly higher odds of meeting weight goals than women in usual care (odds ratio [OR] 1.28 [95% CI 1.10, 1.47]). The proportion meeting weight goals was significantly higher in the intervention than usual care at 6 weeks (25.5 vs. 22.4%; OR 1.17 [1.01, 1.36]) and 6 months (30.6 vs. 23.9%; OR 1.45 [1.14, 1.83]). Condition differences were reduced at 12 months (33.0 vs. 28.0%; OR 1.25 [0.96, 1.62]). At 6 months, women in the intervention retained significantly less weight than women in usual care (mean 0.39 kg [SD 5.5] vs. 0.95 kg [5.5]; mean condition difference -0.64 kg [95% CI -1.13, -0.14]) and had greater increases in vigorous-intensity physical activity (mean condition difference 15.4 min/week [4.9, 25.8]).

Conclusions: A DPP-derived lifestyle intervention modestly reduced postpartum weight retention and increased vigorous-intensity physical activity.
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http://dx.doi.org/10.2337/dc15-1254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4686847PMC
January 2016

Pioglitazone Use and Risk of Bladder Cancer and Other Common Cancers in Persons With Diabetes.

JAMA 2015 Jul;314(3):265-77

Division of Research, Kaiser Permanente Northern California, Oakland.

Importance: Studies suggest pioglitazone use may increase risk of cancers.

Objective: To examine whether pioglitazone use for diabetes is associated with risk of bladder and 10 additional cancers.

Design, Setting, And Participants: Cohort and nested case-control analyses among persons with diabetes. A bladder cancer cohort followed 193,099 persons aged 40 years or older in 1997-2002 until December 2012; 464 case patients and 464 matched controls were surveyed about additional confounders. A cohort analysis of 10 additional cancers included 236,507 persons aged 40 years or older in 1997-2005 and followed until June 2012. Cohorts were from Kaiser Permanente Northern California.

Exposures: Ever use, duration, cumulative dose, and time since initiation of pioglitazone as time dependent.

Main Outcomes And Measures: Incident cancer, including bladder, prostate, female breast, lung/bronchus, endometrial, colon, non-Hodgkin lymphoma, pancreas, kidney/renal pelvis, rectum, and melanoma.

Results: Among 193,099 persons in the bladder cancer cohort, 34,181 (18%) received pioglitazone (median duration, 2.8 years; range, 0.2-13.2 years) and 1261 had incident bladder cancer. Crude incidences of bladder cancer in pioglitazone users and nonusers were 89.8 and 75.9 per 100,000 person-years, respectively. Ever use of pioglitazone was not associated with bladder cancer risk (adjusted hazard ratio [HR], 1.06; 95% CI, 0.89-1.26). Results were similar in case-control analyses (pioglitazone use: 19.6% among case patients and 17.5% among controls; adjusted odds ratio, 1.18; 95% CI, 0.78-1.80). In adjusted analyses, there was no association with 8 of the 10 additional cancers; ever use of pioglitazone was associated with increased risk of prostate cancer (HR, 1.13; 95% CI, 1.02-1.26) and pancreatic cancer (HR, 1.41; 95% CI, 1.16-1.71). Crude incidences of prostate and pancreatic cancer in pioglitazone users vs nonusers were 453.3 vs 449.3 and 81.1 vs 48.4 per 100,000 person-years, respectively. No clear patterns of risk for any cancer were observed for time since initiation, duration, or dose.

Conclusions And Relevance: Pioglitazone use was not associated with a statistically significant increased risk of bladder cancer, although an increased risk, as previously observed, could not be excluded. The increased prostate and pancreatic cancer risks associated with ever use of pioglitazone merit further investigation to assess whether they are causal or are due to chance, residual confounding, or reverse causality.
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http://dx.doi.org/10.1001/jama.2015.7996DOI Listing
July 2015

Outreach to diversify clinical trial participation: A randomized recruitment study.

Clin Trials 2015 Jun 2;12(3):205-11. Epub 2015 Feb 2.

Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.

Background/aims: Racial and ethnic minorities remain underrepresented in clinical research, yet few recruitment strategies have been rigorously evaluated.

Methods: We experimentally tested whether targeted recruitment letters acknowledging diabetes health disparities and health risks specific to recipients' racial/ethnic group improved two metrics of trial participation: willingness to be screened and enrollment. This experiment was efficiently nested within a randomized clinical trial examining a preventive lifestyle intervention among women at high risk for diabetes. Pregnant women with gestational diabetes or impaired glucose tolerance (N = 445) were randomized to receive a targeted recruitment letter with health risk information specific to their racial/ethnic group (n = 216), or a standard letter with risk information for the general population (n = 229). All letters were bilingual in English and Spanish.

Results: The targeted as compared to the standard letter did not improve screening or enrollment rates overall or within separate racial/ethnic groups. Among Latina women who preferred Spanish, the targeted letter showed trends for improved screening (66.7% vs 33.3%, p = .06) and enrollment rates (38.9% vs 13.3%, p = .13). In contrast, among Latina women who preferred English, the targeted letter significantly lowered screening (29.6% vs 57.1%, p = .04) and showed trends for lowered enrollment rates (25.9% vs 50.0%, p = .07).

Conclusion: Results from this randomized study appear to suggest that recruitment letters with diabetes health risk information targeted to recipients' race/ethnicity may improve one metric of clinical trial participation among Latina women who prefer Spanish, but not English. Larger experimental studies, incorporating input from diverse participant stakeholders, are needed to develop evidence-based minority recruitment strategies.
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http://dx.doi.org/10.1177/1740774514568125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4424096PMC
June 2015

Metformin use and lung cancer risk in patients with diabetes.

Cancer Prev Res (Phila) 2015 Feb;8(2):174-9

Division of Research, Kaiser Permanente Northern California, Oakland, California.

Methodologic biases may explain why observational studies examining metformin use in relation to lung cancer risk have produced inconsistent results. We conducted a cohort study to further investigate this relationship, accounting for potential biases. For 47,351 patients with diabetes ages ≥40 years, who completed a health-related survey administered between 1994 and 1996, data on prescribed diabetes medications were obtained from electronic pharmacy records. Follow-up for incident lung cancer occurred from January 1, 1997, until June 30, 2012. Using Cox regression, we estimated lung cancer risk associated with new use of metformin, along with total duration, recency, and cumulative dose (all modeled as time-dependent covariates), adjusting for potential confounding factors. During 428,557 person-years of follow-up, 747 patients were diagnosed with lung cancer. No association was found with duration, dose, or recency of metformin use and overall lung cancer risk. Among never smokers, however, ever use was inversely associated with lung cancer risk [HR, 0.57; 95% confidence interval (CI), 0.33-0.99], and risk appeared to decrease monotonically with longer use (≥5 years: HR, 0.48; 95% CI, 0.21-1.09). Among current smokers, corresponding risk estimates were >1.0, although not statistically significant. Consistent with this variation in effect by smoking history, longer use was suggestively associated with lower adenocarcinoma risk (HR, 0.69; 95% CI, 0.40-1.17), but higher small cell carcinoma risk (HR, 1.82; 95% CI, 0.85-3.91). In this population, we found no evidence that metformin use affects overall lung cancer risk. The observed variation in association by smoking history and histology requires further confirmation.
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http://dx.doi.org/10.1158/1940-6207.CAPR-14-0291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4316372PMC
February 2015

Maternal gestational weight gain and offspring risk for childhood overweight or obesity.

Am J Obstet Gynecol 2014 Sep 13;211(3):259.e1-8. Epub 2014 Apr 13.

Division of Research, Kaiser Permanente Northern California, Oakland, CA.

Objective: The objective of the study was to evaluate the association between gestational weight gain, per the 2009 Institute of Medicine (IOM) recommendations, and offspring overweight/obesity at 2-5 years of age.

Study Design: This was a prospective cohort study of 4145 women who completed a health survey (2007-2009) and subsequently delivered a singleton at Kaiser Permanente Northern California (2007-2010). Childhood overweight/obesity was defined as a body mass index (BMI) z-score of the 85th percentile or greater of the Centers for Disease Control and Prevention child growth standards. Gestational weight gain was categorized according to the 2009 IOM recommendations. Logistic regression was used; meeting the IOM recommendations was the referent.

Results: Exceeding the IOM recommendations was associated with a 46% increase in odds of having an overweight/obese child (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.17-1.83), after adjusting for maternal prepregnancy BMI, race/ethnicity, age at delivery, education, child age, birthweight, gestational age at delivery, gestational diabetes, parity, infant sex, total metabolic equivalents, and dietary pattern. The OR (95% CI) for childhood overweight/obesity among women gaining below the IOM recommendations was 1.23 (0.88-1.71). The associations between gaining outside the IOM recommendations and childhood obesity were stronger among women with a normal prepregnancy BMI (OR, 1.63; 95% CI, 1.03-2.57) (below); OR, 1.79; 95% CI, 1.32-2.43) (exceeded).

Conclusion: Gestational weight gain outside the IOM recommendations is associated with increased odds of childhood overweight/obesity, independent of several potential confounders and mediators. Gestational weight gain had a greater impact on childhood overweight/obesity among normal-weight women, suggesting that the effect may be independent of genetic predictors of obesity.
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http://dx.doi.org/10.1016/j.ajog.2014.02.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5084619PMC
September 2014

A pragmatic cluster randomized clinical trial of diabetes prevention strategies for women with gestational diabetes: design and rationale of the Gestational Diabetes' Effects on Moms (GEM) study.

BMC Pregnancy Childbirth 2014 Jan 15;14:21. Epub 2014 Jan 15.

Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, USA.

Background: Women with gestational diabetes (GDM) are at high risk of developing diabetes later in life. After a GDM diagnosis, women receive prenatal care to control their blood glucose levels via diet, physical activity and medications. Continuing such lifestyle skills into early motherhood may reduce the risk of diabetes in this high risk population. In the Gestational Diabetes' Effects on Moms (GEM) study, we are evaluating the comparative effectiveness of diabetes prevention strategies for weight management designed for pregnant/postpartum women with GDM and delivered at the health system level.

Methods/design: The GEM study is a pragmatic cluster randomized clinical trial of 44 medical facilities at Kaiser Permanente Northern California randomly assigned to either the intervention or usual care conditions, that includes 2,320 women with a GDM diagnosis between March 27, 2011 and March 30, 2012. A Diabetes Prevention Program-derived print/telephone lifestyle intervention of 13 telephonic sessions tailored to pregnant/postpartum women was developed. The effectiveness of this intervention added to usual care is to be compared to usual care practices alone, which includes two pages of printed lifestyle recommendations sent to postpartum women via mail. Primary outcomes include the proportion of women who reach a postpartum weight goal and total weight change. Secondary outcomes include postpartum glycemia, blood pressure, depression, percent of calories from fat, total caloric intake and physical activity levels. Data were collected through electronic medical records and surveys at baseline (soon after GDM diagnosis), 6 weeks (range 2 to 11 weeks), 6 months (range 12 to 34 weeks) and 12 months postpartum (range 35 to 64 weeks).

Discussion: There is a need for evidence regarding the effectiveness of lifestyle modification for the prevention of diabetes in women with GDM, as well as confirmation that a diabetes prevention program delivered at the health system level is able to successfully reach this population. Given the use of a telephonic case management model, our Diabetes Prevention Program-derived print/telephone intervention has the potential to be adopted in other settings and to inform policies to promote the prevention of diabetes among women with GDM.
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http://dx.doi.org/10.1186/1471-2393-14-21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897959PMC
January 2014

Risk of large-for-gestational-age newborns in women with gestational diabetes by race and ethnicity and body mass index categories.

Obstet Gynecol 2013 Jun;121(6):1255-1262

Division of Research, Kaiser Permanente Northern California, Oakland, California.

Objective: To compare the prevalence of large-for-gestational-age (LGA) newborns across categories of body mass index (BMI) in five racial and ethnic groups.

Methods: This cohort study examined 7,468 women with gestational diabetes mellitus (GDM) who delivered a live newborn between 1995 and 2006 at Kaiser Permanente Northern California. The racial and ethnic groups were non-Hispanic white, African American, Hispanic, Asian, and Filipina. The BMI was classified using the World Health Organization International guidelines (normal, 18.50-24.99; overweight, 25.00-29.99; obese, 30.00-34.99; obese class II, 35.00 or higher). Having an LGA newborn was defined as birth weight more than 90th percentile for the study population's race or ethnicity and gestational age--specific birth weight distribution. Logistic regression was used to estimate odds of having an LGA newborn by BMI and race and ethnicity.

Results: Overall prevalence of LGA newborns was highest in African American women (25.1%), lowest in Asians (13.9%), and intermediate among Hispanic (17.3%), white (16.4%), and Filipina women (15.3%). The highest increased risk of LGA newborns was observed among women with class II obesity in most racial and ethnic groups, and African American and Asian women with class II obesity had a four-fold increased risk of LGA newborns compared with women of normal weight in the same racial and ethnic group.

Conclusions: African American women with GDM have a greater risk of LGA newborns at a lower BMI than other racial and ethnic groups. Clinicians should be aware that among women with GDM, there may be significant racial and ethnic differences in the risk of LGA newborns by BMI threshold.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5079180PMC
http://dx.doi.org/10.1097/AOG.0b013e318291b15cDOI Listing
June 2013

Pregnancy glycemia in Mexican-American women without diabetes or gestational diabetes and programming for childhood obesity.

Am J Epidemiol 2013 Apr 15;177(8):768-75. Epub 2013 Mar 15.

Center for Environmental Research and Children's Health, School of Public Health, University of California, Berkeley, Berkeley, CA, USA.

In the present study, we estimated the association between pregnancy glucose levels and offspring body mass index (BMI) z scores at 2, 3.5, 5, and 7 years of age, as well as z score trajectories across this age range, among Mexican-American women without diabetes or gestational diabetes. Beginning in 1999-2000, the Center for the Health Assessment of Mothers and Children of Salinas prospectively followed women from Monterey County, California (52 obese and 214 nonobese women) and their children. Plasma glucose values obtained 1 hour after a 50-g oral glucose load comprised the exposure. Offspring BMIs were compared with national data to calculate z scores. Increasing pregnancy glucose levels were associated with increased offspring BMI z scores at 7 years of age; a 1-mmol/L increase in glucose corresponded to an increase of 0.11 (standard deviation = 0.044) z-score units (P < 0.05). In nonobese women only, the mean z score over this age range increased with increasing glucose levels. The average BMI z score at 4.5 years of age increased by 0.12 (standard error, 0.059) units for each 1-mmol/L increase in glucose (P = 0.04). In obese women only, increasing glucose was associated with increases in BMI z score over time (P = 0.07). Whether interventions to reduce glucose values in women free of disease could mitigate childhood obesity remains unknown.
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http://dx.doi.org/10.1093/aje/kws312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3668427PMC
April 2013

Pregnancy glucose levels in women without diabetes or gestational diabetes and childhood cardiometabolic risk at 7 years of age.

J Pediatr 2012 Dec 11;161(6):1016-21. Epub 2012 Jul 11.

Center for Environmental Research and Children's Health, School of Public Health, University of California-Berkeley, Berkeley, CA, USA.

Objective: To estimate the association between pregnancy glucose values in women without recognized pregestational diabetes or gestational diabetes and cardiometabolic risk in their children.

Study Design: This longitudinal cohort study of 211 Mexican American mother-child pairs participating in the Center for the Health Assessment of Mothers and Children of Salinas study used multiple logistic regression to estimate the children's risk of nonfasting total cholesterol, nonfasting triglycerides, blood pressure (BP), and waist circumference (WC) ≥75th percentile at 7 years of age associated with a 1-mmol/L (18-mg/dL) increase in maternal pregnancy glucose level, measured 1 hour after a 50-g oral glucose load.

Results: The ORs for children in the upper quartile of diastolic BP, systolic BP, and WC associated with a 1-mmol/L increase in pregnancy glucose level were 1.39 (95% CI, 1.10-1.75), 1.38 (95% CI, 1.10-1.73), and 1.25 (95% CI, 1.02-1.54), respectively. Prepregnancy obesity was independently associated with increased odds of children belonging to the upper quartile of WC; maternal sugar-sweetened beverage consumption and gestational weight gain prior to the glucose test were not independently associated with any of the cardiometabolic outcomes.

Conclusion: In Mexican American women without recognized pregestational diabetes or gestational diabetes, we found an association between increasing pregnancy glucose values and the children's diastolic and systolic BPs and WC at 7 years of age. Whether interventions to reduce pregnancy glucose values, even if below levels diagnostic of overt disease, will mitigate high BP and abdominal obesity in late childhood remains to be determined.
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http://dx.doi.org/10.1016/j.jpeds.2012.05.049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404294PMC
December 2012

Change in body mass index between pregnancies and the risk of gestational diabetes in a second pregnancy.

Obstet Gynecol 2011 Jun;117(6):1323-1330

From the Division of Research, Kaiser Permanente of Northern California, Oakland, California.

Objective: To estimate the association between interpregnancy change in body mass index (BMI) and the risk of gestational diabetes mellitus (GDM) in a second pregnancy.

Methods: In a retrospective cohort analysis of 22,351 women, logistic regression models provided adjusted estimates of the risk of GDM in women gaining 3.0 or more 2.0-2.9, and 1.0-1.9 BMI units, or losing 1.0-2.0 and more than 2.0 units between pregnancies (one BMI unit corresponds to 5.9 pounds for the average height [5 feet 4 inches] of the study population). Women with stable BMIs (±1.0 BMI unit) comprised the reference.

Results: For those with GDM in the first pregnancy, the age-adjusted risk of GDM in the second pregnancy was 38.19% (95% confidence interval [CI] 34.96-41.42); for those whose first pregnancy was not complicated by GDM, the risk was 3.52% (95% CI 3.27-3.76). Compared with women who remained stable, interpregnancy BMI gains were associated with an increased risk of GDM in the second pregnancy (odds ratio [OR] 1.71 [95% CI 1.42-2.07] for gaining 1.0-1.9 BMI units; OR 2.46 [95% CI 2.00-3.02] for 2.0-2.9 BMI units; and OR 3.40 [95% CI 2.81-4.12] for 3.0 or more BMI units). The loss of BMI units was associated with a lower risk of GDM only among women who were overweight or obese in the first pregnancy (OR 0.26 [95% CI 0.14-0.47] for the loss of at least 2.0 BMI units). In overweight and obese women, those with GDM in the first pregnancy that did not develop the condition again gained fewer BMI units than those experiencing recurrent GDM (mean change 0.66 [95% CI 0.25-1.07] compared with 2.00 [95% CI 1.56-2.43] BMI units, respectively).

Conclusion: Interpregnancy increases in BMI between the first and second pregnancy increases a woman's risk of GDM pregnancy.
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http://dx.doi.org/10.1097/AOG.0b013e31821aa358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222684PMC
June 2011

A pregnancy and postpartum lifestyle intervention in women with gestational diabetes mellitus reduces diabetes risk factors: a feasibility randomized control trial.

Diabetes Care 2011 Jul 3;34(7):1519-25. Epub 2011 May 3.

Kaiser Permanente of Northern California, Oakland, California, USA.

Objective: To pilot, among women with gestational diabetes mellitus (GDM), the feasibility of a prenatal/postpartum intervention to modify diet and physical activity similar to the Diabetes Prevention Program. The intervention was delivered by telephone, and support for breastfeeding was addressed.

Research Design And Methods: The goal was to help women return to their prepregnancy weight, if it was normal, or achieve a 5% reduction from prepregnancy weight if overweight. Eligible participants were identified shortly after a GDM diagnosis; 83.8% consented to be randomly assigned to intervention or usual medical care (96 and 101 women, respectively). The retention was 85.2% at 12 months postpartum.

Results: The proportion of women who reached the postpartum weight goal was higher, although not statistically significant, in the intervention condition than among usual care (37.5 vs. 21.4%, absolute difference 16.1%, P=0.07). The intervention was more effective among women who did not exceed the recommended gestational weight gain (difference in the proportion of women meeting the weight goals: 22.5%, P=0.04). The intervention condition decreased dietary fat intake more than the usual care (condition difference in the mean change in percent of calories from fat: -3.6%, P=0.002) and increased breastfeeding, although not significantly (condition difference in proportion: 15.0%, P=0.09). No differences in postpartum physical activity were observed between conditions.

Conclusions: This study suggests that a lifestyle intervention that starts during pregnancy and continues postpartum is feasible and may prevent pregnancy weight retention and help overweight women lose weight. Strategies to help postpartum women overcome barriers to increasing physical activity are needed.
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http://dx.doi.org/10.2337/dc10-2221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120183PMC
July 2011