Gestational Diabetes History and Cardiovascular Health Assessed by Life’s Essential 8 across Postpartum Intervals

Abstract

Background

Gestational diabetes is a well‐established risk factor for cardiovascular disease. However, its long‐term impact on postpartum cardiovascular health (CVH), particularly assessed via the Life’s Essential 8 (LE8) metrics, remains unclear.

Methods

Data from the 2007 to 2018 National Health and Nutrition Examination Survey data set were analyzed for women aged ≥20 years with complete LE8 metrics and available gestational diabetes history data. LE8 scores (range, 0–100) comprehensively assessed CVH through 4 behavioral domains (diet, physical activity, nicotine exposure, sleep) and 4 biomedical domains (blood lipids, blood glucose, blood pressure, body mass index). Multivariable linear regression models, adjusted for sociodemographic covariates, evaluated associations between gestational diabetes history and mean LE8 scores (overall, biomedical, behavioral). Postpartum intervals were stratified into 10‐year categories to examine temporal variations.

Results

Among 6721 participants (mean age, 53.12±15.95 years), 650 (9.7%) reported gestational diabetes history. Mean overall LE8 score was 63.72±13.52 (biomedical: 68.12±18.63; behavioral: 59.32±18.80). Adjusted models demonstrated significantly lower LE8 scores in gestational diabetes groups: total β=−3.88 (95% CI, −4.90 to −2.86), biomedical β=−7.88 (95% CI, −9.25 to −6.51). Subgroup analyses by age at gestational diabetes diagnosis revealed significantly greater LE8 score reductions in women with later‐onset gestational diabetes (>35 years: β=−5.87, 95% CI −7.99 to −3.75) compared with earlier‐onset (≤35 years: β=−3.37, −4.51 to −2.24). The adverse association between gestational diabetes history and CVH was predominantly concentrated within the first 2 decades postpartum, with progressively diminishing effects beyond this period (<10 years: β=−5.15; 10–19 years: β=−6.29).

Conclusions

A history of gestational diabetes, especially diagnosed after age 35 years, is associated with significantly worse postpartum CVH, particularly within the first 2 decades. Early identification and proactive CVH management are crucial.

Nonstandard Abbreviations and Acronyms

CVH

cardiovascular health

LE8

Life’s Essential 8

NHANES

National Health and Nutrition Examination Survey

Clinical Perspective.

What Is New?

• We applied Life’s Essential 8 to quantify the long‐term cardiovascular health trajectory after gestational diabetes, defining the first 2 decades postpartum as the critical window of subclinical decline.

• We identified a more severe cardiovascular health deterioration in women diagnosed with gestational diabetes at or beyond age 35 years, compared with those diagnosed earlier.

What Are the Clinical Implications?

• Integrate Life’s Essential 8 assessments into postpartum care to enable early detection during the critical first 2 decades, while prioritizing women diagnosed with gestational diabetes at age ≥35 years for more intensive monitoring and preventive interventions.

Cardiovascular disease (CVD) is a leading cause of death among women globally, responsible for ≈35% of annual female deaths. ¹ , ² While CVD prevalence is quite high across the general population, women encounter unique risk factors, including pregnancy‐related conditions such as gestational diabetes. Characterized by pregnancy‐onset glucose intolerance, ³ gestational diabetes is a prevalent complication with an estimated global prevalence between 7% and 14%. ⁴ , ⁵ The rising incidence of gestational diabetes in the United States parallels global trends. ⁶ In addition to causing acute obstetric complications, including preterm birth, ⁷ , ⁸ stillbirth, ⁹ , ¹⁰ and macrosomia, ¹¹ gestational diabetes history is associated with persistent adverse cardiometabolic profiles. Evidence suggests that even after postpartum glucose normalization, transient gestational diabetes exposure may contribute to sustained vascular impairment, ¹² , ¹³ , ¹⁴ potentially mediated by chronic inflammation. ¹⁵ , ¹⁶ Critically, this vascular impairment exists independently of subsequent type 2 diabetes development. ¹⁷ However, whether the association between gestational diabetes history and vascular dysfunction varies across postpartum intervals remains poorly characterized. This gap in knowledge highlights the need for further investigation to disentangle the temporal patterns linking gestational diabetes to long‐term cardiovascular outcomes and inform targeted interventions.

Current research on the cardiovascular consequences of gestational diabetes predominantly focuses on clinical CVD end points (eg, myocardial infarction, stroke) or early vascular dysfunction markers. ¹⁸ This end point–centric approach neglects earlier stages of cardiovascular decline, a critical window where preventive strategies could mitigate progression to overt disease. Accordingly, the American Heart Association formalized the concept of cardiovascular health (CVH), shifting the focus of preventive cardiology from managing established disease to quantifying modifiable risk factors and health behaviors. ¹⁹ Life’s Essential 8 (LE8) is the current standard for CVH assessment. It operationalizes this approach through a validated framework integrating 8 domains. A key feature of LE8 is its continuous scoring system (0–100 points), which transcends binary classifications by capturing gradations of cardiovascular health. By combining continuous scoring with multidimensional domain integration (behavioral and biomedical), LE8 enables sensitive detection of subclinical CVH impairment. ²⁰ This combination makes LE8 particularly well suited for identifying early deviations from optimal CVH in populations at elevated risk, such as women with a history of gestational diabetes.

Therefore, leveraging the LE8 metric, our first objective of this study was to assess the association between gestational diabetes history and postpartum CVH (LE8 scores) in women. The second objective was to determine variations in this association across different postpartum periods, an aspect previously unexplored.

Methods

Data Availability Statement

The data used in this study are derived from the National Health and Nutrition Examination Survey (NHANES), which is publicly available. Access to the NHANES data sets (including demographic, clinical, and laboratory variables) can be obtained through the official website: https://wwwn.cdc.gov/nchs/nhanes/.

Study Design and Participants

This study used data from NHANES, a nationally representative program that evaluates the health of US civilians through a stratified, multistage sampling method. ²¹ , ²² NHANES collects both self reported data via in‐home interviews and clinical measurements conducted at mobile examination centers. The National Center for Health Statistics conducts the survey under Institutional Review Board–approved protocols, ensuring written informed consent from all participants.

For this study, 6 NHANES cycles (2007–2018) were analyzed, including women aged 20 to 80 years. Participants were questioned about prior diagnoses of diabetes, sugar diabetes, or gestational diabetes by a health care professional during pregnancy. Women who answered “yes” were classified as having gestational diabetes (n=650), while those who answered “no” were classified as not having gestational diabetes (n=6071). ²³ Responses such as “Refused,” “Borderline,” or “Don’t know” were excluded. Additionally, women with incomplete LE8 data, missing covariates, or a prior diabetes diagnosis were excluded, resulting in a final sample size of 6721 women.

Although NHANES does not include clinician‐diagnosed gestational diabetes data, maternal recall of gestational diabetes history within 2 to 10 years postpartum has been validated with sensitivities of 70% to 100% and specificities of 90% to 98%. ²⁴ , ²⁵ Participants also reported age at first live birth, number of live births, and, for those reporting gestational diabetes, the age at initial diagnosis. Inclusion and exclusion criteria are detailed in Figure S1.

Definitions of Updated Cardiovascular Metrics in LE8

The LE8 scoring algorithm is composed of 4 behavioral factors (dietary habits, smoking, physical activity, and sleep) and 4 physiological measures (body mass index [BMI], blood glucose levels, non–high‐density lipoprotein cholesterol, and blood pressure). Detailed methods for calculating LE8 scores based on these metrics from NHANES data are available in Table S1. ²⁰ , ²⁶ A 0 to 100 score was assigned to each of the 8 CVH components. The overall LE8 score was derived by calculating the unweighted average of the scores for all 8 components. Participants were divided into 3 groups by LE8 score: 80 to 100 points indicated high CVH, 50 to 79 points signified moderate CVH, and scores of 0 to 49 points were categorized as low CVH. ²⁰ In this study, the same classification criteria and thresholds were applied to evaluate health behaviors and physiological factors, allowing further exploration of the relationship between gestational diabetes history and long‐term CVH in women.

Dietary intake was assessed using the Healthy Eating Index 2015, ²⁷ with the scoring criteria outlined in Table S1. Healthy Eating Index 2015 scores were derived from two 24‐hour dietary recalls combined with food pattern equivalents based on US Department of Agriculture data. ²⁸ A simplified individual‐level scoring algorithm was used to compute the Healthy Eating Index 2015 scores, following the Statistical Analysis System code provided by the National Cancer Institute. ²⁹ Information on smoking habits, physical activity, sleep, medical history, and diabetes status was collected through self‐reported questionnaires. Physical measurements, including blood pressure, weight, and height, were recorded during clinical examinations. BMI was calculated as weight (kg) divided by height (m²), while blood samples were analyzed centrally for lipid profiles, glucose, and hemoglobin A_1c.

Covariates

Confounders were identified using a directed acyclic graph to explore relationships between gestational diabetes history and postpartum CVH (Figure S2). Covariates included age at NHANES participation ³⁰ (model 1) and additional factors in a fully adjusted model (model 2): age at menarche, ³¹ race and ethnicity (Hispanic, non‐Hispanic White, non‐Hispanic Black, Other race including multi‐racial), family income–poverty ratio (≤1.0, 1.0–3.0, >3.0), education level (less than high school, high school or equivalent, some college, college or above), marital status (married/living with partner, widowed/ divorced/separated, never married), ³² number of live births (≤1, >1), and alcohol drinking (yes, no).

Statistical Analysis

Descriptive statistics were used to compare demographic characteristics and LE8 metrics between women with and without gestational diabetes history. For continuous variables, differences were evaluated using independent samples t tests (for comparisons between 2 groups) or one‐way ANOVA (for comparisons across ≥3 groups); categorical variables were analyzed using χ² tests. The primary analysis used multiple linear regression to assess the association between gestational diabetes history and LE8 scores, quantified as continuous variables. Separate models were run for the LE8 total scores and its biomedical and behavioral domain scores. Two adjustment models were specified: Model 1 was adjusted for age at NHANES participation; model 2 was further adjusted for age at menarche, family income–poverty ratio, education, marital status, number of live births and alcohol drinking. To assess for potential effect modification by race and ethnicity, we conducted subgroup analyses stratified by race and ethnicity in both model 1 and model 2. Additionally, we formally tested for interaction effects by including product terms between gestational diabetes history and race and ethnicity in the regression models, with statistical significance evaluated using likelihood ratio tests. The results of these analyses are presented in a forest plot. In a supplementary analysis, the LE8 score was categorized into low, moderate, and high levels. The associations between gestational diabetes history and these categorical outcomes were evaluated using multinomial logistic regression, which provided odds ratios for both moderate‐versus‐low and high‐versus‐low comparisons, using the same adjustment strategy as the primary analysis. Secondary analyses examined individual biomedical factors to explore the specific impact of gestational diabetes.

We also performed analyses comparing the entire non‐gestational diabetes group (reference) separately to 2 gestational diabetes subgroups: (1) women diagnosed at <35 years and (2) women diagnosed at ≥35 years. The results of these comparisons are presented in a forest plot. Additionally, in a supplementary analysis restricted to women with gestational diabetes, we directly compared those diagnosed at ≥35 years to those diagnosed at <35 years (reference) to further explore the impact of diagnostic age. We calculated the postpartum time interval as the woman’s age at survey participation minus her age at the time of pregnancy. Stratified analyses were then conducted by this interval (<10, 10–19, 20–29, 30–39, 40–49, and ≥50 years). All analyses were performed using SPSS version 26.0 (IBM, Armonk, NY) and R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria), with a 2‐tailed P value <0.05 was considered statistically significant.

Results

Participant Characteristics and LE8 Scores

Among the included participants (mean age, 53.12±15.95 years), 650 (9.7%) reported a history of gestational diabetes. The overall LE8 score averaged 63.72±13.52, with domain‐specific scores of 68.12±18.63 for the biomedical domain and 59.32±18.80 for the behavioral domain. Participants with gestational diabetes history were younger at screening (45.65±12.05 versus 53.92±16.11 years) and more likely to be non‐Hispanic White, married/living with a partner, and have some college education. Additionally, women with gestational diabetes history had a higher number of live births (>1) and were more likely to report no alcohol drinking (Table 1). Differences in LE8 scores and all demographic characteristics are detailed in Table S2.

Table 1.

Characteristics of the Study Population According to the Presence or Absence of Gestational Diabetes History

Characteristics	Total (n=6721)	Lifetime history of gestational diabetes (n=650 [9.7%])	No lifetime history of gestational diabetes (n=6071 [90.3%])	P value
Age, y, mean±SD
At menarche	12.73±1.76	12.45±1.82	12.76±1.76	<0.001*
At screening	53.12±15.95	45.65±12.05	53.92±16.11	<0.001*
Race and ethnicity, n (%)				<0.001*
Non‐Hispanic Black	1364 (20.3)	116 (17.8)	1248 (20.6)
Non‐Hispanic White	2966 (44.1)	250 (38.5)	2716 (44.7)
Hispanic	1827 (27.2)	198 (30.5)	1629 (26.8)
Other race†	564 (8.4)	86 (13.2)	478 (7.9)
Education, n (%)				<0.001*
Less than high school	1702 (25.3)	148 (22.8)	1554 (25.6)
High school or equivalent	1537 (22.9)	116 (17.8)	1421 (23.4)
Some college	2153 (32.0)	241 (37.1)	1912 (31.5)
College or above	1329 (19.8)	145 (22.3)	1184 (19.5)
Family income‐poverty ratio, n (%)				0.032*
≤1.0	1563 (23.3)	148 (22.8)	1415 (23.3)
1.0–3.0	2957 (44.0)	271 (41.7)	2686 (44.2)
>3.0	2201 (32.7)	231 (35.5)	1970 (32.4)
Marital status, n (%)				<0.001*
Married/living with partner	4016 (59.8)	449 (69.1)	3567 (58.8)
Widowed/divorced/separated	2178 (32.4)	141 (21.7)	2037 (33.6)
Never married	525 (7.8)	59 (9.1)	466 (7.7)
Number of live births, n (%)				<0.001*
≤1	531 (8.0)	115 (17.7)	416 (6.9)
>1	6183 (92.0)	528 (81.2)	5655 (93.1)
Alcohol drinking, n (%)				0.018*
Yes	904 (13.5)	107 (16.5)	797 (13.1)
No	5817 (86.5)	543 (83.5)	5274 (86.9)
Life’s Essential 8 scores, mean±SD
Overall	63.72±13.52	62.00±14.00	63.91±13.45	0.001*
Biomedical domain	68.12±18.63	64.49±19.66	68.51±18.48	<0.001*
Body mass index	54.75±34.77	46.88±34.06	55.59±34.74	<0.001*
Blood pressure	70.96±32.14	75.77±29.76	70.44±32.34	<0.001*
Blood lipids	67.78±30.81	65.69±30.73	68.00±30.81	0.070
Glycemia	78.99±27.33	69.63±32.01	80.00±26.58	<0.001*
Behavioral domain	59.32±18.80	59.30±18.82	59.50±18.64	0.797
Diet	46.26±32.43	44.32±32.07	46.47±32.46	0.108
Physical activity	33.60±45.86	35.60±46.90	33.38±45.75	0.241
Smoking status	76.64±37.33	76.00±38.02	76.71±37.25	0.645
Sleep health	80.79±26.02	82.09±26.52	80.65±25.97	0.180

^* P<0.05.

^†Other race including multi‐racial.

Gestational Diabetes History and LE8 Scores

Participants with a history of gestational diabetes demonstrated significantly lower overall LE8 scores (−3.88 points [95% CI, −4.90 to −2.86]) and biomedical domain scores (−7.88 points [95% CI, −9.25 to −6.51]) compared with those without gestational diabetes. No significant difference was observed in behavioral domain scores (0.12 points [95% CI, −1.35 to 1.59]). Testing for interaction revealed no significant effect modification by race and ethnicity in the association between gestational diabetes history and LE8 scores (P‐interaction >0.05). Subgroup analyses revealed variations in these associations across race and ethnicity groups. The greatest reduction in overall LE8 scores was observed among non‐Hispanic White participants (−4.35 points [95% CI, −5.99 to −2.72]), while the largest decrease in biomedical domain scores was found among Hispanic participants (−9.11 points [95% CI, −11.58 to −6.65]; Figure 1. Logistic regression models further showed that participants with gestational diabetes had significantly lower odds of achieving both moderate (odds ratio, 0.61 [95% CI, 0.49–0.76]) and high (odds ratio, 0.35 [95% CI, 0.25–0.49]) overall LE8 scores compared with the low‐score reference group. Similarly, reduced odds were observed for achieving moderate (odds ratio, 0.50 [95% CI, 0.40–0.62]) and high (odds ratio, 0.29 [95% CI, 0.22–0.37]) biomedical domain scores (Table S3).

Figure 1. Associations between gestational diabetes history and postpartum LE8 scores: subgroup analysis with interaction by race and ethnicity.

Multivariable linear regression model for the association between history of gestational diabetes and postpartum LE8 scores, stratified by race and ethnicity with interaction terms included to quantify subgroup differences. Model 1 adjusted for age at NHANES participation; model 2 adjusted for age at NHANES participation, age at menarche, race and ethnicity, education, family income–poverty ratio, marital status, number of live births, and alcohol drinking. *P<0.05. LE8 indicates Life’s Essential 8; and NHANES, National Health and Nutrition Examination Survey.

Gestational Diabetes History and Specific Biomedical Metrics

In secondary analyses, gestational diabetes history was associated with elevated BMI (1.76 units [95% CI, 1.18–2.33]), fasting glucose (21.92 mg/dL [95% CI, 18.19–25.65), hemoglobin A_1c (0.56% [95% CI, 0.48–0.63]), systolic blood pressure (2.4 mm Hg [95% CI, 0.07–2.79]), and diastolic blood pressure (0.95 mm Hg [95% CI, 0.04–1.86]). High‐density lipoprotein cholesterol was lower by 3.50 mg/dL (95% CI, −4.74 to −2.22), and non–high‐density lipoprotein cholesterol was higher by 6.50 mg/dL (95% CI, 3.07–9.93) (Table 2).

Table 2.

Associations Between History of Gestational Diabetes and Estimated Values for the 4 Components of Postpartum Life’s Essential 8 Biomedical Domain

Metrics	Mean±SD		Model 1		Model 2
	Gestational diabetes	Non‐gestational diabetes	β (95% CI)	P value	β (95% CI)	P value
Body mass index	31.65±7.56	30.01±7.21	1.54 (1.02 to 2.14)	<0.001*	1.76 (1.18 to 2.33)	<0.001*
Blood pressure, mm Hg
Systolic	120.39±16.64	124.16±19.48	1.15 (−0.22 to 2.53)	0.100	1.43 (0.07 to 2.79)	0.039*
Diastolic	70.85±10.45	69.43±11.19	0.90 (−0.01 to 1.81)	0.051	0.95 (0.04 to 1.86)	0.040*
Blood lipids, mg/dL
HDL cholesterol	52.96±15.23	57.38±16.00	−3.30 (−4.59 to −2.01)	<0.001*	−3.50 (−4.76 to −2.24)	<0.001*
Non–HDL cholesterol	144.83±45.65	140.64±41.65	6.65 (3.23 to 10.07)	<0.001*	6.50 (3.07 to 9.93)	<0.001*
Glycemia
Fasting glucose, mg/dL	125.70±54.38	106.70±29.57	22.81 (19.05 to 25.56)	<0.001*	21.92 (18.19 to 25.65)	<0.001*
Hemoglobin A1c, %	6.16±1.50	5.75±0.96	0.55 (0.48 to 0.64)	<0.001*	0.56 (0.48 to 0.63)	<0.001*

Model 1 adjusted for age at NHANES participation. Model 2 adjusted for age at NHANES participation, age at menarche, race and ethnicity, education, family income–poverty ratio, marital status, number of live births, alcohol drinking. HDL indicates high‐density lipoprotein; and NHANES, National Health and Nutrition Examination Survey.

^* P<0.05.

Influence of Age at Gestational Diabetes Diagnosis on CVH

In the primary analysis using the full cohort, both groups of women with a history of gestational diabetes showed significantly lower CVH scores compared with women without gestational diabetes. Women diagnosed before age 35 years demonstrated a reduction of 3.37 points (95% CI, −4.51 to −2.24) in overall LE8 score, while those diagnosed at or after age 35 years showed a greater reduction of 5.87 points (95% CI, −7.99 to −3.75). Similarly, biomedical domain scores were lower by 7.02 points (95% CI, −8.55 to −5.49) and 10.67 points (95% CI, −13.49 to −7.84) in the earlier and later diagnosis groups, respectively. No significant differences were observed in the behavioral domain scores (Figure 2). In a supplementary analysis restricted to women with gestational diabetes (Table S4), those diagnosed at or after age 35 years demonstrated significantly poorer CVH compared with those diagnosed before age 35 years (reference group), with the overall LE8 score being −2.41 points lower (95% CI, −5.01 to −0.19).

Figure 2. Associations between age in years at first report of gestational diabetes and postpartum LE8 scores, biomedical domain scores and behavioral domain scores.

Model 1 adjusted for age at NHANES participation; Model 2 adjusted for age at NHANES participation, age at menarche, race and ethnicity, education, family income–poverty ratio, marital status, number of live births, and alcohol drinking. *P<0.05. LE8 indicates Life’s Essential 8; and NHANES, National Health and Nutrition Examination Survey.

Postpartum Interval and Declining Trends in CVH

In fully adjusted models, the adverse impact of gestational diabetes on overall LE8 scores and biomedical domain scores demonstrated a gradually decreasing trend with increasing postpartum interval. The most pronounced effects were observed within the first 2 decades postpartum (Figure 3). To be specific, among participants with a gestational diabetes history, the overall LE8 scores were reduced by 5.15 (95% CI, −7.15 to −3.15) compared with those without during the first decade postpartum, by 6.29 (−8.32 to −4.25) during the second decade, by 4.68 (−7.05 to −2.32) during the third decade, and by 4.38 (−7.38 to −1.39) during the fourth decade. Beyond 40 years, CVH levels became comparable between gestational diabetes and non–gestational diabetes groups, with no significant differences. The biomedical domain score exhibited a similar trend, with the largest reductions occurring during the first 2 decades postpartum (Table S5).

Figure 3. Adjusted associations between gestational diabetes history and LE8 scores across postpartum intervals (with 95% CIs).

Models were adjusted for age at NHANES participation, age at menarche, race and ethnicity, education, family income‐poverty ratio, marital status, number of live births, alcohol drinking. A, Associations between gestational diabetes history and overall LE8 scores across different postpartum intervals. B, Associations between gestational diabetes history and LE8 biomedical domain scores across different postpartum intervals. Additional numerical details are presented in Table S5. LE8 indicates Life’s Essential 8; and NHANES, National Health and Nutrition Examination Survey.

Discussion

In this cross‐sectional nationwide analysis of US women, we identified an association between gestational diabetes history and less favorable CVH, characterized by a 3.88‐point reduced overall LE8 and 7.88‐point reduced biomedical domain scores, whereas no significant reduction was observed in the behavioral domain. Subgroup analyses revealed a stronger association among women diagnosed with gestational diabetes at ≥35 versus <35 years. Furthermore, when stratified by postpartum intervals, the negative association between gestational diabetes history and CVH diminished with increasing time since delivery, with the most pronounced association observed within the first 2 decades postpartum.

Our findings align with prior evidence linking gestational diabetes history to adverse cardiovascular outcomes, though existing studies predominantly focus on clinical CVD end points rather than preclinical CVH. For example, a Canadian retrospective cohort study reported elevated CVD risk in young women with prior gestational diabetes, ³³ and a US prospective cohort observed a 2‐fold increase in coronary artery calcification incidence across glucose tolerance strata. ³⁴ However, scant research has examined the association between gestational diabetes and preclinical CVH, an optimal stage for preventive intervention. To our knowledge, only Dorans et al have investigated this relationship using Life’s Simple 7 among women aged 20 to 44 years. ³⁵ However, this study was constrained by critical limitations: the narrow age range excluded high‐risk older populations, Life’s Simple 7’s categorical scoring obscured health gradations, and the framework could not resolve dose–response relationships. Building on previous efforts, our study combined a nationally representative sample spanning broader age ranges with the advanced LE8 framework. As a refinement of Life’s Simple 7, LE8’s optimized definitions encompass the complete spectrum of health behaviors and metabolic factors. ¹⁹ Crucially, this framework enables identification of high‐risk individuals decades before clinical CVD onset through multidimensional preclinical risk quantification. ²⁰

Our study reveals that a history of gestational diabetes primarily impairs the biomedical domain of LE8 scores, with minimal impact on the behavioral domain. Biomedical components—particularly BMI, blood lipids, and glycemia—emerged as key drivers of this association. Previous studies have also demonstrated that gestational diabetes influences biological health indicators. ³⁶ For instance, women with a history of gestational diabetes tend to exhibit elevated fasting blood sugar, triglycerides, and low‐density lipoprotein levels. ³⁷ , ³⁸ Notably, chronic inflammation is a plausible mechanistic pathway underlying this relationship. Studies suggest that gestational diabetes–induced metabolic dysregulation may trigger persistent low‐grade inflammation, ³⁹ , ⁴⁰ which subsequently perturbs cardiometabolic biomarkers. Thus, targeting inflammatory pathways could represent a strategic approach to mitigate gestational diabetes–related biomedical risk. In contrast, the negligible association with behavioral domains (eg, diet, physical activity) warrants further investigation. We hypothesize that this phenomenon may result from the fact that, although gestational diabetes initially affects behavioral factors, these influences might not persist across decades postpartum or over longer periods.

Subgroup analyses revealed that women diagnosed with gestational diabetes ≥35 years had significantly poorer CVH than those diagnosed <35 years. This finding suggests that the later onset and diagnosis of gestational diabetes, often coinciding with advanced maternal age, may be linked to an increased risk of future CVH decline. This aligns with the established epidemiological trend where advancing maternal age substantially elevates gestational diabetes risk—increasing by 7.9% per year beyond age 18 years. ⁴¹ Crucially, both phenomena likely originate from shared modifiable risk factors such as obesity, insulin resistance, and chronic inflammation, which accumulate with age and concurrently drive gestational diabetes onset and CVH decline. This synergy suggests that later‐onset gestational diabetes serves as a clinical indicator of accelerated cardiometabolic aging. Consequently, women diagnosed with gestational diabetes at advanced maternal age warrant prioritized cardiovascular surveillance, particularly focusing on biomedical domains (BMI, lipids, glycemia) where deficits are most pronounced. Proactively managing their modifiable risks, rather than focusing on age itself, represents a tangible strategy to lower the future incidence of CVD.

To date, longitudinal studies have advanced our understanding of gestational diabetes’s long‐term cardiovascular risks, yet their inherent design constraints, particularly finite follow‐up durations rarely exceeding 25 years, restrict insights into risk trajectories across the full postpartum life span. For instance, the Nurses’ Health Study II (median 25.7‐year follow‐up) and Canadian cohorts (25‐year follow‐up) linked gestational diabetes to increased myocardial infarction and stroke ⁴² , ⁴³ but could not assess associations beyond midlife or in preclinical stages. While our cross‐sectional design cannot establish causality, it addresses temporal limitations by sampling women across a substantially longer time span, with participants stratified into 10‐year postpartum intervals. This approach uniquely captures how the association between gestational diabetes history and CVH evolves: We observed the strongest correlation with CVH impairment within 0 to 20 years postpartum, followed by progressive attenuation in subsequent decades. These findings provide a foundation for future longitudinal cohorts to track CVH trajectories, revealing a previously unrecognized concentration of risk in early postpartum decades. Pending such validation, our data suggest that clinicians consider prioritizing CVH monitoring for women with prior gestational diabetes within 20 years after delivery.

Maternal health during pregnancy is pivotal in shaping overall postpartum health. ⁴⁴ As a prevalent obstetric complication, gestational diabetes adversely impacts both pregnancy outcomes and maternal CVH. This study highlights pregnancy as a crucial window for the improvement of postpartum CVH, emphasizing that well‐timed interventions during this phase can profoundly influence mothers’ long‐term health trajectories. Concretely for clinical translation, we propose 3 key actions: First, women with gestational diabetes history, particularly those diagnosed after the age of 35 years, should be classified as a vulnerable group for vascular health concerns. Focused follow‐up during the initial 2 decades after childbirth is critical for mitigating long‐term risks. Second, given that women with a gestational diabetes history tend to exhibit higher BMI, blood glucose, and lipid levels when contrasted with those without gestational diabetes, tailored dietary guidance is essential to support BMI regulation. Regular screening for blood glucose and lipid profiles, accompanied by timely interventions, is also imperative. Furthermore, integrating CVH optimization across reproductive life stages via enhanced gestational diabetes screening, preconception counseling, and standardized postpartum follow‐up protocols. Effective improvement in women’s long‐term CVH requires a concerted effort from individuals, health care providers, and society as a whole.

Our study possesses several strengths and acknowledges potential limitations. First, we used the most recent LE8 metric scores as our evaluative instrument. Recognized as a comprehensive and reliable tool for assessing CVH, the use of LE8 enhances the precision and validity of our findings. Second, leveraging nationally representative NHANES data (2007–2018) enabled robust analysis of a large, diverse cohort of US women (aged 20–80 years), providing sufficient power to detect associations across age strata and postpartum intervals. Third, to our knowledge, this is the first investigation to characterize age‐specific variations in gestational diabetes–associated CVH impairment while mapping its temporal evolution across extended postpartum periods. Collectively, these advances offer clinically actionable insights: the identification of high‐risk subgroups (eg, ≥35 years’ gestational diabetes diagnosis), time‐sensitive intervention windows (0–20 years postpartum), and domain‐specific targets (biomedical metrics) directly inform precision prevention strategies for reducing cardiometabolic risks. We also acknowledge several limitations. First, as a cross‐sectional study, our design cannot establish a causal relationship between gestational diabetes history and subsequent impaired CVH. Specifically, the postpartum interval analysis reflects cross‐sectional associations rather than longitudinal trajectories. Meanwhile, although we observed significant and consistent associations, particularly within the biomedical domain, it could reflect unmeasured confounding (eg, shared genetic predispositions, underlying metabolic traits, or lifelong lifestyle factors) that may drive both gestational diabetes and lower LE8 scores. Prospective studies are needed to confirm causality. ⁴⁵ , ⁴⁶ Second, for the longest intervals (≥50 years postpartum), smaller sample sizes and potential survival bias necessitate cautious interpretation of point estimates. Third, the ascertainment of gestational diabetes history relied on self‐reporting, a method susceptible to recall bias. ⁴⁷ Finally, for women with multiple pregnancies, attributing impact to specific gestational diabetes–affected pregnancies is limited.

Conclusions

In a nationally representative sample of US women aged 20 to 80 years, a history of gestational diabetes was associated with poorer CVH, particularly reduced LE8 scores and biomedical domain deficits. Women diagnosed with gestational diabetes at ≥35 years exhibited more severe CVH impairment. The association was most pronounced during the first 2 decades postpartum and attenuated thereafter.

Sources of Funding

This work was supported by the National Natural Science Foundation of China (82373580, 82173531), the National Key Research and Development Program of China (2022YFC2702901), the Research Funds of Center for Big Data and Population Health of IHM (JKS2022019), and the Foundation for Scientific Research Improvement of Anhui Medical University (2021xkjT009).

Disclosures

None.

Supporting information

Tables S1–S5

Figures S1–S2