Long-Term Adherence to Modifiable Factors and Incident Cardiovascular Disease Among Women With a History of Gestational Diabetes: A Prospective Cohort Study

Frank Qian; Jiaxi Yang; Deirdre K. Tobias; Sylvia H. Ley; Jorge E. Chavarro; Gang Liu; Zhangling Chen; Edwina Yeung; Qi Sun; Walter C. Willett; Frank B. Hu; Cuilin Zhang

doi:10.1161/JAHA.124.038936

Long-Term Adherence to Modifiable Factors and Incident Cardiovascular Disease Among Women With a History of Gestational Diabetes: A Prospective Cohort Study

Frank Qian
, Jiaxi Yang
, Deirdre K. Tobias
, Sylvia H. Ley
, Jorge E. Chavarro
, Gang Liu
, Zhangling Chen
, Edwina Yeung
, Qi Sun
, Walter C. Willett
, Frank B. Hu
, Cuilin Zhang^*

^*Corresponding author for this work

Epidemiology

Harvard T.H. Chan School of Public Health
Boston Medical Center
National University of Singapore
Harvard Medical School
Tulane University
Harvard University
Huazhong University of Science and Technology
The Second Xiangya Hospital of Central South University
National Institutes of Health
Joslin Diabetes Center

Research output: Contribution to journal › Article › Academic › peer-review

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Abstract

BACKGROUND:

Women with prior gestational diabetes are at increased risk of cardiovascular disease (CVD), but whether and to what extent this risk is modifiable is unknown.

METHODS:

NHSII (Nurses' Health Study II) participants (N=4355), who reported a gestational diabetes diagnosis between 1989 and 2001 and were free of type 2 diabetes, CVD, and cancer at baseline were included. Incident CVD included nonfatal myocardial infarction, fatal coronary heart disease, nonfatal/fatal stroke, angiographically confirmed angina, and coronary revascularizations. Modifiable factors were updated every 2 to 4 years. Optimal modifiable factors included body mass index <25.0 kg/m2, favorable Alternative Healthy Eating Index-2010 score (top 40%), ≥150 minutes moderate-intensity or ≥75 minutes vigorous-intensity physical activity/week, noncurrent smoking, and moderate alcohol intake (5.0-14.9 g/day). Multivariable-adjusted Cox models were used to estimate hazard ratios (HR) and 95% CIs with CVD.

RESULTS:

During a median 27.9 years of follow-up, 188 incident CVD events occurred. Compared with women with zero optimal factors, HR for CVD among women with one, two, three, or four optimal factors was 0.56 (95% CI, 0.22-1.42), 0.40 (95% CI, 0.16-1.02), 0.32 (95% CI, 0.12-0.84), and 0.14 (95% CI, 0.05-0.46), respectively (P-trend<0.0001). There were no incident CVD events in women with all 5 optimal factors. Compared with women with stable modifiable factors, those who increased the number of optimal factors had a lower risk of CVD: 0.30 (95% CI, 0.16-0.55), and those who decreased the number of optimal factors had higher risk: 2.05 (95% CI, 1.28-3.29).

CONCLUSIONS:

Long-term adherence to and improvements in optimal modifiable factors were associated with lower CVD risk after gestational diabetes.

Original language	English
Article number	e038936
Pages (from-to)	e038936
Journal	Journal of the American Heart Association
Volume	14
Issue number	16
DOIs	https://doi.org/10.1161/JAHA.124.038936
Publication status	Published - 5 Aug 2025

Bibliographical note

Publisher Copyright:
© 2025 The Author(s). Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

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10.1161/JAHA.124.038936Licence: CC BY-NC-ND

Long‐Term Adherence to Modifiable Factors and Incident Cardiovascular Disease Among Women With a History of Gestational DiabetesFinal published version, 324 KBLicence: CC BY

Cite this

Qian, F., Yang, J., Tobias, D. K., Ley, S. H., Chavarro, J. E., Liu, G., Chen, Z., Yeung, E., Sun, Q., Willett, W. C., Hu, F. B., & Zhang, C. (2025). Long-Term Adherence to Modifiable Factors and Incident Cardiovascular Disease Among Women With a History of Gestational Diabetes: A Prospective Cohort Study. Journal of the American Heart Association, 14(16), e038936. Article e038936. https://doi.org/10.1161/JAHA.124.038936

@article{18c125646aab491fad41d35063738ad0,

title = "Long-Term Adherence to Modifiable Factors and Incident Cardiovascular Disease Among Women With a History of Gestational Diabetes: A Prospective Cohort Study",

abstract = "BACKGROUND: Women with prior gestational diabetes are at increased risk of cardiovascular disease (CVD), but whether and to what extent this risk is modifiable is unknown. METHODS: NHSII (Nurses' Health Study II) participants (N=4355), who reported a gestational diabetes diagnosis between 1989 and 2001 and were free of type 2 diabetes, CVD, and cancer at baseline were included. Incident CVD included nonfatal myocardial infarction, fatal coronary heart disease, nonfatal/fatal stroke, angiographically confirmed angina, and coronary revascularizations. Modifiable factors were updated every 2 to 4 years. Optimal modifiable factors included body mass index <25.0 kg/m2, favorable Alternative Healthy Eating Index-2010 score (top 40\%), ≥150 minutes moderate-intensity or ≥75 minutes vigorous-intensity physical activity/week, noncurrent smoking, and moderate alcohol intake (5.0-14.9 g/day). Multivariable-adjusted Cox models were used to estimate hazard ratios (HR) and 95\% CIs with CVD. RESULTS:During a median 27.9 years of follow-up, 188 incident CVD events occurred. Compared with women with zero optimal factors, HR for CVD among women with one, two, three, or four optimal factors was 0.56 (95\% CI, 0.22-1.42), 0.40 (95\% CI, 0.16-1.02), 0.32 (95\% CI, 0.12-0.84), and 0.14 (95\% CI, 0.05-0.46), respectively (P-trend<0.0001). There were no incident CVD events in women with all 5 optimal factors. Compared with women with stable modifiable factors, those who increased the number of optimal factors had a lower risk of CVD: 0.30 (95\% CI, 0.16-0.55), and those who decreased the number of optimal factors had higher risk: 2.05 (95\% CI, 1.28-3.29).CONCLUSIONS: Long-term adherence to and improvements in optimal modifiable factors were associated with lower CVD risk after gestational diabetes.",

author = "Frank Qian and Jiaxi Yang and Tobias, \{Deirdre K.\} and Ley, \{Sylvia H.\} and Chavarro, \{Jorge E.\} and Gang Liu and Zhangling Chen and Edwina Yeung and Qi Sun and Willett, \{Walter C.\} and Hu, \{Frank B.\} and Cuilin Zhang",

note = "Publisher Copyright: {\textcopyright} 2025 The Author(s). Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.",

year = "2025",

month = aug,

day = "5",

doi = "10.1161/JAHA.124.038936",

language = "English",

volume = "14",

pages = "e038936",

journal = "Journal of the American Heart Association",

issn = "2047-9980",

publisher = "American Heart Association Inc.",

number = "16",

}

Qian, F, Yang, J, Tobias, DK, Ley, SH, Chavarro, JE, Liu, G, Chen, Z, Yeung, E, Sun, Q, Willett, WC, Hu, FB & Zhang, C 2025, 'Long-Term Adherence to Modifiable Factors and Incident Cardiovascular Disease Among Women With a History of Gestational Diabetes: A Prospective Cohort Study', Journal of the American Heart Association, vol. 14, no. 16, e038936, pp. e038936. https://doi.org/10.1161/JAHA.124.038936

Long-Term Adherence to Modifiable Factors and Incident Cardiovascular Disease Among Women With a History of Gestational Diabetes: A Prospective Cohort Study. / Qian, Frank; Yang, Jiaxi; Tobias, Deirdre K. et al.
In: Journal of the American Heart Association, Vol. 14, No. 16, e038936, 05.08.2025, p. e038936.

Research output: Contribution to journal › Article › Academic › peer-review

TY - JOUR

T1 - Long-Term Adherence to Modifiable Factors and Incident Cardiovascular Disease Among Women With a History of Gestational Diabetes

T2 - A Prospective Cohort Study

AU - Qian, Frank

AU - Yang, Jiaxi

AU - Tobias, Deirdre K.

AU - Ley, Sylvia H.

AU - Chavarro, Jorge E.

AU - Liu, Gang

AU - Chen, Zhangling

AU - Yeung, Edwina

AU - Sun, Qi

AU - Willett, Walter C.

AU - Hu, Frank B.

AU - Zhang, Cuilin

N1 - Publisher Copyright: © 2025 The Author(s). Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

PY - 2025/8/5

Y1 - 2025/8/5

N2 - BACKGROUND: Women with prior gestational diabetes are at increased risk of cardiovascular disease (CVD), but whether and to what extent this risk is modifiable is unknown. METHODS: NHSII (Nurses' Health Study II) participants (N=4355), who reported a gestational diabetes diagnosis between 1989 and 2001 and were free of type 2 diabetes, CVD, and cancer at baseline were included. Incident CVD included nonfatal myocardial infarction, fatal coronary heart disease, nonfatal/fatal stroke, angiographically confirmed angina, and coronary revascularizations. Modifiable factors were updated every 2 to 4 years. Optimal modifiable factors included body mass index <25.0 kg/m2, favorable Alternative Healthy Eating Index-2010 score (top 40%), ≥150 minutes moderate-intensity or ≥75 minutes vigorous-intensity physical activity/week, noncurrent smoking, and moderate alcohol intake (5.0-14.9 g/day). Multivariable-adjusted Cox models were used to estimate hazard ratios (HR) and 95% CIs with CVD. RESULTS:During a median 27.9 years of follow-up, 188 incident CVD events occurred. Compared with women with zero optimal factors, HR for CVD among women with one, two, three, or four optimal factors was 0.56 (95% CI, 0.22-1.42), 0.40 (95% CI, 0.16-1.02), 0.32 (95% CI, 0.12-0.84), and 0.14 (95% CI, 0.05-0.46), respectively (P-trend<0.0001). There were no incident CVD events in women with all 5 optimal factors. Compared with women with stable modifiable factors, those who increased the number of optimal factors had a lower risk of CVD: 0.30 (95% CI, 0.16-0.55), and those who decreased the number of optimal factors had higher risk: 2.05 (95% CI, 1.28-3.29).CONCLUSIONS: Long-term adherence to and improvements in optimal modifiable factors were associated with lower CVD risk after gestational diabetes.

AB - BACKGROUND: Women with prior gestational diabetes are at increased risk of cardiovascular disease (CVD), but whether and to what extent this risk is modifiable is unknown. METHODS: NHSII (Nurses' Health Study II) participants (N=4355), who reported a gestational diabetes diagnosis between 1989 and 2001 and were free of type 2 diabetes, CVD, and cancer at baseline were included. Incident CVD included nonfatal myocardial infarction, fatal coronary heart disease, nonfatal/fatal stroke, angiographically confirmed angina, and coronary revascularizations. Modifiable factors were updated every 2 to 4 years. Optimal modifiable factors included body mass index <25.0 kg/m2, favorable Alternative Healthy Eating Index-2010 score (top 40%), ≥150 minutes moderate-intensity or ≥75 minutes vigorous-intensity physical activity/week, noncurrent smoking, and moderate alcohol intake (5.0-14.9 g/day). Multivariable-adjusted Cox models were used to estimate hazard ratios (HR) and 95% CIs with CVD. RESULTS:During a median 27.9 years of follow-up, 188 incident CVD events occurred. Compared with women with zero optimal factors, HR for CVD among women with one, two, three, or four optimal factors was 0.56 (95% CI, 0.22-1.42), 0.40 (95% CI, 0.16-1.02), 0.32 (95% CI, 0.12-0.84), and 0.14 (95% CI, 0.05-0.46), respectively (P-trend<0.0001). There were no incident CVD events in women with all 5 optimal factors. Compared with women with stable modifiable factors, those who increased the number of optimal factors had a lower risk of CVD: 0.30 (95% CI, 0.16-0.55), and those who decreased the number of optimal factors had higher risk: 2.05 (95% CI, 1.28-3.29).CONCLUSIONS: Long-term adherence to and improvements in optimal modifiable factors were associated with lower CVD risk after gestational diabetes.

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U2 - 10.1161/JAHA.124.038936

DO - 10.1161/JAHA.124.038936

M3 - Article

C2 - 40762324

AN - SCOPUS:105013821337

SN - 2047-9980

VL - 14

SP - e038936

JO - Journal of the American Heart Association

JF - Journal of the American Heart Association

IS - 16

M1 - e038936

ER -

Long-Term Adherence to Modifiable Factors and Incident Cardiovascular Disease Among Women With a History of Gestational Diabetes: A Prospective Cohort Study

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