Exercise in Gestational Diabetes

Objectives After completing this Module the participant will be able to Discuss the value of regular activity Recognize the limitations regarding exercise especially during the third trimester

Background Physical activity can prevent or delay type 2 DM in individuals at risk Studies show that pre-pregnancy exercise helps to prevent GDM during pregnancy. More intensity equals more benefits. Any activity has more benefit than no physical activity in prevention of GDM. Oken et al, 2006, Zhang et al, 2006, Dempsey JC et al 2004

Types of Exercise Aerobic Exercise: Aerobic means “using oxygen for energy”. use large muscles (legs, shoulders, chest, and arms) can be performed continuously burns calories and is critical to losing fat and keeping it off. Resistance Training helps in increasing the number of Insulin receptors Improves sensitivity of insulin receptors in skeletal muscle maintains muscle while losing fat. Upper arm resistance training shown to lower blood glucose Upper arm resistance training for 2-3 days / week for a period of 4-8 weeks especially in the last trimester of pregnancy has been shown to be beneficial to lower blood glucose Jovanovic-Peterson et al 1989.

Benefits of Exercise in GDM Exercise causes significant decrease in: fasting plasma glucose 1hour plasma glucose HbA1c insulin requirement Jovanovic-Peterson et al 1989; Brankston et al, 2004.

Where to start Activity should be discussed with a medical practitioner Start with light to moderate exercise, i.e. 10 minute walk after meals, upper body exercises while seated 30 minutes a day total is recommended Appropriate exercise Low-impact aerobics, swimming, yoga, light weights Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260. Harris, GD, White, RD. Diabetes management and exercise in pregnant patients with diabetes. Clinical Diabetes. 2005;23(4):165-168 Harris, White, 2005 Metzger, Buchanan et al 2007 6

Medical contraindications for exercise in pregnancy Haemodynamically significant heart disease, eg. Mod- severe valvular heart disease, cardiomyopathy, cyanotic heart disease Restrictive lung disease Preclampsia Incompetent cervix/ cerclage Multiple gestation at risk for premature labour Persistent second or third trimester bleeding Placenta praevia after 26 weeks gestation Ruptured membranes ACOG Committee on Obstetric Practice, 2002.

Relative contraindications for exercise in pregnancy Severe anaemia Unevaluated cardiac arrhythmia Chronic bronchitis Poorly controlled type 1 diabetes Extreme morbid obesity (BMI > 40) Extreme Underweight (BMI< 12) Exercise in multiple gestation should be supervised History of extreme sedentary lifestyle Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker Intrauterine growth restriction in current pregnancy Relative meaning exercise should be gradually initiated and carefully monitored. ACOG Committee on Obstetric Practice, 2002.

Caution Strenuous exercise could cause Need to monitor Fetal distress Uterine contractions Maternal hypertension Increased risk of soft tissue injury Need to monitor Blood glucose before and after exercise for women on insulin or sulphonylureas

Education before exercise Avoid exercise in supine position after 2nd trimester (due to possibility of supine hypotension) Heart rate should not exceed 140 bpm Stop activity if contractions are felt If on insulin avoid exercising when insulin is peaking know how to recognize and treat hypoglycemia carry fast acting glucose Do you teach women how to feel for contractions? Do women know how to count their pulse? Harris, GD, White, RD. Diabetes management and exercise in pregnant patients with diabetes. Clinical Diabetes. 2005;23(4):165-168 Harris, White, 2005 10

Summary Any physical activity is better than no physical activity during pregnancy Even lower levels of physical activity have shown benefit in control of blood sugars. Aerobic activity of moderate intensity for 30mins/day on most days of the week has shown benefits in metabolic control. Upper body resistance training in addition to aerobic activity has probable synergistic effects in lowering blood sugars. Dempsy et al 2004, Liu et al 2008, Jovanovic-Peterson et al, 1989, ACOG Committee on Obstetric Practice, 2002

References Artal R, O’Toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med. 2003 February;37(1):6–12. doi: 10.1136/bjsm.37.1.6 Harris, GD, White, RD. Diabetes management and exercise in pregnant patients with diabetes. Clinical Diabetes. 2005;23(4):165-168. Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260. Oken E, Ning Y, Rifas-Shiman SI, Radesky JS, Rich-Edwards JW, Gillman MW. Association of physical activity and inactivity before and during pregnancy with glucose tolerance. Obstet Gynecol 2006; 208: 2100-7. Zhang C, Solomon CG, Manson JE, Hu FB. A prospective study of pregravid physical activity and sedentary behaviours in relation to the risk of gestational diabetes mellitus. Arch Intern Med. 2006; 166: 543-8 Contd..... 12

References Contd.... Brankson gN, Mitchell BF, Ryan EA, Okun NB. Resistance exercise decreases the need for insujlin in overeight women with gestational diabetes mellitus. Am. J. Obstet Gynecol 2004; 190:188-93. Dempsey JC, Butler CL, Sorenson TK et al. A case-control study of maternal recreational physical activity and risk of gestational diabetes mellitus. Diabetes Res Clin Practi 2004;66 203-215. Jovanovic-Peterson L, Durak EP, Peterson CM, Randomised trial of diet versus diet plus cardiovascular conditioning on glucose levels in gestational diabetes. Am. J. Obstet Gynecol. 1989; 161: 415-419. ACOG Committee on Obstetric Practice. ACOG committee opinion. Number 267, January 2002: exercise during pregnancy and the postpartum period. Inj. J. Gynecal Obstet 2002; 77: 79-81. 13