Preventing Type 2 Diabetes in Women With Gestational Diabetes: Three Theoretical Perspectives on Behavior Change

Gestational diabetes (GDM) affects 1 in 6 pregnancies worldwide¹ and around a third of those diagnosed with GDM will develop Type 2 diabetes mellitus (T2DM) within 15 years.² Follow-up care for people with GDM therefore offers an opportunity to detect blood glucose abnormalities early and reduce the risk of T2DM complications.² Recommendations for postpartum GDM care focus on glucose testing and health education for lifestyle changes.³ Guidelines recommend that people with GDM should undergo glucose testing with an oral glucose tolerance test or with hemoglobin A1c (HbA1c) at 6 to 12 weeks postpartum to exclude T2DM. HbA1c or fasting glucose testing at regular 1 to 3 year intervals is advised to identify progression to T2DM.³ People diagnosed with GDM should be offered lifestyle advice on weight control, diet, and exercise, which may be delivered via structured education programs.³

Although guidelines emphasize the importance of providing follow-up care to people with prior GDM,³ this care is often lacking. A recent editorial in The Lancet highlights the slow progress made in implementing GDM follow-up care, despite its potential to improve long-term cardiometabolic health.⁴ Uptake of glucose screening is poor globally, with only a third of people with prior GDM receiving regular screening as recommended.⁵ Barriers to screening include a lack of clear guidance about T2DM risk, competing responsibilities such as work or childcare, and poor continuity between pregnancy and primary care services.⁶ Behavioral interventions for T2DM prevention have also had mixed success.⁷ Only 2 of 13 controlled trials regarding lifestyle interventions for people with prior GDM showed significant reduction in T2DM, and there is evidence of publication bias.⁸ All this suggests that postpartum glucose screening and education interventions have not had the desired effect.

Public health interventions are complex, involving multiple stakeholders and unpredictable outcomes. One way to understand and improve these interventions is by using theory: frameworks of ideas or concepts to explain how something works or why something happens. Theoretical frameworks can help policymakers and health care professionals understand the behavior of key stakeholders, identify appropriate strategies for change, and predict possible outcomes. By incorporating social, psychological, and behavioral factors, theory provides useful insight when developing new interventions or assessing why existing ones have not been successful. However, interventions for T2DM prevention in people with GDM often lack theoretical grounding, and few studies specify a theoretical framework for their intervention.⁹

This article examines challenges in GDM follow-up and considers solutions by drawing upon 3 theoretical frameworks from health psychology and sociology: the Health Action Process Approach (HAPA),¹⁰ Link and Phelan's theory of stigma,¹¹ and Bourdieu's social practice theory.¹² Each theory offers a different but complementary perspective on the behavioral changes required for effective T2DM prevention. We offer suggestions for more robust, theoretically-grounded models of GDM follow-up care to improve postpartum metabolic health and reduce T2DM risk.

The 3 theoretical frameworks outlined here highlight different facets of behavior change. The HAPA model offers insight into how people may be supported to overcome individual barriers to behavior change but overlooks the social environment in which they make decisions. Social practice theory adds context by highlighting how an individual's beliefs, feelings, and behaviors are shaped by wider social structures. By using social practice theory, health care providers could understand the psychological factors outlined in HAPA (eg, action self-efficacy) as dependent on access to resources. Stigma theory integrates individual and structural factors, demonstrating how the discrediting of certain individuals can shape their behaviors and affect their social position.

T2DM interventions relying on behavior change must help individuals to make these changes within the context of their lives, families, and social networks. GDM follow-up care pathways should be accessible, designed to make people's participation in health care easy, and remove barriers to attending appointments or laboratory screening. Considerations might include on-site childcare, automatic referrals from pregnancy care to primary care providers, and offering glucose testing in postnatal midwife or pediatric appointments. One good example is the American College of Obstetricians and Gynecologists’ recent recommendation that people with GDM should be offered the first postpartum glucose screening during the birth hospitalization (instead of 4-12 weeks after) to maximize participation.²⁰

Being persistently identified as at risk even after pregnancy may worsen the negative impact of GDM upon people's self-image. Similarly, regular screening may exacerbate health anxiety and perceived stigma. The challenge is to develop effective interventions while ensuring that the recipients do not feel stigmatized. When possible, segregating people with GDM into separate antenatal or postpartum services should be avoided. GDM lifestyle education and glucose screening may be incorporated into postpartum primary care appointments, and T2DM prevention could take the form of affirmative health promotion for the whole family.¹⁶

It is crucial to consider patients’ habitus and access to resources when designing T2DM prevention programs. As a minimum, social determinants of health such as education level and socioeconomic status should be included in the evaluation of any T2DM prevention program to identify inequities in health outcomes or access to services. Many studies of lifestyle interventions fail to report or adjust for these factors.²¹ Those designing interventions or caring for people with GDM must consider stigma and social exclusion as key factors impeding the uptake of screening and the adoption of healthier behaviors.

The theories discussed here can support health professionals to understand patients’ behavior, including why they may not engage with T2DM prevention efforts, and to consider how patients can be better supported. T2DM prevention is a multidisciplinary responsibility that should be considered by primary care providers, midwives, and obstetricians alike, from the earliest stage of a pregnancy affected by GDM. Midwives are closely involved with people with GDM during pregnancy, yet are not mentioned in seminal reviews or guidelines on GDM care.^{3, 15} Accordingly, surveys have shown that only half of midwives screen patients with prior GDM during postpartum visits.²² Interventions for T2DM prevention should involve the entire perinatal interprofessional team and consider how health promotion can be embedded throughout pregnancy and postpartum care.

When designing interventions to prevent T2DM in people with GDM, it is important to recognize that people's motivation and volition for behavior change are shaped by their experiences and sociocultural backgrounds. To be successful, interventions should acknowledge people's health beliefs and behaviors as part of longstanding social, cultural, and historical narratives. Health care professionals have an important role to play in T2DM prevention: for example, by helping individuals develop action plans specific to their sociocultural context or through advocating for access to culturally appropriate education resources.

Approaching public health interventions from a theoretical perspective allows policymakers and health care professionals to recognize the complex interplay of influences on health behavior and uncover the mechanisms most amenable to intervention. The 3 theoretical approaches we have presented offer insight into why GDM follow-up care may be unsuccessful and provide suggestions for how postpartum care of people with GDM can be improved in future.

The authors have no conflicts of interest to disclose.