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Recommendations Summary

GDM: Physical Activity 2016

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    GDM: Physical Activity

    Unless contraindicated, the registered dietitian nutritionist (RDN) should encourage women with gestational diabetes mellitus (GDM) to engage in a goal to achieve daily moderate exercise of 30 minutes or more per day. In addition to a healthy diet, exercise can help improve blood glucose control and achieve weight gain recommendations. Both aerobic exercise and non–weight-bearing exercise (e.g., stretching, swimming, yoga, etc.) have been shown to lower blood glucose levels in women with GDM. Lifestyle therapy for GDM results in lower birth weight and a lower incidence of large-for-gestational-age births and pre-eclampsia.

    Rating: Strong
    Conditional

    • Risks/Harms of Implementing This Recommendation

      • High-intensity or prolonged exercise in excess of 45 minutes can lead to hypoglycemia [American College of Obstetricians and Gynecologists (ACOG), 2015]
      • Pregnant women engaging in physical activity should be advised to ensure adequate caloric intake and to remain well hydrated (ACOG, 2015)  
      • Contact sports (ice hockey, boxing, soccer, basketball), activities with a high risk of falling (skiing surfing, off-road cycling, gymnastics, horseback riding), scuba diving, sky diving, and hot yoga or hot pilates should be avoided (ACOG, 2015).

    • Conditions of Application

      • Healthcare provider consultation is warranted or required prior to beginning any exercise program (ACOG, 2015) 
      • This recommendation applies to women with GDM for whom physical activity during pregnancy is not contraindicated. 
        • Absolute contraindications include, but are not limited to: Hemodynamically significant heart disease, restrictive lung disease, incompetent cervices or cerclage, multiple gestation at risk of premature labor, persistent second or third trimester bleeding, placenta previa after 26 weeks of gestation, premature labor during the current pregnancy, ruptured membranes, preeclampsia or pregnancy induced hypertension (HTN) and severe anemia,  and women with relative (ACOG, 2015)
        • Relative contraindications include, but are not limited to: Anemia, unevaluated maternal cardiac arrhythmia, chronic bronchitis, poorly controlled type 1 diabetes, extreme morbid obesity, extreme underweight [body mass index (BMI) below 12kg/m2], history of extremely sedentary lifestyle, intrauterine growth restriction in current pregnancy, poorly controlled HTN, orthopedic limitations, poorly controlled seizure disorder, poorly controlled hyperthyroidism, heavy smoker (ACOG, 2015)
          • Pregnant women with relative contraindications to physical activity may be able to incorporate physical activity with individualized recommendations provided by their health care provider (ACOG, 2015).
      • Pregnant women who were sedentary or obese prior to their pregnancy should follow a gradual progression to physical activity goals (ACOG, 2015) 
        • Overweight or obese women should start with low-intensity, short periods of exercise and gradually increase as able (ACOG, 2015).
      • Pregnant women who regularly engaged in physical activity before they were pregnant can continue to engage in high intensity aerobic activity in the absence of contraindications (ACOG, 2015)
      • Safe activities within moderate intensity include: Walking, swimming, stationary cycling, low-impact aerobics, modified yoga, modified pilates, running or jogging, racquet sports or strength training (ACOG, 2015).

    • Potential Costs Associated with Application

      There are no obvious costs that may be associated with the application of this recommendation.

    • Recommendation Narrative

      The recommendation is based on The Endocrine Society's Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline (Blumer et al, 2013) as follows:

      • Management of Elevated Blood Glucose
        • "2.3b. We recommend that the initial treatment of gestational diabetes should consist of medical nutrition therapy and daily moderate exercise for 30 minutes or more. Rating: 1/+++ (Strong recommendation / Moderate quality evidence)"
        • Summary of support for the recommendation:
          • "Lifestyle therapy for GDM results in a lower incidence of reduced birth weight, large-for-gestational-age births, and preeclampsia. Both aerobic exercise and non–weight-bearing exercise have been shown to lower blood glucose levels in women with GDM."
      Summary

      Physical activity recommendations for pregnant women do not differ from recommendations for the general public (ACOG, 2015). Physical activity during pregnancy is considered safe and desirable for pregnant women in the absence of complications or contraindications (ACOG, 2015; Office of Disease Prevention & Health Promotion, 2008). After a thorough evaluation from the healthcare provider, initial treatment of GDM should include a working goal toward daily moderate exercise of 30 minutes or more (Blumer et al, 2013). Pregnant women should use perceived exertion as a method to monitor exercise intensity. Physical activity has been found to lower blood glucose levels and promote recommended weight status in women with GDM (ACOG, 2013, 2015; Blumer et al, 2013).

    • Recommendation Strength Rationale

      The Academy of Nutrition and Dietetics and the GDM Expert workgroup concur with The Endocrine Society's Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline recommendation rating for "Management of Elevated Blood Glucose." 

    • Minority Opinions

      None.

  • Supporting Evidence

    The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

    • References
    • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

      • Academy Quality Management Committee and Scope of Practice Subcommittee of Quality Management Committee. Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. J Acad Nutr Diet. 2013 Jun;113(6 Suppl):S17-28. doi: 10.1016/j.jand.2012.12.008. PMID: 23454020.
      • American College of Obstetricians and Gynecologists (ACOG). Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015;126:e135-142. 
      • ACOG. Committee on Practice Bulletins--Obstetrics. Practice Bulletin No. 137: Gestational diabetes mellitus. Obstet Gynecol. 2013 Aug;122 (2 Pt 1): 406-416. PMID: 23969827.
      • Blumer I, Hadar E, Hadden DR, Jovanovic L, Mestman JH, Murad MH, Yogev Y. Diabetes and pregnancy: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2013 Nov; 98(11): 4, 227-4, 249. doi: 10.1210/jc.2013-2465. PMID: 24194617.
      • Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services.  Additional Considerations for some adults. 2008 Physical Activity Guidelines for Americans. Accessed October 3, 2016 from: https://health.gov/paguidelines/guidelines/chapter7.aspx.