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The Effectiveness of Regular Exercise Programs in the Prevention of

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 Volume 74, Number 5
OBSTETRICAL AND GYNECOLOGICAL SURVEY
Copyright © 2019 Wolters Kluwer Health,
Inc. All rights reserved. CME REVIEW ARTICLE
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of
15
36 AMA PRA Category 1 Credits™ can be earned in 2019. Instructions for how CME credits can be earned appear on the last page
of the Table of Contents.

The Effectiveness of Regular Exercise

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Programs in the Prevention of Gestational

Diabetes Mellitus—A Systematic Review
Beata Makaruk, PhD,* Anna Galczak-Kondraciuk, MSc,† Wanda Forczek, PhD,‡
Weronika Grantham, MA,† and Małgorzata Charmas, PhD§
*Lecturer, Faculty of Health Sciences and Tourism in Biała Podlaska, and †Lecturer, Faculty of Physical Education and Sport
in Biała Podlaska, Józef Piłsudski University of Physical Education, Warsaw, Poland; ‡Assistant Professor, Department of
Biomechanics, Faculty of Physical Education and Sport University of Physical Education, Kraków, Poland; and §Senior Lecturer,
Faculty of Physical Education and Sport in Biała Podlaska, Józef Piłsudski University of Physical Education, Warsaw, Poland

Importance: Physical activity is recognized as one of the most important tools in the management of gesta-
tional diabetes mellitus (GDM).
Objective: The aim of this review was to compare and analyze regular prenatal exercise programs and exam-
ine their effectiveness in the prevention of GDM.
Evidence Acquisition: The following databases were used: Academic Search Complete, Health Source–
Consumer Edition, Health Source–Nursing/Academic Edition, Master File Premier, MEDLINE, and SportDiscus
with full text. The inclusion criteria were as follows: a randomized study, regular training program throughout
pregnancy, and supervised by a prenatal activity specialist.
Results: The 10 articles selected for the review were divided into 2 groups. The first group comprised 2 studies
presenting successful interventions in the prevention of GDM, whereas the second group included 8 articles with
no statistically significant effects of the training programs in GDM prevention. Beginning an exercise program at
early stages of the pregnancy and high adherence were common features of the effective programs.
Conclusions: When designing and carrying out the program, the beginning of the intervention and adher-
ence should be considered. To increase adherence, the program should be attractive and it should meet the
participants' needs.
Relevance: This review might be used for identifying factors deciding whether an exercise program is an
effective intervention to prevent the development of GDM. Moreover, it might also prove useful in the prep-
aration of future guidelines for designing and implementing regular exercise programs effective in preventing
GDM in pregnant women by gynecologists, obstetricians, midwives, trainers, and prenatal specialists.
Target Audience: Obstetricians and gynecologists, family physicians.
Learning Objectives: After participating in this activity, physicians should be better able to compare and
analyze regular prenatal exercise programs; identify the most effective exercise programs in the prevention
of GDM; distinguish factors decisive in gravid participants' involvement in regular physical activity sessions;
and prepare for preparation of the future guidelines regarding regular exercise programs effective in
preventing GDM.

All authors, faculty, and staff in a position to control the content of
this CME activity and their spouses/life partners (if any) have disclosed
that they have no financial relationships with, or financial interests in,
any commercial organizations relevant to this educational activity.
This work has been prepared under the research project of the
Faculty of Physical Education and Sport in Biała Podlaska, Józef
Piłsudski University of Physical Education in Warsaw (DS. 285)
financed by the Ministry of Science and Higher Education in Poland.
Correspondence requests to: Weronika Grantham, MA, Akademicka
2 21–500 Biała Podlaska, Józef Piłsudski University of Physical
Education, Warsaw, Poland. E-mail: weronika.grantham@awf-bp.
edu.pl; weronika.grantham@gmail.com.

www.obgynsurvey.com | 303

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304 Obstetrical and Gynecological Survey
Gestational diabetes mellitus (GDM) is defined as glu-
cose intolerance that is first diagnosed during pregnancy1
with both short- and long-term health consequences for
the mother and her child. This condition affects 1% to
20% of all pregnant women.2 The prevalence of GDM
varies, depending on race and ethnicity as well as screen-
ing and diagnostic criteria in different countries.3–8
Abnormal insulin secretion resulting in hyperglycemia
in GDM can lead to serious health complications in a
mother.9,10 These complications may include an increased
risk of birth complications, postpartum hemorrhage, and
cesarean delivery.4,6 Complications for a neonate might
include macrosomia at birth,6,11,12 obesity, and type 2 di-
abetes in the future.13 Abnormal maternal glucose toler-
ance may also increase the risk of diabetic fetopathy.11
The FIGO (International Federation of Gynecology
and Obstetrics) recognized physical activity, next to nu-
trition and counseling, as the most important tool in the
treatment of GDM.14 Several studies revealed that reg-
ular physical activity is an integral part of noninvasive
management of GDM, as it improves glucose metabolism,
decreases insulin resistance, increases insulin sensitivity,15
helps to maintain normal glucose levels,16 and either
slows down or eliminates the need for insulin therapy.17–20
Present recommendations of the American College of
Obstetricians and Gynecologists21 advise a minimum
of 30 minutes of moderate exercise on most, if not all,
days, in the absence of any medical or obstetric compli-
cations. Physical activity for pregnant women is often
studied with the use of questionnaires22–24 or single
bouts of exercise and exercise tests.25–27 However, reg-
ular exercise programs together with their components
according to the FITT principle, that is, their frequency,
intensity, time duration, and types of exercises used,28,29
as well as their influence on GDM prevention, are yet to
be studied extensively.
Although previous systematic reviews have investi-
gated the correlations between physical activity and
GDM,30–33 they did not evaluate regular exercise pro-
grams and their role in preventing GDM. Therefore,
the aim of this study was to present the effectiveness
of several regular exercise programs during pregnancy
and to compare their components (frequency, intensity,
time duration, and type of exercises used). Moreover,
an additional aim was to identify potential key factors
for the exercise program to be effective in preventing
GDM, which, in turn, might help to develop exercise
program guidelines in the future.
METHODS
A systematic review was conducted to evaluate
whether the selected exercise programs reduced the
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
risks of GDM and to compare the effectiveness of
these interventions.
The PRISMA (Preferred Reporting Items for System-
atic reviews and Meta-Analyses) guidelines incorporat-
ing risks of bias and strength of recommendations were
used as a methodological template for this review.34
Eligibility Criteria
The inclusion criteria were as follows: (1) random-
ized controlled trials (RCTs) or control trials (CTs) in
which the only intervention used was a specifically de-
signed regular exercise programme supervised and led
by a pregnancy exercise specialist; (2) programs had
to be defined in terms of the type, intensity, duration,
and frequency of exercises used; (3) The participants
were healthy pregnant women, without contraindica-
tions to exercise, and without GDM diagnosis at the
baseline of the experiment; (4) trials had to report neo-
natal and maternal outcomes; and (5) The exercise pro-
gram had to be the only intervention used (studies
examining the influence of both an exercise program
and a dietary intervention, for instance, were excluded
from this review). The studies that did not fulfill all of
the above criteria were excluded from this review (Fig. 1).
Search Strategy
The search strategies were designed to identify records
of RCTs or CTs of regular exercise programs for healthy
gravid women. Two independent researchers conducted
literature searches between July 2 and 6, 2018 using the
following databases: EBSCOhost–Academic Search
Complete, Health Source–Consumer Edition, Health
Source-Nursing/Academic Edition, Master File Premier,
MEDLINE, and SportDiscus with full text. The searches
were restricted to the articles published after 2008 in the
English language. The following search terms were used
in different combinations, depending on the database:
pregnant OR pregnancy OR gestation OR gestational
OR gestate OR maternity OR maternal OR prenatal,
AND exercise OR physical OR activity OR fitness OR
training, AND program OR programme OR regular,
AND diabetes OR glucose OR insulin, AND random*
OR trial.
With Academic Search Complete, Health Source–
Consumer Edition, and Health Source–Nursing/Academic
Edition (search through EBSCO platform and thesau-
rus; restrictions: journals, no type restrictions), the re-
sults revealed 179 records. Exact duplicates were
removed from the results. With Master File Premier,
the results revealed 15 records. With Medline, the results
revealed 264 records. With SportDiscus (search through
 Effectiveness of Regular Exercise Programs • CME Review Article 305

FIG. 1. PRISMA flow chart.

the thesaurus; restrictions: scientific articles, no type re- Study Selection

strictions), the results revealed 26 records.
Types of Studies
Any RCTs or CTs that assessed any physical activity
programs for pregnant women and their correlation
with GDM were included. Other forms of research were
excluded from this review.
Although selecting the articles to be included in this
review, titles and abstracts were initially read, followed
by the full texts. Studies that did not fulfill the inclusion
criteria were excluded. The research team members re-
viewed the articles independently. When a disagree-
ment arose, the team members found a resolution
together. After limiting the search with inclusion
criteria, a total of 484 articles remained for the analysis.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

306 Obstetrical and Gynecological Survey

The duplicates were removed, and the further reading
of the titles and abstracts was carried out by 3 indepen-
dent researchers to assess eligibility and methodology
of the articles. This process allowed for the identifica-
tion of 31 full text articles, with disagreements solved
by the whole research team. Of those 31 articles poten-
tially addressing the subject, 10 articles were selected
for the final analysis (Tables 1 and 2).
RESULTS
We identified 10 studies from 5 countries, including
Norway,35,36 Spain,37–41 Brazil,42 the Netherlands (a
study43 with its protocol),44 and China.45 Of these, only
2 programs were found to be effective in reducing the
incidence of GDM.41,45 The remaining 8 programs
did not present statistically significant influence on
the development of GDM.35–40,42,43 For each of the
identified programs, information was provided regard-
ing its duration, frequency, intensity, and the types of
exercises used.
The number of participants in both exercise and con-
trol groups, intensity monitoring methods, and the dura-
tion of the interventions (together with the initial and
terminal weeks of starting the intervention) are presented
in Table 1.
In the majority of the included training programs,
each session consisted of 3 parts: warm-up, main part,
and cool-down (see Table 2). The warm-up part lasted
for 5 to 12 minutes.37–45 There were exceptions, how-
ever. The program by Garnæs et al35 was divided into
2 parts: endurance training (35 minutes) and resistance
training (25 minutes). The authors did not describe
the aformentioned parts of the session as a warm-up,
main part, or cool-down. In the program of Stafne
et al,36 on the other hand, the duration of the first part
of the session was 30 to 35 minutes.
In 9 of 10 programs,36–45 warm-up was performed
with moderate intensity, defined as 9 to 14 points on
the Borg rating scale of perceived exertion.46 Only in
the program by Garnæs et al,35 the first part of the ses-
sion was given 12 to 15 points on the Borg scale.
In the majority of the analyzed programs, warm-up ses-
sions included similar training elements, such as walking
and light stretching exercises or aerobics.36–42,45 In sev-
eral programs, training simulators, for example, station-
ary bicycles43,44 or treadmills,35 were used.
The duration of the main part of the exercise ses-
sion was between 20 and 35 minutes in the following
programs.35–38,40 In the remaining programs, the main
part was longer: the program by Oostdam et al,43,44
40 minutes; by Cordero et al,41 42 minutes; by Barakat
et al,39 40 minutes; by da Silva et al,42 50 minutes; and

TABLE 1
Selected Programs and Their Characteristics
Participants Initial/Terminal Total Training
Intensity and Weeks of the Sessions/Frequency—
Exercise Control Measurement Training Program The Number of
Author Group Group Methods (Gestational Weeks) Sessions Weekly Duration, wk
1 Barakat et al (2012) n = 40 n = 43 HR monitor (Accurex 6–9/38 90–99/3 30–33
Plus, Polar Electro OY)
<70% HRmax
2 Oostdam et al (2012) n = 49 n = 52 13–14 on the Borg scale 15/delivery (40) 50/2 25
ActiTrainer monitor
3 Stafne et al (2012) n = 429 n = 426 13–14 on the Borg scale 18–22/32–36 42–54/3 14–18
4 Barakat et al (2013) n = 210 n = 218 10–12 on the Borg scale 10–12/38–39 81–90/3 27–30
HR monitor (Accurex
Plus, Polar Electro OY)
5 Cordero et al (2015) n = 101 n = 156 12–14 on the Borg scale 10–14/40 78–90/3 26–30
HR monitor (Accurex
Plus, Polar Electro OY)
6 Barakat et al (2016) n = 382 n = 383 12–14 on the Borg scale 9–11/38–39 84–87/3 28–30
HR monitor (Accurex
Plus, Polar Electro OY)
7 Garnæs et al (2016) n = 46 n = 45 12–15 on the Borg scale 12–18/34–37/ 57–75/3 19–25
delivery (40)
8 Barakat et al (2014) n = 137 n = 114 12–14 on the Borg scale 9–13/39–40 71–93/3 29–30
9 da Silva et al (2017) n = 213 n = 426 12–14 on the Borg scale 16/36 60/3 20
10 Wang et al (2017) n = 150 n = 150 9–16 on the Borg scale <12/36–37 72–75/3 24–25
55%–65% HRmax
HR indicates heart rate.

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 TABLE 2
Training Sessions' Components: Effects of the Programs
Training Session Parameters Effects of the Program
in the Exercise Group
Warm-up Main Part Cool-down
(as Compared With the
Control Group)
Duration, Types of Duration, Types of Duration, Types of
Author min Intensity Exercises Used min Intensity Exercises Used min Intensity Exercises Used Mother
1 Barakat et al 7–8 ≤70% Walking, stretching 25 ≤70% Low-resistance 7–8 ≤70% Walking, relaxation, No significant effects on
(2012) HRmax HRmax exercises in HRmax exercises, pelvic GDM prevalence
the gym hall floor exercises
7–8 ≤70% 25 ≤70% Resistance exercises, 7–8 ≤70% Swimming, No significant effects on
HRmax HRmax swimming, walking HRmax walking in weight gain
in the swimming pool the pool
2 Oostdam et al 5–10 13–14 sB Low-intensity 40 13–14 sB Aerobic (cycle 5–10 13–14 sB Cool-down No significant effects on
(2012) activity, eg, ergometers, treadmills, exercises GDM prevalence
slow cycling cross trainers, and No significant effects
stationary rowing on weight gain
machines) and
strength exercises
(free weights)
3 Stafne et al 30–35 13–14 sB Low-impact 20–25 13–14 sB Strength exercises (body 5–10 13–14 sB Light stretching, No significant effects on
(2012) aerobics weight as resistance): body GDM prevalence
upper and lower limbs, awareness, No data about weight
back extensors, deep breathing, gain
abdominal muscles, and relaxation
and pelvic floor muscles exercises
4 Barakat et al 10–12 10–12 sB Walking and 25–30 10–12 sB Moderate-intensity 10–12 10–12 sB Walking, light No significant effects on
(2013) light static resistance exercises static stretching, GDM prevalence
stretching of and aerobic dance relaxation, and Reduced weight gain
most muscle once a week pelvic floor during pregnancy
groups exercises (P < 001)
5 Cordero et al 10 12–14 sB On land: 42 12–14 sB On land: 8 66–76 bpm Flexibility work, Reduced incidence of
(2015) Psychophysical Low-impact relaxation and GDM (P = 0.009)

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preparation: aerobics, fitness, visualization Reduced weight gain
displacements, dance, cardio boxing, exercises, during pregnancy
locomotive games, rhythm and percussion, self- and (P = 0.04)
and light stretches resistance exercises, pair massage
Effectiveness of Regular Exercise Programs • CME Review Article

pelvic floor exercises

10 12–14 sB In water: 30 12–14 sB Swimming laps 10 12–14 sB Stretching,
displacements, (except butterfly relaxation, and
smooth body style), step climbs, breathing
movements lunges, and strength
exercises in the water
(Continued on next page)
307
 308
TABLE 2. (Continued)

Training Session Parameters Effects of the Program

in the Exercise Group
Warm-up Main Part Cool-down
(as Compared With the
Control Group)
Duration, Types of Duration, Types of Duration, Types of
Author min Intensity Exercises Used min Intensity Exercises Used min Intensity Exercises Used Mother
6 Barakat et al 10–12 12–14 sB Walking and 25–30 12–14 sB Moderate-resistance 10–12 12–14 sB Walking, light No significant effects on
(2016) light static exercises, aerobic static stretching, GDM prevalence
stretching of exercise, and relaxation, and Reduced weight gain
most muscle aerobic dance pelvic floor during pregnancy
groups exercises (P = 0.01)
7 Garnæs et al 35 12–15 sB Treadmill walking 20 12–15 sB Resistance training No significant effects on
(2016) 80% HRmax or jogging for large muscle GDM prevalence
(endurance groups, squats, No significant effects
training) push-ups, on weight gain
diagonal lifts
on all fours, and
oblique abdominal
crunches, plank,
pelvic floor exercises
8 Barakat et al 5 12–13 sB Walking, static 30 55%–60% Toning and joint 5 12–14 sB Cool-down No significant effects on
(2014) stretching HRmax mobilization exercises, GDM prevalence
aerobic dance,
and specific
exercises for
major muscle groups
10 55%–60% Balancing exercises
HRmax
10 55%–60% Pelvic floor exercises
Obstetrical and Gynecological Survey

HRmax
9 da Silva et al 5 12–14 sB Warm-up 50 12–14 sB Aerobic activities 5 12–14 sB Stretching No significant effects
(2017) exercises (tread-mill or exercises on the GDM

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

stationary bike) prevalence
and strength training No significant effects
(dumbbells, on weight gain
machines, or
elastic bands)
 Effectiveness of Regular Exercise Programs • CME Review Article 309

by Wang et al,45 30 to 60 minutes (progressive, individ-

(P < 0.001) in week 25
Reduced weight gain
ually prescribed).
and at the end of
Reduced incidence
of GDM P < 0.01

In the main (second) part of each session, Stafne

pregnancy et al36 applied strength exercises, using body weight
as resistance (for both upper and lower limbs), as well
as exercises involving deep abdominal muscles and pel-
vic floor muscles. Each exercise was performed 10
times, in the sets of 3, with the intensity of 13 to 14
points on the Borg scale.
The program by Garnæs et al35 included resistance
12–14 sB Cool-down

exercises, which maintained the intensity of 12 to 15

of easy
cycling

points on the Borg scale. They included exercises for

large muscle groups (such as squats, push-ups, diagonal
lifts on all fours, and oblique abdominal crunches).
They were performed in 3 sets of 10 repetitions for each
exercise, with a 1-minute rest between the sets.
In addition to 2 sessions in a gym hall, Cordero et al41
introduced 1 session of aquatic activity. The main part
of the land activity consisted of low-impact aerobic ex-
5

ercises (such as aerobics, fitness, modern dance, Latin

dance, cardio boxing, rhythm and percussion), body
toning exercises using 2-kg dumbbells (involving the
intervals, duration
cycling (different
intensities of the

individual ability)

majority of muscle groups except for abdominal exer-

30–45/60 12–14 sB Interval stationary

of the cycling
progressively

cises, 2 series of 15 repetitions were completed for each

according to
increased

muscle group), exercises in a supine position (lasting

only up to 2 minutes), and pelvic floor muscle exercises
(initiated with the phase of identification and aware-
ness, and then gradually increasing in the volume of
15–16 sB
10–12 sB
12–14 sB
13–15 sB

work). The water-based sessions were structured as fol-

lows: displacements while swimming (except butterfly
style) and strength exercises. The intensity of both
water- and land-based training was maintained at the
level of 12 to 14 points on the Borg scale.
Barakat et al37 divided their program into land and wa-
ter activities. The main part of both land and aquatic ses-
sions lasted for 25 minutes. The land sessions consisted
Low-intensity

of toning, very light resistance, as well as joint mobiliza-

stationary
cycling

tion exercises, engaging major muscle groups. They

were performed in 1 set of 10 to 12 repetitions each (ab-
dominal curls, 3-kg barbells or low-to-medium). One set
of aerobic dance was also applied every 2 weeks. Water
sessions included, for example, swimming laps, jogging,
55%–65%
HRmax
9–11 sB

walking in the pool, stretching, and strength exercises in

water using major muscle groups. Aquatic tools were
also used.
In another experiment by Barakat et al,38 the main
5

component of the program included toning, resistance,

and joint mobilization exercises (shoulder shrugs and
rotations, arm elevations, leg lateral elevations, pelvic
Wang et al
(2017)

tilts and rocks), which engaged major muscle groups

(pectoral, dorsal, shoulder, upper and lower limb mus-
cles). They were performed in 1 set of 10 to 12 repetitions.
10

Barbells (3 kg) and Therabands were also used. In

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

310 Obstetrical and Gynecological Survey
addition, 1 session a week also included low impact
aerobic dance. The intensity of the main part was be-
tween 10 and 12 points on the Borg scale.
Then, Barakat et al39 divided a 40-minute long main
part of the session into sections: 30 minutes of toning
and joint mobilization exercises, aerobic dance, and
exercises for major muscle groups (legs, buttocks,
and abdomen), 10 minutes of balancing exercises, and
10 minutes of pelvic floor muscle exercises. The inten-
sity was between 12 and 13 points on the Borg scale.
In the study by Barakat et al,40 the main exercise ses-
sion lasting for 25 to 30 minutes included resistance ex-
ercises performed for major muscle groups (pectoral,
back, shoulder, upper and lower limb muscles), aerobic
exercises, aerobic dance, and flexibility exercises. One
set of 10 to 12 repetitions was performed with the use
of 2 kg/exercise barbells and Therabands. The intensity
was between 12 and 14 points on the Borg scale.
In the research by Oostdam et al,43,44 the main part of
the session consisted of 1 or 2 individualized aerobic ex-
ercises (cycle ergometers, treadmills, cross-trainers, and
rowing machines) and 4 to 6 strength exercises. The in-
tensity was between 13 and 14 points on the Borg scale.
In the case of Wang et al,45 the main part consisted
of stationary cycling for 25 minutes (after a 5-minute
warm-up). It began with 5 minutes of continuous
moderate-intensity cycling (12–14 on the Borg scale).
Next, interval cycling was performed consisting of
30 seconds of rapid pedaling (sprints, higher-intensity
efforts) every 2 minutes with 3 to 5 repetitions (15 to
16 on the Borg scale). This was followed by 5 minutes
of continuous cycling at a low to moderate intensity
(10–12 on the Borg scale), before beginning another
period of interval cycling. During this interval phase,
continuous moderate-intensity cycling at the level of
12 to 14 on the Borg scale was combined with 1-minute
periods of pedaling against increased resistance (hill
climb) at the intensity of 13 to 15 on the Borg scale. These
periods alternated every 2 minutes for 3 repeats. In addi-
tion, the exercise duration was individually modified ac-
cording to the participant's ability, increasing to 45 to
60 minutes, by adding 5-minute intervals or continuous
moderate-intensity cycling.
Da Silva et al,42 on the other hand, divided their entire
program into 3 stages, with different durations of the
main part. The intensity of each stage was maintained be-
tween 12 and 14 points on the Borg scale. The first stage
(week 1 to 4) included a 50-minute main part, consisting
of 15-minute aerobic exercises and 35-minute strength
training or floor exercises (sets of 3, 12 repetitions each).
In the second stage (weeks 5 to 10), a 50-minute main
part was divided into 20-minute aerobic exercises and
30-minute strength training or floor exercises (sets of 3,
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
10 repetitions each). The main part of the third stage
(weeks 11 to 16) was divided into 25-minute aerobic ex-
ercises and 25-minute strength training or floor exercises
(sets of 3, 8 repetitions each).
In the majority of the articles, the cool-down part of
their training programs lasted between 5 and 12 minutes
and generally consisted of stretching, breathing, and re-
laxation exercises, as well as pelvic floor exercises.36–44
Only Garnæs et al35 did not describe the cool-down
part in the sessions. In the study of Wang et al,45 the
cool-down period was slightly different, including
slow cycling.
DISCUSSION
The aim of this work was to compare selected regular
training programs and to assess their influence on the
prevention of GDM.
In the selected studies, when discussing the safety of
prenatal physical activity as well as its influence on a
mother and her fetus, the authors referred to the guide-
lines of the American College of Obstetricians and Gy-
necologists.21 In recent years, the number of studies
showing that physical activity is safe for the mother
and the fetus has been growing steadily.47–49 However,
there is still a need to explore the influence of regular
exercise programs on GDM prevention. A question
arose as to what components of a training program (fre-
quency, intensity, time duration, and types of exercises
used) are decisive in proving an intervention successful
in preventing GDM.
The analyzed documents, apart from the significant
components of a training program such as its duration,
intensity, frequency, and types of exercises used, also
presented other important factors that could be decisive
in gravid participants' involvement in such regular
physical activity sessions (see below).
Training Programs Effective in the
Prevention of GDM
Cordero et al41 and Wang et al45 presented 2 programs
that proved successful in the prevention of GDM. The
components that these programs had in common, were
as follows: (1) the start of the intervention, as they both
started at early stages of the pregnancy (weeks 10–14);
(2) long duration of the program, with a high number
of completed exercise sessions (72–90 sessions); (3)
high adherence to the exercise program; and (4) both
the same frequency (sessions thrice weekly) and the du-
ration of a single session of up to 60 minutes.
The program by Cordero et al41 was also character-
ized by a holistic approach to physical activity, which
differentiated it from other programs. Not only did the
 Effectiveness of Regular Exercise Programs • CME Review Article
authors describe the types of exercises used in much de-
tail (which were varied and included both land and wa-
ter exercises), but also emphasized the importance of
psychological preparation and body awareness exer-
cises. Moreover, the researchers showed the importance
of respecting the group dynamics by the prenatal exer-
cise specialist and ensuring the possibility of choosing
the activities by the participants as well as increasing
the attractiveness of the program by the use of specific
music types and various props, which could influence
the adherence to the exercise plan.
The study by Wang et al,45 on the other hand, pre-
sented the only program that included the type of exer-
cise different from exercises applied in other studies,
that is, interval cycling. According to the authors, it
was selected because of its attractiveness to the partici-
pants, based upon a study in which it was found that in-
terval cycling brings enjoyment to pregnant women.50
It was also related to the fact that brief slightly higher-
intensity intervals were applied compared with other
moderate-intensity programs.
Training Programs Not Effective in the
Prevention of GDM
The aforementioned 8 remaining studies did not prove
to be effective in the reduction of GDM.35–40,42–44
In the programs by Garnæs et al,35 Stafne et al,36 da
Silva et al,42 and Oostdam et al,43,44 the common factors
were as follows: (1) the start of the intervention, as they
started at later stages of the pregnancy (weeks 12–22);
(2) shorter duration of the program, with a lower number
of completed exercise sessions (42–75 sessions); and (3)
low adherence to the exercise program.
In the remaining programs,37–40 it could be noted that
despite an early start of the intervention (weeks 6–13), a
high number of completed exercise sessions (81–90),
and high adherence to the exercise regime, they did
not prove to reduce the incidence of GDM significantly.
However, they revealed a positive influence on other
GDM-related pregnancy outcomes, such as fewer cases
of GDM in the exercise group (but not statistically sig-
nificant),37 fewer cases of macrosomia and Caesarean
delivery in the exercise group, which are often related
to GDM,38 better control of excessive maternal weight
gain,39 and 2 times lower risk of developing GDM in
the exercise group (but not statistically significant).40
CONCLUSIONS
Further studies and intervention trials are needed to es-
tablish a correlation between the volume of physical ac-
tivity and gestational diabetes. Further research should
focus on the optimal amount and intensity of physical
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
311
activity that would be effective in the reduction of
GDM occurrence. Obviously, a higher level of physical
activity is related to other healthy habits including health-
ier diets. Although it was not a subject of our review, fu-
ture studies should also consider maternal characteristics
such as body mass index, diet, or age as these parameters
might significantly affect study results.
In conclusion, our study revealed a very limited num-
ber of articles (2 of 10) describing training programs ef-
fective in the prevention of GDM. Due to their common
features, we found that several factors may enhance the
effectiveness of any future prevention programs reduc-
ing the risk of GDM. The beginning of the intervention
should take place at early pregnancy stages, that is, in
the first trimester. This will ensure a longer duration
of the program and more sessions completed by the par-
ticipants. An individual approach to each participant in
terms of the types of exercises used as well as their inten-
sity affects the expected influence of an exercise program
on reducing the risk of GDM. Adherence also seems to be
of vital importance when designing and realizing the pro-
gram. To increase adherence, the program should be at-
tractive to the participants and should meet their needs.
Besides, additional elements involved in exercise sessions
such as a variety of exercise types (both on land and in
water) or the use of music and props might be encourag-
ing for pregnant women to comply with the program.
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