The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20

Effect of exercise during pregnancy to prevent

gestational diabetes mellitus: a systematic review
and meta-analysis

Ying Yu, Rongrong Xie, Cainuo Shen & Lianting Shu

To cite this article: Ying Yu, Rongrong Xie, Cainuo Shen & Lianting Shu (2017): Effect of exercise
during pregnancy to prevent gestational diabetes mellitus: a systematic review and meta-analysis,
The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2017.1319929

To link to this article: https://doi.org/10.1080/14767058.2017.1319929

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Apr 2017.
Published online: 14 May 2017.

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 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE, 2017
https://doi.org/10.1080/14767058.2017.1319929

REVIEW ARTICLE

Effect of exercise during pregnancy to prevent gestational diabetes mellitus:

a systematic review and meta-analysis
Ying Yua, Rongrong Xiea, Cainuo Shena and Lianting Shub
a
Obstetrics and Gynecology Department, Fenghua People’s Hospital of Ningbo, Zhejiang, China; bObstetrics and Gynecology
Department, Fenghua Maternal and Child Health Hospital, Zhejiang, China

ABSTRACT ARTICLE HISTORY

Introduction: Exercise showed some potential in preventing gestational diabetes mellitus. Received 22 January 2017
However, the results remained controversial. We conducted a systematic review and meta-ana- Revised 9 April 2017
lysis to evaluate the impact of exercise during pregnancy on gestational diabetes mellitus. Accepted 12 April 2017
Downloaded by [Gothenburg University Library] at 05:31 09 January 2018

Methods: PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were sys-
tematically searched. Randomized controlled trials (RCTs) assessing the influence of exercise dur- KEYWORDS
ing pregnancy on gestational diabetes mellitus were included. Two investigators independently Exercise; gestational
searched articles, extracted data, and assessed the quality of included studies. The primary out- diabetes mellitus; incidence
come was the incidence of gestational diabetes mellitus. Meta-analysis was performed using ran- of gestational diabetes;
dom-effect model. meta-analysis; systematic
Results: Six RCTs involving 2164 patients were included in the meta-analysis. Compared with con- review
trol intervention, exercise intervention was associated with significantly decreased incidence of ges-
tational diabetes mellitus (Std. mean difference ¼ 0.59; 95%CI ¼ 0.39–.88; p ¼ .01), but had no effect
on gestational age at birth (Std. mean difference ¼ 0.03; 95%CI ¼ 0.12 to 0.07; p ¼ .60), the num-
ber of preterm birth (OR ¼ 0.85; 95%CI ¼ 0.43–1.66; p ¼ .63), glucose 2-h post-OGTT (Std. mean dif-
ference ¼ 1.02; 95%CI ¼ 2.75 to 0.71; p ¼ .25), birth weight (Std. mean difference ¼ 0.13;
95%CI ¼ 0.26 to 0.01; p ¼ .06), and Apgar score less than 7 (OR ¼ .78; 95%CI ¼ 0.21–2.91; p ¼ .71).
Conclusions: Compared to control intervention, exercise intervention could significantly
decrease the risk of gestational diabetes mellitus, but showed no impact on gestational age at
birth, preterm birth, glucose 2-h post-OGTT, birth weight, and Apgar score less than 7.

Introduction exercise, dietary, and weight gain counseling was

reported to decrease the incidence of gestational dia-
Gestational diabetes mellitus was ubiquitous in clinical
betes mellitus and attenuate the typical decline in glu-
work, and could increase the incidence of pre-eclamp-
cose tolerance [8–10]. Many RCTs demonstrated that
sia, macrosomia, and cesarean delivery [1]. These poor
exercise intervention could significantly reduce the
outcomes affected the long-term health of both the
incidence of gestational diabetes mellitus, and glucose
mothers and their offspring [2,3]. Overweight and
2-h post-OGTT [11–15].
obese pregnant women were found to have a greater
In contrast to this promising finding, however, accu-
than two-fold increased risk of developing gestational
mulating relevant RCTs showed that exercise interven-
diabetes mellitus compared to non-obese women [4].
tion showed no effect on the incidence of gestational
Overweight and obesity were determined based on the
diabetes mellitus, gestational age at birth, glucose 2-h
body mass index recommendations of the Group of
post-OGTT, and birth weight [15–17]. Considering
China Obesity Task Force of the Chinese Ministry of
these inconsistent effects, we therefore conducted a
Health on account of interracial differences: over-
systematic review and meta-analysis of RCTs to investi-
weight, 24  BMI <28 kg/m2; obese, BMI 28 kg/m2 [5].
gate the effect of exercise during pregnancy on gesta-
Exercise intervention was known as an important
tional diabetes mellitus.
part of lifestyle intervention for gestational diabetes
mellitus. In non-pregnant patients, regular exercise
Materials and methods
was reported to have some ability to reduce the risk
of type 2 diabetes, cardiovascular disease, and meta- This systematic review and meta-analysis were con-
bolic syndrome [6,7]. Life style intervention including ducted according to the guidance of the Preferred

CONTACT Lianting Shu shu0030040371@sina.com Obstetrics and Gynecology Department, Fenghua Maternal and Child Health Hospital, Zhejiang,
China
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
 2 Y. YU ET AL.
Reporting Items for Systematic Reviews and Meta-ana-
lysis statement [18] and the Cochrane Handbook for
Systematic Reviews of Interventions [19]. All analyses
were based on previous published studies, thus no
ethical approval and patient consent were required.
Literature search and selection criteria
PubMed, EMbase, Web of science, EBSCO, and the
Cochrane library were systematically searched from
inception to March 2017, with the following keywords:
exercise or physical activity, and gestational diabetes.
To include additional eligible studies, the reference
lists of retrieved studies and relevant reviews were
also hand-searched and the process above was per-
formed repeatedly until no further article was identi-
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fied. Conference abstracts meeting the inclusion
criteria were also included.
The inclusion criteria were as follows: study popula-
tion, pregnant woman; intervention, exercise; control,
standard care; outcome measure, incidence of gesta-
tional diabetes mellitus; and study design, RCT.
Data extraction and outcome measures
The following information was extracted for the
included RCTs: first author, publication year, sample
size, baseline characteristics of patients, exercise inter-
vention, control, study design, the incidence of gesta-
tional diabetes mellitus, gestational age at birth,
preterm birth, glucose 2-h post-OGTT, birth weight,
and Apgar score less than 7. The author would be
contacted to acquire data when necessary.
The primary outcome was the incidence of gesta-
tional diabetes mellitus. Secondary outcomes included
gestational age at birth, preterm birth, glucose 2-h
post-OGTT, birth weight, and Apgar score less than 7.
Quality assessment in individual studies
The Jadad Scale was used to evaluate the methodo-
logical quality of each RCT included in this meta-ana-
lysis [20]. This scale consisted of three evaluation
elements: randomization (0–2 points), blinding (0–2
points), dropouts, and withdrawals (0–1 points). One
point would be allocated to each element if they have
been mentioned in article, and another one point
would be given if the methods of randomization and/
or blinding had been described appropriately and in
detail. If methods of randomization and/or blinding
were inappropriate, or dropouts and withdrawals had
not been recorded, then one point was deducted.
The score of Jadad Scale varied from 0 to 5 points.
An article with Jadad score 2 was considered to be
of low quality. If the Jadad score 3, the study was
thought to be of high quality [21].
Statistical analysis
Standard Mean differences (Std. mean difference) with
95% confidence intervals (CIs) for continuous outcomes
(gestational age at birth, glucose 2-h post-OGTT and
birth weight) and odds risks (ORs) with 95%CIs for
dichotomous outcomes (the incidence of gestational
diabetes mellitus, preterm birth, and Apgar score less
than 7) were used to estimate the pooled effects. All
meta-analyses were performed using random-effects
models with DerSimonian and Laird weights.
Heterogeneity was tested using the Cochran Q statistic
(p < .1) and quantified with the I2 statistic, which
described the variation of effect size that was attribut-
able to heterogeneity across studies. An I2 value greater
than 50% indicated significant heterogeneity.
Sensitivity analysis was performed to detect the influ-
ence of a single study on the overall estimate via omit-
ting one study in turn when necessary. Owing to the
limited number (<10) of included studies, publication
bias was not assessed. p < .05 in two-tailed tests was
considered statistically significant. All statistical analyses
were performed with Review Manager Version 5.3 (The
Cochrane Collaboration, Software Update, Oxford, UK).
Results
Literature search, study characteristics, and
quality assessment
The flow chart for the selection process and
detailed identification was presented in Figure 1.
Figure 1. Flow diagram of study searching and selection
process.
 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3

Table 1. Characteristics of included studies.

Exercise group Control group
Fasting Fasting
Maternal glucose Maternal glucose Jada
Author Number Ethnicity age (years) BMI, kg/m2 (mmol/L) Number Ethnicity age (years) BMI, kg/m2 (mmol/L) scores
Wang [15] 150 – 32.14 ± 4.57 26.75 ± 2.74 5.04 ± 0.37 150 – 32.50 ± 4.91 26.82 ± 2.76 5.04 ± 0.41 5
Guelfi [16] 85 76 (caucasian) 33.6 ± 4.1 N ¼ 18 (30) 4.3 ± 0.4 87 68 (caucasian) 33.8 ± 3.9 N ¼ 20 (30) 4.3 ± 0.3 4
Nobles [17] 124 69 (hispanic) N ¼ 51 (20–24 y) N ¼ 83 (30) – 127 82 (hispanic) N ¼ 45(20–24 y) N ¼ 73 (30) – 4
Cordero [12] 101 – 33.6 ± 4.1 22.5 ± 3.2 – 156 – 32.9 ± 4.5 23.6 ± 4 – 3
Barakat [11] 210 – 31 ± 3 24.1 ± 4.1 – 218 – 31 ± 4 23.7 ± 3.8 – 3
Stafne [13] 429 – 30.5 ± 4.4 24.7 ± 3.0 10.1 ± 5.42 327 – 30.4 ± 4.3 25.0 ± 3.4 10.7 ± 5.47 4

899 publications were identified through the initial Sensitivity analysis

search of databases. Ultimately, six RCTs were included
Low heterogeneity was observed among the included
in the meta-analysis [11–13,15–17].
studies for the incidence of gestational diabetes melli-
The baseline characteristics of the six eligible RCTs
tus. Thus, we did not perform sensitivity analysis by
in the meta-analysis were summarized in Table 1. The
Downloaded by [Gothenburg University Library] at 05:31 09 January 2018

omitting one study in each turn to detect the source

six studies were published between 2012 and 2017,
and sample sizes ranged from 172 to 330 with a total
of 2164. There was no significant difference of mater-
nal age, BMI, and fasting glucose in pregnant woman
at baseline. Three included studies reported that preg-
nant women in exercise intervention group obtained a
supervised cycling program (three times/week)
[12,15,16]. Three included studies reported that preg-
nant women in exercise intervention group obtained
physical activity based on American College of
Obstetricians and Gynecologists (ACOG) guidelines
[11,13,17]. And, the pregnant women in control inter-
vention group got usual daily activities in included
RCTs.
Among the six RCTs, five studies reported the inci-
dence of gestational diabetes mellitus [11,12,15–17],
five studies reported gestational age at birth
[11,13,15–17], three studies reported preterm birth
[15–17], three studies reported glucose 2-h post-OGTT
[13,15,16], five studies reported birth weight
[11,13,15–17], and two studies reported Apgar score
less than 7 [13,16]. Jadad scores of the six included
studies varied from 3 to 5, all five studies were consid-
ered to be high-quality ones according to quality
assessment.
Primary outcome: the incidence of gestational
diabetes mellitus
This outcome data was analyzed with a random-effects
model, the pooled estimate of the five included RCTs
suggested that compared to control group, exercise
intervention was associated with a significantly
decreased incidence of gestational diabetes mellitus
(Std. mean difference ¼ 0.59; 95%CI ¼ 0.39–0.88;
p ¼ .01), with low heterogeneity among the studies
(I2 ¼ 46%, heterogeneity p ¼ .11) (Figure 2).
of heterogeneity.
Secondary outcomes
However, compared to control intervention, exercise
intervention was found to have no influence on gesta-
tional age at birth (Std. mean difference ¼ 0.03;
95%CI ¼ 0.12 to 0.07; p ¼ .60; Figure 3), the number
of preterm birth (OR ¼ 0.85; 95%CI ¼ 0.43–1.66; p ¼ .63;
Figure 4), glucose 2-h post-OGTT (Std. mean differ-
ence ¼ 1.02; 95%CI ¼ 2.75 to 0.71; p ¼ .25; Figure 5),
birth weight (Std. mean difference ¼ 0.13;
95%CI ¼ 0.26 to 0.01; p ¼ .06; Figure 6), and Apgar
score less than 7 (OR ¼ 0.78; 95%CI ¼ 0.21–2.91;
p ¼ .71; Figure 7). “Barakat 2013” represented the index
of corresponding figure (i.e. gestational age at birth in
Figure 3 and birth weight in Figure 6) in pregnant
women without gestational diabetes mellitus, while
“Barakat 2013þ” represented the index of correspond-
ing figure in pregnant women with gestational dia-
betes mellitus.
Discussion
Our meta-analysis suggested that compared to control
intervention, exercise intervention could significantly
decrease the incidence of gestational diabetes melli-
tus, but had no significant influence on gestational
age at birth, preterm birth, glucose 2-h post-OGTT,
birth weight and Apgar score less than 7. Exercise
intervention was reported to improve maternal cardio-
vascular fitness, exercise automaticity, and reduce gen-
eral psychological distress [16]. In addition, exercise
intervention was not associated with reduced pree-
clampsia compared to standard care [13,16]. Safety
issue of exercise intervention was confirmed because
 4 Y. YU ET AL.

Figure 2. Forest plot for the meta-analysis of the incidence of gestational diabetes mellitus.
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Figure 3. Forest plot for the meta-analysis of gestational age at birth (day).

Figure 4. Forest plot for the meta-analysis of preterm birth.

Figure 5. Forest plot for the meta-analysis of glucose 2-h post-OGTT (mmol/L).

Figure 6. Forest plot for the meta-analysis of birth weight (g).


Figure 7. Forest plot for the meta-analysis of Apgar score less than 7.
of no increase in miscarriage, fetal loss, short cervical
length, or preterm birth [15].
One recent meta-analysis reported that exercise
intervention showed no substantial influence on low-
ering the incidence of gestational diabetes mellitus,
but did not report the analysis of preterm birth, glu-
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cose intolerance, and birth weight etc [22]. Our meta-
analysis clearly concluded that exercise intervention
could significantly decrease the risk of gestational dia-
betes mellitus, and analyzed other outcome data
including gestational age at birth, preterm birth, glu-
cose 2-h post-OGTT, birth weight, and Apgar score less
than 7. And, they showed no significant difference
between exercise intervention and control
intervention.
There were some conflicting results regarding the
effect of exercise intervention on gestational diabetes
mellitus. The incidence of gestational diabetes melli-
tus was not decreased after antenatal exercise (mod-
erate-intensity aerobic, strength, and flexibility
exercises by three times a week for 45–60 min) [11].
However, a program of aerobic, strength, and flexibil-
ity exercises by three times per week was reported
to significantly reduce the risk of gestational diabetes
mellitus [12]. Vigorous intensity activity before and
after pregnancy showed some potential in preventing
gestational diabetes mellitus [23]. Exercise in the
second trimester might be late to reduce the inci-
dence of gestational diabetes mellitus because endo-
crine and metabolic changes began in the first
trimester [15,24].
Several limitations should be taken into account.
Firstly, our analysis was based on only six RCTs and
more clinical trials were needed to investigate this
issue. The different duration time and intensity of
exercise in the included studies might have an influ-
ence on the pooled results of this meta-analysis.
Future studies should focus on exploring the optimal
duration time and intensity of exercise in pregnant
women. Next, dietary habits were not described in
detail in the included RCTs. Finally, some unpublished
and missing data might lead bias to the pooled
effect.
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 5
Conclusions
Exercise intervention had an important ability to pre-
vent gestational diabetes mellitus and should be rec-
ommended to be administrated in pregnant women.
Ethical approval
This article does not contain any studies with human partici-
pants or animals performed by any of the authors.
Disclosure statement
No potential conflict of interest was reported by the authors.
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