Exercise as a Therapeutic Intervention in Gestational Diabetes Mellitus

Clinical practice guidelines on physical activity and exercise for pregnant women with gestational diabetes mellitus: A systematic review

AIM

This review aimed to appraise clinical guidelines about exercise for women with gestational diabetes mellitus and summarize consensus and inconsistent recommendations.

BACKGROUND

Exercise is an effective non-pharmacological therapeutic for gestational diabetes mellitus, but the variety of relevant clinical practice guidelines is confusing for healthcare professionals.

DESIGN

This is a systematic review of clinical practice guidelines.

DATA SOURCES

Websites of guideline development institutions, eight literature databases and organizations of obstetricians, gynaecologists, midwives, and medical sports associations were searched for guidelines published from January 2011 to October 2021.

REVIEW METHODS

Two reviewers independently extracted recommendations. Four reviewers assessed guideline quality using the AGREE II instrument independently.

RESULTS

Fifteen guidelines were included. All women with diabetes are recommended to exercise during pregnancy. The consistent recommendations were for pre-exercise screening, for 30 min per exercise session on 5 days of the week or every day after meals, exercise at moderate intensity, using aerobic and resistance exercise, and walking. The main non-consistent recommendations included warning signs for women on insulin during exercise, minimum duration per session, intensity assessment, duration and frequency of sessions for strengthening and flexibility exercise and detailed physical activity giving birth.

CONCLUSIONS

Guidelines strongly support pregnant women with diabetes to exercise regularly. Research is needed to make non-consistent recommendations clear.

The Impact of a Single Supervised Exercise Session in the Third Trimester of Pregnancy on the Physical Activity Levels of Pregnant Women-A Pilot Study

BACKGROUND

Despite the numerous beneficial effects of physical exercise during pregnancy, the levels of physical activity remain low. The aim of the study is to investigate the impact of a single supervised physical exercise session on the overall physical activity levels of pregnant women.

METHODS

During the third trimester, pregnant women attending our outpatient clinic were requested to assess their physical activity levels using the International Physical Activity Questionnaire (IPAQ). Additionally, they were invited to participate in a supervised 30 min mild-moderate-intensity aerobic exercise session (stationary bike ergometer) under the guidance of medical personnel. Subsequently, physical activity levels were reevaluated at the time of delivery.

RESULTS

Prior to the intervention, 3 out of 50 (6%) women engaged in mild-moderate physical activity for 150 min per week, while 20 out of 50 (40%) women participated in mild-moderate activity for 15-30 min, twice a week. Following the intervention, these percentages increased to 10 out of 50 (20%) and 31 out of 50 (62%), respectively (p < 0.05).

CONCLUSIONS

This pilot study suggests that a single exercise session supervised by medical personnel may significantly improve the low physical activity levels observed in pregnant women.

The Association of Nutrition and Exercise Behaviors of Women with Diabetes in Pregnancy with Infant Breastfeeding Practices

Background: Although breastfeeding confers significant benefits to infants, women with diabetes in pregnancy experience unique nutrition and health challenges, which may influence infant feeding practice. This study aimed to determine the association between nutrition and exercise behaviors of women with diabetes in pregnancy and breastfeeding at birth and 6 months. Methods: A secondary data analysis of a longitudinal study on maternal pregestational diabetes mellitus (DM) and gestational diabetes (GDM) and infant development was conducted. Women self-reported engaging in nutrition behaviors, such as using meal plans, and exercise health behaviors. Primary outcomes were exclusive breastfeeding at birth and any breastfeeding at 6 months. Logistic regression models adjusted for significant maternal-infant covariates. Results: Of n = 48 women with diabetes in pregnancy, 94% had GDM and 6% had pregestational type 1 or type 2 DM. Forty percent of women exclusively breastfed at birth and 68% partially or exclusively breastfed at 6 months (of n = 34 with complete 6-month data). Women who cooked their own meals had two times greater adjusted odds of exclusive breastfeeding at birth (adjusted odds ratio [AOR] = 1.94, 95% confidence interval [CI] = 1.12-5.11), and women who exercised during pregnancy had seven times greater adjusted odds of any breastfeeding at 6 months (AOR = 7.2, 95% CI = 1.10-42.8). Conclusion: Nutrition and exercise behaviors were associated with exclusive breastfeeding at birth and any breastfeeding at 6 months. Health behaviors to effectively manage diabetes during pregnancy may inform efforts to improve breastfeeding initiation and duration, and future studies in a larger sample are needed.

Physical Activity as a Modern Intervention in the Fight against Obesity-Related Inflammation in Type 2 Diabetes Mellitus and Gestational Diabetes

Diabetes is one of the greatest healthcare problems; it requires an appropriate approach to the patient, especially when it concerns pregnant women. Gestational diabetes mellitus (GDM) is a common metabolic condition in pregnancy that shares many features with type 2 diabetes mellitus (T2DM). T2DM and GDM induce oxidative stress, which activates cellular stress signalling. In addition, the risk of diabetes during pregnancy can lead to various complications for the mother and foetus. It has been shown that physical activity is an important tool to not only treat the negative effects of diabetes but also to prevent its progression or even reverse the changes already made by limiting the inflammatory process. Physical activity has a huge impact on the immune status of an individual. Various studies have shown that regular training sessions cause changes in circulating immune cell levels, cytokine activation, production and secretion and changes in microRNA, all of which have a positive effect on the well-being of the diabetic patient, mother and foetus.

Irisin participates in the beneficial effects of exercise in preventing gestational diabetes mellitus in overweight and obese pregnant women and a mouse model

Objective

We aimed to explore whether irisin participates in the beneficial effects of exercise in preventing gestational diabetes mellitus (GDM) in overweight and obese pregnant women.

Study design

Sixty overweight and obese pregnant women each in the exercise and control groups were randomly selected from our previous randomized controlled trial. Eighteen obese model mice were generated and divided into exercise and control groups in which body weight, abdominal circumference, anal temperature, glucose tolerance test, and insulin tolerance test were recorded. The plasma irisin level, the expression of PGC-1α/FNDC5 and brown (UCP1) and beige adipose (CD137, TMEM26, and TBX-1) marker genes were detected in muscle and adipose tissue.

Results

In the human study, women in the exercise group had a significantly higher irisin level and lower insulin resistance level than those in the control group. Enhanced expression of beige adipose tissue marker genes (CD137, TMEM26, and TBX-1) in omental adipose tissue and the CD137 gene in subcutaneous adipose tissue were found in the exercise group compared to the control group. In a mouse model, body weight and abdominal circumference were decreased, while glucose homeostasis and insulin sensitivity were significantly improved, and anal temperature was elevated after exercise intervention. A significantly higher level of irisin was revealed in the exercise group after undergoing exercise treatment. The expression of the beige adipose marker genes CD137 and TBX-1 was significantly higher in the exercise group than in the control group in posterior subcutaneous adipose tissue from the inguinal area and interscapular adipose tissue respectively.

Conclusion

Our observations show that regular exercise during pregnancy can increase irisin levels, promote white fat beiging/browning, improve glucose homeostasis and enhance body energy expenditure, which may be one of the mechanisms by which exercise prevents GDM.

Longer physical exercise duration prevents abnormal fasting plasma glucose occurrences in the third trimester: Findings from a cohort of women with gestational diabetes mellitus in Shanghai

OBJECTIVE

This study aims to investigate the relationship between daily physical exercise (PE) duration and frequency of abnormal plasma glucose (PG) times both during fasting and 2 h after a standard diet in women with gestational diabetes mellitus (GDM).

METHODS

We established a cohort involving 878 GDM women. GDM was confirmed by a diagnostic 75-g oral glucose tolerance test. Information was extracted from the delivery records and antenatal checkup forms. Physical exercise information was collected through a questionnaire.

RESULTS

Over 80% of GDM women were under 35 years old. An abnormal fasting PG with ≥1 occurrence presented in 742/878 (84.51%), and the abnormal PG 2 h after standard diet with ≥1 occurrence presented in 634/878 (72.21%). Compared to GDM women with ≥4 occurrences of abnormal fasting PG, GDM women with 0 occurrences (odds ratio (OR) = 2.56), one occurrence (OR = 1.94), two occurrences (OR = 2.29), and three occurrences (OR = 2.16) had a higher proportion of PE duration being in the 45-60-min/day group than those in the <45-min/day group, and GDM women also had a higher proportion of PE during being in the 61-90- and >90-min/day group than those in the <45-min/day group. However, the duration of PE was not associated to the number of abnormal PG occurrences 2-h after the standard diet.

CONCLUSION

Moderate-intensity PE duration in GDM women was negatively associated with the number of abnormal fasting PG occurrences but not with the number of PG occurrences 2 h after the standard diet.

Gut Microbiome Changes in Gestational Diabetes

Gestational diabetes mellitus (GDM), one of the most common endocrine pathologies during pregnancy, is defined as any degree of glucose intolerance with onset or first discovery in the perinatal period. Physiological changes that occur in pregnant women can lead to inflammation, which promotes insulin resistance. In the general context of worldwide increasing obesity in young females of reproductive age, GDM follows the same ascending trend. Changes in the intestinal microbiome play a decisive role in obesity and the development of insulin resistance and chronic inflammation, especially in patients with type 2 diabetes mellitus (T2D). To date, various studies have also associated intestinal dysbiosis with metabolic changes in women with GDM. Although host metabolism in women with GDM has not been fully elucidated, it is of particular importance to analyze the available data and to discuss the actual knowledge regarding microbiome changes with potential impact on the health of pregnant women and newborns. We analyzed peer-reviewed journal articles available in online databases in order to summarize the most recent findings regarding how variations in diet and metabolic status of GDM patients can contribute to alteration of the gut microbiome, in the same way that changes of the gut microbiota can lead to GDM. The most frequently observed alteration in the microbiome of patients with GDM was either an increase of the Firmicutes phylum, respectively, or a decrease of the Bacteroidetes and Actinobacteria phyla. Gut dysbiosis was still present postpartum and can impact the development of the newborn, as shown in several studies. In the evolution of GDM, probiotic supplementation and regular physical activity have the strongest evidence of proper blood glucose control, favoring fetal development and a healthy outcome for the postpartum period. The current review aims to summarize and discuss the most recent findings regarding the correlation between GDM and dysbiosis, and current and future methods for prevention and treatment (lifestyle changes, pre- and probiotics administration). To conclude, by highlighting the role of the gut microbiota, one can change perspectives about the development and progression of GDM and open up new avenues for the development of innovative therapeutic targets in this disease.

Effect of Exercise on the Resting Metabolic Rate and Substrate Utilization in Women with Gestational Diabetes Mellitus: Results of a Pilot Study

Regular physical activity during pregnancy has a positive effect on the mother and fetus. However, there is scarce data regarding the effect of exercise in pregnancies complicated by gestational diabetes mellitus (GDM). The aim of the present parallel, non-randomized, open-label, pilot, clinical study was to examine the effect of two exercise programs on the resting metabolic rate (RMR) and substrate utilization in pregnancies complicated by GDM, compared with usual care (advice for the performance of exercise). Forty-three pregnant women diagnosed with GDM between the 24th and 28th gestational week, volunteered to participate. Three groups were formed: Usual care (n = 17), Walking (n = 14), and Mixed Exercise (n = 12). The Usual care group was given advice on maintaining habitual daily activities without any additional exercise. The Walking group exercised regularly by walking, in addition to the habitual daily activities. Finally, the Mixed Exercise group participated in a program combining aerobics and strength exercises. Training intensity was monitored continuously using lightweight, wearable monitoring devices. The Walking and Mixed Exercise groups participated in the training programs after being diagnosed with GDM and maintained them until the last week of gestation. RMR and substrate utilization were analyzed using indirect calorimetry for all participants twice: between 27th and 28th gestational week and as close as possible before delivery. No differences were observed between groups regarding body composition, age, and medical or obstetrical parameters before or after the exercise programs. RMR was increased after the completion of the exercise interventions in both the Walking (p = 0.001) and the Mixed Exercise arms (p = 0.002). In contrast, substrate utilization remained indifferent. In conclusion, regular exercise of moderate intensity (either walking, or a combination of aerobic and strength training) increases RMR in women with GDM compared to the lack of systematic exercise. However, based on the present, pilot data, these exercise regimes do not appear to alter resting substrate utilization.

Exercise Intervention Improves Blood Glucose Levels and Adverse Pregnancy Outcomes in GDM Patients: A Meta-Analysis

Objective

The objective of this study is to systematically evaluate the effect of exercise on gestational diabetes (GDM).

Methods

The databases of PubMed, Cochrane Library, Web of Science, Embase, CNKI, VIP, and Wanfang were searched to collect publications regarding physical exercises and GDM. The two researchers screened the literature, extracted the data, and analyzed the risk of bias of the included data using RevMan 5.3 software. The primary outcomes analyzed included the fasting blood glucose, 2-h postprandial blood glucose, glycosylated hemoglobin, premature delivery, cesarean section, neonatal macrosomia, premature rupture of membranes, and neonatal hypoglycemia.

Results

A total of 9 studies with 1289 GDM patients were included. Compared with the control group, exercise could significantly reduce the 2-h postprandial blood glucose (MD = −0.62, 95% CI (-0.91 to -0.34), Z = 4.29, P < 0.0001), improve HbA1c(RR = −0.47, 95% CI (-0.81 to -0.13), Z = 2.69, P = 0.007), reduce the cesarean section rate (RR = 0.83, 95% CI (0.71-0.98), Z = 2.25, P = 0.02), and decrease the incidence of neonatal macrosomia in GDM patients (RR = 0.57, 95% CI (0.34-0.95), Z = 2.17, P = 0.03).

Conclusion

Exercise intervention can improve the blood glucose level of GDM patients, such as 2-h postprandial blood glucose and HbA1c. Meanwhile, exercise can also reduce adverse pregnancy outcomes, such as premature birth and macrosomia. Therefore, prescribing exercise to GDM patients can effectively manage GDM and improve adverse pregnancy outcomes.

Social Nervous Exercise Intervention and Its Association with Fasting Blood Glucose on Diabetes Mellitus Gestational

BACKGROUND: Gestational diabetes mellitus (GDM) has been identified as a major complication of pregnancies and has remained a major cause of perinatal morbidity and mortality, in both mother and child. Exercise can be used as a strategy to reduce hyperglycemia experienced during GDM. Regular exercise is important for a healthy pregnancy and can lower the risk of developing GDM. For women with GDM. Exercise is safe and can affect the pregnancy outcomes beneficially. The role of exercise about increases skeletal muscle glucose uptake and minimizing hyperglycemia. Social nervous (SaSo) exercise is a moderate-intensity exercise intervention that plays a role in controlling blood glucose through autonomic nervous stimulation so that it has an effect on glucose homeostasis. Social nervous exercise can stimulate the parasympathetic or myelinated vagus nerves. The social nerve or the social nervous system is the vagus nerve nc-X which is supported by cranial nerves, namely, nerves V, VII, IX, and XI centered in the nucleus ambiguous. AIM: The aim of the study is to determine the impact of a social nervous (SaSo) exercise training program consisting of warm-up, core (prayer movements), and cooling exercises on glucose homeostasis parameters in pregnant women diagnosed with GDM. METHODS: Thirty-seven pregnant women diagnosed with GDM at 24–28 weeks of gestation were allocated into two groups, thats the experimental group (n=19) with the SaSo program being regularly monitored and the control group (n=18) receiving only standard antenatal care for GDM. The Saso program started from the time diabetes was diagnosed until 6 weeks of intervention. Interventions were performed twice per week and sessions lasted 40–45 min. RESULTS: The baseline results for the experimental and control groups were homogeneous, without differences in the baseline variables (p > 0.05). Social nervous exercise the experimental group significantly reduced fasting blood glucose levels (p < 0.001) compared to the control group. CONCLUSIONS: A social nervous exercise program has a beneficial effect on fasting blood glucose levels in late pregnancy.

Diet and Pre-Intervention Washout Modifies the Effects of Probiotics on Gestational Diabetes Mellitus: A Comprehensive Systematic Review and Meta-Analysis of Randomized Controlled Trials

Dynamic interactions among gestational diabetes mellitus (GDM), gut microbiota, inflammation, oxidative stress, and probiotics are increasingly acknowledged. This meta-analysis aimed to summarize the effects of probiotics in GDM, focusing on lifestyle intervention and pre-intervention washout, in addition to metabolic, inflammation, oxidative stress, and pregnancy outcomes. Three electronic databases (i.e., PubMed, Scopus, and CENTRAL) were searched from inception until October 2020. A meta-analysis was performed, and the effect sizes were reported as either mean differences or odds ratios with 95% confidence intervals. Altogether, 10 randomized controlled trials enrolling 594 participants were included. The meta-analysis indicated that probiotics supplementation effectively reduced fasting plasma glucose by 3.10 mg/dL, and subgroup analyses suggested that the duration of intervention, number of species, pre-intervention washout period, and dietary intervention may determine the effects of probiotics. Probiotics also reduced the level of inflammatory markers (high-sensitivity C-reactive protein, interleukin-6, tumor necrosis factor-α, and malondialdehyde), incidence of macrosomia, and newborn hospitalization. In conclusion, this meta-analysis suggests that probiotics may have positive effects on metabolic, inflammation, oxidative stress, and neonatal outcomes in women with GDM. Additionally, diet and pre-intervention washout may modify the effects of probiotics. Future studies are warranted on a larger scale to ascertain the clinical significance.

TIMER: A Clinical Study of Energy Restriction in Women with Gestational Diabetes Mellitus

Medical nutrition therapy is an integral part of gestational diabetes mellitus (GDM) management; however, the prescription of optimal energy intake is often a difficult task due to the limited available evidence. The present pilot, feasibility, parallel, open-label and non-randomized study aimed to evaluate the effect of a very low energy diet (VLED, 1600 kcal/day), or a low energy diet (LED, 1800 kcal/day), with or without personalized exercise sessions, among women with GDM in singleton pregnancies. A total of 43 women were allocated to one of four interventions at GDM diagnosis: (1) VLED (n = 15), (2) VLED + exercise (n = 4), (3) LED (n = 16) or (4) LED + exercise (n = 8). Primary outcomes were gestational weight gain (GWG), infant birth weight, complications at delivery and a composite outcomes score. Secondary outcomes included type of delivery, prematurity, small- for-gestational-age (SGA) or large-for-gestational-age (LGA) infants, macrosomia, Apgar score, insulin use, depression, respiratory quotient (RQ), resting metabolic rate (RMR) and middle-upper arm circumference (MUAC). GWG differed between intervention groups (LED median: 12.0 kg; VLED: 5.9 kg). No differences were noted in the type of delivery, infant birth weight, composite score, prevalence of prematurity, depression, RQ, Apgar score, MUAC, or insulin use among the four groups. Regarding components of the composite score, most infants (88.4%) were appropriate-for-gestational age (AGA) and born at a gestational age of 37–42 weeks (95.3%). With respect to the mothers, 9.3% experienced complications at delivery, with the majority being allocated at the VLED + exercise arm (p < 0.03). The composite score was low (range 0–2.5) for all mother-infant pairs, indicating a “risk-free” pregnancy outcome. The results indicate that adherence to a LED or VLED induces similar maternal, infant and obstetrics outcomes.

Mediterranean Diet and Lifestyle Habits during Pregnancy: Is There an Association with Small for Gestational Age Infants? An Italian Single Centre Experience

Background. The small-for-gestational-age (SGA) in infants is related to an increased risk of developing Non-Communicable Diseases later in life. The Mediterranean diet (MD) is related to lower odds of being SGA. The study explored retrospectively the association between SGA, maternal MD adherence, lifestyle habits and other SGA risk factors during pregnancy. Methods. One hundred women (16–44 years) with a pregnancy at term were enrolled. Demographic data, parity, pre-gestational BMI, gestational weight gain, pregnancy-related diseases, and type of delivery were collected. The MD adherence (MEDI-LITE score ≥ 9), physical activity level, and smoking/alcohol consumption were registered. SGA neonates were diagnosed according to the neonatal growth curves. Results. Women were divided into “SGA group” vs. “non-SGA group”. The MD was adopted by 71% of women and its adherence was higher in the “non-SGA group” (p = 0.02). The prevalence of pregnancy-related diseases (gestational diabetes/pregnancy-induced hypertension) was higher in the “SGA group” (p = 0.01). The logistic regression showed that pregnancy-related diseases were the only independent risk factor for SGA. Conclusions. MD may indirectly reduce the risk of SGA since it prevents and exerts a positive effect on pregnancy-related diseases (e.g., gestational diabetes and hypertension). The small sample size of women in the SGA group of the study imposes a major limitation to the results and conclusions of this research, suggesting however that it is worthy of further investigation.