DIABETICMedicine

DOI: 10.1111/j.1464-5491.2010.02995.x

Original Article: Epidemiology

The risk of overt diabetes mellitus among women with
gestational diabetes: a population-based study

G. Chodick*†, U. Elchalal‡, T. Sella*†, A. D. Heymann*†, A. Porath*, E. Kokia*† and

V. Shalev*†
*Medical Division, Maccabi Healthcare Services, Tel Aviv, †Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv and ‡Department of Obstetrics & Gynecology,
Hadassah University Hospital and Hebrew University-Hadassah Medical School, Jerusalem, Israel

Accepted 16 February 2010

Abstract
Aims To determine the incidence of postpartum diabetes mellitus in the years following a diagnosis of gestational diabetes
mellitus (GDM) and to determine whether the severity of GDM, represented by the magnitude of the deviation of diagnostic tests
from the normal values or requirement for medications, is associated with the development of diabetes.
Methods A retrospective cohort study was performed among 185 416 pregnant women who had glucose challenge test or 3 h
oral glucose tolerance test (OGTT) in a large health maintenance organization in Israel. Subsequent diagnosis of diabetes was
ascertained by using an automated patient registry.
Results A total of 11 270 subjects were diagnosed with GDM, comprising 6.07% of the cohort. During a total follow-up
period of 1 049 334 person-years there were 1067 (16.9 per 1000 person-years) and 1125 (1.1 per 1000 person-years)
diagnoses of postpartum diabetes among GDM and non-GDM women, respectively. The cumulative risk of incident diabetes in
GDM patients with up to 10 years of follow-up was 15.7%, compared with 1% among the non-GDM population. Gestational
diabetes mellitus was associated with nearly an eightfold higher risk of postpartum diabetes after adjusting for important
confounders, such as socioeconomic status and body mass index. Among women with a history of GDM, the number of
abnormal OGTT values and use of insulin were associated with a substantially higher risk for developing diabetes.
Conclusions Three or four abnormal OGTT values and GDM requiring insulin or oral hypoglycaemic medications are
important predictors of postpartum diabetes risk in women with a history of GDM.
Diabet. Med. 27, 779–785 (2010)

Keywords diabetes mellitus, Gestational diabetes, glucose challenge test, Israel, oral glucose tolerance test
Abbreviations BMI, body mass index; CI, confidence interval; GCT, glucose challenge test; GDM, gestational diabetes
mellitus; HbA1c, glycated haemoglobin; ICD-9, The International Classification of Diseases (9th Revision); MHS,
Maccabi Healthcare Services; OGTT, oral glucose tolerance test

increased Cesarean section rate [4]. In addition, a history of

Introduction
Gestational diabetes mellitus (GDM) is defined as carbohydrate
intolerance of varying severity with onset or first recognition
during pregnancy [1]. In the USA, GDM affects between 2% and
5% of pregnant women [2], which is increasing with time in all
ethnic groups [3]. Gestational diabetes mellitus is associated with
adverse pregnancy outcomes, such as macrosomia and an
Correspondence to: Gabriel Chodick, PhD, Maccabi Healthcare Services, 27
Ha’Mered Street, Tel Aviv 68125, Israel.
E-mail: hodik_g@mac.org.il
GDM is associated with an increased long-term risk for the
development of Type 2 diabetes mellitus [5].
Following O’Sullivan’s classical report [6], many studies
have documented the association between GDM and increased
risk of diabetes mellitus. However, a comprehensive systematic
review [7] of the studies on women with GDM found a large
variability in the cumulative incidence of diabetes mellitus,
ranging from 2.6 to over 70% in studies with a follow-up of
6 wk to 28 years postpartum. In addition, most of these
studies were limited by selective and small patient numbers
(n < 1000), short length of follow-up (<2 years), use of diverse

ª 2010 The Authors.

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DIABETICMedicine Risk of overt diabetes following gestational diabetes • G. Chodick et al.
tests for glucose tolerance in pregnancy, and lack of
information on potential risk factors, such as personal
anthropometric measures or severity of GDM.
In Israel, the standardized modality of screening is a glucose
challenge test (GCT), a measurement of serum glucose
concentration 1 h after a 50 g oral glucose load. A glucose
value of 7.8 mmol ⁄ l (140 mg ⁄ dl) or above is considered
abnormal and necessitates a second test, the 3 h oral glucose
tolerance test (OGTT), for diagnosis of GDM.
In the Diabetes Prevention Program, both lifestyle
modification (such as body weight loss) and treatment with
metformin were found to be effective in delaying the progression
from impaired glucose tolerance to diabetes mellitus in women
with previous GDM [8]. Thus, calculating the exact long-term
patterns of diabetes mellitus incidence in women with GDM and
identifying patients at increased risk is of growing importance for
effective screening and evidence-based case management. Given
the considerable variability in the reported risk of diabetes
mellitus among GDM patients, we sought to determine the long-
term incidence of postpartum diabetes mellitus in the years
following a diagnosis of GDM and to examine whether severity
of GDM is associated with a higher risk of developing diabetes
mellitus.
Patients and methods
Maccabi Healthcare Services (MHS) is the second largest health
maintenance organization in Israel, insuring 1.8 million
members countrywide. In 2008, MHS covered 24.6% of the
total population and 26.1% of the 1.56 million Israeli women
aged 15–45 years. The annual number of births in MHS
(n = 39 291) comprised 24.1% of all births in Israel [9].
According to the Israeli National Health Insurance Act, MHS
may not bar any citizen who wishes to join it, and therefore every
section in the Israeli population is represented in MHS.
Nonetheless, MHS coverage in the non-Jewish populations is
substantially lower compared with the Jewish one.
Over recent years, MHS has developed a central registry
consisting of all patients diagnosed with diabetes mellitus using
the following entry criteria: laboratory test results of glycated
haemoglobin (HbA1c) ‡ 7.25% or glucose ‡11.1 mmol ⁄ l
(200 mg ⁄ dl), (for individuals that are included in the register
on this criterion alone, supporting data for the diagnosis of
diabetes is required at 6 months), or two or more purchases of
diabetes medication over a 2 month period. Also included are
patients with a diagnosis of diabetes (according to ICD-9 code) in
the medical chart with HbA1c ‡ 6.5% or fasting glucose
‡6.9 mmol ⁄ l (125 mg ⁄ dl). These criteria have been validated
and provide a specificity of 99.9% [10].
We collected data on all 50 g glucose challenge tests performed
in MHS between 13 March 1995 and 27 May 2009. We
excluded all women who had any indication of pre-existing
diabetes mellitus, who had received infertility treatments or who
were not in the relevant age range (15–50 years old). Women
with GDM were defined according to the Carpenter & Coustan
780
[11] modification of the National Diabetes Data Group criteria
conversion method, based on the presence of two or more of the
following values in the 100 g OGTT: fasting serum glucose
concentration exceeding 5.3 mmol ⁄ l (95 mg ⁄ dl); 1 h serum
glucose concentration 10.0 mmol ⁄ l (180 mg ⁄ dl) or above;
2 h serum glucose concentration exceeding 8.6 mmol ⁄ l
(155 mg ⁄ dl); and 3 h serum glucose concentration exceeding
7.8 mmol ⁄ l (140 mg ⁄ dl). All other study subjects were defined as
non-GDM.
Data collection and outcomes
We examined the MHS database records of women in the study
cohort from date of glucose challenge testing in the most recent
pregnancy to death, leaving MHS, date of diagnosis of
postpartum diabetes mellitus, or 1 June 2009, whichever
occurred earlier. Diagnosis of postpartum diabetes was
detected using the patient’s entry data to the MHS Diabetes
Registry during this period. The MHS database was used to
collect a range of clinical and demographic parameters at index
date. Height and weight were measured by a nurse or a physician
during office visits. Body mass index (BMI) was categorized into
normal weight (<25 kg ⁄ m2), overweight (25–29 kg ⁄ m2) and
obese (‡30 kg ⁄ m2) using the World Health Organization
classification [12]. Socioeconomic level was categorized into
quintiles according to the poverty index of the member’s
enumeration area as defined by 1995 national census based on
several parameters, including household income, educational
qualifications, crowding, material conditions and car ownership
[13]. Gestational diabetes mellitus was further categorized into
GDM with no insulin treatment, managed conservatively, and
GDM requiring treatment with insulin or oral hypoglycaemic
agent, which was identified through pharmaceutical purchases.
Data on mortality were retrieved from the Israel National
Population Registry, which maintains a registry of all citizens and
permanent residents, using record linkage based on a unique
identification number. To control for differences in access to care
and an increased frequency of laboratory tests for detection of
diabetes mellitus among GDM patients, we included the number
of postpartum 75 g OGTT and fasting plasma glucose tests in the
multivariable models.
Statistical analysis
The Chi-square test for categorical variables and analysis of
variance for continuous variables were performed to determine
significant differences in baseline characteristics between study
groups. We used the Kaplan–Meier method to calculate the
cumulative incidence rate for the development of postpartum
diabetes. The proportional Cox regression model with years
of follow-up as the time scale was used to estimate hazard
ratios and 95% confidence intervals (CI) [14] for variables
significantly associated with increased risk of developing
postpartum diabetes. Significance level was set at P = 0.05.
The proportional hazards assumption was checked graphically
ª 2010 The Authors.
Journal compilation ª 2010 Diabetes UK. Diabetic Medicine, 27, 779–785
 Original article DIABETICMedicine

and found to be reasonably fulfilled. Survival analyses were
repeated with restriction only for patients with GDM.
Results
A total of 11 270 subjects were diagnosed with GDM,
comprising 6.1% of 185 416 study subjects. Baseline
characteristics of GDM and non-GDM patients are given in
Table 1. The GDM patients were significantly (P < 0.001) more
likely to be older (32.7 vs. 30.6 years), overweight or obese
(36.77 vs. 17.06%). Overall, 125 subjects died and 17745
individuals left MHS during the total follow-up period.
During a total follow-up period of 1 049 334 person-years
(5.7 person-years per participant), there were 1067 (16.9 per
1000 person-years) and 1125 (1.09 per 1000 person-years)
diagnoses of postpartum diabetes among GDM and non-GDM
women, respectively. The cumulative risk of incident diabetes in
GDM patients with up to 10 years of follow-up was 15.7%,
compared with 1% among the non-GDM population. The risk
of developing diabetes mellitus among GDM subjects increased
linearly with follow-up time, with no evidence of a plateau in
incidence of 10 years postpartum. The similar cumulative
incidence of diabetes mellitus over 9 years of follow-up in the
present cohort and a previous cohort from Melbourne
(Australia), where the diagnosis of diabetes mellitus was based
on a 75 g OGTT and fasting blood glucose tests, are depicted in
Fig. 1.
In a multivariable logistic regression, women diagnosed with
GDM had an adjusted 7.7-fold higher hazard ratio (95% CI,
7.1–8.4) of diabetes mellitus compared with non-GDM women.
Other variables associated with diabetes mellitus were older age,
low socioeconomic status and BMI. Women with a BMI of
‡30 kg ⁄ m2 had a hazard ratio of 5.1 (95% CI, 4.4–6.0) to
develop diabetes mellitus compared with normal-weight women
(Table 2). In addition, having frequent fasting blood glucose tests
was also associated with increased risk of diabetes mellitus.

Table 1 Characteristics of study participants and clinical outcomes during follow-up period, according to gestational diabetes mellitus (GDM) status

No GDM (n = 174 146) GDM (n = 11 270) Total (n = 185 416)

n % of total n % of total n % of total P value*

Mean age at index 30.59 (5.18) 32.74 (5.51) 30.72 (5.22) <0.001
date [years (sd)]
Mean GCT 108.14 (28.55) 162.07 (27.01) 110.11 (30.24) <0.001
[mg ⁄ dl (sd)]
Mean GCT 6.01 (1.59) 9.00 (1.50) 6.12 (1.68)
[mmol ⁄ l (sd)]
Socioeconomic Lowest quartile 33067 18.99% 2190 19.43% 35257 19.02% <0.001
status Second quartile 67 515 38.77% 3991 35.41% 71 505 38.56%
Third quartile 29 447 16.91% 2076 18.42% 31 523 17.00%
Highest quartile 38 729 22.24% 2633 23.36% 41 362 22.31%
NA 5388 3.10% 380 3.37% 5768 3.11%
Smoking Current 17 996 10.33% 1207 10.71% 19 203 10.36% <0.001
Past 3338 1.92% 251 2.23% 3589 1.94%
Never 140 929 80.93% 9270 82.25% 150 199 81.01%
Unknown 11 883 6.82% 542 4.81% 12 425 6.70%
Body mass index <25 kg ⁄ m2 35 330 20.29% 1649 14.63% 36 979 19.94% <0.001
25–30 kg ⁄ m2 17 429 10.01% 1885 16.73% 19 314 10.42%
>30 kg ⁄ m2 12 285 7.05% 2259 20.04% 14 544 7.84%
Unknown 109 102 62.65% 5477 48.60% 114 579 61.80%
Parity 1 46 511 26.71% 2965 26.31% 49 476 26.68% <0.001
2 55 226 31.71% 3056 27.12% 58 282 31.43%
3 41 592 23.88% 2730 24.22% 44 322 23.90%
4+ 30 817 17.70% 2519 22.35% 33 336 17.98%
Year of 1995–1998 29 783 17.10% 1995 17.70% 31 778 17.14% <0.001
index date 1999–2002 40 477 23.24% 3439 30.51% 43 916 23.69%
2003–2005 37 616 21.60% 2788 24.74% 40 404 21.79%
2006–2009 66 270 38.05% 3048 27.06% 69 318 37.39%
Study end-points Mean 5.17 years (3.95 years) 5.70 years (3.65 years) 5.66 years (4.00 years) <0.001
follow-up
(sd)
Deaths 100 0.06% 25 0.22% 125 0.07% <0.001
Left MHS 17 114 9.83% 631 5.60% 17 745 9.57% <0.001
Incident DM 1067 0.61% 1125 9.98% 2192 1.18% <0.001

DM, diabetes mellitus; GCT, glucose challenge test; and MHS, Maccabi Healthcare Services.
*For comparisons between GDM and non-GDM populations.

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DIABETICMedicine Risk of overt diabetes following gestational diabetes • G. Chodick et al.

Proportion with diabetes mellitus

0.2 crude incidence density rates of diabetes mellitus among GDM
MHS, GDM
subjects with two, three and four positive OGTT values were
9.7, 25.4 and 80.1 per 1000 person-years, respectively. The rate
Melbourne, GDM of development of diabetes among women who had GDM,
0.1
according to the number of positive OGTT values (log-rank
P < 0.001) is given in Fig. 2. According to this survival analysis,
the 10 year risk of diabetes mellitus in women with two
Melbourne, non-GDM abnormal values was 10.1%, compared with 22.1% and
51.5% in women with three or four abnormal values,
0.0 MHS, non-GDM
0 3 6 9 respectively. In a multivariable model, increased number of
Years abnormal OGTT values was associated with increased risk of
diabetes mellitus. Other factors positively associated with
FIGURE 1 The cumulative incidence of diabetes mellitus by life-table
postpartum diabeties mellitus among GDM patients were age
analysis in Maccabi Healthcare Services (MHS, Israel) and Melbourne
(Australia) [15]. at pregnancy, low gravidity, low socioeconomic status, obesity
and GDM treated with insulin (Table 3).

In stratified analyses among GDM patients, the number of

positive values on 3 h OGTT was positively associated with
age, BMI, glucose challenge test level and an increased
proportion of GDM patients treated with insulin. For
example, women who had all four values above the cut-off
levels had a mean prior glucose challenge test level of
180 mg ⁄ dl (10 mmol ⁄ l) and 29% of them were treated with
insulin, compared with 159 mg ⁄ dl (8.83 mmol ⁄ l) and 5.7%
among women with GDM who had two positive values. The
Discussion
The results of the present study suggest that GDM, and
particularly GDM treated with insulin or other hypoglycaemic
agents, and three or four abnormal OGTT values, are important
predictors of future development of diabetes mellitus. As shown
in Fig. 1, the cumulative risk for diabetes mellitus in the present
study is almost identical to the results of a previous study from
Mercy Hospital for Women in Melbourne, Australia [15], in

Table 2 Adjusted hazard ratios and 95% confidence intervals (CI) for factors associated with diabetes mellitus in women with and without a history
of gestational diabetes

n Hazard ratio 95% CI P value*

Age Per year 185 415 1.03 (1.02, 1.04) <0.001

Parity 1 49475 1 (ref.) — —
2 58 282 0.80 (0.70, 0.91) <0.001
3 44 322 0.77 (0.68, 0.87) <0.001
4+ 33 336 0.80 (0.71, 0.91) <0.001
Body mass <25 kg ⁄ m2 36 978 1 (ref.) — —
index (kg ⁄ m2) 25–30 kg ⁄ m2 19 314 2.28 (1.93, 2.71) <0.001
>30 kg ⁄ m2 14 544 5.12 (4.38, 5.97) <0.001
Missing 114 579 1.34 (1.14 1.58) <0.001
Socioeconomic Highest quartile 35 257 1 (ref.) — —
Status† Third quartile 71 505 1.22 (1.06, 1.41) 0.006
Second quartile 31 523 1.29 (1.14, 1.45) <0.001
Lowest quartile 41 362 1.66 (1.45, 1.90) <0.001
Number of None 29 394 1 (ref.) — —
postpartum 1 47 353 3.08 (1.89, 5.01) <0.001
glucose tests 2 33 280 2.93 (1.80, 4.78) <0.001
3–5 48 160 4.67 (2.97, 7.36) <0.001
6–10 21,600 10.01 (6.38, 15.71) <0.001
11 or more 5628 35.91 (22.88, 56.35) <0.001
Smoking† Never 19 203 1 (ref.) — —
Current 3589 1.10 (0.95, 1.26) 0.197
Past 150 198 0.85 (0.64, 1.14) 0.271
GDM No 174 145 1 (ref.) — —
Yes 11 270 7.70 (7.05, 8.41) <0.001

*P value for deviation from 1.

†Patients with missing data are not shown.

ª 2010 The Authors.

782 Journal compilation ª 2010 Diabetes UK. Diabetic Medicine, 27, 779–785
 Original article DIABETICMedicine

found in studies from Ontario [16] and Nova Scotia [17] in

No. of abnormal values Canada, based on administrative service claims. The results from
2
0.6 3 all four large cohort studies indicate that gestational diabetes is
4 associated with a long-term increased risk of diabetes, with no
Cumulative incidence

indication of leveling-off after 5 years of follow-up, as was

suggested in a previous systematic review of 28 studies that were
0.4
published between 1965 and 2001 [7]. In addition to differences
between investigated populations in risk factors such as parity,
prepregnancy BMI, pregnancy weight gain and more general
0.2 differences between investigated populations such as ethnicity
and lifestyle, this discrepancy may be attributed to many of the
reviewed studies being relatively small (n < 1000) or having only
0.0 a short follow-up period, and therefore statistically
0 2 4 6 8 10 12 14 underpowered to detect a significant long-term increase in risk.
Follow-up (years) In the multivariable risk factor analysis, women with a history
of GDM had a nearly eightfold higher risk of developing
FIGURE 2 The cumulative incidence of diabetes mellitus by life-table postpartum diabetes mellitus compared with non-GDM women.
analysis during a 14 year period of follow-up among gestational diabetes
Our risk estimate is well within the 95% confidence interval of a
patients, according to number of abnormal oral glucose tolerance test values.
pooled relative risk calculated in the Mercy Hospital study [15],
as well as in a meta-analysis of six controlled follow-up studies
which 17% of the women who were diagnosed with GDM [18]. However, a substantially higher adjusted hazard ratio
developed diabetes within 10 years postpartum, based on 75 g (37.28; 95% CI, 34.00–40.88) was found in the Ontario cohort
and fasting blood glucose tests. Somewhat higher risks were study [16] on 659 164 subjects. This exceptionally high relative

Table 3 Adjusted hazard ratios and 95% confidence intervals (CI) for factors associated with diabetes mellitus in women with a history of gestational diabetes

n Hazard ratio 95% CI P value*

Age Per year 11270 1.04 (1.03, 1.05) <0.001

Parity 1 2965 1 (ref.) — —
2 3056 0.86 (0.72, 1.02) 0.08
3 2730 0.80 (0.67, 0.95) 0.009
4+ 2519 0.81 (0.68, 0.95) 0.01
Socioeconomic Highest quartile 2190 1 (ref.)
status† Third quartile 3991 1.08 (0.89, 1.32) 0.424
Second quartile 2076 1.14 (0.97, 1.35) 0.111
Lowest quartile 2633 1.40 (1.16, 1.68) <0.001
Body mass index <25 kg ⁄ m2 1649 1 (ref.) — —
25–30 kg ⁄ m2 1885 1.68 (1.33, 2.12) <0.001
>30 kg ⁄ m2 2259 2.68 (2.16, 3.33) <0.001
Missing 5477 1.13 (0.90, 1.42) 0.298
Smoking† Never 1207 1 (ref.) — —
Current 251 1.09 (0.90, 1.32) 0.378
Past 9270 0.83 (0.54, 1.29) 0.408
Abnormal OGTT 2 7849 1 (ref.) — —
values 3 2753 1.92 (1.67, 2.20) <0.001
4 668 4.00 (3.40, 4.71) <0.001
GDM treatment Conservative 10 256 1 (ref.) — —
Insulin ⁄ oral hypoglycaemic 1014 2.77 (2.39, 3.20) <0.001
Number of postpartum glucose tests None 1234 1 (ref.) — <0.001
1 1639 1.96 (1.04, 3.70) 0.04
2 1567 1.73 (0.91, 3.26) 0.09
3–5 3252 2.27 (1.28, 4.05) 0.005
6–10 2330 4.44 (2.52, 7.84) <0.001
11+ 1248 12.51 (7.11, 22.01) <0.001

GDM, gestational diabetes mellitus; and OGTT, oral glucose tolerance test.
*P value for deviation from 1.
†Patients with missing data are not shown.

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DIABETICMedicine
risk is intriguing given that the crude relative risk after 9 years of
follow-up was less than 10.
Among the GDM population, we found that three and four
abnormal OGTT values were associated with a nearly two- and
fourfold higher risk of developing diabetes compared with
women having two abnormal values, respectively. Although such
association has been rarely reported [19], our observation is
consistent with several studies indicating that among women
with an OGTT test, those with one abnormal value have a
twofold greater risk of subsequent diabetes compared with
women having no abnormal values [20]. This pattern of linear
increase in the risk of diabetes mellitus with increasing number of
abnormal OGTT tests reflects the continuum between normal
glucose tolerance, impaired glucose tolerance and ultimately,
diabetes.
Body mass index was a strong predictor for the development of
postpartum diabetes mellitus. Women with a BMI of 30 kg ⁄ m2
or above had more than a fivefold higher risk compared with
women at a normal BMI level. This is in agreement with many
[21], but not all [22], studies on GDM patients that found a
positive association between pregestational, gestational and
postgestational BMI and the risk of developing diabetes mellitus.
This relationship has been explained by modifiable risk factors,
such as low level of physical activity, increased dietary fat, and
avoidance of other lifestyle factors that adversely influence
insulin resistance [23]. Following several studies which have
shown that progression to Type 2 diabetes is potentially
preventable by lifestyle or medical intervention in high-risk
subjects [8], our results underline the importance of promoting
secondary prevention efforts aimed to prevent or control the
progression of gestational diabetes to Type 2 diabetes
mellitus.
The present historical prospective study examining the
association between GDM and postpartum diabetes mellitus is
one of the largest done to date with respect to follow-up period
and size of study population. The utilization of the validated
MHS diabetes registry, with its high validity and on-going, real-
time updating reduces the threat of misclassification bias in our
assessment of diabetes incidence. An additional strength of the
present database study is the very low turnover rate of the study
population (approximately 10% discontinued membership
during the entire study period), affording minimal loss to
follow-up, compared with relatively high losses to follow-up in
many of the previous longitudinal studies that have attempted to
follow women with gestational diabetes [15,24,25]. The bias
resulting from higher drop-out rates and diminished cohort
retention is particularly important longer after delivery, and thus
is particularly important in long follow-up studies. Furthermore,
nearly 85% of our cohort were tested for fasting blood glucose
during the follow-up period, thus reducing the bias resulting from
closer diabetes screening of GDM women. Other study
advantages include a prospective study design, the use of
administrative databases to avoid the problem of differential
recall bias, and the systematic and comprehensive collection of
personal sociodemographic data and medical history.
784
Risk of overt diabetes following gestational diabetes • G. Chodick et al.
Some important limitations of our study include our inability
to control for important modifiable and non-modifiable risk
factors, such as physical activity [26] and family history of
diabetes [27]. Body mass index was missing for 48.6% and
62.7% of the GDM and non-GDM women, respectively. The
small but statistically significant increased risk of diabetes
mellitus in women with missing information on weight or
height suggests that data on BMI was somewhat less available for
women with higher BMI. This potential information bias could
have resulted in an overestimation of the association between
GDM and diabetes mellitus. Also, similar to other diabetes
registries, the MHS diabetes registry does not distinguish
between Type 1 and Type 2 diabetes mellitus; however, the
majority of women in whom diabetes develops after gestational
diabetes tend to have Type 2 diabetes [15]. In one report [28], the
prevalence of glutamic acid decarboxylase antibodies (a marker
for autoimmune or Type 1 diabetes) in women with GDM
suggested that only 5% of the women who developed diabetes
had Type 1 diabetes. The diagnosis of GDM remains
controversial, without universal acceptance of a particular set
of diagnostic criteria; however, the crude rate of GDM in our
study (6.1%) is comparable with a previous study among Jewish
women in Israel (5.7%) [29], supporting the external validity of
our findings. Our definition of GDM was based on OGTT tests,
and therefore women who had a glucose challenge test level of
‡7.8 mmol ⁄ l (140 mg ⁄ dl) but who did not have an OGTT (12%
of the cohort) were considered as non-GDM women. This
conservative approach may have led to attenuated calculated risk
ratios.
Our study used survival analysis to assess a large cohort of
women with and without GDM to determine long-term
cumulative risk of diabetes mellitus and predictors for later
development of diabetes mellitus. Primary care providers can
use our results of antepartum indices (e.g. number of abnormal
OGTT values, GDM treated with insulin, older age, obesity
etc.) as informative risk markers to identify those at highest risk
for Type 2 diabetes who would most benefit from targeted
interventions to prevent or delay the progression of impaired
glucose tolerance to Type 2 disease, such as frequent screening
tests, lifestyle changes and use of anti-diabetic medications
[30].
Competing interests
There was no external funding or support for the study. Gabriel
Chodick had full access to all the data in the study and takes
responsibility for the integrity of the data and the accuracy of the
data analysis.
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