Obesity and Physical Activity During Pregnancy and Postpartum: Evidence, Guidelines, and Recommendations - The Early Postpartum Period - Obesity During Pregnancy in Clinical Practice

Obesity During Pregnancy in Clinical Practice

9. Obesity and Physical Activity During Pregnancy and Postpartum: Evidence, Guidelines, and Recommendations

Danielle Symons Downs¹, Kelly R. Evenson² and Lisa Chasan-Taber³

(1)

Departments of Kinesiology and OB/GYN, College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA

(2)

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

(3)

Department of Public Health, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA

Danielle Symons Downs

Email: dsd11@psu.edu

Abstract

This chapter provides clinicians and researchers with an overview of the physical activity and pregnancy/postpartum literature to promote physical activity, understand the determinants and outcomes of physical activity participation among pregnant and postpartum women, recognize the scant literature pertaining to overweight and obese women, and inform next steps in practice, prevention, and research. We discuss (a) physical activity guidelines; (b) prevalence rates of physical activity during pregnancy and postpartum; (c) determinants, health outcomes, and critical gaps in the literature of pre- and postnatal physical activity; and (d) recommendations for research and practice to facilitate physical activity initiation, motivation, and maintenance across the transition to motherhood.

Keywords

ExerciseRecommendationsPre- and postnatal periodsHealth

Those who think they have not time for bodily exercise will sooner or later have to find time for illness. Edward Stanley, Earl of Derby, 1873

Key Points

· Most pregnant and postpartum women fail to meet national guidelines for physical activity which may elevate their risk for morbidity and contribute to the intergenerational impact of obesity on their offspring.

· Several key determinants of physical activity behavior in pregnancy and postpartum have been identified (e.g., education, income, social/emotional support, attitude/beliefs, environmental influences); however, these determinants are not well understood among overweight and obese women and therefore warrant future research attention.

· Prenatal physical activity may reduce negative health outcomes such as gestational diabetes mellitus, preeclampsia, excessive gestational weight gain, and postpartum weight retention; however, currently there is no “gold standard” intervention for effectively promoting pre- and postnatal physical activity to consistently reduce these adverse outcomes across women of diverse socioeconomic and racial backgrounds.

· Future attention in research and practice is needed to promote and disseminate the physical activity guidelines in clinical care, better understand how to motivate overweight/obese pregnant and postpartum women to engage in physical activity, and identify practical, safe, and effective physical activity intervention strategies.

Statement of the Problem

The majority of pregnant and postpartum women do not achieve the minimum physical activity recommendations from either the United States (US) government [1] or the American College of Obstetricians and Gynecologists (ACOG, later “College” became “Congress”); [2] this is of concern, given that physical activity during pregnancy is associated with improved weight control and maintenance of fitness as well as possible reduced risk of gestational diabetes and improved psychological functioning [2–4]. Women who are active in postpartum tend to have less anxiety, depression, lactation-induced bone loss, and urinary stress incontinence, as well as improved cardiovascular fitness and psychological well-being [1, 4–6].

Physical Activity Guidelines

In 1949, the US Children’s Bureau issued a standard recommendation for prenatal Physical activity (PA): In the absence of maternal complications, pregnant women can continue housework, gardening, daily walks (up to 1 mile in several short bouts), and even swimming occasionally but should avoid sports participation [7, 8]. Moderate PA formed the basis of prenatal exercise programs of the 1970s and 1980s, which were highly specific and focused mainly on improving maternal fitness and easing labor and delivery.

ACOG issued their first guidelines for prenatal physical activity in 1985 [9]. These guidelines were based on the consensus opinion of a panel of obstetricians and endorsed the safety of most aerobic physical activity but advised caution with high-impact activities, such as running. The guideline included restrictions for exercise duration (not longer than 15 min for strenuous activity), heart rate (not greater than 140 beats/min), and core body temperature (not greater than 100.4 °F/38 °C). These specific parameters for exercise were dropped in later versions of the ACOG guidelines, updated in 1994 [10] and 2002 [2].

The 2002 guidelines recommended at least 30 min of moderate exercise per day on most, if not all, days of the week, provided that there are no medical or obstetric complications. They suggest that participating in a wide range of recreational physical activities is safe and included guidance for absolute and relative contraindications to exercise (Table 9.1) and warning signs to terminate exercise (Table 9.2).

Table 9.1

Absolute and relative contraindications to aerobic exercise from the ACOG (2002) guidelines

Absolute contraindications	Relative contraindications
Hemodynamically significant heart disease	Chronic bronchitis
Incompetent cervix/cerclage	Poorly controlled type 1 diabetes mellitus
Multiple gestation at risk for premature labor	Extreme morbid obesity
Persistent second- or third-trimester bleeding	Extreme underweight
Placenta previa after 26 weeks’ gestation	Heavy smoker
Preeclampsia/pregnancy-induced hypertension	History of extremely sedentary lifestyle
Premature labor during the current pregnancy	Orthopedic limitations
Restrictive lung disease	Poorly controlled hypertension
Ruptured membranes	Poorly controlled seizure disorder
	Poorly controlled hyperthyroidism
	Severe anemia
	Unevaluated maternal cardiac arrhythmia
	Intrauterine growth restriction in current pregnancy

See page 172 of the ACOG (2002) guidelines [2]

Table 9.2

Warning signs to terminate exercise from the ACOG (2002) guidelines

Warning sign
Vaginal bleeding
Dyspnea prior to exertion
Dizziness
Headache
Chest pain
Muscle weakness
Calf pain or swelling (need to rule out thrombophlebitis)
Preterm labor
Decreased fetal movement
Amniotic fluid leakage

See page 172 of the ACOG (2002) guidelines [2]

In 2008, the US government [1] released the “Physical Activity Guidelines for Americans” which included a section focused on pregnant women. They recommended at least 150 min of moderate-intensity aerobic physical activity per week for pregnant women who were not already highly active or doing vigorous-intensity physical activity and without obstetric/medical complications. This report also put forward, for the first time, guidelines for vigorous-intensity aerobic physical activity, stating that “pregnant women who habitually engage in vigorous-intensity aerobic activity or are highly active can continue physical activity during pregnancy and the postpartum period, provided they remain healthy and discuss with their healthcare provider how and when activity should be adjusted over time” ([1], p. 42). They provided strong scientific evidence for the safety of moderate-intensity physical activity, stating that it does not elevate the risk for low birth weight, preterm delivery, or early pregnancy loss. Moreover, it highlighted the growing but yet inconclusive evidence that physical activity can reduce the risk of pregnancy complications (e.g., preeclampsia, gestational diabetes mellitus) and the length of labor. Both the ACOG and United Status Department of Health and Human Services (USDHHS) guidelines specified specific activities pregnant women should avoid, such as the supine position during exercise during the second and third trimester. These recommendations are summarized in Table 9.3.

Table 9.3

Specific physical activities or positions to avoid during pregnancy

Activities or positions to avoid during pregnancy
Supine position (on back face up) during exercise after the first trimester
Motionless standing
Contact sports (i.e., soccer, basketball)
Activities with a high fall risk (i.e., skiing, vigorous racquet sports, horseback riding)
Scuba diving
High altitude exercise (>6,000 ft)

Note: Referenced in ACOG [2] and USDHHS [1]

Recent calls have been made for ACOG to update their 2002 prenatal physical activity guidelines in light of the growing body of research on maternal prenatal physical activity over the past decade [11]. Revisions are needed that could provide greater specificity by defining moderate-intensity physical activity, addressing the specific weekly energy expenditure to be attained, as well as clarifying the impact of incorporating vigorous physical activity on maternal and infant health outcomes. Also, in light of the increasing obesity epidemic worldwide, updated physical activity guidelines are also needed to address the special issues surrounding obesity in pregnancy. In particular, recent findings [12] indicate that fetal exposure in utero to maternal obesity, excessive gestational weight gain, and abnormal glucose tolerance critically influence the risk of subsequent overweight/obesity in the offspring. This evidence highlights the need for physical activity guidelines targeted to overweight/obese pregnant women with the goal of reducing the intergenerational impact of obesity [13].

In terms of postpartum physical activity, the consensus across the guidelines is that prepregnancy physical activity routines should be resumed gradually after giving birth, as soon as it is medically and physically safe to do so [1, 2]. In general, women are able to return to their prepregnancy physical activity levels approximately 6-8 weeks after a normal and healthy vaginal delivery and slightly longer after a cesarean delivery (i.e., following medical approval from one’s health-care provider). The 2008 US governmental physical activity guidelines for postpartum women are the same as for the general population (e.g., at least 150 min of moderate-intensity aerobic activity spread throughout the week; [1]). There is no evidence to date that physical activity has a negative impact on postpartum women’s health or negatively affects breastfeeding behaviors.

Prevalence of PA During Pregnancy and Postpartum

The US prevalence of physical activity during pregnancy comes from surveillance studies that have relied on self-reported physical activity (see Table 9.4). From the National Health and Nutrition Examination Survey [14], pregnant women reported an average of 0.6 h/week of transportation activity, 1.6 h/week of moderate to vigorous household activity, and 1.8 h of moderate to vigorous leisure activity. A subset of the leisure activities was classified as aerobic (mean 1.5 h/week), accounting for 88.5 % of the proportion of hours/week on aerobic exercise compared to all leisure activities. Pregnant women were classified as meeting the recommendations [1] if they reported at least 150 min/week of moderate-intensity aerobic activity. Overall, 14 % met the recommendation, and when including vigorous activities, almost one-quarter (23 %) met the recommendation for physical activity.

Table 9.4

Summary of US surveillance studies of self-reported physical activity during pregnancy

Acronym	NMIHS	BRFSS	NHANES
Study full name	National Maternal and Infant Health Survey	Behavioral Risk Factor Surveillance System	National Health and Nutrition Examination Survey
Reference	Zhang and Savitz [25]	Evenson et al. [29]; Petersen et al. [139]	Evenson and Wen [14]
Years reported	1988	1994, 1996, 1998, 2000	1999–2006
Method of collection	Telephone survey	Telephone survey	In-person interview
Sample size	9,953	1,979 in the year 2000	1,280
Results	Approximately 35 % reported exercising before and during pregnancy; walking was the most popular exercise, followed by swimming and aerobic exercise	66 % of pregnant women (in 2000) reported any leisure activity in the past month, with walking as the most common activity, followed by gardening, swimming laps, and aerobics	23 % reported any transportation activity (i.e., to/from work/school), 54 % reported any moderate to vigorous household activity, and 57 % reported any moderate to vigorous leisure activity, all in the past month
Limitations	Did not collect gestational age; long period of recall (on average 17 months after delivery); duration and frequency of exercise not collected	Did not collect gestational age

Self-reported physical activity is subject to social desirability bias and misreporting due to the difficulties in recall [15]. In addition, surveillance questions are often limited in number and detail, sometimes missing key components of physical activity behavior. In 2003, accelerometry was added to the NHANES and included a sufficient number of pregnant women who wore the accelerometer to be reported upon [16]. From 2003 to 2006, 359 pregnant women ≥16 years wore an accelerometer for 1 week. Women participated in a mean of 12 min/day of moderate physical activity and 0.3 min/day of vigorous physical activity. Mean moderate to vigorous physical activity varied by trimester: 12 min/day in first trimester, 14 min/day in second trimester, and 8 min/day in third trimester (see Fig. 9.1). On average, women spent 57 % of their monitored time in sedentary behaviors. In multivariable adjusted models, moderate to vigorous physical activity was higher in the first and second trimester compared to the third trimester and among women with higher household income compared to lower household income.

Figure 9.1

Weighted mean accelerometer minutes of moderate and vigorous physical activity per day among US pregnant women (From NHANES (2003–2006); Evenson et al. [16]. Open Access Agreement)

The prevalence of physical activity during postpartum is less well understood, but a number of studies agree that the absolute amounts are below recommendations for most women [17–23]. One observational cohort study found that while pregnant women decreased their physical activity from 17–22 weeks’ gestation to 27–30 weeks’ gestation, they did increase their physical activity at 3 months postpartum [24]. At 12 months postpartum, physical activity was stable, although the differing modes of activity that made up this activity differed from the prenatal period. For example, while indoor household activities that required at least moderate effort declined during the postpartum period, care-giving activities requiring at least moderate effort increased.

Review of Exercise During Pregnancy and Postpartum: Determinants, Outcomes, and Critical Gaps in the Literature

Determinants of Physical Activity in Pregnancy

Identifying determinants of prenatal physical activity is essential to inform future intervention studies designed to increase prenatal physical activity. However, such studies in overweight/obese women are sparse. This is critical as previous studies have found lower levels of physical activity during pregnancy among women who were overweight [25, 26]. In a recent review, Gaston and Cramp [27] found that the relationship between weight or BMI and prenatal physical activity was conflicting. While some studies observed no association between prepregnancy weight or BMI and physical activity level during pregnancy, others found that women of greater weight or BMI were 1.3–1.79 times more likely to discontinue their involvement in physical activity after becoming pregnant. Similarly, recent findings from the Pregnancy, Infection, and Nutrition 3 Study (PIN3) found that women who were overweight or obese prior to pregnancy were less likely to perform any recreational physical activity in late pregnancy as compared to lean women [28].

In general, two important sociodemographic factors known to be positively associated with participation in prenatal physical activity are greater education and income [27, 29–31], whereas physical activity frequency and duration are well documented to decline with advancing maternal and gestational age [32]. Also, women with higher levels of social support (e.g., perceived sense of accountability, support from friends/family), informational support (e.g., how to safely and effectively engage in prenatal physical activity), and emotional support have higher physical activity levels. At the environmental level, perceived community safety, the use of physical activity as a means of transportation, access to childcare, and access to trails, parks, and built environments that are conducive to physical activity are also commonly cited motivating factors [20, 23]. While studies have found that physical activity levels are higher among nulliparous women than among women with children [30, 31, 33], studies which have included household/childcare in the assessment of physical activity have found that women with children were less likely to become inactive throughout pregnancy [34–37].

Determinants of Physical Activity in Postpartum

Studies evaluating the determinants of postpartum physical activity are sparse. The existing studies suggest that women with greater levels of prenatal physical activity and higher family income are more likely to be active during postpartum [30]. Blum et al. [38] administered the Kaiser Physical Activity Survey (KPAS) to 91 postpartum women in Maine and found that women with older infants reported greater increases in household/childcare physical activity and lower occupational physical activity from prepregnancy to postpartum as compared to women with younger infants. In general, women who maintained or increased activity and/or sports participation from prepregnancy to postpartum had better overall maternal well-being and significantly better perception of partner’s/husband’s participation in childcare and support for maternal role from family and friends, compared to women reporting no or decreased activity participation. In another study, Hinton and Olsen [39] reported that being married and the husband’s physical activity frequency were positively associated with the mother’s postpartum physical activity frequency.

Other qualitative and quantitative studies indicate a number of barriers to physical activity during postpartum, including physical discomfort, parenting duties, tiredness, lack of time, not prioritizing their health over other competing responsibilities, lack of spousal/partner support, social isolation, lack of childcare, family responsibilities, higher number of children, financial, neighborhood safety, and weather [17–23, 40–45]. These studies also indicate a number of enablers to physical activity including stress relief and increased energy, weight loss, social support, and returning to work (corresponding with childcare) [17–19, 23, 38, 42, 45–47]. Environmental enablers to physical activity have also been described, such as access to safe places to walk and play [40, 45]. While overweight/obese women may experience many of these same barriers and enablers to pregnancy and postpartum physical activity, research about the unique challenges these women experience with engaging in physical activity before, during, and after pregnancy is sparse.

Outcomes of Physical Activity in Pregnancy: Gestational Diabetes Mellitus, Preeclampsia, and Excessive Gestational Weight Gain in Overweight/Obese Women

Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy with a prevalence rate varying from 1 to 20 % depending on the population studied and diagnostic criteria applied [48, 49]. Obesity increases the risk of GDM [50, 51]. Indeed, there is evidence that the incidence of GDM may be increasing as the prevalence of obesity among women of reproductive age increases [52–54]. GDM, in turn, increases the risk of subsequent development of diabetes later in life, and this risk is even higher in obese women [55]. Within 15 years of delivery, 70 % of obese women with GDM, compared with 30 % of lean women, will go on to develop type 2 diabetes [56]. GDM is also related to other short- as well as long-term adverse health outcomes for both mothers and their offspring such as maternal hypertensive disorders, cesarean delivery, large-for-gestational-age birth, neonatal hypoglycemia, and neonatal death [57]. In the long term, offspring are at increased risk for obesity, glucose intolerance, and type 2 diabetes [58–60].

Prior observational epidemiologic studies have suggested that prepregnancy physical activity may have a protective role in GDM onset. A meta-analysis found a 55 % lower risk of GDM for women in the highest prepregnancy physical activity quartile compared with those in the lowest quartile (pooled odds ratio [OR] = 0.45, 95 % confidence interval [CI] 0.28–0.75; p = 0.002), as well as a 24 % lower risk of GDM for women in the highest physical activity group during pregnancy compared with those in the lowest physical activity group (pooled OR = 0.76, 95 % CI 0.70–0.83; p < 0.0001) [61].

A recent Cochrane Review comparing the impact of physical activity interventions to usual prenatal care [62] found no significant difference in GDM incidence (three trials, 826 women, risk ratio (RR) 1.10, 95 % confidence interval (CI) 0.66–1.84). In addition, none of the five included trials which evaluated insulin sensitivity found significant differences. Of these studies, two were conducted among obese pregnant women; however, both were small studies and only one evaluated risk of GDM [63, 64]. In the first study, Ong et al. [63] investigated the effect of a supervised 10-week home-based exercise program, beginning at week 18 of gestation, on glucose tolerance and aerobic fitness in 12 previously sedentary obese women. The control arm had reduced glucose tolerance (higher blood glucose levels at 1 and 2 h of the post-intervention oral glucose tolerance test) as compared to the exercise arm, although this was not statistically significant. In the second study, Callaway et al. [64] randomized 50 obese women to an individualized exercise program with an energy expenditure goal of 900 kcal per week (n = 25) or to routine obstetric care (n = 25). While insulin resistance did not differ between the groups, 73 % of women in the intervention group achieved more than 900 kcal/week of exercise-based physical activity at 28 weeks compared with 42 % of women in the control arm. The review concluded that there is limited randomized controlled trial evidence available on the effect of physical activity during pregnancy for preventing pregnancy glucose intolerance or GDM. Larger, well-designed randomized trials, with standardized behavioral interventions, are needed to assess the effects of physical activity on preventing GDM. Seven trials are currently ongoing (see Appendix 9.1) [62].

Preeclampsia

Hypertensive disorders of pregnancy affect approximately 8 % of pregnancies [65] and include preeclampsia (defined as gestational hypertension with proteinuria) and gestational hypertension (defined as new onset hypertension in pregnancy after 20 weeks’ gestation). Obesity increases the risk of hypertensive disorders of pregnancy [54, 66]. For example, in a large prospective cohort study in Washington State (the Omega Study), Frederick et al. found that every unit increase in prepregnancy BMI resulted in an 8 % increased risk of preeclampsia, with overweight women having almost a twofold increased risk and obese women having over a fourfold increased risk [67]. Consistent with this finding, a significant decrease in risk of hypertensive disorders of pregnancy has been observed when BMI decreases [68]. Hypertensive disorders are the second leading cause of maternal mortality, accounting for 19 % of pregnancy-related deaths for women following a live birth and 20 % of pregnancy-related deaths for women following a still birth [69]. Preeclampsia is associated with an increased risk of preterm delivery, neonatal intensive care unit admission, and fetal death [70].

A recent systematic review [71] found a trend toward a protective effect of PA in the prevention of preeclampsia. Specifically, while six case–control studies found that physical activity had a protective effect on the development of preeclampsia (OR = 0.77, 95 % CI 0.64–0.91), the ten prospective cohort studies found no significant difference (OR = 0.99, 95 % CI 0.93–1.05). The only randomized clinical trial found that the incidence of preeclampsia was 14.6 % (95 % CI, 5.6–29.2) among the walking group and 2.6 % (95 % CI 0.07–13.8) among the stretching group [72].

Because overweight is an established risk factor for preeclampsia, several of these studies evaluated whether physical activity might be particularly beneficial for reduction of preeclampsia risk in this group. In a cohort of 2,793 women in Denmark, Hegaard et al. found that protective effect of recreational physical activity on preeclampsia risk was strongest in overweight women (OR = 0.10, 95 % CI 0.02–1.2), although not significantly so [73]. In contrast, in the Norwegian Mother and Child Cohort Study, Magnus et al. found that the protective effect of exercise was absent among obese women (OR = 1.39, 95 % CI 0.83–2.32), although there was the suggestion of a reduction in risk among overweight women (OR = 0.68, 95 % CI 0.44–1.04) [74, 75]. Rudra et al. found the significant trend of decreased preeclampsia risk with increased perceived exertion was apparent in both overweight and normal weight women [76].

Gestational Weight Gain

High gestational weight gain (GWG) is independently associated with postpartum weight retention and the long-term development of obesity [77]. Indeed, GWG is the strongest predictor for weight retention [78]. Overweight and obese women are at particular risk for excessive GWG [79]. Because overweight is characterized by insulin resistance and increased systemic inflammatory response [80], it is also associated with increased risk of GDM and preeclampsia [81, 82]. Recent studies also indicate a relationship between high GWG, an abnormal metabolic environment in utero, and increased risk of large-for-gestational-age infants, neonatal death [57], and subsequent childhood adiposity and morbidity [60]. There is observational evidence that physical activity may be a modifiable risk factor for excessive GWG [77]. In observational studies, vigorous physical activity, total physical activity, and walking have been associated with a lower risk of excessive GWG [83–85]. A recent systematic review of randomized controlled trials comparing supervised prenatal exercise intervention with routine standard prenatal care in women who were overweight/obese during pregnancy found that supervised exercise interventions were associated with lower GWG (five trials, n = 216 participants, mean difference of −0.36 kg, 95 % confidence interval −0.64 to −0.09 kg) [86].

Furthermore, a systematic review of lifestyle interventions in overweight/obese pregnant women to improve maternal and perinatal outcomes [51] found that prenatal lifestyle interventions in obese pregnant women reduce maternal pregnancy weight gain (10 RCTs; n = 1,228; −2.21 kg (95 % confidence interval −2.86 kg to −1.59 kg)) although findings were not significant for non-RCTs (six; n = 1,534). Both the successful and non-successful studies included those which were personalized, individual-based, and combined physical activity with dietary guidance. Degrees of weight gain restriction achieved were modest overall, and all the trials were assessed to be of low to medium quality [51]. Future studies are therefore needed to determine the optimal intensity, duration, and type of exercise intervention to reduce excessive GWG among pregnant women overall as well as specifically among overweight/obese pregnant women.

Outcomes of Physical Activity During Postpartum

Overweight/obese women tend to retain more weight postpartum because the majority of this group gains more weight during pregnancy than is recommended, and therefore, there is more weight to lose in postpartum [55, 78]. Weight loss can be achieved in the immediate postpartum period [87], with studies finding that both caloric restriction as well as physical activity are needed to reduce weight [88, 89] as compared to physical activity interventions alone [90]. However, few intervention studies have been specifically designed to reduce postpartum weight retention in overweight or obese women [88–90].

Lovelady et al. conducted a 10-week supervised exercise and dietary program in overweight, exclusively breastfeeding women. Women in the intervention group lost more weight (4.8 ± 1.7 kg vs. 0.8 ± 2.3 kg, p < 0.001) and increased aerobic fitness as compared with the control groups [88]. A second study which randomized overweight women to an exercise program and a structured diet found that the intervention arm successfully lost weight and most maintained weight loss by 1 year after delivery [89]. However, support from professionals and family is crucial for women to engage in physical activity during the postpartum period [38].

Weight loss interventions which begin during pregnancy [90, 91] may be more effective than those initiated only in the postpartum period [89, 92, 93] given the strong association between GWG and postpartum weight retention and the fact that it may be difficult to reduce postpartum weight retention without first preventing excessive GWG during pregnancy [94].

It remains unclear whether clinically relevant postpartum weight loss can be achieved in obese and overweight postpartum women and what form of physical activity intervention would be optimal. The Active Mothers Postpartum (AMP) trial enrolled a total of 450 overweight or obese women at 6 weeks postpartum [93]. Women randomized to the intervention were offered eight healthy-eating classes, ten physical activity classes, and six telephone-counseling sessions over 9 months. There were no significant group differences in mean weight loss, improvement of diet, or increased physical activity. Findings suggest that home-based interventions via mail, telephone, or the Internet/e-mail may be more feasible and successful in this population.

In addition, O’Toole examined the impact of an individualized, structured diet and physical activity intervention on weight loss in 40 overweight women during the first year postpartum [89]. Women were randomized to either a structured intervention which involved individualized diet and physical activity prescriptions or to a self-directed program. At 1 year postpartum, women in the intervention arm had a significant weight loss (7.3 kg, p < 0.01), a significant decrease in percent body fat (6 %, p < 0.01), but no change in fat-free mass, while women in the self-directed program had no significant change in these factors. Also recently, Bertz et al. evaluated whether a combined 12-week dietary and physical activity behavior modification intervention compared with stand-alone dietary and physical activity interventions or to usual care led to reduced body weight in 68 lactating Swedish women with a prepregnancy BMI of 25–35 kg/m^2.[95]. The dietary intervention resulted in clinically relevant weight loss, which was sustained 9 months after treatment. However, the combined physical activity and diet treatment did not yield significant weight or body-composition changes beyond those of dietary treatment alone.

Critical Gaps in the Literature

Despite the increasing body of literature aiming to better understand PA prevalence as well as determinants and outcomes of physical activity in pregnancy and postpartum, there are nevertheless critical gaps in the literature. The following section will discuss the following particular gaps: limitations in measuring physical activity during pregnancy, a general lack of understanding about overweight/obese women’s beliefs about being active and strategies for overcoming barriers, and a lack of a “best practice” or a “gold standard” intervention to promote physical activity among overweight/obese pregnant and postpartum women.

Measurement of Physical Activity During Pregnancy

To date, assessment of physical activity during pregnancy and postpartum is predominately conducted via self-report, such as with questionnaires or diaries, rather than with objective measurements, such as accelerometers or pedometers [96]. Several advantages of self-report measures include the lower burden it places on the participant and the reduction in equipment cost as compared to objective assessment of physical activity. Questionnaires can be designed to collect mode of physical activity and perception of intensity. A major disadvantage to both questionnaires and diaries is the potential for recall bias. Moreover, keeping a diary may change the woman’s physical activity behavior, and consistent with this concern, diaries have been used as motivational tools in prior intervention studies. Questions to consider when selecting a self-reported instrument can be found in Table 9.5.

Table 9.5

Questions to consider when choosing a physical activity questionnaire or diary assessment for pregnant women

Question	Common options
How will the assessment be delivered?	Paper, electronic, phone, text messaging, e-mail, interactive website
What is the appropriate length of the recall period?	Today, yesterday, past week, past month, since becoming pregnant
Are the major components of physical activity assessed?	The major components of physical activity include mode (type of physical activity), frequency, duration, and intensity
Is it important to know where or with whom the activity occurred?	Consideration could be given to whether the physical and social context is important to collect, assessed by asking where and with whom the physical activity was performed
Can the method assess recommendations for physical activity?	For the US, this would be based on ACOG [2] and US government [1]
Does the assessment evaluate sedentary behavior?	Sedentary behavior is characterized predominately by sitting and associated with low levels of energy expenditure
Was assessment of validity and reliability conducted in a population that is similar to my population?	Assessments may require cultural adaptation
Should objective assessments of physical activity be considered?	Accelerometers, pedometers

Note: Adapted from Evenson and Wen [96]

Objective measurement of physical activity is becoming more common among studies of pregnant and postpartum women. Several advantages to objective measures of pregnancy physical activity include the elimination or reduction of literacy, recall bias, and cultural differences. These objective measures (e.g., activity monitors) can also provide a more precise estimation of total physical activity. Disadvantages include cost and dependency on the participant to wear the monitor. The monitors are often worn for up to 1 week and thus do not reflect longer-term patterns of physical activity. They may be inadvertently worn incorrectly if placed at the hip, due to changes in the pregnant woman’s girth [97]. Several studies have noted that compliance to wearing accelerometers declines during pregnancy [98, 99]. This is most likely to occur when participants are instructed to remove the monitor while sleeping, and periods of sleep increase in later pregnancy. Another reason for decline in compliance may be the increasing discomfort associated with wearing the monitor later in pregnancy. To date, the majority of pedometers that have been used in pregnancy only assess locomotion-type activities well (i.e., running, walking) and have not differentiated intensity level. With newer devices, these limitations will likely be overcome.

Overweight/Obese Women’s Beliefs About Physical Activity During Pregnancy and Postpartum

To date, there has been a critical lack of understanding about overweight/obese women’s beliefs about being active and strategies for overcoming barriers. Several studies not focused among overweight/obese women have documented pregnant women’s PA beliefs during pregnancy, including that PA contributes to overall well-being [100–102], relieves stress [103], reduces anxiety and depressive symptoms [104], helps to control gestational weight gain [101, 104], and manages gestational diabetes [45]. In postpartum, salient physical activity beliefs are that physical activity assists with postpartum weight loss [101, 105], improves mood, and reduces stress [40]. Common barriers to physical activity in pregnancy are increased size, fatigue, and fear of harming the baby [101] and in postpartum are lack of time, companionship support for physical activity, childcare responsibilities, and health issues (e.g., recovering from labor/delivery) [19, 23, 40, 101, 102].

While overweight/obese women may experience many of these same physical activity beliefs and barriers, there is nevertheless little understanding about the unique challenges these women experience with engaging in physical activity before, during, and after pregnancy. One US study by Chang and colleagues [17] found that obese postpartum mothers’ personal experience of physical discomfort (e.g., inability to climb stairs, knee and back pain) and their body size made engaging in physical activity difficult. Another study conducted in the United Kingdom by Weir and colleagues [106] also identified feeling uncomfortable engaging in physical activity due to size (e.g., harder to move when heavier) as well as the perception that physical activity was less important than eating healthy for the baby as salient barriers to prenatal physical activity. Of particular concern, the women in this study were generally unconcerned about weight gain in pregnancy despite the adverse effects of high gestational weight gain on maternal and infant health outcomes. Future research is needed to better understand the physical activity beliefs and barriers of overweight/obese women and the extent to which these psychological factors influence their physical activity attitudes and behaviors and perspectives on gestational weight gain. It is possible that for overweight/obese women, the perceived barriers of physical activity greatly overshadow the benefits, and therefore, there is an important need to identify intervention strategies that effectively reduce barriers and improve their physical activity motivation and behavior.

Lack of “Best Practice” Interventions to Promote Physical Activity During Pregnancy and Postpartum

Although the prenatal physical activity guidelines have been revised on several occasions since the 1985 ACOG recommendations and these adaptations have led to greater support for and promotion of physical activity, there is still a considerable gap in the literature. Specifically, there is an absence of a “gold standard” intervention to promote pre- and postnatal physical activity. A recent systematic review [107] examined interventions to promote physical activity during pregnancy in an effort to identify best practices. Ten intervention studies met the inclusion criteria (i.e., randomized controlled trials measuring efficacy of intervention aiming to change physical activity in pregnant women) of which only two focused on physical activity as the primary target (other targets were gestational weight gain, gestational diabetes, and preeclampsia) and only three reported statistically significant differences between the physical activity intervention and control groups (see Table 9.6). The interventions included a variety of behavioral strategies aiming to promote PA (see Table 9.6); however, none were uniquely associated with positive outcomes. The authors concluded that little is known about the efficacy of interventions for physical activity during pregnancy and offered several suggestions for future research such as designing theoretically based studies to better understand factors influencing physical activity participation, expanding interventions beyond pregnant women to include other important social influences (e.g., family members, social networks, medical providers), and increasing generalizability of evidence to special populations such as ethnic minority groups and overweight and obese pregnant women.

Table 9.6

Interventions to promote physical activity

Reference	Sample	Strategies	Summary findings
Ferrara et al. [54]	N = 163 pregnant women with gestational diabetes	Intervention: in-person and telephone counseling, self-monitoring diaries	No significant differences between intervention and control groups
Ferrara et al. [54]	N = 163 pregnant women with gestational diabetes	Control: print materials about gestational diabetes and infant safety
Gaston and Prapavessis [138]	N = 70 pregnant women	Intervention: educational brochure on exercise during pregnancy	Significant increase in PA for intervention group compared to both control groups
Gaston and Prapavessis [138]	N = 70 pregnant women	Attention control: brochure about diet Usual care control: no intervention
Guelinckx et al. [55]	N = 122 obese pregnant women	Active intervention: brochure on nutrition and PA to limit gestational weight gain and group counseling with behavioral modification	No significant differences between intervention and comparison groups
Guelinckx et al. [55]	N = 122 obese pregnant women	Passive intervention: brochure only Usual care control: no intervention
Huang et al. [132]	N = 189 pregnant women from Taiwan	Intervention: PA counseling, brochure, individualized PA plan, self-monitoring PA records, problem solving, goal setting	Significant increase in PA for intervention group compared to controls
Huang et al. [132]	N = 189 pregnant women from Taiwan	Usual care control: leaflet about PA
Jackson et al. [115]	N = 287 pregnant women	Intervention: Video Doctor counseling session, in-depth behavioral risk assessment, tailored counseling messages, printed output	Significant increase in PA for intervention group but no significant group differences
Jackson et al. [115]	N = 287 pregnant women	Usual care control: no intervention
Kropp et al. [133]	N = 152 pregnant women	Intervention: motivational enhancement therapy for pregnant substance abuse users including discussion on substance abuse, personalized feedback about PA	No significant differences between intervention and control groups
Kropp et al. [133]	N = 152 pregnant women	Usual care control: counseling sessions but no personalized messaging
Hui et al.^a [134]	N = 190 pregnant women	Intervention: community-based group exercise sessions, instructed home exercise/dietary counseling	Significant increase in PA for intervention group compared to controls
Hui et al.^a [134]	N = 190 pregnant women	Usual care control: no intervention
Luoto et al. [135, 136]	N = 399 pregnant women at risk for gestational diabetes	Intervention: PA counseling with tailored weekly action plans and review of PA logs, booklet on PA, and optional group meetings/exercise Usual care control: no intervention	No significant differences between intervention and control groups
Yeo et al. [72, 137]	N = 79 sedentary pregnant women	Walking intervention: 40-min moderate-intensity walking on 5 days a week with training and supervision Comparison group: stretching intervention: video-guided stretching on 5 days a week with training and supervision	No significant differences between intervention and comparison groups

Note: Usual care control = received standard of prenatal care; Table adapted from Pearce et al. [107]; ^aHui et al. [134] Pearce et al. [107]

There is also a lack of interventions that have effectively promoted postpartum physical activity. While physical activity in postpartum offers a number of benefits, the primary focus for women in early postpartum is recovering from delivery and taking care of the infant. Physical activity is not generally recommended before 6–8 weeks postpartum (depending on vaginal or cesarean delivery), and from that point on, women are largely left to their own to return to their prepregnancy physical activity routine or initiate physical activity altogether. Furthermore, physical activity guidelines do not exist for postpartum which adds to the complexity of defining how to promote physical activity during this time. Mottola [13] suggested that for postpartum physical activity programs to succeed, they must consider the impact of factors such as time management, social support, cultural sensitivity, breastfeeding, childcare, and promoting physical activities that include mother-child interactions (e.g., stroller walking, interactive classes). In addition, postpartum women should get the approval of their health-care provider before starting a physical activity program, and they should start slowly and gradually increase frequency and intensity over time.

Next Steps in Practice, Prevention, and Research

Despite the increase in empirical evidence over the past several decades aiming to promote physical activity during and after pregnancy, women remain generally inactive during this important time in the life cycle, and this low activity is a precursor to later morbidity such as obesity, diabetes, and cardiovascular diseases. While there is no question that physical activity promotion remains an important and necessary focus of research and intervention efforts, it is of even greater importance to identify how to effectively motivate women, particularly overweight and obese women, to engage in physical activity during and after pregnancy. Below, we offer some suggestions for the next steps in research and practice to facilitate pre- and postnatal physical activity initiation, motivation, and maintenance.

Emphasis on Physical Activity Recommendations in Clinical Care

Most health-care providers are not specifically trained to counsel pregnant women about physical activity, and guidance on engaging in prenatal physical activity is not a part of the standard of care. For example, [108] found that 75 % of physicians in the 1990s were not aware of physical activity guidelines for pregnancy/postpartum. Unfortunately, almost two decades later, the general consensus is that counseling pregnant women about physical activity is not the “norm” in clinical care. For example, two recent studies [109, 110] found the two main barriers of prenatal care providers for physical activity counseling were a lack of knowledge/formal training and uncertainty or doubt about one’s ability to provide effective physical activity counseling. Although the current physical activity guidelines recommend that healthy pregnant women without obstetric complications can engage in 150 min/week of moderate-intensity physical activity (and with a doctor’s consent, continue some forms of vigorous physical activity), Evenson and Pompeii [109] found that 74 % of physicians recommended moderate-intensity physical activity and even less (6 %) recommended vigorous-intensity physical activity to their prenatal patients.

Another study [110] examined health-care provider advice to overweight/obese pregnant women and found that 58 % of women received little to no advice on appropriate physical activity during pregnancy. Also, of the 42 % of women who did discuss physical activity with their providers, the focus of the counseling was on being cautious about and/or limiting physical activity. Moreover, the majority of women perceived that their provider lacked knowledge of physical activity recommendations for frequency and intensity. These authors suggested that providers’ insufficient knowledge of physical activity guidelines is unlikely to shape positive physical activity expectations for overweight/obese women. Thus, more focused efforts are needed to better educate and train health-care providers about physical activity benefits, guidelines, and safety aspects in an effort to promote physical activity within standard prenatal care.

Furthermore, recent evidence [111, 112] suggests that provider knowledge varies across subgroups of pregnant women. For example, Stotland et al. [112] found that despite having the highest rates of high GWG nationally, White women were the least likely to receive counseling about health behaviors (e.g., nutrition, physical activity) in pregnancy. Also, Symons Downs et al. [113] found that provider recommendations varied across parity. More specifically, 32 % of women felt they received insufficient prenatal health information (e.g., GWG, physical activity, healthy eating) and attributed this lack of information to physicians’ assumptions that they already had health knowledge from prior pregnancies.

Thus, as a general recommendation, health-care providers may consider distributing information on the physical activity guidelines to all of their prenatal patients regardless of their prepregnancy weight or activity status. This information can be delivered on multiple occasions at appointments (e.g., handouts, websites) over the course of prenatal care. There is evidence that when primary care providers ask about physical activity, patients show much higher motivation to change their behavior; such change may not be sustained if women are asked only once [114].

Dissemination of Physical Activity Recommendations

In addition to integrating the physical activity guidelines into standard prenatal care, other strategies to disseminate the guidelines include mechanisms such as websites, social media (e.g., Facebook, Twitter), public health messaging (e.g., radio, TV), and mobile phone applications. For example, a recent randomized trial tested the impact of an interactive, computerized Video Doctor counseling tool on health behaviors in pregnancy [115] and found significant increases in self-reported physical activity and diet behaviors from baseline to follow-up. Understanding how to integrate technology into clinical care can help to assist clinicians with effective physical activity and diet counseling. Studies are also needed to examine different dissemination methods to identify which strategies are most effective across subgroups of pregnant and postpartum women (e.g., whether there are differences in effectiveness of mechanisms across women of different weight, parity, and socioeconomic status groups).

Dissemination of Gestational Weight Gain (GWG) Guidelines Identifying Effective Strategies to Promote Physical Activity

While studies have shown that GWG is influenced by health-care provider recommendations, approximately one-third of women report that they did not receive prenatal counseling on GWG [116]. Approximately 30–60 % of pregnant women have reported not receiving weight gain advice, and among those patients who received advice, approximately one-third reported receiving advice that was inconsistent with IOM guidelines [117–119]. Barriers to the provision of such advice and related educational materials may include limited time within the constraints of clinical practices, insufficient training, concern about the sensitivity of the topic, the perception that counseling is ineffective, and lack of third-party payer reimbursement [120].

Understanding How to Motivate Overweight/Obese Pregnant and Postpartum Women to Engage in Physical Activity

Research studies are needed to identify how to help overweight/obese pregnant and postpartum women overcome physical activity barriers and facilitate physical activity motivation. Interventions should be designed that first consider formative research (e.g., focus groups, structured interviews) with overweight/obese women to understand their unique challenges and needs. This research should also be theoretically driven to better understand the complex interactions among the psychological, behavioral, biological, and social/ecological determinants of physical activity during and after pregnancy to inform intervention design and development.

Identifying Effective Strategies to Promote Physical Activity

Research studies are needed to compare the delivery of multiple behavioral strategies to better understand which approaches are most effective at promoting physical activity during and after pregnancy. Understanding which program components and intervention strategies have the strongest impact will inform the development of future interventions in an effort to identify a “gold standard.” For example, research is needed that examines model interventions that have been effective in nonpregnant populations (e.g., the Diabetes Prevention Program: http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/) to determine which components and strategies may be effectively modified and applied to pregnant/postpartum women. More specifically, the DPP successfully demonstrated that modest weight loss and increased physical activity could reduce the incidence of diabetes in a group of prediabetic (nonpregnant) patients by 58 %. However, both the recruitment methodology and the intervention were too expensive to implement in real-world settings, leading to requests for proposals requiring less expensive methods to be developed and tested [121]. In addition, the DPP recruited an educated and English-literate population. Translating the DPP as well as other effective intervention studies conducted in nonpregnant populations to be used during pregnancy and postpartum could be promising. Such interventions should be tailored to ethnically/racially and socioeconomically diverse population, and they would also need to consider that the time and childcare pressures faced by pregnant and especially postpartum women are barriers to attendance at group meetings at scheduled times and that travel to and from venues would deter many [122, 123]. In fact, studies in nonpregnant populations [47, 124, 125] have found that individually tailored lifestyle interventions delivered in person, via telephone, and via mail produce greater or comparable changes in behavior at a more cost-efficient level compared with group-based interventions.

Example: Best Practice, Prevention Approach, or Research Design

As noted above, there is not a single “gold standard” intervention to promote physical activity during or after pregnancy. However, the following section provides an overview of some recent promising approaches for physical activity promotion among pregnant and postpartum women.

Several ongoing interventions are currently investigating the impact of lifestyle changes including physical activity on GDM risk. In one of the only trials to include a significant proportion of Hispanic women, the Behaviors Affecting Baby and You (B.A.B.Y) Study (clinical trial #NCT00728377) is an ongoing exercise trial among an ethnically diverse sample of prenatal care patients in Western Massachusetts at high risk of gestational diabetes mellitus (60 % Latina; [126]). Women are randomized to a 12-week motivationally targeted, individually tailored physical activity intervention involving multimodal contacts (in person, mail, and telephone) or to a comparison health and wellness intervention. The overall goal of the physical activity intervention is to encourage pregnant women to achieve physical activity guidelines during pregnancy through increasing walking and developing a more active lifestyle. The intervention takes into account the specific social, cultural, economic, and physical environmental challenges faced by pregnant women of diverse socioeconomic and ethnic backgrounds. Preliminary findings among the first 110 randomized prenatal care patients (60 % Hispanic) found that the exercise arm (n = 58) experienced a smaller decrease (−1.0 MET-h/week) in total activity vs. the control arm (n = 52) (−10.0 MET-h/week; p = 0.03) and a higher increase in sports/exercise (0.9 MET-h/week) vs. the control arm (−0.01 MET-h/week; p = 0.02) [127].

Another ongoing trial, Estudia Vida (clinical trial #NCT01141582), is designed to evaluate the feasibility of implementing a lifestyle intervention among pregnant, overweight, and obese Hispanic women at increased risk for GDM [128]. The lifestyle intervention was a 6-month program consisting of 6 monthly in-person educational sessions and 5 biweekly booster telephone calls. Assessments of physical activity, diet, glycemic control, markers of insulin resistance, and blood lipids were conducted at three time points: at baseline, in midpregnancy, and at 6 weeks postpartum. Health outcomes were abstracted from medical records. Among eligible women, 88 (49.4 %) agreed to participate, and a total of 68 women (77.3 %) were successfully randomized into a lifestyle intervention group (n = 33, 48.5 %) and a standard care group (n = 35, 51.5 %). Physical activity, diet, and covariate assessment completion rates ranged from 87.9 to 100 % during pregnancy and from 75 to 87.9 % postpartum, with no statistically significant differences between study groups. On average, women in the intervention group attended 4 (1.45 SD) sessions with 93.5 % attending at least three sessions. Clinical outcomes were obtained for 100 % of the participants. This study suggests that a lifestyle intervention delivered primarily via individualized sessions and telephone is feasible for overweight and obese Hispanic women at risk of GDM. However, strategies for helping pregnant Hispanic women to overcome barriers to participation are needed for such studies to be successful.

Another randomized intervention trial, Active MOMS (DK07586702), compared the effects of two theoretically based interventions (semi-intensive, face-to-face, guided exercise, minimal-contact, home-based lifestyle physical activity) to a standard of care control group on the physical activity behaviors and motivational determinants of 105 pregnant women with and without GDM [129, 130]. From baseline (20 weeks’ gestation) to follow-up (32 weeks’ gestation), women randomized to the semi-intensive physical activity intervention had higher leisure physical activity min/week, accelerometer counts/min, and physical activity attitude, subjective norm, and intention than women in the control group. They also had higher pedometer steps/day, physical activity attitude, and body satisfaction than women in the minimum-contact intervention. More women in the semi-intensive intervention (43 %) met physical activity guidelines than the minimum-contact intervention (23 %) and control (7 %). Also, GDM women had lower physical activity behaviors and motivational determinants than non-GDM women, placing them at even higher risk for low activity and sedentary behaviors both during and after pregnancy.

Specific to overweight/obese women, Mottola et al. [131] examined the effect of a Nutrition and Exercise Lifestyle Intervention Program (NELIP) on weight-related outcomes among 65 overweight/obese pregnant women compared to a matched historical cohort (n = 260). NELIP included individualized nutrition plans and a walking program using a pedometer to count steps. They found that 80 % of women in NELIP had GWG within the guidelines and postpartum weight retention was minimal (i.e., average 2.2 kg at 8 weeks postpartum) with no significant difference in weight retention between overweight and obese women. Because women in this trial were not randomized to intervention and control groups, future research is needed to test the efficacy of this intervention approach to replicate the study findings and determine the generalizability of this program at a population-based level.

Furthermore, ongoing interventions designed to reduce postpartum weight retention include Estudia Parto. The overall goal of this new randomized controlled trial (clinical trial # NCT01679210) is to test the efficacy of a culturally and linguistically modified, individually tailored lifestyle intervention to reduce risk factors for type 2 diabetes and cardiovascular disease among postpartum Hispanic women with a history of abnormal glucose tolerance during pregnancy. Specific aims are to evaluate the impact of the intervention on postpartum weight loss, biomarkers associated with insulin resistance (i.e., glucose, insulin, HbA_1c, leptin, TNF-α, HOMA, AUCgluc, adiponectin), other cardiovascular risk factors (i.e., blood lipids, blood pressure, CRP, fetuin-A, albumin-to-creatinine ratio), and the adoption and maintenance of postpartum behaviors associated with weight loss and prevention of diabetes risk (i.e., physical activity, diet). Eligible Hispanic women will be recruited after routine GDM screening and randomly assigned to a lifestyle intervention (n = 150) or a comparison health and wellness (control) intervention (n = 150). Targets of the intervention are to achieve IOM guidelines for postpartum weight loss, ACOG (2002) PA guidelines, and the American Diabetes Association guidelines for diet. The intervention draws from social cognitive theory and the transtheoretical model and addresses the specific social, cultural, economic, and physical environmental challenges faced by underserved Hispanic women. Measures of adherence will include accelerometers and dietary recalls.

Conclusion

Despite the fact that the physical activity and pregnancy/postpartum literature has evolved significantly over the past several decades and prenatal physical activity guidelines have become more relaxed to promote the maternal-fetal health benefits of exercise, most pregnant and postpartum women are not sufficiently active. Even more concerning is the low prevalence rate of physical activity among overweight and obese pregnant and postpartum women. In an effort to understand how to better promote physical activity during pregnancy and postpartum, salient determinants of activity have been identified; however, these have not been well understood among obese pregnant women and warrant future attention. Moreover, prenatal physical activity may reduce negative health outcomes such as gestational diabetes mellitus, preeclampsia, excessive gestational weight gain, and postpartum weight retention; however, greater dissemination of the physical activity guidelines in clinical practice is needed to educate and inform women of these benefits for widespread impact. Important areas for future research and practice include understanding how to motivate pregnant and postpartum women (especially obese women) to be active and identifying practical, safe, and effective physical activity intervention strategies (including a gold standard intervention for dissemination) to improve maternal health and reduce the onset of long-term morbidity.

Appendix 9.1: Additional Reading Material

Another seven trials (Chasan-Taber et al. 2009;Ko 2008; Melo 2008; Newnham et al. 2011; Oostdam et al. 2009; Ramirez-Velez et al. 2009; Shen 2008) are ongoing and will be considered for inclusion in the next update of this review (see Characteristics of ongoing studies).

Chasan-Taber L, Marcus BH, Stanek 3rd E, Ciccolo JT, Marquez DX, Solomon CG, et al. A randomized controlled trial of prenatal physical activity to prevent gestational diabetes: design and methods. J Womens Health. 2009;18(6):851–9.

Ko CW. Effect of physical activity on metabolic syndrome in pregnancy and fetal outcome. ClinicalTrials.gov (http://clinicaltrials.gov/) (Accessed 9 Apr 2008).

Melo A. Exercise and pregnancy: randomised clinical trial. Current Controlled Trials (www.controlled-trials.com/) (Accessed 17 Mar 2010).

Newnham J. Fournier P. Guelfi K. Grove R. Wallman K. Doherty D. Preventing gestational diabetes mellitus using a home-based supervised exercise program during pregnancy. Exercise for pregnant women for preventing gestational diabetes mellitus (Review) 17. Copyright © 2012 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd. ClinicalTrials.gov (http://clinicaltrials.gov/), (Accessed 25 July 2011). (NCT01283854).

Oostdam N, Van Poppel MN, Eekhoff EM, Wouters MG, Van Mechelen W. Design of FitFor2 study: the effects of an exercise program on insulin sensitivity and plasma glucose levels in pregnant women at high risk for gestational diabetes. BMC Pregnancy Childbirth. 2009;9:1.

Ramirez-Velez R, Aguilar AC, Mosquera M, Garcia RG, Reyes LM, Lopez-Jaramillo P. Clinical trial to assess the effect of physical exercise on endothelial function and insulin resistance in pregnant women. Trials. 2009;10:104.

Shen G. Impact of diet and exercise activity on pregnancy outcomes (IDEA). ClinicalTrials.gov (http://clinicaltrials.gov/) (Accessed 20 Feb 2008).

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