Lactation Duration and Progression to Diabetes in Women Across the Childbearing Years: The 30-Year CARDIA Study

Abstract

Importance: Lactation duration has shown weak protective associations with incident diabetes (3%-15% lower incidence per year of lactation) in older women based solely on self-report of diabetes, studies initiated beyond the reproductive period are vulnerable to unmeasured confounding or reverse causation from antecedent biochemical risk status, perinatal outcomes, and behaviors across the childbearing years.

Objective: To evaluate the association between lactation and progression to diabetes using biochemical testing both before and after pregnancy and accounting for prepregnancy cardiometabolic measures, gestational diabetes (GD), and lifestyle behaviors.

Design, setting, and participants: For this US multicenter, community-based 30-year prospective cohort study, there were 1238 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study of young black and white women ages 18 to 30 years without diabetes at baseline (1985-1986) who had 1 or more live births after baseline, reported lactation duration, and were screened for diabetes up to 7 times during 30 years after baseline (1986-2016).

Exposures: Time-dependent lactation duration categories (none, >0 to 6 months, >6 to <12 months, and ≥12 months) across all births since baseline through 30 years.

Main outcomes and measures: Diabetes incidence rates per 1000 person-years and adjusted relative hazards (RH) with corresponding 95% CIs, as well as proportional hazards regression models adjusted for biochemical, sociodemographic, and reproductive risk factors, as well as family history of diabetes, lifestyle, and weight change during follow-up.

Results: Overall 1238 women were included in this analysis (mean [SD] age, 24.2 [3.7] years; 615 black women). There were 182 incident diabetes cases during 27 598 person-years for an overall incidence rate of 6.6 cases per 1000 person-years (95% CI, 5.6-7.6); and rates for women with GD and without GD were 18.0 (95% CI, 13.3-22.8) and 5.1 (95% CI, 4.2-6.0), respectively (P for difference < .001). Lactation duration showed a strong, graded inverse association with diabetes incidence: adjusted RH for more than 0 to 6 months, 0.75 (95% CI, 0.51-1.09); more than 6 months to less than 12 months, 0.52 (95% CI, 0.31-0.87), and 12 months or more 0.53 (0.29-0.98) vs none (0 days) (P for trend = .01). There was no evidence of effect modification by race, GD, or parity.

Conclusions and relevance: This study provides longitudinal biochemical evidence that lactation duration is independently associated with lower incidence of diabetes. Further investigation is required to elucidate mechanisms that may explain this relationship.

Figure.. Incidence Rates of Diabetes Mellitus Among Lactation Duration Categories Stratified by GD Status in Women

Crude incidence rates and corresponding 95% CIs (whiskers) of diabetes in black and white women enrolled in the Coronary Artery Risk Development in Young Adults trial subsequent to postbaseline births and lactation during 30 years of follow-up (1986-2016). The incidence rates of diabetes (cases per 1000 person-years) were based on systematic testing up to 7 times and were stratified by GD status for postbaseline births. The entire sample comprised 1238 women (GD = 155; non-GD = 1083), and overall P < .001 (P for trend for women with GD = .02; P for trend for women without GD = .001). See Table 1 for further data. GD indicates gestational diabetes.