Pregnancy Health: Lifestyle Interventions to Reduce the Risk of Gestational Diabetes

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to pregnancy health:

Song C, Li J, Leng J, Ma R C, and Yang X. Lifestyle intervention can reduce the risk of gestational diabetes: a meta-analysis of randomized controlled trials. Obesity Reviews 2016;17:960 9.

The published review included 29 studies. The CPSTF finding is based on results from the published review, additional analyses of data from included studies, and expert input from team members and the CPSTF.

The United States Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation (Grade B recommendation; USPSTF 2016).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

Compared to usual care, lifestyle interventions reduced the overall risk of developing gestational diabetes by 32% (29 studies).

• Interventions that provided supervised exercise classes alone or in combination with other lifestyle reduced the risk by 32% (13 studies).
• Interventions that provided education and counseling for diet and physical activity reduced the risk by 31% (16 studies).

The CPSTF recommendation is reinforced by another published systematic review that reported similar findings (Shepherd et al., 2017).

Based on results for interventions in different settings and populations, findings should be applicable to interventions in clinical or hospital settings in high income countries.

The intervention should be effective with participants recruited before their second trimester (any gestational age), regardless of pre-pregnancy BMI, maternal age (though interventions were more effective for participants 30 years and older), or risk level for developing gestational diabetes (though interventions were more effective for participants with higher risk levels).

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• Among those who did not develop gestational diabetes, did lifestyle interventions lead to other health benefits?
• Besides education and counseling, what else needs to be covered (e.g. goal setting, action plan, follow-up monitoring of progress)?
• Does intervention effectiveness vary in different populations, including low-income and predominantly racial or ethnic minority populations?

Intervention settings:

• Interventions were implemented in the United States (6 studies), the European Union (16 studies), Australia (2 studies), Canada (2 studies), the United Kingdom (1 study), and India (1 study).
• Intervention settings included hospitals (16 studies), and clinics (12 studies); one study did not report setting.

Participant characteristics:

• The women who participated in the included studies had a median age of 30 years (28 studies), and a median BMI of 26.8 kg/m² (28 studies).
• Most of the studies recruited women with mean or median gestational age 15 weeks (19 studies).

Intervention characteristics:

• Programs were delivered by dieticians (11 studies), fitness specialists (5 studies), health coaches or trainers (4 studies), obstetricians or gynecologists (3 studies), a food technologist (1 study), or a nutritionist (1 study).
• Studies were delivered by one (17 studies) or two (9 studies) types of professionals.
• Intervention types included the following:
  • Education and counseling for diet alone (3 studies)
  • Education and counseling for diet and physical activity (7 studies)
  • Constructing and maintaining meal plan for diet alone (2 studies)
  • Supervised exercise classes for physical activity (10 studies)
  • Combination of any of the above components (6 studies)

No content is available for this section.

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Song C, Li J, Leng J, Ma R C, and Yang X. Lifestyle intervention can reduce the risk of gestational diabetes: a meta-analysis of randomized controlled trials. Obesity Reviews 2016;17:960 9.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Barakat R, Cordero Y, Coteron J, Luaces M, Montejo R. Exercise during pregnancy improves maternal glucose screen at 24 28 weeks: a randomised controlled trial. Br J Sports Med 2011:bjsports-2011-090009.

Barakat R, Pelaez M, Lopez C, Lucia A, Ruiz JR. Exercise during pregnancy and gestational diabetes-related adverse effects: a randomised controlled trial. Br J Sports Med 2013:bjsports-2012-091788.

Barakat R, Perales M, Bacchi M, Coteron J, Refoyo I. A program of exercise throughout pregnancy. Is it safe to mother and newborn? American Journal of Health Promotion 2014;29(1):2-8.

Bogaerts A, Devlieger R, Nuyts E, Witters I, Gyselaers W, Van den Bergh B. Effects of lifestyle intervention in obese pregnant women on gestational weight gain and mental health: a randomized controlled trial. International Journal of Obesity 2013;37(6):814.

Cordero Rodriguez Y, Mottola MF, Vargas J, Blanco M, Barakat Carballo RO. Exercise in associated with a reduction in gestational diabetes mellitus. Medicine & Science in Sports & Exercise 2014;47(7):1328-33.

Dodd JM, Turnbull D, McPhee AJ, et al. Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial. BMJ 2014;348:g1285.

Harrison CL, Lombard CB, Strauss BJ, Teede HJ. Optimizing healthy gestational weight gain in women at high risk of gestational diabetes: a randomized controlled trial. Obesity 2013;21(5):904-9.

Hui A, Back L, Ludwig S, et al. Lifestyle intervention on diet and exercise reduced excessive gestational weight gain in pregnant women under a randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology 2012;119(1):70-7.

Hui AL, Back L, Ludwig S, et al. Effects of lifestyle intervention on dietary intake, physical activity level, and gestational weight gain in pregnant women with different pre-pregnancy Body Mass Index in a randomized control trial. BMC Pregnancy and Childbirth 2014;14(1):331.

Ko CW, Napolitano PG, Lee SP, Schulte SD, Ciol MA, Beresford SA. Physical activity, maternal metabolic measures, and the incidence of gallbladder sludge or stones during pregnancy: a randomized trial. American Journal of Perinatology 2014;31(01):039-48.

Koivusalo SB, R n K, Klemetti MM, et al. Gestational diabetes mellitus can be prevented by lifestyle intervention: the Finnish Gestational Diabetes Prevention Study (RADIEL): a randomized controlled trial. Diabetes Care 2015:dc150511.

Luoto R, Kinnunen TI, Aittasalo M, et al. Primary prevention of gestational diabetes mellitus and large-for-gestational-age newborns by lifestyle counseling: a cluster-randomized controlled trial. PLoS Medicine 2011;8(5):e1001036.

Luoto R, Laitinen K, Nermes M, Isolauri E. Impact of maternal probiotic-supplemented dietary counselling on pregnancy outcome and prenatal and postnatal growth: a double-blind, placebo-controlled study. British Journal of Nutrition 2010;103(12):1792-9.

Nobles C, Marcus BH, Stanek III EJ, et al. Effect of an exercise intervention on gestational diabetes mellitus: a randomized controlled trial. Obstetrics and Gynecology 2015;125(5):1195.

Oostdam N, Van Poppel M, Wouters M, et al. No effect of the FitFor2 exercise programme on blood glucose, insulin sensitivity, and birthweight in pregnant women who were overweight and at risk for gestational diabetes: results of a randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology 2012;119(9):1098-107.

Petrella E, Malavolti M, Bertarini V, et al. Gestational weight gain in overweight and obese women enrolled in a healthy lifestyle and eating habits program. Journal of Maternal-Fetal & Neonatal Medicine 2014;27(13):1348-52.

Phelan S, Phipps MG, Abrams B, Darroch F, Schaffner A, Wing RR. Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study. American Journal of Clinical Nutrition 2011;93(4):772-9.

Polley BA, Wing R, Sims C. Randomized controlled trial to prevent excessive weight gain in pregnant women. International Journal of Obesity 2002;26(11):1494.

Poston L, Bell R, Croker H, et al. Effect of a behavioural intervention in obese pregnant women (the UPBEAT study): a multicentre, randomised controlled trial. Lancet Diabetes & Endocrinology 2015;3(10):767-7.

Price BB, Amini SB, Kappeler K. Exercise in pregnancy: effect on fitness and obstetric outcomes a randomized trial. Medicine & Science in Sports & Exercise 2012;44(12):2263-9.

Quinlivan JA, FISHER J. A randomised trial of a four-step multidisciplinary approach to the antenatal care of obese pregnant women. Australian and New Zealand Journal of Obstetrics and Gynaecology 2011;51(2):141-6.

Renault KM, N rgaard K, Nilas L, et al. The Treatment of Obese Pregnant Women (TOP) study: a randomized controlled trial of the effect of physical activity intervention assessed by pedometer with or without dietary intervention in obese pregnant women. American Journal of Obstetrics and Gynecology 2014;210(2):134.

Ruiz JR, Perales M, Pelaez M, Lopez C, Lucia A, Barakat R. Supervised exercise based intervention to prevent excessive gestational weight gain: A randomized controlled trial. Paper presented at: Mayo Clinic Proceedings 2013.

Stafne SN, Salvesen K , Romundstad PR, Eggeb TM, Carlsen SM, M rkved S. Regular exercise during pregnancy to prevent gestational diabetes: a randomized controlled trial. Obstetrics & Gynecology 2012;119(1):29-36.

Thornton YS, Smarkola C, Kopacz SM, Ishoof SB. Perinatal outcomes in nutritionally monitored obese pregnant women: a randomized clinical trial. Journal of the National Medical Association 2009;101(6):569-77.

Vinter CA, Jensen DM, Ovesen P, Beck-Nielsen H, J rgensen JS. The LiP (Lifestyle in Pregnancy) study: a randomized controlled trial of lifestyle intervention in 360 obese pregnant women. Diabetes Care 2011:DC_111150.

Walsh JM, McGowan CA, Mahony R, Foley ME, McAuliffe FM. Low glycaemic index diet in pregnancy to prevent macrosomia (ROLO study): randomised control trial. BMJ 2012;345:e5605.

Wolff S, Legarth J, Vangsgaard K, Toubro S, Astrup A. A randomized trial of the effects of dietary counseling on gestational weight gain and glucose metabolism in obese pregnant women. International Journal of Obesity 2008;32(3):495.

Implementation Resource

Rural Health Information Hub, Maternal Health Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of maternal health programs in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• Models Addressing Perinatal Health

Refer to the existing systematic review for information about the search strategy:

Song C, Li J, Leng J, Ma R C, and Yang X. Lifestyle intervention can reduce the risk of gestational diabetes: a meta-analysis of randomized controlled trials. Obesity Reviews 2016;17:960 9.

Song C, Li J, Leng J, Ma R C, and Yang X. Lifestyle intervention can reduce the risk of gestational diabetes: a meta-analysis of randomized controlled trials. Obesity Reviews 2016;17:960 9.

Shepherd E, Gomersall JC, Tieu J, Han S, Crowther CA, Middleton P. Combined diet and exercise interventions for preventing gestational diabetes mellitus. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.: CD010443. DOI:10.1002/14651858.CD010443.pub3.

U.S. Preventive Services Task Force. Final Update Summary: Gestational Diabetes Mellitus, Screening. September 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/gestational-diabetes-mellitus-screening

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• All pregnant women could potentially benefit from these lifestyle interventions. If resources are limited, however, evidence suggests interventions are more effective among women who are at higher risk for developing gestational diabetes.
• Programs should encourage women to continue participating throughout their pregnancy.
• Lifestyle interventions that included supervised exercise classes led to consistent reductions in risk for developing gestational diabetes.
  • Interventions considered in this review typically provided 50-60 minute, supervised exercise classes three times per week.
  • Classes were of moderate intensity and included land or aquatic exercises.
  • Classes can be resource-intensive. Implementers should consider the following:
    • Trained personnel to supervise participants
    • Possibility of work compensation for time spent in classes
    • The availability of childcare
    • Established protocols for classes that offer intense exercise during pregnancy to prevent injury and adverse pregnancy outcomes
    • The need for reimbursement if healthcare professionals are involved
    • Facilities where classes will be held selected settings should take into account distance and accessibility to potential participants; settings could range from free or low priced community centers to private gyms
    • Support elements to help participants adopt a sustainable exercise routine; especially for patients who did not engage in regular exercise prior to the intervention

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the number of diabetes cases diagnosed yearly — D-01
• Reduce cesarean births among low-risk women with no prior births — MICH-06