DOI: 10.1111/j.1471-0528.2011.03184.

x
General obstetrics
www.bjog.org

Lifestyle intervention on diet and exercise

reduced excessive gestational weight gain in
pregnant women under a randomised
controlled trial
A Hui,a L Back,a S Ludwig,a P Gardiner,b G Sevenhuysen,c H Dean,d E Sellers,d J McGavock,d
M Morris,e S Bruce,f R Murray,f GX Shena
a
Department of Internal Medicine b Department of Kinesiology and Recreation Management c Department of Human Nutritional Sciences
d
Department of Paediatrics and Child Health e Department of Obstetrics and Gynaecology and f Department of Community Health Sciences,
University of Manitoba, Winnipeg, Manitoba, Canada
Correspondence: Dr GX Shen, Diabetes Research Group, University of Manitoba, 835-715 McDemort Avenue, Winnipeg, Manitoba,
Canada R3E 3P4. Email gshen@ms.umanitoba.ca

Accepted 13 September 2011. Published Online 21 October 2011.

Objective To examine the effect of an exercise and dietary
intervention during pregnancy on excessive gestational weight gain
(EGWG), dietary habit and physical activity in pregnant women.
Design Randomised controlled trial.
Setting Community-based study.
Population Nondiabetic urban-living pregnant women (<26 weeks
of gestation).
Methods Participants in the intervention group were provided
with community-based group exercise sessions, instructed home
exercise and dietary counselling between 20 and 36 weeks of
gestation. Participants in both groups received physical activity
and food intake surveys at enrolment and 2 months after the
enrolment.
Main outcome measures Prevalence of EGWG and measures of
physical activity and food intakes between the two groups.
Results A total of 190 pregnant women, 88 in the control group
and 102 in the intervention group, completed the study.
Decreased daily intakes of calorie, fat, saturated fat and cholesterol
were detected in participants in the intervention group at
2 months after enrolment compared with the control group
(P < 0.01). Participants in the intervention group had higher
physical activity 2 months after enrolment compared with the
control group (P < 0.01). The lifestyle intervention during
pregnancy reduced the prevalence of EGWG in the intervention
group compared with the control group (P < 0.01) according to
the guidelines of the Institute of Medicine.
Conclusion The findings suggest that lifestyle intervention during
pregnancy increased physical activity, improved dietary habits and
reduced EGWG in urban-living pregnant women.
Keywords Dietary intervention, exercise, gestational weight gain,
pregnancy.

Please cite this paper as: Hui A, Back L, Ludwig S, Gardiner P, Sevenhuysen G, Dean H, Sellers E, McGavock J, Morris M, Bruce S, Murray R, Shen G.
Lifestyle intervention on diet and exercise reduced excessive gestational weight gain in pregnant women under a randomised controlled trial. BJOG
2012;119:70–77.

gestational-age babies and metabolic syndrome in children.3

Introduction
The prevalence of type II diabetes mellitus and obesity has
rapidly increased in North America, particularly in chil-
dren.1,2 Obesity is one of the major aetiological factors for
type II diabetes mellitus and cardiovascular disease. Preg-
nancy influences the postpartum bodyweights of mothers
and their offspring. Maternal obesity may result from pre-
pregnancy obesity or excessive gestational weight gain
(EGWG). Maternal obesity is associated with large-for-
High values for pre-pregnancy body mass index are associ-
ated with gestational diabetes mellitus and future type II
diabetes mellitus in women.4 EGWG is defined as inappro-
priately large weight gain during pregnancy assessed
according to the guidelines of the Institute of Medicine
(IOM).5,6 EGWG increases the risk of fetal macrosomia,
maternal overweight and postpartum weight retention.7
The prevention of EGWG during pregnancy potentially
improves maternal and neonatal outcomes.

70 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
 Exercise and dietary intervention on gestational weight gain

Inappropriate food intake and inadequate levels of phys-

Enrolment
Eligible
(n = 227)
ical activity have been recognised as important contribut-
ing factors to the epidemics of obesity and type II diabetes
mellitus.8 The American Congress of Obstetricians and Enrolled
(n = 224)
Excluded (n = 3)
Medical (n = 1)
Gynecologists has recommended mild-to-moderate exercise Obstetrical (n = 2)

for all pregnant women without contraindications to exer-

Randomised

Allocation
cise.9 Several groups examined the impact of lifestyle inter- (n = 224)

ventions (dietary intervention with or without increased

physical activity) on the prevalence of EGWG or gesta- Control group Intervention group
(n = 112) (n = 112)
tional weight gain, but the results of the interventions on
EGWG, dietary habit or physical activity were equivo- Miscarriage Miscarriage
(n = 3)
cal.10–18 The IOM revised the guidelines of EGMG in (n = 1)

2009 responding to the worldwide epidemic of obesity.5 No intervention

Exercise and dietary
intervention
The effect of lifestyle intervention during pregnancy on

Follow up
EGWG according to the 2009 IOM guidelines remains
unclear. Discontinued (n = 23) Discontinued (n = 7)
Relocation (n = 1)
We hypothesise that a newly developed exercise and die- Relocation (n = 2)
Loss to follow up (n = 6)
Work or study (n = 8)
tary intervention during pregnancy19 may improve dietary Loss to follow up (n = 13)

habit, increase physical activity and reduce EGWG in preg-

nant women. The goal of the present study is to assess the

Analysis
efficacy of the lifestyle intervention on EGWG, food intake Analysed
Analysed
(n = 88)
(n = 102)
and physical activity in urban-living pregnant women
through a randomised controlled trial (RCT). Figure 1. Consorted chart of the study.

Methods
Participants
Nondiabetic pregnant women (<26 weeks of pregnancy,
n = 227) living in Winnipeg were recruited on a voluntary
basis between July 2004 and February 2010 from prenatal
classes or community clinics through posters and local
newspaper advertisements in Winnipeg. All applicants read
and signed an informed consent. Three applicants were
excluded by physicians because of medical or obstetric con-
traindications to exercise during pregnancy, the remaining
224 pregnant women were approved and randomised into
control or intervention groups. Randomisation was per-
formed using a computer-generated randomisation alloca-
tion table by a staff member without involvement in the
study design. After randomisation, participants received a
sealed envelope labelled with the assigned randomisation
number, which contained instructions for participants. The
nature of the study meant that participants and study staff
were not blinded to the types of interventions. After
recruitment, four participants had miscarriages before the
start of intervention (one in the control group and three in
the intervention group). Thirty participants withdrew from
the study (23 in the control group and seven in the inter-
vention group) because of relocation, time commitment
(work or study) or loss of contact for undefined reasons.
A total of 190 participants completed the programme, 88
in the control group and 102 in the intervention group,
and their data were analysed (Figure 1).
Registration of clinical trial
The enrolment for the trial started in July 2004 and
the trial was retrospectively registered with http://clinical
trials.gov on 13 June 2007. Updates or changes were made
eight times as required. Besides the addition of funding
sources and the website of the study, the major changes in
the design of the trial are summarised as follows: the study
start and end dates were changed from 2006–12 to 2004–15
(the initial recruitment of pilot participants in 2004–05
were added to the trial; the assessment of EGWG will end
in 2014); the estimated enrolment was changed from 1600
to 500 based on our achieved enrolment during the last
6 years.
Instructed exercise
A community-based exercise programme specifically
designed for pregnant women developed in our previous
studies19 was provided to participants in the intervention
group. Recommended exercise included walking, mild-to-
moderate aerobic, stretching and strength exercises. An
exercise regimen, three to five times per week (including a
weekly exercise session and multiple home sessions) of
mild-to-moderate exercise for 30–45 minutes/session was
recommended to participants in the intervention group.
It was recommended that the exercise programme started
between 20 and 26 weeks of pregnancy and ended at
36 weeks of pregnancy. The group exercise sessions were
held in air-conditioned gymnasia in community centres

ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG 71
 Hui et al.
located in residential areas. Participants had options for
attending daytime or evening exercise sessions. Floor aero-
bic, stretching and strength exercises were led by licensed
fitness trainers in group sessions for participants to learn
skills for exercise during pregnancy. An exercise instruc-
tion video designed for pregnant women by exercise phy-
siologists was provided to participants in the intervention
group to assist their home exercise. Participants in the
intervention group were taught to record daily physical
activities in activity logbooks, which were collected weekly
by the project coordinator from the participants in the
intervention group.
Dietary intervention
Dietary interviews and counselling were provided twice to
each participant in the intervention group by registered
dietitians, the first at enrolment and the second 2 months
after enrolment. The dietary interview was assisted with a
Food Choice Map, a computerised dietary interview tool.
The Food Choice Map consists of a specifically designed
board or ‘map’, 91 magnetic stickers with pictures of com-
mon foods and bar codes, and software20 modified for
pregnant women. Food Choice Map assessment for nutri-
tional intake was recently validated in women of reproduc-
tive age.21 During interviews, participants recalled their
food intakes in a typical week. Participants and dietitians
jointly placed stickers on the map. Bar codes and locations
of stickers on the map represent the frequency, types and
quantity of food intakes, which were scanned into the com-
puter at the end of each interview.20 Participants’ daily
intakes for total calorie and nutrients were instantly analy-
sed. Dietitians provided personalised dietary counselling to
participants based on their Food Choice Map interview
results, pregnancy week, weight gain and the Health Can-
ada guidelines for food intake in pregnancy.22,23 The dieti-
tian assessed the changes in dietary pattern in the
participants in the intervention group during the second
dietary interview at 2 months after enrolment and provided
further advice if it was indicated.
Control group
Participants in the control group received standard prenatal
care recommended by the Society of Obstetricians and
Gynecologists of Canada24 and were provided with a pack-
age of up-to-date information on physical activity and
nutrition healthy pregnancy from the Health Canada.25
Exercise instruction or dietary intervention was not pro-
vided to participants in the control group.
Assessment of physical activity and food intake
Recreational physical activities of all participants were
semi-quantified using an activity questionnaire on a
PARMed-X form for Pregnancy designed by the Canadian
72 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
Society of Exercise Physiology, which was validated previ-
ously using peak oxygen consumption.26 Unfit (physical
activity index = 0) during pregnancy was defined as recrea-
tional activity <1–2 times/week plus <20 minutes/time.
Active (physical activity index = 1) was defined as recrea-
tional activity 1–2 times/week, >20 minutes/time or
>2 times/week but <20 minutes/time. Fit (physical activity
index = 2) was defined as recreational activity >2 times/
week plus >20 minutes/time. Food intakes of all partici-
pants were assessed using 3-day food records27 and the
method was previously validated.28 The results of food
intake were analysed using NutriBase 6.0 software (Cyber-
Soft, Inc., Phoenix, AZ, USA).
Data collection
Data on delivery route, maternal weight at delivery room,
birthweight and birthweight-related obstetric procedures
(induction, forceps or caesarean section) were collected
from hospital medical charts. The diagnosis of gestational
diabetes mellitus was made according to the 2008 guide-
lines of the Canadian Diabetes Association.29 Large-for-
gestational-age was determined based on birthweight and
gestational age as previously described.30 EGWG was calcu-
lated by subtracting the upper limit of normal weight gain
for corresponding pre-pregnancy BMI following the 1990
or 2009 guidelines of IOM3,5 from the actual weight gain
(difference between pre-pregnancy weight and bodyweight
at delivery room).
Outcomes
The primary outcome of the present study was the preva-
lence of EGWG. Other measured variables included food
intake, physical activity, the prevalence of large-for-gesta-
tional-age, gestational diabetes mellitus, weight-related
obstetric procedures, gestational weight gain and birth-
weights.
Power assessment and statistical analysis
The results of our pilot study detected EGWG in seven of
19 participants in the control group, but two out of 20 in
the intervention group. With an estimated dropout rate of
16%, the sample size for detecting a significant difference
in the primary outcome, EGWG, between the control and
intervention groups was 86/group (a = 0.05) with 80%
power for the chi-square test. The effect size for sample size
estimation for EGWG based on the results of the pilot
study was 0.37 with Phi coefficient assessment. Demo-
graphic variables (age, pre-pregnancy weight, height, BMI
and annual family income), dietary intake, physical activity
index, birthweights and gestational weight gain were analy-
sed using the Student’s t-test. Bonferroni correction was
used for data with multiple variables. The prevalence of
gestational diabetes mellitus, EGWG, First Nations status
 Exercise and dietary intervention on gestational weight gain

and large-for-gestational-age infants was assessed using the 3-day food records at baseline and 2 months after enrol-
chi-squared test. Data analyses were conducted by statisti- ment. The remaining participants submitted the first, but
cians without knowledge of participants. not the second, food records. At the baseline, no significant
difference in total calorie, protein, carbohydrate, fat, satu-
rated fat, fibres or cholesterol intake was detected between
Results
participants in the control and intervention groups who
A total of 190 participants (88 in the control group and completed both food records (Table 2). Participants in the
102 in the intervention group) completed their programme intervention group at 2 months after enrolment had signifi-
and delivered babies before 31 July 2010. No significant cantly lower intake of total calorie, fat, saturated fat and
difference was detected in age, pre-pregnancy weight, cholesterol compared with that in the control group
height, BMI, First Nations status, or annual family income (P = 0.00004–0.002). The ratios of daily carbohydrate, pro-
between the two groups (Table 1). tein or fat intake versus total calorie intake between the
Over half (55.8%) of participants (53 in the control two groups at baseline were not significantly different.
group and 53 in the intervention group) completed both At 2 months after enrolment, participants in the interven-
tion group had a significantly lower ratio of fat compared
with those in the control group (27.0% versus 31.5%,
P = 0.001) (Table 2). No significant difference after Bonfer-
Table 1. Demographic information of pregnant women in control
roni correction in the intake of starch, very lean meat, lean
and intervention groups
meat, medium-fat meat, high-fat meat, vegetables, fruits,
Control Intervention skim milk, 1–2% fat milk, whole fat milk or dietary fats
(n = 88) (n = 102) (oil and fats) was detected between the control and inter-
vention groups at baseline or 2 months after enrolment
Age (years) 28.7 ± 5.9 30.1 ± 5.2 (Table 3).
Pre-pregnancy weight (kg) 70.7 ± 15.7 68.0 ± 16.9 In participants who completed the programme, 179
Height (cm) 165.8 ± 7.3 165.3 ± 6.4
(93.7%) (84 in the control group and 95 in the interven-
Pre-pregnancy BMI (kg/m2) 25.7 ± 5.1 24.9 ± 5.4
tion group) submitted both physical activity questionnaires
Family annual income ($) 48,602 ± 29,628 50,833 ± 23,792
First Nations (number/%) 22/25.0 19/17.4 at baseline and 2 months after enrolment, and the other
11 participants submitted one of the two questionnaires.
BMI, body mass index; First Nations, Canadian Aboriginals with First The baseline levels of physical activity index of participants
Nations status.
in the intervention group were not significantly different
Values are expressed in mean ± SD or number versus percentage in
the group.
from that in the control group. All participants in the
intervention group had self-reported home exercise for

Table 2. Daily intakes of nutrients of pregnant women in control and intervention groups

Daily intake Control (n = 53) Intervention (n = 53) P values

Baseline 2 months Baseline 2 months a b

Total calorie 2139 ± 580 2416 ± 848 2095 ± 661 1991 ± 458 0.71 0.002
Carbohydrate (g) 288 ± 76.2 324 ± 126 291 ± 83.4 283 ± 71.0 0.86 0.04
Protein (g) 90.2 ± 34.9 94.6 ± 34.4 86.2 ± 26.1 85.5 ± 21.0 0.50 0.11
Fat (g) 71.7 ± 27.3 86.8 ± 36.2 70.4 ± 36.6 62.5 ± 24.4 0.84 0.0001
Saturated fat (g) 25.1 ± 10.5 29.2 ± 13.2 21.1 ± 10.9 19.7 ± 9.2 0.06 0.00004
Cholesterol (mg) 270 ± 173 323 ± 220 219 ± 118 208 ± 104 0.08 0.001
Fibre (g) 22.2 ± 10.1 23.3 ± 11.8 25.2 ± 10.1 24.3 ± 9.9 0.13 0.63
Carbohydrate ratio (%) 53.3 ± 6.6 52.6 ± 7.7 55.1 ± 6.5 55.8 ± 5.8 0.14 0.02
Protein ratio (%) 16.6 ± 3.7 15.7 ± 3.3 16.4 ± 3.6 17.1 ± 3.7 0.85 0.04
Fat ratio (%) 30.3 ± 6.0 31.5 ± 7.5 28.6 ± 7.6 27.0 ± 6.5 0.20 0.001

a, Control versus Intervention at baseline; b, Control versus Intervention at 2 months after enrolment; Ratio, % of daily calorie from macro-
nutrient.
Values are expressed in mean ± SD and analysed using Student’s t test. Underlining indicates P values with statistical significance after Bonferroni
correction.

ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG 73
 Hui et al.

Table 3. Daily servings in food groups in pregnant women in control and intervention groups

Daily intake Control (n = 53) Intervention (n = 53) P values

Baseline 2 months Baseline 2 months a b

Starch 7.43 ± 3.63 7.41 ± 4.13 7.56 ± 4.55 7.11 ± 2.51 0.87 0.66
Very lean meat 1.46 ± 2.03 1.71 ± 2.28 2.02 ± 2.35 1.54 ± 1.67 0.19 0.66
Lean meat 1.78 ± 2.36 1.35 ± 1.71 1.53 ± 2.05 1.87 ± 2.11 0.55 0.17
Medium-fat meat 1.14 ± 1.44 1.69 ± 2.51 0.71 ± 0.87 0.76 ± 1.00 0.07 0.01
High-fat meat 1.14 ± 1.92 0.75 ± 1.09 0.68 ± 0.89 0.62 ± 0.95 0.12 0.50
Vegetables 2.86 ± 3.58 2.14 ± 2.38 2.59 ± 2.92 2.51 ± 2.47 0.67 0.43
Fruits 2.53 ± 2.12 2.66 ± 1.55 2.93 ± 2.38 2.95 ± 1.89 0.36 0.39
Skim milk 0.96 ± 1.30 0.87 ± 1.28 1.11 ± 1.20 1.43 ± 1.26 0.54 0.02
1–2% fat milk 0.75 ± 1.15 0.74 ± 1.15 0.29 ± 0.53 0.29 ± 0.75 0.01 0.02
Whole fat milk 0.12 ± 0.33 0.16 ± 0.52 0.09 ± 0.23 0.06 ± 1.15 0.60 0.15
Oil and fats 5.17 ± 3.63 5.51 ± 3.47 5.14 ± 5.08 4.08 ± 2.85 0.97 0.02

a, Control versus Intervention at baseline; b, Control versus Intervention at 2 months after enrolment; Oil and fats, dietary fats including butter,
cooking oil, dressing and cream.
Values are expressed in mean ± SD and analysed using Student’s t test (no significant difference in above variables was detected between control
and intervention groups after Bonferroni correction).

3–5 times/week between 20 and 36 weeks of gestation. No participants in the control group and two in the interven-
serious adverse effect of exercise (syncope, chest pain, tion group received caesarean sections. The prevalence of
shortness of breath, vaginal bleeding or miscarriage) was gestational diabetes mellitus or caesarean section between
detected in participants in the intervention group during the two groups was not significantly different in the sample
the study. At 2 months after the enrolment, the levels of size of the present study (Table 5).
physical activity index were significantly higher in the Weight gains of participants between the two groups
intervention group compared with baseline (P = 0.0001) or (control group: 15.2 ± 5.9 kg and intervention group:
that in the control group at a comparable pregnancy period 14.1 ± 6.0 kg) were not significantly different. According to
(P = 0.00002). No significant difference in the levels of the 2009 IOM guidelines,5 54.5% of participants in the
physical activity index was detected between the control control group (48 out of 88) had EGWG. The participants
and intervention groups at baseline (Table 4).
Gestational weeks, birth weights of offspring and the
prevalence of large-for-gestational-age infants were not sig- Table 5. Pregnancy outcomes of pregnant women in control and
intervention groups
nificantly different between the two groups. Three partici-
pants in the control group (3.3%) and two in the Variables Control Intervention P value
intervention group (1.8%) developed gestational diabetes (n = 88) (n = 102)
mellitus during the study. Participants with gestational dia-
betes mellitus received standard treatment following the Gestational weeks (week) 39.4 ± 1.5 39.6 ± 1.2 0.33
guidelines of the Canadian Diabetes Association.29 Three Gestational weight 15.2 ± 5.9 14.1 ± 6.0 0.28
gain (kg)
EGWG (2009 IOM 48 36 0.008
guidelines)
Table 4. Physical activity data Baby birthweight (g) 3,516 ± 530 3,490 ± 509 0.73
Large-for-gestational-age 15/17.0 12/11.8 0.41
Control Intervention P value
(n/%)
(n = 84) (n = 95)
Gestational diabetes (n/%) 3/3.4 2/2.0 0.87
Cesarean section (n/%) 3/3.4 2/2.0 0.87
Baseline 1.62 ± 0.64 1.51 ± 0.73 0.27
2 months after 1.45 ± 0.72 1.85 ± 0.44 0.00002 EGWG, excessive gestational weight gain; IOM, Institute of Medi-
enrolment cine.
Values are expressed in mean ± SD and analysed using Student’s
Values are expressed as mean ± SD and analysed using Student’s t test and chi-square assay. Underlining indicates P values with sta-
t test. Underlining indicates P values with statistical significance. tistical significance.

74 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG

IOM 2009
60
40 **
EGWG (%)
20
0 demonstrated that a lifestyle intervention significantly
Control Intervention
Figure 2. Effect of lifestyle intervention on excessive gestational
weight gain (EGWG) based on the 2009 Institute of Medicine (IOM)
guidelines. Control group (n = 88); intervention group (n = 102). Values
are expressed in percentages of the groups and analysed using the chi-
square test. **P < 0.01 versus the control group.
in the intervention group had significantly lower prevalence
of EGWG (35.3%, 36 out of 102) compared with that in
the control group (chi-square 7.10, 95% CI 0.47–0.90,
P = 0.008) (Figure 2).
Discussion
The present study demonstrated that a community-based
exercise and individualised dietary intervention during
pregnancy significantly reduced the prevalence of EGWG
according to the criteria of the IOM guidelines in urban-
living pregnant women, which was associated with
enhanced physical activity and healthier dietary habit com-
pared with the control group (Table 1).
A number of studies have been conducted to examine
the effect of lifestyle interventions on EGWG or gestational
weight gain, but the results were inconsistent. Borberg
et al.10 reported in 1980 that dietary advice reduced gesta-
tional weight gain in obese pregnant women in a nonran-
domised study. Olson et al.11 described that gestational
weight monitoring and the mail-in dietary education pro-
gramme reduced the risk of EGWG in low-income women,
but not in non-low-income pregnant women, compared
with historical records of a separate group of women in an
RCT.11 Claesson et al.,12 found that an exercise program
reduced gestational weight gain in pregnant women in a
nonrandomised study. Wolff et al.13 demonstrated that die-
tary counselling significantly reduced gestational weight
gain in obese pregnant women, but did not find significant
difference in EGWG between the control and intervention
groups in an RCT. Asbee et al.14 found that dietary and
lifestyle counselling reduced gestational weight gain, but
did not significantly reduce the rate of EGWG in pregnant
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
Exercise and dietary intervention on gestational weight gain
women compared with controls in an RCT. Mottola et al.15
recently reported that 80% of women receiving a nutrition
plus exercise programme during pregnancy did not have
EGWG in a single-arm study.15 Gray-Donald et al., Polley
et al. and Guelinekx et al.16–18 did not find significant
changes in EGWG or gestational weight gain induced by
dietary intervention in general or obese pregnant women in
RCT or nonrandomised study. The results of the present
study demonstrated that instructed exercise plus individua-
lised dietary counselling during pregnancy significantly
reduced the prevalence of EGWG in pregnant women in an
urban community. The present study for the first time
reduced EGWG in a whole intervention group, but not in
a sub-population only, of pregnant women in an RCT.
The 2009 IOM guidelines for EGWG adopted the World
Health Organization criteria for obesity and reduced up-
limits of normal weight gain for overweight or obese preg-
nant women.5 The prevalence of EGWG was relatively
higher in the control group in the present study according
to the 2009 IOM guidelines than that using the 1990 guide-
lines (54% versus 44%) as expected. The prevalence of
EGWG in the intervention group using the 2009 guidelines
was proportionally increased compared with the 1990
guidelines (35% with the 2009 guidelines and 27% with the
1990 guidelines). Significant decreases in EGWG were
detected in the intervention group compared with the con-
trol groups using either the 2009 or the 1990 IOM guide-
lines (P < 0.008 or P < 0.015). The findings suggested that
the lifestyle intervention applied in the present study effec-
tively reduced EGWG assessed using the previous or cur-
rent IOM guidelines. The application of the 2009 IOM
guidelines in the monitoring of gestational weight gain may
help to prevent EGWG in pregnant women who were pre-
viously considered as low risk for maternal obesity under
the 1990 IOM guidelines, which may further decrease the
prevalence of obesity in women at population level.
Food intake is critical for the management of gestational
weight gain. Results from previous studies suggest that
changes in gestational weight gain partially depended on
the intensity of dietary interventions.31,32 Computer-
assisted dietary interviews and individualised dietary coun-
selling were provided to each participant twice during a
pregnancy in the intervention group in the present study.
The results of the present study demonstrated that a
healthier dietary pattern characterised by higher ratio of
protein, carbohydrate and lower ratio of fat intake was
detected in participants in the intervention group com-
pared with that in the control group. Decreased intake in
total fat, saturated fat and cholesterol in participants in the
intervention groups may result from the reduced consump-
tion of medium-fat meat, 1–2% fat milk or dietary fats,
and the increased intake of skim milk (Table 3). Healthy
75
 Hui et al.
dietary habit probably contributes to the reduced preva-
lence of EGWG in participants in the intervention group in
the present study. The improvement in the prevalence of
EGWG in the pregnant women in the intervention group
may justify the intensity of the dietary intervention.
Multiple factors may influence the effect of exercise on
EGWG, including the types or intensity of lifestyle inter-
vention, monitoring, compliance, and socioeconomic and
environmental factors.33 Home exercise is the main stream
of the exercise programme recommended to pregnant
women in the present study. A specifically designed video
exercise instruction was provided to participants in the
intervention group in the present study to assist their home
exercise. The aerobic and strength exercises demonstrated
in the video instruction require minimal space or facilities,
making them feasible for city-living pregnant women in
various weather and socioeconomic conditions. Weekly
group exercise led by a professional trainer helped partici-
pants to acquire and validate knowledge and skills for exer-
cise during pregnancy. Group exercise may also help to
develop acceptance and adhesion of pregnant women to
the healthy lifestyle programme. The activity logbook and
follow-up visits helped the monitoring of physical activity
in participants. The levels of physical activity index were
significantly increased in participants in the intervention
group compared with that in the control group at
2 months after enrolment. This suggests that the majority
of participants in the intervention group followed the rec-
ommended exercise programme during the study. Increased
physical activity may also contribute to the reduced EGWG
in participants in the intervention group.
In conclusion, the present study demonstrated that a
community-based exercise and dietary intervention reduced
the prevalence of EGWG in urban-living pregnant women,
which was associated with increased physical activity and
improved dietary habit compared with the control group.
Making lifestyle changes could be physically and mentally
challenging. Pregnant women tend to be more motivated to
suggestions on lifestyle modification compared with other
stages of their lives, which is possibly because of their con-
cerns for the health of the fetus.34 A healthy lifestyle adopted
during pregnancy potentially exerts an extended impact on
the health of mothers and their children, which remains to
be examined through long-term follow-up study.
Disclosure of interests
The authors do not have any conflict of interest regarding
the content of results presented in the text.
Contribution to authorship
AH and LB were the main contributors for data and were
involved in the manuscript preparation; GXS, SL, PG, GS,
HD, ES, JM, RM and MM contributed to the design of the
76 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
project, data interpretation and manuscript preparation;
RM and SB provided advice on statistical analysis.
Details of ethics approval
The study protocol and the informed consent form were
approved by the Health Research Ethics Board in the
University of Manitoba (the study was first approved on
28 June 2004 and the most recent renewal was received
on 28 January 2011, Reference No. H2004-002).
Funding
The study was supported by operating grants from the
Lawson Foundation, the Canadian Institutes of Health
Research and the Public Health Agency of Canada.
Acknowledgements
The authors are grateful for help with recruitment from
the Healthy Start for Mom & Me Prenatal Program in
Winnipeg and the Winnipeg Regional Health Authority. j
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