GDM: Physical Activity (2008)
Recruitment Postpartum women who had GDM responding to a survey packet mailed to them within 6 months of having a baby. 60 packets mailed and 28 were returned, representing a 47% response rate.
Design Cross-Sectional Study
Blinding used (if applicable) Not described
Intervention (if applicable) Survey including two questionnaires, the Exercise Beliefs Questionnaire and Leisure-Time Exercise Questionnaire (LTEQ) as well as questions assessing the number of days and minutes participants currently engaged in moderate to strenuous exercise.
Statistical Analysis A content anaylsis was conducted to rank order the exercise beliefs. Percentages, means and standard deviations are reported. Content validity was established by having two Theory of Planned Behavior experts examine the participants' responses and 100% content validity agreement was established. Mean comparisons using t-tests were used to determine whether there were differences in the total number of beliefs reported during pregnancy compared wth postpartum.
Pearson correlations were used to examine the associations between women's behavioral, normative and control beliefs and total prepregnancy, pregnancy and postpartum LTEQ exercise scores.
Timing of Measurements Questionnaires completed within 6 months postpartum of having a baby
Dependent Variables
- Exercise behavior, pre, during and post pregnancy
Independent Variables
- Behavioral (advantages) beliefs
- Normative (social) beliefs
- Control (barriers) beliefs
Control Variables Not used
Initial N: 28 women
Attrition (final N): 28
Age: Mean age 32 years
Ethnicity: 92% Caucasian, 8% Asian
Other relevant demographics:
- 100% married
- 75% with a family hx of diabetes
- 73% at least college educated
- 77% with a family income of at least $40,000
- 75% of the women were working and 68% were on maternity leave
- 97% of the women gave birth to their first child vaginally
- 37% were breastfeeding
- 19% were formula feeding
- 44% were doing both formula and breast
Anthropometrics Mean BMI 32 (20 to 51) classifying the average participant as obese. Participants gained an average of 28 (4-60) pounds during pregnancy.
Location: Central Pennsylvania
Exercise beliefs reported during pregnancy and postpartum
| Beliefs | % | Beliefs | % |
| Pregnancy | Postpartum | ||
| Behavioral beliefs (advantages) | Behavioral beliefs (advantages) | ||
| Control blood glucose | 43 | Lose weight | 61 |
| Feel better/have more energy | 39 | Get fit (endurance/muscle tone) | 29 |
| Control weight gain | 30 | Have time for self | 21 |
| Help with labor/deliver | 11 | Increase energy | 11 |
| Help with recovery | 7 | Decrease risk of type 2 diabetes | 7 |
| Lower cholesterol | 7 | ||
| Normative beliefs (social influences) | Normative beliefs (social influences) | ||
| Husband/partner | 57 | Husband/partner | 71 |
| Other family members (parents, siblings) | 50 | Other family members (parents, siblings) | 54 |
| Doctor/nurse | 14 | Children | 47 |
| Friends | 11 | Friends | 11 |
| Coworkers | 11 | Coworkers | 11 |
| Children | 11 | ||
| Control beliefs (barriers or obstructing factors) | Control beliefs (barriers or obstructing factors) | ||
| Fatigue | 39 | No time | 50 |
| Pain/Discomfort | 32 | Taking care of children | 46 |
| Sickness (nausea, vomiting) | 18 | Fatigue | 20 |
| No time | 18 | Other priorities | 14 |
| Afraid to exercise | 14 | Breast-feeding | 7 |
| Taking care of children | 14 | ||
| Complications (torn placenta, bed rest) | 14 | No access to exercise equipment | 7 |
| Size (too big) | 7 | Work | 7 |
Exercise beliefs and behaviors
| Variable | Means + SD (range) |
| Total number of exercise beliefs (pregnancy) | |
| Behavioral (advantages) | 2.64 + 1.62 (0-7) |
| Normative (social influences) | 2.04 + 1.37 (0-5) |
| Control (barriers) | 1.64 + 1.31 (0-5) |
| Total number of exercise beliefs (postpartum) | |
| Behavioral (advantages) | 2.62 + 1.39 (0-6) |
| Normative (social influences) | 2.14 + 1.04 (1-4) |
| Control (barriers) | 1.50 + 1.23 (0-5) |
| Total LTEQ exercise behavior | |
| Prepregnancy | 23.94 + 20.00 (0-67) |
| Pregnancy | 22.04 + 15.38 (0-53) |
| Postpartum | 28.77 + 21.28 (0-71) |
| Number of days exercising (postpartum) | 3.07 + 1.76 (0-7) |
| Number of minutes exercising (postpartum) | 30.93 + 20.98 (0-90) |
Other Findings
Walking was the most frequently reported type of exercise during women's first (58%), second (61%) and third (62%) trimesters and postpartum (75%), followed by a combination of activities such as yoga, aerobic activity and swimming.
Women exercised more postpartum than during pregnancy t (25) = 2.29, P = .03.
Women's prepregnancy exercise was slightly greater than their pregnancy exercise, but it was not statistically different from their pregnancy and postpartum exercise. Thus there was a trend to reduce exercise during pregnancy and statistically significant increase after pregnancy.
The number of behavioral beliefs reported during pregnancy was positively associated wtih women's pregnancy (r=.68, p<.001) and postpartum (r = .43, p<.05) exercise behavior.
No significant associations were found for the number of normative and control beliefs reported and women's exercise behavior.
Only 39% of the women in this study were currently meeting exercise recommendations.
Women with GDM believed that controlling blood glucose was the most important advantage of exercising during their pregnancy and postpartum it was controlling their weight.
Only 7% of women believe that exercising postpartum would decrease their risk of type 2 diabetes despite the fact that part of the standard of care for these women included an emphasis on prevention of diabetes later in life. Therefore further research should explore whether in the clinical setting one should simply explore the postpartum weight-related beliefs of women with GDM.
Consistent with previous studies, a woman's husband/partner had the strongest normative influence on her exercise, both during the pregnancy and postpartum, followed by other members' beliefs.
Only 14% of women reported that a doctor/nurse motivated them to exercise, illustrating the fact that better strategies for encouraging exercise in the health care setting are needed.
The main barrier to exercise during pregnancy was fatigue and postpartum it was having no time.
Women reported relatively the same number of control beliefs as they did behavioral beliefs, so that it does not appear that women with GDM encounter a greater number of exercise barriers compared with exercise advantages.
In contrast to the hypothesis, women exercised more postpartum than before and during their their pregnancy. The authors speculate that this is because women with GDM are more sensitized to their overall health and obesity risk.
As predicted, the total number of behavioral advantages reported during pregnancy was associated with women's pregnancy and postpartum exercise behavior. No associations between the number of barriers or social influences reported and exercise behavior were found. Thus, the more advantages a women had for exercise, the more she actually exercised during her pregnancy and postpartum.
This paper sheds some much needed insight onto the various exercise beliefs held by women as it relates to GDM and should help guide future studies.
It would be interesting to see what women's beliefs regarding exercise were pre-pregnancy and how this influenced behavior. As the authors suggest, this could be explored in a prospective study. Likewise, it would be interesting to see how some of the specific normative and control beliefs, such husband/partner or no time, were associated with exercise behaviors for all time periods.
A minor note, but it would have been interesting to note how many of these women received GDM education during their pregnancy and from whom they received the information. Was it simply a nurse or a doctor, or were they referred to Diabetes Education/Diabetes Educators including a dietitian and a nurse.
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Quality Criteria Checklist: Primary Research
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| Relevance Questions | |||
| 1. | Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) | Yes | |
| 2. | Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? | Yes | |
| 3. | Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? | Yes | |
| 4. | Is the intervention or procedure feasible? (NA for some epidemiological studies) | Yes | |
| Validity Questions | |||
| 1. | Was the research question clearly stated? | Yes | |
| 1.1. | Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? | Yes | |
| 1.2. | Was (were) the outcome(s) [dependent variable(s)] clearly indicated? | Yes | |
| 1.3. | Were the target population and setting specified? | Yes | |
| 2. | Was the selection of study subjects/patients free from bias? | ??? | |
| 2.1. | Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? | Yes | |
| 2.2. | Were criteria applied equally to all study groups? | Yes | |
| 2.3. | Were health, demographics, and other characteristics of subjects described? | Yes | |
| 2.4. | Were the subjects/patients a representative sample of the relevant population? | ??? | |
| 3. | Were study groups comparable? | Yes | |
| 3.1. | Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) | N/A | |
| 3.2. | Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? | N/A | |
| 3.3. | Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) | N/A | |
| 3.4. | If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? | Yes | |
| 3.5. | If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) | Yes | |
| 3.6. | If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? | N/A | |
| 4. | Was method of handling withdrawals described? | N/A | |
| 4.1. | Were follow-up methods described and the same for all groups? | N/A | |
| 4.2. | Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) | N/A | |
| 4.3. | Were all enrolled subjects/patients (in the original sample) accounted for? | N/A | |
| 4.4. | Were reasons for withdrawals similar across groups? | N/A | |
| 4.5. | If diagnostic test, was decision to perform reference test not dependent on results of test under study? | N/A | |
| 5. | Was blinding used to prevent introduction of bias? | N/A | |
| 5.1. | In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? | N/A | |
| 5.2. | Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) | N/A | |
| 5.3. | In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? | N/A | |
| 5.4. | In case control study, was case definition explicit and case ascertainment not influenced by exposure status? | N/A | |
| 5.5. | In diagnostic study, were test results blinded to patient history and other test results? | N/A | |
| 6. | Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? | Yes | |
| 6.1. | In RCT or other intervention trial, were protocols described for all regimens studied? | N/A | |
| 6.2. | In observational study, were interventions, study settings, and clinicians/provider described? | Yes | |
| 6.3. | Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? | N/A | |
| 6.4. | Was the amount of exposure and, if relevant, subject/patient compliance measured? | N/A | |
| 6.5. | Were co-interventions (e.g., ancillary treatments, other therapies) described? | N/A | |
| 6.6. | Were extra or unplanned treatments described? | N/A | |
| 6.7. | Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? | Yes | |
| 6.8. | In diagnostic study, were details of test administration and replication sufficient? | N/A | |
| 7. | Were outcomes clearly defined and the measurements valid and reliable? | Yes | |
| 7.1. | Were primary and secondary endpoints described and relevant to the question? | Yes | |
| 7.2. | Were nutrition measures appropriate to question and outcomes of concern? | N/A | |
| 7.3. | Was the period of follow-up long enough for important outcome(s) to occur? | Yes | |
| 7.4. | Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? | Yes | |
| 7.5. | Was the measurement of effect at an appropriate level of precision? | N/A | |
| 7.6. | Were other factors accounted for (measured) that could affect outcomes? | N/A | |
| 7.7. | Were the measurements conducted consistently across groups? | N/A | |
| 8. | Was the statistical analysis appropriate for the study design and type of outcome indicators? | Yes | |
| 8.1. | Were statistical analyses adequately described and the results reported appropriately? | Yes | |
| 8.2. | Were correct statistical tests used and assumptions of test not violated? | Yes | |
| 8.3. | Were statistics reported with levels of significance and/or confidence intervals? | Yes | |
| 8.4. | Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? | N/A | |
| 8.5. | Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? | N/A | |
| 8.6. | Was clinical significance as well as statistical significance reported? | Yes | |
| 8.7. | If negative findings, was a power calculation reported to address type 2 error? | N/A | |
| 9. | Are conclusions supported by results with biases and limitations taken into consideration? | Yes | |
| 9.1. | Is there a discussion of findings? | Yes | |
| 9.2. | Are biases and study limitations identified and discussed? | Yes | |
| 10. | Is bias due to study's funding or sponsorship unlikely? | Yes | |
| 10.1. | Were sources of funding and investigators' affiliations described? | Yes | |
| 10.2. | Was the study free from apparent conflict of interest? | Yes | |