Review

The role of exercise in reducing the risks

of gestational diabetes mellitus
Sarah A Hopkins1 & Raul Artal*1
Gestational diabetes mellitus (GDM) is the most common medical complication of pregnancy and
is particularly prevalent among obese women. Both GDM and obesity confer significant comorbidities
for the mother and her offspring, including perinatal complications, excessive fetal growth and
long-term risks for maternal and offspring obesity and diabetes. Exercise has well-documented
health benefits and reduces peripheral insulin resistance in nonpregnant individuals, a major risk
factor for the development of diabetes. Observational studies conducted in large population-based
cohorts suggest that women who are the most active before pregnancy are less insulin-resistant
in late pregnancy and have lower rates of GDM. This article will review the evidence supporting a
role for exercise in the prevention of GDM, the management of glycemic control in women with
established GDM, and the reduction of GDM-associated maternal and offspring health
consequences. Wherever possible, the discussion will focus on studies carried out on obese women.
However, there are many areas where strong evidence is lacking in obese populations, and it may
be inferred from similar studies performed in normal weight pregnant women.

Gestational diabetes mellitus & maternal
obesity
Gestational diabetes mellitus (GDM) is the most
common medical complication of pregnancy and
is defined as glucose intolerance or high blood glu-
cose concentrations (hyperglycemia), with onset
or first recognition during pregnancy. The preva-
lence of GDM varies from 1 to 20% and is rising
worldwide in line with increasing trends of mater-
nal obesity and Type 2 diabetes mellitus (T2DM)
[1,2] . The incidence of GDM rises disproportion-
ately with increasing obesity. A recent meta-ana­
lysis of 20 population-based studies estimated that
the risk of developing GDM is 2.14-fold higher
for overweight (BMI: 25.0–29.9), 3.56-fold higher
for obese (BMI: ≥30.0) and 8.56-fold higher for
severely obese women (BMI: ≥40.0) compared
with normal weight pregnant women (BMI:
<25.0) [3] . Obesity and GDM have been recog-
nized as independent risk factors for a number
of adverse maternal and fetal outcomes, includ-
ing diabetes, hypertension, operative deliveries,
macrosomia and neonatal complications [4–6] .
More recently, we have begun to understand that
maternal obesity and GDM are also associated
with significant lifelong consequences for the next
generation [7,8] . As obesity and GDM share many
of the same health consequences, obese women
and their offspring are at a greater risk for adverse
outcomes (Figure 1) .
Pathophysiology of GDM
During normal pregnancy, metabolic changes
promote adequate nutritional availability to
support the demands of fetal growth. A pro-
gressive and marked insulin resistance develops
in maternal skeletal muscle, beginning around
mid-pregnancy and progressing during the third
trimester to levels that approximate the insulin
resistance seen in T2DM [9] . Hormones and
adipo­k ines secreted from the placenta, includ-
ing TNF-a, placental lactogen, placental growth
hormone, cortisol and progesterone, are probable
triggers of insulin resistance in pregnancy, owing
to rapid reversal at delivery [10] .
Normal pregnancy is characterized by increased
insulin secretion from pancreatic b cells to com- 1
Department of Obstetrics/Gynecology
& Women’s Health, Saint Louis
pensate for peripheral insulin resistance. This University, St Louis, MO 63103, USA
can be displayed as a hyperbolic relationship *Author for correspondence:
Tel.: +1 314 781 4772 ext. 1
between insulin sensitivity (the inverse of insulin Fax: +1 314 781 1330
resistance) and insulin secretion from pancreatic artalr@slu.edu
b cells (Figure 2) . The development of GDM occurs
when a mother does not secrete enough insulin
in order to be able to meet the metabolic stress
of peripheral insulin resistance. The reciprocal
relation­ship is preserved in most GDM women,
but occurs at much lower level of insulin secretion. Keywords
That is, women with GDM secrete 40–70% less • exercise • fetal growth
insulin for any degree of insulin resistance [11,12] . • gestational diabetes mellitus
Therefore, pregnancy-induced insulin resistance • glycemic control • insulin
resistance • insulin sensitivity
may unmask the b-cell dysfunction characteristic
• obesity • perinatal
of GDM [13] . complications • physical activity
Serial assessments of insulin sensitivity start- • Type 2 diabetes mellitus
ing before pregnancy have also demonstrated
slightly greater insulin resistance persisting into
the third trimester in women with GDM com-
pared with normal pregnant women [11] . This
resistance applies to both the action of insulin part of

10.2217/WHE.13.52 © 2013 Future Medicine Ltd Women's Health (2013) 9(6), 569–581 ISSN 1745-5057 569
Review – Hopkins & Artal
Mother Pregnancy
↑ Pre-eclampsia
Offspring Congenital
– CNS
– Cardiac
Fetal programming
– ↑ LGA
– ↑ Macrosomia
– Increased fat mass
Figure 1. Short- and long-term health consequences of gestational diabetes mellitus for
mothers and their offspring.
GDM: Gestational diabetes mellitus; LGA: Large for gestational age.
to stimulate glucose disposal [12] , as well as to
suppress hepatic glucose production [12,14] and
circulating fatty acid concentrations [14] . In vitro
studies of adipose and skeletal muscle tissue from
women with GDM have revealed abnormalities
in the insulin signaling pathway [15,16] , abnormal
subcellular localization of GLUT-4 transport-
ers [17] and decreased expression of peroxisome
proliferator-activated receptor-g [15] , all of which
could contribute to reduced insulin-mediated
glucose transport.
Biological plausibility of exercise in GDM
prevention & treatment
Similarities in the underlying pathophysiol-
ogy of GDM and T2DM would suggest that
effective strategies for the prevention of T2DM
in nonpregnant individuals might also be suc-
cessful in the prevention of GDM. The role
of regular exercise in preventing or delaying
the onset of T2DM through improvements in
glucose metabolism has been well documented
[18–21] . Intervention studies have demonstrated
improvements in whole-body insulin-stimulated
glucose uptake following exercise training in both
insulin-resistant individuals [22] and Type 2 dia-
betics [23] . Regular physical activity can also lead
to improvements in insulin sensitivity through an
increase in fat-free mass, the predominant site of
insulin-dependent glucose disposal [24] . It is likely
570 www.futuremedicine.com
Labor Postpartum and beyond
↑ Induction of labor ↑ Recurrent GDM
↑ Cesarean section ↑ Type 2 diabetes
↑ Operative deliveries
↑ Labor complications
Neonatal complications Long-term outcome
Prematurity ↑ Obesity
Perinatal asphyxia ↑ Type 1 diabetes
Respiratory distress ↑ Type 2 diabetes
↑ Metabolic syndrome
Metabolic complications
(hypoglycemia and
hypocalcemia)
Polycythemia and
hyperviscosity
Low iron stores
Hyperbilirubinemia
Cardiomyopathy
that the mechanisms responsible for alterations in
insulin sensitivity and glucose uptake in response
to exercise in nonpregnant populations may also
be observed in pregnant women.
Pregnancy as an optimal window for
intervention
Pregnancy offers a unique opportunity for easy
and frequent access to medical care and is con-
sidered an ideal time for medical and lifestyle
interventions. Patients may be motivated to
make changes that could optimize their preg-
nancy outcome. Physical activity provides an
accessible and affordable outlet by which the
predisposing factors for the development of obe-
sity and future diabetes in both the mother and
offspring may be modified during the course of
pregnancy. Furthermore, a behavioral change
adopted in pregnancy may persist after delivery
and help prevent, or delay, the development of
T2DM and other long-term complications.
Can exercise prevent GDM?
A number of observational studies have demon-
strated that women who report regular physical
activity both before and during early pregnancy
have a lower risk of developing GDM [25–28] .
These studies have used a variety of validated
physical activity questionnaires to examine self-
reported exercise behaviors among a range of
future science group
 The role of exercise in reducing the risks of gestational diabetes mellitus –
population-based study cohorts. After reviewing
data from eight large studies, a recent meta-analy-
sis reported a 55% reduction in the risk of GDM
for women in the highest quantiles of prepreg-
nancy physical activity compared with the low-
est (odds ratio [OR]: 0.45; 95% CI: 0.28–0.75;
p = 0.002) [29] . Regular physical activity in early
pregnancy was also associated with a reduction
in GDM risk, however, the impact appears to be
somewhat reduced compared with pregravid exer-
cise (OR: 0.76; 95% CI: 0.70–0.83; p < 0.001).
These findings may reflect a dose–response rela-
tionship between intensity or volume of physical
activity and GDM risk, as has previously been
described with similar health outcomes in the
nonpregnant population [30] . While the optimal
volume of physical activity for GDM prevention
is unclear, current observational data support the
public health recommendation of accumulat-
ing 150 min of moderate-intensity activity each
week to confer significant reduction in the risk
of developing diabetes [19] .
The beneficial association between physical
activity and lower GDM risk may, at least, par-
tially reflect the underlying relationship between
an active lifestyle and leaner body composition
[25,26] . Alterations in GDM risk in observational
studies have been adjusted for prepregnancy BMI
and, therefore, reflect an independent effect of
regular physical activity on GDM risk. How-
ever, few studies have examined whether the
effect of physical activity on GDM risk varies
by prepregnancy body size. There are some sug-
gestions that the protective effect of exercise
may be stronger in women with a higher BMI,
who have a higher risk for developing GDM. In
1997, a study published by Dye et al. utilized a
population-based birth registry in central New
York State between October 1995 and July 1996,
with 12,800 women included in the analysis [31] .
When stratified by prepregnancy BMI, low levels
of physical activity was associated with increased
rates of GDM among women with a BMI greater
than 33 kg/m2 (OR: 1.9; 95% CI: 1.2–3.1). By
contrast, in the lower BMI categories, women
who reported regular exercise had a slightly
higher incidence of GDM than nonexercisers. By
contrast, a study by Oken et al. found that the
protective effect of prepregnancy physical activity
for the development of abnormal glucose toler-
ance was only significant in women with a BMI
less than 25 kg/m2 [26] , while other studies have
found no interaction between prepregnancy BMI
and the association between physical activity
and GDM risk [25,27] . These conflicting findings
may be related to the type and timing of physical
future science group Women's Health (2013) 9(6)
Review
activity questionnaires. In the study by Dye et al.,
physical activity was assessed after delivery. It is
possible that women in the lower BMI catego-
ries (<33 kg/m2) who developed GDM reported
physical activity that was initiated after their
GDM diagnosis, and were therefore misclassi-
fied. These findings may also reflect an interac-
tion between the timing of exercise and underly-
ing differences in the pathophysiology of GDM
between lean and obese women. Regular exercise
during the prenatal period may have more impact
on the prevention of GDM in obese women, in
whom the development of GDM may rely more
upon the contribution of obesity-associated insu-
lin resistance, in addition to an underlying b-cell
defect. By contrast, the development of GDM in
lean women may reflect a greater reliance on a
b-cell defect that may limit the ability of exercise
to prevent the onset of GDM. Additional stud-
ies to examine these interactions are warranted
before targeted recommendations can be made
on the basis of prepregnancy size.
3000
Control: baseline
Exercise: baseline
Control: late gestation
2000
Exercise: late gestation
AIR (mU/l)
1000
0
0 5 10 15 20 25
Si (10-4/min µU/ml)
Figure 2. Changes in insulin sensitivity and insulin secretion in normal
pregnancy, with or without regular aerobic exercise. A hyperbolic-like
relationship between Si­ (the inverse of insulin resistance) and AIR in exercise and
control participants at baseline and in late pregnancy (for further results from this
study, please refer to [32] ). Both groups showed a reduction in Si­­ and increase in AIR
with advancing gestation, resulting in a shift to the left along a hypothetically
‘normal’ hyperbolic relationship (dashed line). The significant overlap between
groups provides visual confirmation that exercise training did not have an effect on
overall glucose metabolism. Increased insulin secretion in late gestation is a normal
physiological response to maintain glucose uptake in the presence of markedly
reduced Si. In individuals with normal b-cell function, a hyperbolic curve best
characterizes the relationship between Si­ and AIR required to maintain
normoglycemia. In women with gestational diabetes mellitus, the hyperbolic
relationship is generally preserved but with an entire leftward shift of the curve.
Consequently, women with gestational diabetes mellitus secrete much less insulin
for any degree of insulin resistance.
AIR: Insulin secretion; Si­: Insulin sensitivity.
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Review – Hopkins & Artal

Investigators have recently turned their atten-
tion towards examining whether a prescribed
exercise program initiated in pregnancy can
reduce the risk of developing GDM. Seven ran-
domized controlled trials, published between
2009 and 2012, are summarized in Table 1 [32–38] .
In contrast to observational data, a recent sum-
mary of five of these studies concluded that they
could find no clear effect on preventing GDM
[39] . There are a number of potential reasons to
explain the lack of significant findings from the
randomized controlled trials published to date.
First, there have only been a limited number of
trials conducted in a small number of women.
With the exception of two recently published tri-
als [34,38] , all of the other trials have included less
than 100 patients. Therefore, it is likely that a
lack of statistical power and the failure to control
for significant confounding factors, such as diet
and gestational weight gain, may have contrib-
uted to nonsignificant findings in both individual
trials and the published meta-analysis. Power
calculations to determine adequate sample size
were reported in only one of the five included
studies [34] . In this study, the authors estimated
that 381 patients were required in each group.
This calculation was based upon having statis-
tical power to detect a predicted reduction in
GDM incidence from 9% in the control group
to 4% in the exercise intervention group. Stud-
ies in high-risk populations may not require as
many participants, particularly if the incidence
of GDM in the control group is higher and the
effect of exercise training may be more protective.

Table 1. Randomized controlled trials of exercise interventions in pregnancy reporting on gestational diabetes
mellitus prevention or exercise-induced alterations in glycemic control.
Study Subjects Intervention GDM incidence (%) Insulin sensitivity/glycemic Ref.
(year) (n) control
Low-risk population (women with a range of BMIs, with mean BMI <30.0 kg/m2 )
Hopkins Exercise: 47 16 weeks starting at week 20 GA Intervention: 0 No effect on pregnancy-associated [32]
et al. Control: 37 Home-based stationary cycling Control: 0 alterations in maternal insulin
(2010) 5 × 40 min/week at 65% VO2max (NS) sensitivity
Adherence (total sessions): 75%
Barakat Exercise: 40 ~30–35 weeks starting at weeks 6–9 Intervention: 0 Reduced 1‑h blood glucose after 50-g [33]
et al. Control: 43 Land and water aerobics Control: 7 glucose challenge (103.8 vs
(2012) 3 × 35–45 min/week at <70% HRmax (NS) 236.9 mg/dl; p < 0.001)
Adherence (total sessions): 85%
Stafne Exercise: 357 ~12 weeks starting at weeks 18–22 GA Intervention: 7 No differences between groups in [34]
et al. Control: 327 Aerobic, strength and balance Control: 6 HOMA-IR after adjustment for
(2012) 1 × 60 min supervised/week (NS) decreased insulin resistance in
>2 × 45 unsupervised/week intervention group at baseline (2.63
Adherence (>3 days/week): 55% vs 2.78; p = 0.10†)
Barakat Exercise: 255 ~26–30 weeks starting at weeks 10–12 Intervention: 19.5 Reduced 2‑h blood glucose (116.8 vs [38]
et al. Control: 255 Aerobic, strength and flexibility Control: 28 123.9 mg/dl; p = 0.012)
(2013) 3 × 50–55 min/week at <70% HRmax (p = 0.04) ‡
Adherence (total sessions): >95%
High-risk population (overweight or obese women and/or other risk factors for insulin resistance)
Ong Exercise: 6 10 weeks starting at week 18 GA Not reported Increased 1‑ and 2‑h blood glucose in [35]
et al. Control: 6 Home-based stationary cycling control, but not in exercise subjects
(2009) 3 × 35–50 min/week at 55–65% HRmax and late pregnancy (p = 0.072)
Adherence (total sessions): 94%
Callaway Exercise: 22 ≥24 weeks starting at week 12 GA Intervention: 23 No differences between groups in [36]
et al. Control: 19 Home-based exercise program Control: 16 HOMA-IR at 28 weeks GA
(2010) EE goal of >900 kcal/week (NS) (2.89 vs 3.53; p = 0.11)
Adherence (achieved goal):
73% at week 28 GA; 53% at week 36 GA
Oostdam Exercise: 40 17 weeks starting at week 15 GA Intervention: 14.6 No differences between groups in [37]
et al. Control: 45 2 × 60 min supervised/week Control: 21.6 HOMA-IR at 32 weeks GA
(2012) Adherence (50% sessions): 16% (NS) (0.052 vs 0.045; p > 0.05)
†
10% of control group exercised >3 days/week.
‡
Not significant after adjustment for maternal age and body weight.
EE: Energy expenditure; GA: Gestational age; GDM: Gestational diabetes mellitus; HOMA-IR: Homeostasis model assessment – estimated insulin resistance;
HRmax: Maximal heart rate; NS: Not significant; VO2max: Maximal aerobic capacity.

572 www.futuremedicine.com future science group

 The role of exercise in reducing the risks of gestational diabetes mellitus –
Noncompliance to an exercise program and
low-intensity exercise volumes have also been
limitations of some of the trials. Stafne et al.
randomized 855 Norwegian women (mean
BMI: 25 kg/m2) to a standard exercise program
or routine care control for a 12 week duration,
beginning at 18–22 weeks gestation [34] . The
intervention program included a weekly super-
vised 60-min exercise session, containing a com-
bination of aerobic, strength and balance exer-
cises. Subjects were also encouraged to complete
at least two 45-min unsupervised sessions each
week. Exercise adherence, defined as completion
of at least three exercise sessions per week, was
achieved by only 55% of women in the interven-
tion group and 10% of the control group. On
average, women in the exercise group exercised
on 2.0 days per week compared with the 0.7 days
per week in the control group. No differences in
GDM risk were observed in this study; GDM was
diagnosed in 7% of women in the intervention
group and 6% in the control. Similar findings
were reported in the study by Oostdam et al.,
who randomized 85 Dutch women (mean BMI:
33.5 kg/m2) who were classified as high risk for
GDM to a supervised exercise program or control
from 15 to 32 weeks gestation [37] . Their exercise
program included two 60-min supervised exercise
sessions each week. However, only eight of 53
(16%) intervention individuals who started the
exercise program completed at least 50% of the
required sessions. Furthermore, when physical
activity was assessed using accelerometry at three
follow-ups during pregnancy, the exercise group
spent fewer minutes performing physical activity
per week than controls. GDM was reported in
14.6% of intervention individuals and 21.6% of
controls (p = 0.65). In both of these studies, the
lack of an exercise effect on GDM risk may be,
at least, partially due to the low level of exercise
reported in the intervention group. Commonly
reported barriers to exercise have included a lack
of motivation, physical limitations, and a lack of
resources and time. Future studies should con-
tinue to address perceived barriers to maintain-
ing regular physical activity in obese pregnant
women, and to evaluate optimal exercise prescrip-
tion and program design to maximize compliance
in order to achieve desired health benefits.
Exercise & glycemic control in pregnancy
Maintaining an active lifestyle before pregnancy
has been associated with reduced insulin resis-
tance and better glucose tolerance in late preg-
nancy and may, therefore, protect against the
development of GDM. Retnakaran et al. assessed
future science group Women's Health (2013) 9(6)
Review
glucose tolerance, insulin sensitivity and b-cell
function in 851 (predominantly normal weight)
women who underwent a glucose challenge test
and 3-h oral glucose tolerance test in late preg-
nancy [40] . Glucose tolerance status, ranging from
normal glycemic control to GDM, improved
across increasing quartiles of self-reported physi-
cal activity in the 12 months prior to pregnancy
(p = 0.02). Furthermore, in multiple linear regres-
sion analysis, vigorous exercise prior to pregnancy
was a significant independent predictor of insu-
lin sensitivity in late pregnancy. However, it is
unclear whether these late pregnancy enhance-
ments in glycemic control were due to the effects
of increased pregravid exercise per se, or whether
women who were the most physically active in
the pregravid period maintained their exercise
regimens into their pregnancy.
Few studies have examined the impact of
regular exercise on changes in insulin sensitiv-
ity during pregnancy, particularly in overweight
or obese women. We have recently reported that
15 weeks of moderate-intensity cycling training
in nondiabetic women had no impact upon the
pregnancy-induced changes in insulin sensitivity
in late pregnancy [32] . We randomized a cohort
of healthy nulliparous pregnant women, with a
range of mid-pregnancy BMIs, primarily within
the normal weight range (BMI: 18–32 kg/m2),
to a home-based stationary cycling program or
nonexercise control for the remainder of their
pregnancy. After a ramping period to establish
a regular exercise routine, women in the exer-
cise group were asked to maintain five 40-min
sessions of moderate-intensity exercise per week
at approximately 65% of their predicted aerobic
capacity or maximal aerobic capacity. Our obser-
vations may indicate that the chronic changes
in insulin sensitivity seen in nonpregnant indi-
viduals in response to exercise training may be
over­shadowed in normal weight pregnant women
by the persistent regulation of insulin sensitivity
required to achieve optimal fetal growth (­ Figure 2) .
Future studies should assess the frequency and
intensity of exercise training required to impact
insulin sensitivity in overweight and obese moth-
ers in light of their increased insulin resistance
and elevated risks for GDM. It is likely that
chronic adaptations to regular exercise in preg-
nancy, particularly if accompanied by restricted
gestational weight gain, may be different to
n­ormal weight women.
During normal pregnancy, it appears that the
repeated short-term responses to each exercise
session may play the greatest role in influenc-
ing glycemic control in late pregnancy. Previous
573
Review – Hopkins & Artal
studies have described a significant reduction in
glucose and insulin concentrations for a period
of time following a single exercise session in late
pregnancy [41,42] . In addition, elevated insulin
sensitivity has been demonstrated at least 30 min
following moderate-intensity cycling exercise in
late gestation [43] . With persistent regular exer-
cise, these acute responses may help to regulate
appropriate glycemic control in late gestation
for nondiabetic pregnant women and, therefore,
prevent the development of GDM. However, the
majority of these studies have so far been car-
ried out in normal weight women. Future studies
should focus on the acute and repeated alterations
in glucose and insulin concentrations ­following
exercise in overweight and obese women.
Can exercise play a role in the
management of GDM?
The standard of care for GDM management is
to optimize glycemic control while providing
adequate energy and nutrient requirements for
the developing fetus. Current management of
GDM includes caloric restriction medical nutri-
tion therapy, which is the primary treatment
therapy for 30–90% of women diagnosed with
GDM [44] . Daily self-monitoring of fasting and
postprandial capillary blood glucose is instituted
to maintain euglycemic control. Excessive fetal
growth and fetal distress are primary concerns in
GDM, therefore, frequent fetal assessments with
biophysical profiles and ultrasound assessments
of growth are recommended. Failure to achieve
normo­glycemia leads to the use of antidiabetic
agents. The addition of regular exercise to medi-
cal nutrition therapy may, as in T2DM, delay or
prevent the administration of subcutaneous insu-
lin [19] . Considering that GDM generally resolves
spontaneously at delivery, this may be particularly
important for pregnant women who are reluc-
tant to start a relatively short duration of insulin
injections.
A number of professional societies endorse the
use of exercise as an adjunctive therapy for women
with GDM. The American College of Obstetri-
cians and Gynecologists have recommended that
“women with GDM who lead an active lifestyle
should be encouraged to continue a program of
exercise approved for pregnancy” [45] . Similarly,
the American Diabetes Association have sug-
gested that “women without medical or obstet-
rical contraindications be encouraged to start or
continue a program of moderate exercise as part of
treatment for GDM” [46] . Despite these endorse-
ments, only a handful of well-controlled studies
have examined the role of regular exercise, used in
574 www.futuremedicine.com
combination with a controlled diet, in the man-
agement of GDM. Characteristics of these studies
are displayed in Table 2. The majority of trials have
enrolled small numbers of GDM patients in the
third trimester and incorporated physical activity
programs of predominantly nonweight-bearing
exercise, performed at a low-to-moderate intensity
for approximately 20–45 min, 3 days per week.
The most frequently assessed outcomes include
the requirement for insulin therapy, insulin dos-
age and parameters of glycemic control, including
fasting glucose and insulin concentrations, post-
prandial glucose measurements and glycosylated
hemoglobin.
Artal et al. randomized a group of GDM
patients to 45 min of stationary cycling at 50%
of aerobic capacity or an insulin and diet regimen
[47] . The exercise group showed a good compli-
ance to the program, with over 90% of sessions
completed. Participants in both groups achieved
normal glycemic control after 1 week and were
able to maintain euglycemia until delivery. After
8 weeks of treatment, there were no significant
differences in glycemic control between the
groups. The results of this study expanded on
earlier work by Bung et al., who introduced, for
the first time, exercise as an adjunctive therapy in
pregnancy for patients with GDM who required
antidiabetic agents to manage hyperglycemia.
Women in the exercise group achieved similar
glucose control to those patients on insulin ther-
apy and resulted in a reduction in the number of
women whose GDM needed to be managed by
antidiabetic agents [48] . Pregnancy outcomes were
similar between groups in both studies suggest-
ing that an exercise regimen can be offered as a
safe and efficient t­herapeutic option to patients
with GDM.
When considering the use of antidiabetic
agents and glycemic control, the results of sub-
sequent studies have been conflicting and may
reflect the varied contributions of confounding
factors, such as variation between studies in the
dose of prescribed exercise (duration, frequency
and intensity), low compliance to the exercise
program and a lack of statistical power to iden-
tify significant differences owing to small sam-
ple sizes. In the most recent Cochrane database
systems review, Ceysens et al. summarized four
randomized controlled trials and found no sig-
nificant impact of exercise training on the use of
insulin therapy (n = 80 patients; risk ratio: 0.98;
95% CI: 0.51–1.87). The authors concluded that
“Further trials, with larger sample size, involving
women with GDM … are needed to evaluate this
intervention” [49] .
future science group
 The role of exercise in reducing the risks of gestational diabetes mellitus – Review

Table 2. Studies examining the use of exercise training in pregnancy for gestational diabetes mellitus
treatment.
Study (year), Subjects Int. Control Results Ref.
study type
Jovanovic- Int.: 10 6-week diet plus exercise Diet only Reduced fasting glucose (70 vs 88 mg/dl; [74]
Peterson et al. Control: 9 Arm ergometry p < 0.001)
(1989), (BMI: n/a) Three sessions of 20 min/week at Reduced 1‑h glucose (106 vs 188 mg/dl;
randomized trial 70% HRmax p < 0.001)
Reduced HbA1c (4.2 vs 4.7%; p < 0.001)
Bung et al. Int.: 17 6+ week diet plus exercise Diet plus No effect on glycemic control vs insulin group [48]
(1991), Control: 17 Stationary cycling insulin Reduced requirement for insulin
randomized trial (BMI: n/a) Three sessions of 45 min/week
at 50% VO2max
Avery et al. Int.: 15 >6-week diet plus exercise Diet only No effect on requirement for insulin (27 vs [75]
(1997), Control: 14 Stationary cycling plus 14%; p = 0.65)
randomized trial (BMI: 26.9) home-based exercise No effect on 2‑h glucose (86 vs 96 mg/dl;
Three to four sessions of p = 0.1)
30 min/week at 70% HRmax
50% supervised sessions
Brankston et al. Int.: 16 6-week diet plus exercise No exercise No effect on requirement for insulin (43.8 vs [50]
(2004), Control: 16 Resistance training 56.3%; p = 0.48)
randomized trial (BMI: 27.0) Three sessions per week Increased latency to onset of insulin therapy
Two-to-three circuits of eight (3.7 vs 1.1 weeks; p < 0.05)
exercises, 15–20 repetitions of Reduced insulin dose (0.22 vs 0.48 U/kg;
each exercise p < 0.05)
Reduced fasting capillary blood glucose (4.7 vs
5.1 mmol/l; p = 0.07)
Reduced postprandial blood glucose (6.0 vs
6.4 mmol/l; p < 0.05)
Artal et al. Int.: 39 >6-week diet plus exercise Diet only Reduced GWG (diet 0.1 vs diet plus exercise [47]
(2007), Control: 57 Walking plus stationary cycling 0.3 kg/week)
prospective (BMI: 34.2) Five-to-six sessions of Reduced macrosomia (gained weight 17% vs
nonrandomized 30 min/week at 60% VO2max did not gain weight 4%)
trial Reduced requirement for insulin (diet 39% vs
diet plus exercise 35%)
Davenport et al. Int.: 10 >6-week diet plus exercise Diet only No effect on requirement for insulin (70% in [51]
(2008), Control: 20 Low-intensity walking both groups)
case–control (BMI: 32.8) Three-to-four sessions of Reduced insulin dose (0.16 vs 0.5 U/kg;
study 25–40 min/week at 30% VO2peak p < 0.05)
Reduced fasting and postprandial capillary
blood glucose (p < 0.05)
de Barros et al. Int.: 32 Diet plus exercise Diet only ↓Requirement for insulin (21.9 vs 56.3%; [52]
(2010), Control: 32 Resistance training p = 0.005)
randomized trial (BMI: 25.4) Three sessions/week ↓Time spent within target glucose range
Two-to-three circuits of eight (63 vs 41%; p = 0.006)
exercises, 15 repetitions of each
exercise
GWG: Gestational weight gain; HbA1c: Glycosylated hemoglobin; HRmax: Maximal heart rate; Int.: Intervention; n/a: Not available; VO2max: Maximal aerobic capacity;
VO2peak: Peak aerobic capacity.

Recent studies have focused on the impact
of exercise training on daily capillary blood
glucose concentrations in GDM patients, with
encouraging results [50–52] . This is an impor-
tant outcome as several studies have found that
controlling capillary glucose concentrations
reduces the risk of fetal overgrowth; a major
complication of GDM [53] . Davenport et al.
enrolled ten overweight women with GDM,
matched by age, prepregnancy BMI and insu-
lin use, with 20 control GDM patients [51] . The
intervention group completed at least 6 weeks
of low-intensity walking performed on average
3.6 ± 0.8-times per week for 20–45 min. In the
week prior to delivery, participants in the exer-
cise group demonstrated reduced capillary blood

future science group Women's Health (2013) 9(6) 575

Review – Hopkins & Artal
glucose concentrations, despite lower insulin
requirements compared with control subjects.
Two other studies, both employing resistance
exercises, have also demonstrated improve-
ments in glycemic control [50,52] . de Barros et al.
recently published the results of a trial involving
64 patients diagnosed with GDM between 24
and 34 weeks gestation. Subjects were random-
ized to circuit-type resistance exercise or con-
trol for the remainder of their pregnancy [52] .
Glycemic control was defined as the percentage
of weeks where at least 80% of weekly capil-
lary blood glucose measurements were below
target limits established by the American Dia-
betes Association [13] . During the study period,
women in the intervention group spent 63%
of the time within the proposed glucose target
range compared with 41% in the control group
(p = 0.006). The resistance exercise program was
also effective in significantly reducing the num-
ber of women who required insulin treatment.
These findings strongly suggest that resistance
exercise may be an effective alternative to aerobic
exercise in the management of GDM. Resistance
training has previously been shown to be effec-
tive in improving insulin sensitivity and glyce-
mic control in individuals with abnormal glu-
cose tolerance and T2DM [54,55] . Importantly,
for some women, resistance exercises may be per-
formed more comfortably than aerobic exercise
in late pregnancy and could assist with posture
and reduce general discomforts of pregnancy.
Can exercise reduce the health
consequences of GDM?
Short- & long-term maternal health
consequences of GDM
Women with diabetes in pregnancy are at
increased risk for developing hypertensive dis-
orders and pre-eclampsia [56] , and are more likely
to require an induction of labor or delivery by
cesarian section [56,57] . Regular exercise in preg-
nancy has been shown to be protective against
the development of pre-eclampsia in non­diabetic
pregnancies [58] , and may provide similar pro-
tection for women with GDM. In addition, a
recently published study examining the role
of moderate-intensity exercise in reducing the
comorbidities of GDM has reported a one-third
reduction in the risk of undergoing acute or elec-
tive cesarean delivery for women who developed
GDM (exercise OR: 1.30; 95% CI: 0.44–3.84
vs control OR: 1.99; 95% CI: 0.98–4.06) [38] .
Taken together, these findings suggest that regu-
lar prenatal exercise may reduce the risk of preg-
nancy complications in women with GDM [59] .
576 www.futuremedicine.com
The development of GDM is a significant risk
factor for future diabetes. Up to 50% of women
will have a recurrence of GDM in a subsequent
pregnancy [60] , while 40–60% will exhibit fur-
ther deterioration of carbohydrate metabolism and
develop T2DM within 10 years [61] . Therefore, if
regular prenatal exercise confers protection against
the development of GDM, it may also help to pre-
vent the future development of T2DM, particu-
larly if women resume exercise postpartum and
remain physically active. The Diabetes Prevention
Program has been one of the most comprehensive
multicenter clinical trials examining the impact of
lifestyle intervention on progression to diabetes in
individuals with impaired glucose tolerance [20] . In
a subset of their cohort, intensive lifestyle inter-
vention, including a program of weight restriction
and regular physical activity in women with prior
GDM, resulted in a 53% reduction in the develop-
ment of T2DM [62] , supporting a role for exercise
in the prevention of future diabetes in women
diagnosed with GDM.
Offspring health consequences of GDM
GDM is associated with elevated risk for deliv-
ering a large-for-gestational-age or macrosomic
infant, defined as greater than the 90th percentile
for expected birth weight for gestational age or
a birth weight greater than 4000 g, respectively
[5,6] . As a consequence of their size, offspring of
GDM mothers are more likely to suffer from sig-
nificant birth trauma, such as shoulder dystocia,
perinatal asphyxia, bone fractures and nerve palsy
[5,63] . Large fetal size at birth also poses additional
maternal risks, with elevated risk of cesarean sec-
tion, cephalopelvic disproportion, uterine rupture
and perineal lacerations [64] .
In obese women, with or without GDM, reg-
ular exercise in pregnancy may ameliorate peri­
pheral insulin resistance, reducing oversupply of
nutrients to the fetus and thereby providing pro-
tection against excessive fetal growth. Few stud-
ies have examined the impact of exercise in preg-
nancy on fetal growth, specifically in overweight
and obese mothers. Some studies have reported
success in restricting excessive weight gain, but
this has not been accompanied by a change in
mean offspring birth weight [47,65] . However,
regular exercise in pregnancy may specifically
protect against delivering a large baby at birth. In
population-based studies, women who maintain
regular physical activity into the third trimester of
pregnancy demonstrate a lower incidence of deliv-
ering an large-for-gestational-age infant [66,67] . A
reduction in GDM-associated macrosomia has
also been reported in women who took part in
future science group
 The role of exercise in reducing the risks of gestational diabetes mellitus –
a moderate-intensity exercise program in preg-
nancy (exercise OR: 1.76; 95% CI: 0.04–78.90
vs control OR: 4.22; 95% CI: 1.35–13.19) [38] . In
overweight and obese women, participation in a
structured diet and exercise intervention has been
shown to elicit a small reduction in the risk of
delivering a macrosomic infant [47,65] . However,
the reduction in macrosomia in obese women was
contingent on the restriction of weight gain [47] ,
suggesting that exercise may not be successful at
preventing macrosomia in obese women without
prevention of excessive gestational weight gain.
There is now growing evidence that the con-
sequences of exposure to a diabetic intrauterine
environment also extend into postnatal life. Off-
spring of mothers with GDM are more likely to
be overweight or obese in childhood and develop
Type 1 or 2 diabetes [8,68,69] . Regular exercise
may help to ameliorate the future obesity risk
for the offspring of GDM women by ‘normal-
izing’ fetal growth and reducing the incidence of
macrosomia at birth. There is some evidence in
nondiabetic women that prenatal exercise may
be associated with better body composition in
childhood [70] . However, no studies have exam-
ined the impact of exercise in pregnancy on
postnatal growth and development in the off-
spring of obese women, with or without GDM.
Future studies examining the role of exercise in
the management of GDM would greatly benefit
from postnatal follow-up of diabetic offspring
to determine whether exercise during preg-
nancy in women at risk for, or diagnosed with,
GDM ameliorates potential long-term health
c­onsequences for their offspring.
Conclusion
Based on the current evidence, maintaining a
physically active lifestyle prior to and during
early pregnancy protects against the develop-
ment of GDM. However, the effectiveness of
beginning an exercise program in the second
half of pregnancy, and the optimal prescription
and quantification of appropriate individual-
ized exercise programs should be the focus of
continued research. Many professional societ-
ies advocate the use of exercise as an adjunctive
therapy for women with GDM. Recent studies
have indicated that an exercise program initiated
after diagnosis of GDM may reduce the require-
ment for insulin therapy and improve glycemic
control in late pregnancy. These benefits may be
long-lasting, as adequate glucose control in preg-
nancy is associated with reduced risk of perinatal
complications and lower incidence of macrosomia
or a large-for-gestational-age infant. In turn, this
future science group Women's Health (2013) 9(6)
Review
provides a potential role for prenatal exercise in
reducing the obesity risks for the next generation.
Future perspective
The global epidemic of obesity continues to accel-
erate at an alarming rate. Nearly three in every
five US women of reproductive age (20–44 years)
are now classified as overweight or obese [71] . By
the end of the next decade, some experts suggest
that the majority of women (perhaps 70%) may
be classified as obese [72] . With increasing obesity,
the rate of GDM diagnosis is also expected to rise.
Of concern, the impact of GDM extends well
beyond the current pregnancy and may impact
the long-term health of not just the mother, but
also future generations. The offspring of GDM
women are themselves at risk for obesity and the
development of subsequent diabetes. For female
offspring, metabolic alterations, such as insulin
resistance occurring as a result of developmental
programming in utero, may have implications for
their future pregnancies. They may enter their
first pregnancy with a greater level of insulin
resistance with greater risk for GDM and deliv-
ering large offspring. Hence, obesity and GDM
may be central to a perpetuating cycle of meta-
bolic and growth abnormalities that ­continue to
drive the ­worldwide obesity epidemic.
The prevention of adverse perinatal outcomes,
and protection against the long-term health risks
of GDM for both the mother and offspring,
through adequate glycemic control and preven-
tion of excessive gestational weight gain, should
be the highest priority in the coming years. How-
ever, in order to guide policy and evidence-based
clinical practice, research efforts must continue
to produce well-designed, adequately powered
studies to determine the precise roles of exercise
in reducing the risks of GDM. Current gaps in
the literature and future research directions are
summarized below:
• Continued research efforts are required to
determine the minimum and/or optimal vol-
ume and type of exercise required for the pre-
vention of GDM. Future work should con-
tinue to examine the contrasting benefits of
aerobic, resistance or a combination of
­modalities on GDM risk;
• Studies examining the impact of beginning an
exercise program in overweight or obese women
during pregnancy have consistently suffered
from poor compliance to the prescribed exercise
program. There is an urgent need to determine
successful strategies to improve adherence to
regular exercise and to overcome perceived
577
Review – Hopkins & Artal

barriers to exercise in the pregnant population.
There are encouraging recent reports that an
individually tailored, motivationally matched
exercise intervention may be feasible and
­efficacious in pregnancy [73] ;­
• There remain large gaps in our understanding
of the physiological impact of regular exercise
in pregnancy on maternal insulin sensitivity.
In particular, the time course of the acute
exercise-induced effects on insulin sensitivity

Executive summary
Gestational diabetes mellitus & maternal obesity
• Gestational diabetes mellitus (GDM) is the most common medical complication of pregnancy, affecting 1–20% of pregnancies.
• Obese women have a 3.6-fold higher risk for developing GDM compared with normal weight women.
• Both maternal obesity and GDM confer significant short- and long-term health risks for both the mother and her offspring.
Pathophysiology of GDM
• The hormonal changes of normal pregnancy are associated with progressive and marked insulin resistance in maternal tissues in the
second half of pregnancy.
• The physiological insulin resistance of pregnancy may unmask underlying b-cell dysfunction in women who develop GDM.
Biological plausibility of exercise in GDM prevention & treatment
• Similarities in the pathophysiology of GDM and Type 2 diabetes mellitus (T2DM) would suggest that effective strategies for the
prevention of T2DM might also be successful in the prevention of GDM.
• The role of regular exercise in preventing or delaying the onset of T2DM is primarily attributed to exercise-associated improvements in
peripheral insulin sensitivity.
• Exercise leads to acute insulin-independent effects on muscle glucose uptake, which last for a short period of time following exercise
and increased tissue sensitivity to insulin that persists as long as regular exercise is continued.
Pregnancy as an optimal window for intervention
• The pregnancy period is an opportune time to counsel obese women to increase their physical activity as they have regular contact
with health professionals and are motivated to make changes that could benefit both their own health and the future health of
their baby.
Can exercise prevent GDM?
• Women who report the highest levels of physical activity in the 12 months before pregnancy have a 55% lower risk of developing
GDM than the least active women.
• Physical activity in early pregnancy is also protective against GDM. Women in the highest quantiles of physical activity reduce their risk
for GDM by 24%.
• To date, there have only been a few randomized controlled exercise intervention trials to prevent GDM, particularly in obese women.
• The effectiveness of exercise interventions in pregnancy to prevent GDM has been limited by noncompliance. Commonly reported
barriers to exercise have included a lack of motivation, physical limitations and lack of resources and time.
Exercise & glycemic control in pregnancy
• Regular exercise in the 12 months prior to pregnancy has been associated with reduced insulin resistance and improved glucose
tolerance in late pregnancy.
• In nondiabetic, low-risk pregnant women, exercise training has not been shown to impact the normal pregnancy alterations in insulin
sensitivity.
• The repeated transient increase in glucose uptake associated with each exercise session may provide a sufficient stimulus to achieve
appropriate glycemic control and prevent the development of GDM.
Can exercise play a role in the management of GDM?
• Exercise is endorsed and recommended by the American College of Obstetricians and Gynecologists, the American Diabetes
Association and the American College of Sports Medicine as an adjunctive therapy for women with GDM.
• Randomized controlled trials in women with GDM have focused on whether regular adding an exercise program to dietary
management can improve overall glycemic control as indicated by daily capillary blood glucose concentrations. Controlling capillary
glucose concentrations reduces the risk of macrosomia; a major complication of GDM.
Can exercise reduce the health consequences of GDM?
• Within the larger Diabetes Prevention Program study, women with previous GDM who were randomized to intensive lifestyle
intervention, including a program of weight restriction and regular physical activity, demonstrated a 53% reduction in the development
of T2DM.
• There is evidence that women who continue regular exercise into late pregnancy, particularly in conjunction with limited weight gain,
have a reduced risk of delivering a large for gestational age infant.
• Regular exercise may ameliorate the risk of future childhood diabetes in the offspring of mothers with GDM by reducing adverse
developmental programming.

578 www.futuremedicine.com future science group

 The role of exercise in reducing the risks of gestational diabetes mellitus – Review

following a bout of exercise in pregnancy may risk of obesity and metabolic dysfunction in the
differ from that observed in nonpregnant indi- offspring during childhood and a­ dolescence;
viduals. This information may be important in
• Finally, it is clear from the current literature
the design of studies to investigate the potential
that the prepregnancy period plays a signifi-
chronic adaptations to maternal insulin sensi-
cant role in determining both GDM risk and
tivity with exercise training in pregnancy.
maternal insulin sensitivity in late pregnancy.
There is also a paucity of research examining
Therefore, continued emphasis should be
exercise-related alterations in insulin sensitivity
placed upon maintaining physical activity
in overweight and obese pregnant women
across the lifespan for continued health and
using precise and reliable ­techniques;
to benefit the health of future generations.
• Similar to GDM prevention, future studies
should seek to define optimal training character­
Financial & competing interests disclosure
istics for the use of exercise as an adjunctive
The authors have no relevant affiliations or financial
therapy in late pregnancy to achieve adequate
involvement with any organization or entity with a finan-
glycemic control in women d ­ iagnosed with
cial interest in or financial conflict with the subject matter
GDM;
or materials discussed in the manuscript. This includes
• Future exercise intervention studies in GDM employment, consultancies, honoraria, stock ownership or
women will greatly benefit from long-term post- options, expert testimony, grants or patents received or
natal follow-up of the offspring of exercise and ­pending, or royalties.
control participants to determine whether pre- No writing assistance was utilized in the production of
natal exercise in GDM women may reduce the this manuscript.

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