Potential protective effect of lactation against incidence of type 2 diabetes mellitus in women with previous gestational diabetes mellitus: A systematic review and meta-analysis

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diabetes mellitus 48 endocrinologydiseases
hyperglycemia 1 endocrinologydiseases
obesity 1 endocrinologydiseases
type 2 diabetes mellitus 42 endocrinologydiseases

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diabetes mellitus 116 Diabetes/Metabolism Research and ReviewsPotential protective effect of lactation against incidence of type 2 diabetes mellitus in women with previous gestational diabetes mellitus: A systematic review and meta‐analysisAlternative
diabetes mellitus 169 effect of lactation against incidence of type 2 diabetes mellitus in women with previous gestational diabetes mellitus : A systematic review and meta‐analysisAlternative Title: Tanase‐Nakao et al.Kanako Tanase‐NakaoNaoko
diabetes mellitus 1059 2/2017Publication date (ppub): 5/2017AbstractSummaryLactation may protect women with previous gestational diabetes mellitus (GDM) from developing type 2 diabetes mellitus, but the results of existing studies are inconsistent,
diabetes mellitus 1106 5/2017AbstractSummaryLactation may protect women with previous gestational diabetes mellitus (GDM) from developing type 2 diabetes mellitus , but the results of existing studies are inconsistent, ranging from null to beneficial. We aimed to
diabetes mellitus 1582 studies (cross‐sectional, case‐control, and cohort study) with information on lactation and type 2 diabetes mellitus incidence among women with previous GDM. We excluded case studies without control data. Data synthesis
diabetes mellitus 1946 low to unclear. Longer lactation for more than 4 to 12 weeks postpartum had risk reduction of type 2 diabetes mellitus compared with shorter lactation (OR 0.77, 95% CI 0.01‐55.86; OR 0.56, 95% CI 0.35‐0.89; OR 0.22,
diabetes mellitus 2092 lactation (OR 0.77, 95% CI 0.01‐55.86; OR 0.56, 95% CI 0.35‐0.89; OR 0.22, 95% CI 0.13‐0.36; type 2 diabetes mellitus evaluation time < 2 y, 2‐5 y, and >5 y, respectively). Exclusive lactation for more than 6 to
diabetes mellitus 2260 respectively). Exclusive lactation for more than 6 to 9 weeks postpartum also had lower risk of type 2 diabetes mellitus compared with exclusive formula (OR 0.42, 95% CI 0.22‐0.81). The findings support the evidence that
diabetes mellitus 2440 The findings support the evidence that longer and exclusive lactation may be beneficial for type 2 diabetes mellitus prevention in women with previous GDM. However, the evidence relies only on observational studies. Therefore,
diabetes mellitus 2743 effect.Tanase‐NakaoK, ArataN, KawasakiM, et al. Potential protective effect of lactation against incidence of type 2 diabetes mellitus in women with previous gestational diabetes mellitus: A systematic review and meta‐analysis. Diabetes
diabetes mellitus 2796 effect of lactation against incidence of type 2 diabetes mellitus in women with previous gestational diabetes mellitus : A systematic review and meta‐analysis. Diabetes Metab Res Rev. 2017;33:e2875https://doi.org/10.1002/dmrr.2875.INTRODUCTION1At
diabetes mellitus 3028 2017;33:e2875https://doi.org/10.1002/dmrr.2875.INTRODUCTION1At present about 415 million adults suffer from diabetes, of which about 90% are type 2 diabetes mellitus .1 Diabetes is associated with life‐threatening morbidity, making the disease not only personal but
diabetes mellitus 3245 but also socioeconomic problem. In 2015, about 5 million people died because of diabetes.1Gestational diabetes mellitus (GDM) is defined as “diabetes diagnosed in the second or third trimester of pregnancy that is not
diabetes mellitus 3535 births.1 Although hyperglycemia usually normalizes immediately after delivery, the risk of lifetime type 2 diabetes mellitus in women who had GDM is more than 7‐fold higher compared with in women with normoglycaemic pregnancies.3
diabetes mellitus 3721 women with normoglycaemic pregnancies.3 Furthermore, up to 50% of women who had GDM developed type 2 diabetes mellitus within 5 years postpartum.4 Therefore, women with GDM are recognized to be at high risk of developing
diabetes mellitus 3998 preventive measures.Intensive lifestyle modification is effective in preventing or delaying type 2 diabetes mellitus in women with previous GDM.5 However, postpartum women may face difficulties in adopting a healthy lifestyle
diabetes mellitus 4341 benefits on maternal glycemic metabolism. Childbearing itself is suggested to put women at risk for type 2 diabetes mellitus when compared with nulliparous women,8, 9 and breastfeeding may “reset” the burden10 and lower the
diabetes mellitus 4878 oxytocin.15It is of great interest whether women with previous GDM, the high risk population for type 2 diabetes mellitus , benefit as well from breastfeeding practice. To date, several observational studies investigating the
diabetes mellitus 5040 practice. To date, several observational studies investigating the association between lactation and type 2 diabetes mellitus incidence after GDM pregnancy have been conducted with mixed results. Although there are several reviews
diabetes mellitus 5480 synthesize the data if available, we aimed to systematically review current findings on lactation for type 2 diabetes mellitus prevention in women with previous GDM.METHODS2This systematic review was performed according to the
diabetes mellitus 6164 intensity and/or duration of any lactation, and (3) it included the incidence of postpartum type 2 diabetes mellitus in the outcome. Observational studies (cross‐sectional, case‐control, and cohort study) were included.
diabetes mellitus 6332 (cross‐sectional, case‐control, and cohort study) were included. Studies with unclear number/rate of type 2 diabetes mellitus onset were excluded (eg, “high” incidence of diabetes, incidence rate of “dysglyceamia”).After
diabetes mellitus 7694 criteriaLactation measures (ie, intention, initiation, intensity, and duration)Diagnostic methods of GDM and type 2 diabetes mellitus Type 2 diabetes mellitus evaluation time‐point, incidence rate, and hazard/risk ratioAdjusted confounders
diabetes mellitus 7718 intention, initiation, intensity, and duration)Diagnostic methods of GDM and type 2 diabetes mellitusType 2 diabetes mellitus evaluation time‐point, incidence rate, and hazard/risk ratioAdjusted confounders for the analysis
diabetes mellitus 7864 incidence rate, and hazard/risk ratioAdjusted confounders for the analysis of breastfeeding and type 2 diabetes mellitus incidenceConclusion on breastfeeding and type 2 diabetes mellitus incidenceOne reviewer (K.T.N.) extracted
diabetes mellitus 7930 analysis of breastfeeding and type 2 diabetes mellitus incidenceConclusion on breastfeeding and type 2 diabetes mellitus incidenceOne reviewer (K.T.N.) extracted data, and another reviewer (M.K.) checked for its integrity.
diabetes mellitus 8305 results using Review Manager software version 5.3 (RevMan5.3). The number of women with GDM and type 2 diabetes mellitus incidence in relation to breastfeeding measures were obtained from the reports or estimated through
diabetes mellitus 16178 oral glucose tolerance test; OR, odds ratio; PA, physical activity; RH, relative hazards; T2DM, type 2 diabetes mellitus .Study design, country3.3Three studies were prospective cohort study,26, 30, 31 2 were retrospective
diabetes mellitus 18676 postpartum by measuring the amount of added formula milk to test the dose‐response effect for type 2 diabetes mellitus prevention and divided the participants into 4 groups: exclusive lactation, mostly lactation, mostly
diabetes mellitus 18998 lactation period.31T2DM evaluation, incidence3.6The diagnostic criteria for the evaluation of type 2 diabetes mellitus incidence were described in 6 studies; 3 studies applied the American Diabetes Association criteria,26,
diabetes mellitus 19235 studies used the National Diabetes Data Group criteria,23, 35 and one was based on self‐report.38Type 2 diabetes mellitus evaluation time ranged from 4 to 12 weeks to up to 19 years postpartum, and type 2 diabetes mellitus
diabetes mellitus 19338 diabetes mellitus evaluation time ranged from 4 to 12 weeks to up to 19 years postpartum, and type 2 diabetes mellitus incidence rate increases in accordance with the evaluation time.Covariables used to adjust for analyzing
diabetes mellitus 19490 accordance with the evaluation time.Covariables used to adjust for analyzing lactation measure and type 2 diabetes mellitus incidence varied by each study. The most frequently adjusted index was BMI, which was used in 5 studies.26,
diabetes mellitus 20215 mother,38 enrollment year,31 and age at DM36 were used in one study.As for the conclusions on type 2 diabetes mellitus incidence, 6 studies26, 30, 31, 32, 35, 36 reported results in favor of lactation, and 3 studies23,
diabetes mellitus 21257 studies.23, 32, 34, 35, 36 All the studies were judged to be “low” for detection biases because type 2 diabetes mellitus incidence could not be influenced by the blinding methods for its assessment. Attrition biases were
diabetes mellitus 21938 postpartum) versus shorter (<4 to 12 wk postpartum) lactation of any intensity for preventing type 2 diabetes mellitus after GDM pregnancy (Figure 2). The remaining studies were not included because of different study
diabetes mellitus 23295 however, only one of them compared the effect of exclusive lactation with exclusive formula for type 2 diabetes mellitus incidence.26 The risk of bias of this study was low (Table S3). The quality of the evidence was judged
diabetes mellitus 23797 more than 12 weeks postpartum has statistically significant association with lower risk of type 2 diabetes mellitus in the long term (ie, >2 y). The effect of longer lactation was not obvious when diabetes was evaluated
diabetes mellitus 24158 95% CI 0.13‐0.36; <2 y, 2‐5 y, and >5 y, respectively). One likely explanation is that type 2 diabetes mellitus incidence after GDM pregnancy increases with time,4 and at least several years of follow‐up are required
diabetes mellitus 24346 several years of follow‐up are required to judge the effect of exposure. Also, women developing type 2 diabetes mellitus in early postpartum (ie, 4‐12 wk postpartum) are definitely of the highest risk. The underlying etiology
diabetes mellitus 24519 definitely of the highest risk. The underlying etiology may be different from those who develop type 2 diabetes mellitus later. In fact, Ziegler et al reported that women with islet autoantibody developed diabetes much faster
diabetes mellitus 24853 effect of lactation was observed in those women.31 All 3 studies in the subgroup evaluating type 2 diabetes mellitus at >3 years excluded early onset DM23, 26 or islet autoantibody‐positive population,31 suggesting
diabetes mellitus 26007 exclusive lactation at 6 to 9 weeks postpartum was associated with lower risk of long‐term type 2 diabetes mellitus compared with exclusive formula (OR 0.42 95% CI 0.22‐0.81).26 The World Health Organization has recommended
diabetes mellitus 26977 observational studies in which we cannot confirm the causal relationship between lactation and type 2 diabetes mellitus . The effect of unknown confoundings or reverse causation cannot be ruled out even in well‐designed
diabetes mellitus 28099 real practice. However, subgroup analysis showed fairly heterogeneous results for long‐term type 2 diabetes mellitus even in populations with diverse background, suggesting that the association remains.CONCLUSION5In conclusion,
diabetes mellitus 28363 lactating for more than 4 to 12 weeks postpartum have lower risk (moderate quality of evidence) of type 2 diabetes mellitus compared with women with shorter lactation period. Also, women with GDM exclusively lactating for more
diabetes mellitus 28540 women with GDM exclusively lactating for more than 6 to 9 weeks postpartum have lower risk of type 2 diabetes mellitus compared with women with formula feeding. The etiology behind this potential long‐term beneficial
diabetes mellitus 28865 well studied. To investigate these unresolved issues between lactation and the prevention of type 2 diabetes mellitus , further studies are warranted in the future.CONFLICTS OF INTERESTNone of the authors has conflict of
hyperglycemia 3446 pregnancy that is not clearly overt diabetes.”2 The GDM occurs in nearly 14% of live births.1 Although hyperglycemia usually normalizes immediately after delivery, the risk of lifetime type 2 diabetes mellitus in women
obesity 27573 for covariables. Breastfeeding practices were reported to be influenced by multiple factors such as obesity ,53 depression,54 insulin treatment during pregnancy,49 and how health conscious a mother is.55 These
type 2 diabetes mellitus 109 Diabetes/Metabolism Research and ReviewsPotential protective effect of lactation against incidence of type 2 diabetes mellitus in women with previous gestational diabetes mellitus: A systematic review and meta‐analysisAlternative
type 2 diabetes mellitus 1099 5/2017AbstractSummaryLactation may protect women with previous gestational diabetes mellitus (GDM) from developing type 2 diabetes mellitus , but the results of existing studies are inconsistent, ranging from null to beneficial. We aimed to
type 2 diabetes mellitus 1575 observational studies (cross‐sectional, case‐control, and cohort study) with information on lactation and type 2 diabetes mellitus incidence among women with previous GDM. We excluded case studies without control data. Data synthesis
type 2 diabetes mellitus 1939 from low to unclear. Longer lactation for more than 4 to 12 weeks postpartum had risk reduction of type 2 diabetes mellitus compared with shorter lactation (OR 0.77, 95% CI 0.01‐55.86; OR 0.56, 95% CI 0.35‐0.89; OR 0.22,
type 2 diabetes mellitus 2085 lactation (OR 0.77, 95% CI 0.01‐55.86; OR 0.56, 95% CI 0.35‐0.89; OR 0.22, 95% CI 0.13‐0.36; type 2 diabetes mellitus evaluation time < 2 y, 2‐5 y, and >5 y, respectively). Exclusive lactation for more than 6 to
type 2 diabetes mellitus 2253 >5 y, respectively). Exclusive lactation for more than 6 to 9 weeks postpartum also had lower risk of type 2 diabetes mellitus compared with exclusive formula (OR 0.42, 95% CI 0.22‐0.81). The findings support the evidence that
type 2 diabetes mellitus 2433 0.22‐0.81). The findings support the evidence that longer and exclusive lactation may be beneficial for type 2 diabetes mellitus prevention in women with previous GDM. However, the evidence relies only on observational studies. Therefore,
type 2 diabetes mellitus 2736 effect.Tanase‐NakaoK, ArataN, KawasakiM, et al. Potential protective effect of lactation against incidence of type 2 diabetes mellitus in women with previous gestational diabetes mellitus: A systematic review and meta‐analysis. Diabetes
type 2 diabetes mellitus 3021 2017;33:e2875https://doi.org/10.1002/dmrr.2875.INTRODUCTION1At present about 415 million adults suffer from diabetes, of which about 90% are type 2 diabetes mellitus .1 Diabetes is associated with life‐threatening morbidity, making the disease not only personal but
type 2 diabetes mellitus 3528 births.1 Although hyperglycemia usually normalizes immediately after delivery, the risk of lifetime type 2 diabetes mellitus in women who had GDM is more than 7‐fold higher compared with in women with normoglycaemic pregnancies.3
type 2 diabetes mellitus 3714 with in women with normoglycaemic pregnancies.3 Furthermore, up to 50% of women who had GDM developed type 2 diabetes mellitus within 5 years postpartum.4 Therefore, women with GDM are recognized to be at high risk of developing
type 2 diabetes mellitus 3991 target of preventive measures.Intensive lifestyle modification is effective in preventing or delaying type 2 diabetes mellitus in women with previous GDM.5 However, postpartum women may face difficulties in adopting a healthy lifestyle
type 2 diabetes mellitus 4334 benefits on maternal glycemic metabolism. Childbearing itself is suggested to put women at risk for type 2 diabetes mellitus when compared with nulliparous women,8, 9 and breastfeeding may “reset” the burden10 and lower the
type 2 diabetes mellitus 4871 and/or oxytocin.15It is of great interest whether women with previous GDM, the high risk population for type 2 diabetes mellitus , benefit as well from breastfeeding practice. To date, several observational studies investigating the
type 2 diabetes mellitus 5033 practice. To date, several observational studies investigating the association between lactation and type 2 diabetes mellitus incidence after GDM pregnancy have been conducted with mixed results. Although there are several reviews
type 2 diabetes mellitus 5473 synthesize the data if available, we aimed to systematically review current findings on lactation for type 2 diabetes mellitus prevention in women with previous GDM.METHODS2This systematic review was performed according to the
type 2 diabetes mellitus 6157 lactation intensity and/or duration of any lactation, and (3) it included the incidence of postpartum type 2 diabetes mellitus in the outcome. Observational studies (cross‐sectional, case‐control, and cohort study) were included.
type 2 diabetes mellitus 6325 (cross‐sectional, case‐control, and cohort study) were included. Studies with unclear number/rate of type 2 diabetes mellitus onset were excluded (eg, “high” incidence of diabetes, incidence rate of “dysglyceamia”).After
type 2 diabetes mellitus 7687 criteriaLactation measures (ie, intention, initiation, intensity, and duration)Diagnostic methods of GDM and type 2 diabetes mellitus Type 2 diabetes mellitus evaluation time‐point, incidence rate, and hazard/risk ratioAdjusted confounders
type 2 diabetes mellitus 7857 time‐point, incidence rate, and hazard/risk ratioAdjusted confounders for the analysis of breastfeeding and type 2 diabetes mellitus incidenceConclusion on breastfeeding and type 2 diabetes mellitus incidenceOne reviewer (K.T.N.) extracted
type 2 diabetes mellitus 7923 the analysis of breastfeeding and type 2 diabetes mellitus incidenceConclusion on breastfeeding and type 2 diabetes mellitus incidenceOne reviewer (K.T.N.) extracted data, and another reviewer (M.K.) checked for its integrity.
type 2 diabetes mellitus 8298 comparable results using Review Manager software version 5.3 (RevMan5.3). The number of women with GDM and type 2 diabetes mellitus incidence in relation to breastfeeding measures were obtained from the reports or estimated through
type 2 diabetes mellitus 16171 OGTT, oral glucose tolerance test; OR, odds ratio; PA, physical activity; RH, relative hazards; T2DM, type 2 diabetes mellitus .Study design, country3.3Three studies were prospective cohort study,26, 30, 31 2 were retrospective
type 2 diabetes mellitus 18669 9 weeks postpartum by measuring the amount of added formula milk to test the dose‐response effect for type 2 diabetes mellitus prevention and divided the participants into 4 groups: exclusive lactation, mostly lactation, mostly
type 2 diabetes mellitus 18991 full lactation period.31T2DM evaluation, incidence3.6The diagnostic criteria for the evaluation of type 2 diabetes mellitus incidence were described in 6 studies; 3 studies applied the American Diabetes Association criteria,26,
type 2 diabetes mellitus 19331 self‐report.38Type 2 diabetes mellitus evaluation time ranged from 4 to 12 weeks to up to 19 years postpartum, and type 2 diabetes mellitus incidence rate increases in accordance with the evaluation time.Covariables used to adjust for analyzing
type 2 diabetes mellitus 19483 accordance with the evaluation time.Covariables used to adjust for analyzing lactation measure and type 2 diabetes mellitus incidence varied by each study. The most frequently adjusted index was BMI, which was used in 5 studies.26,
type 2 diabetes mellitus 20208 weight of mother,38 enrollment year,31 and age at DM36 were used in one study.As for the conclusions on type 2 diabetes mellitus incidence, 6 studies26, 30, 31, 32, 35, 36 reported results in favor of lactation, and 3 studies23,
type 2 diabetes mellitus 21250 studies.23, 32, 34, 35, 36 All the studies were judged to be “low” for detection biases because type 2 diabetes mellitus incidence could not be influenced by the blinding methods for its assessment. Attrition biases were
type 2 diabetes mellitus 21931 12 wk postpartum) versus shorter (<4 to 12 wk postpartum) lactation of any intensity for preventing type 2 diabetes mellitus after GDM pregnancy (Figure 2). The remaining studies were not included because of different study
type 2 diabetes mellitus 23288 31; however, only one of them compared the effect of exclusive lactation with exclusive formula for type 2 diabetes mellitus incidence.26 The risk of bias of this study was low (Table S3). The quality of the evidence was judged
type 2 diabetes mellitus 23790 4 weeks to more than 12 weeks postpartum has statistically significant association with lower risk of type 2 diabetes mellitus in the long term (ie, >2 y). The effect of longer lactation was not obvious when diabetes was evaluated
type 2 diabetes mellitus 24151 0.22 95% CI 0.13‐0.36; <2 y, 2‐5 y, and >5 y, respectively). One likely explanation is that type 2 diabetes mellitus incidence after GDM pregnancy increases with time,4 and at least several years of follow‐up are required
type 2 diabetes mellitus 24339 least several years of follow‐up are required to judge the effect of exposure. Also, women developing type 2 diabetes mellitus in early postpartum (ie, 4‐12 wk postpartum) are definitely of the highest risk. The underlying etiology
type 2 diabetes mellitus 24512 are definitely of the highest risk. The underlying etiology may be different from those who develop type 2 diabetes mellitus later. In fact, Ziegler et al reported that women with islet autoantibody developed diabetes much faster
type 2 diabetes mellitus 24846 protective effect of lactation was observed in those women.31 All 3 studies in the subgroup evaluating type 2 diabetes mellitus at >3 years excluded early onset DM23, 26 or islet autoantibody‐positive population,31 suggesting
type 2 diabetes mellitus 26000 that exclusive lactation at 6 to 9 weeks postpartum was associated with lower risk of long‐term type 2 diabetes mellitus compared with exclusive formula (OR 0.42 95% CI 0.22‐0.81).26 The World Health Organization has recommended
type 2 diabetes mellitus 26970 only on observational studies in which we cannot confirm the causal relationship between lactation and type 2 diabetes mellitus . The effect of unknown confoundings or reverse causation cannot be ruled out even in well‐designed
type 2 diabetes mellitus 28092 woman in real practice. However, subgroup analysis showed fairly heterogeneous results for long‐term type 2 diabetes mellitus even in populations with diverse background, suggesting that the association remains.CONCLUSION5In conclusion,
type 2 diabetes mellitus 28356 lactating for more than 4 to 12 weeks postpartum have lower risk (moderate quality of evidence) of type 2 diabetes mellitus compared with women with shorter lactation period. Also, women with GDM exclusively lactating for more
type 2 diabetes mellitus 28533 Also, women with GDM exclusively lactating for more than 6 to 9 weeks postpartum have lower risk of type 2 diabetes mellitus compared with women with formula feeding. The etiology behind this potential long‐term beneficial
type 2 diabetes mellitus 28858 is not well studied. To investigate these unresolved issues between lactation and the prevention of type 2 diabetes mellitus , further studies are warranted in the future.CONFLICTS OF INTERESTNone of the authors has conflict of

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