A new study is adding to evidence that our conventional understanding of gestational diabetes is incomplete, and its authors are calling for recognition of “different types of gestational diabetes that warrant different approaches to treatment and prevention.”

Currently, most medical advice around how to avoid gestational diabetes focuses on limiting weight gain and increasing physical activity. While those efforts are important, they may have less bearing on the cause of gestational diabetes than previously believed.

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“Our data suggest that in pregnancy, energy balance — the calories consumed versus the calories burned — may not determine the development of gestational diabetes,” said Leanne Redman, PhD, director of the Reproductive Endocrinology and Women’s Health Lab at Louisiana State University’s Pennington Biomedical Research Center.

India has the highest rate of gestational diabetes in the world, with 26.3% of expectant mothers developing high blood sugar levels during their pregnancy. “We do not know the exact cause, but Indians are at higher risk for gestational diabetes,” said Dr Nam Han Cho, then president-elect of the International Diabetes Federation, to The Economic Times in 2017.

A review of clinical trials aimed at gestational diabetes prevention, which involved more than 5,000 pregnant women, found women who increased their physical activity, ate more healthily and restricted their food intake developed gestational diabetes at the same rates as women who made no such lifestyle changes.

Limiting weight gain, eating healthily and getting more physical activity are important behaviors for good health, but the study’s results “do underscore the need to better understand the way that gestational diabetes develops in women with obesity,” Redman said.

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To that end, researchers at Pennington Biomedical Research Center followed for five years 62 women with obesity, nine of whom developed gestational diabetes. They found the women who developed gestational diabetes were more likely to display risk factors, such as excess body fat and insulin resistance, early in their pregnancy, and were more likely to have prediabetes, elevated fasting blood sugar levels, and relatives with diabetes.

Parsing this information more closely can improve recommendations to prevent gestational diabetes for the most at-risk women. “Preventing gestational diabetes is not as simple as reducing weight gain,” said the study’s co-lead author, Jasper Most, PhD. “It may require more individualized approaches based on each person’s risk factors.”

Some women may develop gestational diabetes because their pancreas can’t amp up insulin production to meet the pregnant body’s increased demand for the hormone, Most said; others may develop gestational diabetes because their muscles and livers become more insulin resistant. The researchers next aim to explore and identify potential types of gestational diabetes in their future research.