Physical activity in gestational diabetes
For women with gestational diabetes, provision of an infographic co-created with consumers, in addition to usual education about gestational diabetes, led to worthwhile improvements in both knowledge and self- efficacy about physical activity during their pregnancy. Q&A with Anne Harrison.
You recently published a trial involving women with gestational diabetes mellitus. Why is this an important condition to identify and manage?
Gestational diabetes mellitus (GDM), glucose intolerance of variable severity that occurs during pregnancy (ADA 2019, Metzger 1991), is a common complication in pregnancy (AIHW 2019).
Hyperglycaemia associated with poorly controlled GDM affects both the mother and the baby (ADA 2019, Garrison 2015).
The short-term adverse consequences of hyperglycaemia may include maternal pre-eclampsia, higher incidence of caesarean birth and birth trauma from foetal macrosomia (ACOG 2018).
For the baby, adverse effects may include jaundice, breathing difficulties and shoulder dystocia due to macrosomia causing difficulty and possible trauma if delivered vaginally (ACOG 2018).
GDM also has longer term health implications. For the mother, these include an increase in risk of recurrence of GDM in subsequent pregnancies (England et al 2015, Kim et al 2017), with a seven-fold increased risk of developing type 2 diabetes mellitus (Bellamy et al 2009).
For the child of a GDM pregnancy, there is an increased risk of obesity and type 2 diabetes mellitus later in life, and those born with macrosomia have an increased lifetime risk of cardiovascular disease (Harder et al 2009, Kral 2004).
For these reasons, GDM is an important condition to identify and manage and its increasing prevalence (ACOG 2018, ADA 2019) has potential public health ramifications.
An intervention given to both groups of women in your trial was an education session that included information about exercise. Why is exercise important in gestational diabetes?
Physical activity has substantial benefits and minimal risks for pregnant women (ACOG 2020, Evenson et al 2014, Mottola et al 2018) including those diagnosed with GDM (ACOG 2018, Colberg et al 2013, Harrison et al 2016, NICE 2015).
Benefits include a reduced risk of excessive weight gain (Wang et al 2017), premature birth (Di Mascio et al 2016), lower incidence of pre-eclampsia and caesarean birth (Magro-Malosso et al 2017), lower risk of back pain (Liddle & Pennick 2015), anxiety and depressive symptoms (Davenport et al 2018), and improved physical fitness (Ramirez- Velez et al 2011), postnatal recovery (Price et al 2012), sleep (Youngstedt 2005), and health perception (Barakat et al 2011).
For women diagnosed with GDM, physical activity is important because it also assists glycaemic control (Harrison et al 2016), which is critical for reducing adverse maternal and neonatal complications associated with poorly controlled GDM (ADA 2019).
And, when performed at a moderate intensity on most days of the week, physical activity is a safe and effective adjunctive intervention to GDM management (Harrison et al 2016).
With all those advantages, are women with gestational diabetes usually eager to exercise?
Despite the known benefits, more than 60 per cent of women with GDM do not participate in physical activity as recommended (Anjana et al 2016, Symons Downs & Ulbrecht 2006).
Our previous study found that women diagnosed with GDM believed physical activity during pregnancy was beneficial and important, but the diagnosis of GDM triggered concerns about safety (Harrison et al 2019).
Inconsistency in information, uncertainty about what type and how much physical activity was safe, and the lack of confidence in sources such as the internet were barriers hindering the women’s participation in physical activity.
These factors appeared to create confusion between the women’s attitude and their action (Harrison et al 2019).
In conjunction with the education class given to both groups in your study, one group received an infographic about exercise. How was this infographic created?
As infographics present information visually, with minimal use of text and in a way that is engaging, clear and simple (Krum 2013, Murray et al 2017, Scott et al 2016), we considered this format appropriate to the physical activity messaging needs described by the women with GDM in our prior study (Harrison et al 2019).
To ensure its relevance for these women, the infographic about physical activity for women with GDM was co-created in collaboration with these consumers.
Face-to-face group consultations were conducted with consenting women diagnosed with GDM.
Examples of infographics about physical activity for other health conditions, along with physical activity information from relevant guidelines, were provided to facilitate discussion and prioritising of information and design features, such as layout, colour, font size, amount of text, and style of graphics.
A draft infographic was then shown to additional women with GDM to assist in refining it.
The final consumer co-created infographic included information about the benefits of physical activity during a GDM pregnancy and the duration, frequency and types of suitable physical activities. It was used as the intervention for the trial.
Did the women who received this infographic have better outcomes?
In women with GDM, the provision of the infographic, in addition to usual education about GDM, led to worthwhile improvements in short-term knowledge about physical activity during a GDM pregnancy and self-efficacy to undertake physical activity during their pregnancy.
Consistent with current recommendations for developing patient information (Miller et al 2017, Australian Commission on Safety and Quality in Health Care ND), we suggest the fact the infographic was co-created with women with GDM contributed to its effectiveness, because it made the messaging about physical activity highly relevant to them and provided it in a format that met these women’s specific information needs.
Are physiotherapists able to use the infographic?
Yes, physiotherapists interested in using the infographic are welcome to contact me (AHarrison@mercy.com.au) and to use it with the appropriate acknowledgement of Mercy Health.
Anne Harrison, APAM, has over 30 years’ clinical experience, including 20 years of health management experience. She is currently manager of physiotherapy services at Werribee Mercy Hospital, Mercy Hospitals Victoria Ltd and a doctoral candidate at La Trobe University.
American College of Obstetricians and Gynecologists Committee on Practice Bulletins. (2018). Number 190. Interim Update: Gestational diabetes. Obstetrics & Gynecology, 131(2), e49-e64.
American College of Obstetricians and Gynecologists. (2020). Physical activity and exercise during pregnancy and the postpartum period. ACOG Committee Opinion No. 804. Obstetrics & Gynecology, 135(4), e178-e188. Retrieved April 15,2020, from https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committ...
American Diabetes Association. (2018). Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes – 2018. Diabetes Care, 41, S13–S27.
American Diabetes Association. (2019). Management of Diabetes in Pregnancy: Standards of medical care in diabetes - 2019. Diabetes Care, 42(Suppl 1), S165-S172.
Anjana, R. M., Sudha, V., Lakshmipriya, N., Anitha, C., Unnikrishnan, R., Bhavadharini, B., … Mohan, V. (2016). Physical activity patterns and gestational diabetes outcomes - The wings project. Diabetes Research and Clinical Practice, 116, 253–262. doi:10.1016/j.diabres.2016.04.041
Australian Commission on Safety and Quality in Health Care. (2020). Standard 2: Partnering with Consumers. Tip sheet Health literacy and the NSQHS Standards. Sydney, Australia: NSQHS. Retrieved June 5, 2020, from, https://www.safetyandquality.gov.au/sites/default/files/migrated/Standar...
Australian Institute of Health and Welfare. (2019). Incidence of gestational diabetes in Australia. Canberra (AIHW cat. no. CVD85). Canberra, Australia: Author. Retrieved February 14, 2020, from, https://www.aihw.gov.au/reports/diabetes/incidence-of-gestational-diabet...
Barakat, R., Pelaez, M., Montejo, R., Luaces, M., & Zakynthinaki, M. (2011). Exercise during pregnancy improves maternal health perception: a randomized controlled trial. American Journal of Obstetrics and Gynecology, 204(5), 402.e1–402.e4027.
Bellamy, L., Casas, J-P., Hingorani, A. D., & Williams, D. (2009). Type 2 diabetes after gestational diabetes: a systematic review and meta-analysis. Lancet (London, England), 373(9677), 1773–1779.
Colberg, S. R., Castorino, K., & Jovanovič, L. (2013). Prescribing physical activity to prevent and manage gestational diabetes. World Journal of Diabetes, 4(6), 256–262.
Davenport, M. H., McCurdy, A. P., Mottola, M. F., Skow, R. J., Meah, V. L., Poitras, V. J., … Ruchat, S-M. (2018). Impact of prenatal exercise on both prenatal and postnatal anxiety and depressive symptoms: a systematic review and meta-analysis. British Journal of Sports Medicine, 52(21), 1376–1385.
Di Mascio, D., Magro-Malosso, E. R., Saccone, G., Marhefka, G. D., & Berghella, V. (2016). Exercise during pregnancy in normal-weight women and risk of preterm birth: a systematic review and meta-analysis of randomized controlled trials. American Journal of Obstetrics and Gynecology, 215(5), 561–571.
England, L., Kotelchuck, M., Wilson, H. G., Diop, H., Oppedisano, P., Kim, S. Y., … Shapiro-Mendoza, C. K. (2015). Estimating the Recurrence Rate of Gestational Diabetes Mellitus (GDM) in Massachusetts 1998-2007: Methods and Findings. Maternal and Child Health Journal, 19(10), 2303–2313.
Evenson, K. R., Barakat, R., Brown, W. J., Dargent-Molina, P., Haruna, M., Mikkelsen, E. … Yeo, S. (2014). Guidelines for Physical Activity during Pregnancy: Comparisons From Around the World. American Journal of Lifestyle Medicine, 8(2), 102–121.
Garrison, A. (2015). Screening, diagnosis and management of gestational diabetes mellitus. American Family Physician, 91(7), 460-467.
Harder, T., Roepke, K., Diller, N., Stechling, Y., Dudenhausen, J. W., & Plagemann, A. (2009). Birth weight, early weight gain, and subsequent risk of type 1 diabetes: systematic review and meta-analysis. American Journal of Epidemiology, 169(12), 1428–1436.
Harrison, A. L., Shields, N., Taylor, N. F., & Frawley, H. C. (2016). Exercise improves glycaemic control in women diagnosed with gestational diabetes mellitus: a systematic review. Journal of Physiotherapy, 62(4), 188–196.
Harrison, A. L., Taylor, N. F., Frawley, H. C., & Shields, N. (2019). Women with gestational diabetes mellitus want clear and practical messages from credible sources about physical activity during pregnancy: a qualitative study. Journal of Physiotherapy, 65(1), 37–42.
Kim, C., Berger, D. K., & Chamany, S. (2007). Recurrence of gestational diabetes mellitus: a systematic review. Diabetes Care, 30(5), 1314–1319.
Krum, R. (2013). Cool infographics: effective communication with data visualization and design. Hoboken, NJ: Wiley.
Kral J. G. (2004). Preventing and treating obesity in girls and young women to curb the epidemic. Obesity Research, 12(10), 1539–1546.
Liddle, S. D., Pennick, V. (2015). Interventions for preventing and treating low-back and pelvic pain during pregnancy. The Cochrane Database of Systematic Reviews (9). CD001139.
Magro-Malosso, E. R., Saccone, G., Di Tommaso, M., Roman, A., & Berghella, V. (2017). Exercise during pregnancy and risk of gestational hypertensive disorders: a systematic review and meta-analysis. Acta Obstetricia et Gynecologica Scandinavica, 96(8), 921–931.
Metzger B. E. (1991). Summary and recommendations of the Third International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes, 40 Suppl 2, 197–201.
Miller, C. L., Mott, K., Cousins, M., Miller, S., Johnson, A., Lawson, T., & Wesselingh, S. (2017). Integrating consumer engagement in health and medical research - an Australian framework. Health Research Policy and Systems, 15(1), 9.
Mottola, M. F., Davenport, M. H., Ruchat, S. M., Davies, G. A., Poitras, V. J., Gray, C. E., … Zehr, L. (2018). 2019 Canadian guideline for physical activity throughout pregnancy. British Journal of Sports Medicine, 52(21), 1339–1346.
Murray, I. R., Murray, A. D., Wordie, S. J., Oliver, C. W., Murray, A. W., & Simpson, A. (2017). Maximising the impact of your work using infographics. Bone & Joint Research, 6(11), 619–620.
National Institute for Health and Care Excellence. (2015). Diabetes in pregnancy: management from preconception to the postnatal period. Manchester: NICE; pp.19-22. Retrieved July 15, 2018, from, https://www.nice.org.uk/guidance/ng3/resources/diabetes-in-pregnancy-man...
Price, B. B., Amini, S. B., & Kappeler, K. (2012). Exercise in pregnancy: effect on fitness and obstetric outcomes-a randomized trial. Medicine and Science in Sports and Exercise, 44(12), 2263–2269.
Ramírez-Vélez, R., Aguilar de Plata, A. C., Escudero, M. M., Echeverry, I., Ortega, J. G., Salazar, B., … López-Jaramillo, P. (2011). Influence of regular aerobic exercise on endothelium-dependent vasodilation and cardiorespiratory fitness in pregnant women. The Journal of Obstetrics and Gynaecology Research, 37(11), 1601–1608.
Scott, H., Fawkner, S., Oliver, C., & Murray, A. (2016). Why healthcare professionals should know a little about infographics. British Journal of Sports Medicine, 50(18), 1104–1105.
Symons Downs, D., & Ulbrecht, J. S. (2006). Understanding exercise beliefs and behaviors in women with gestational diabetes mellitus. Diabetes Care, 29(2), 236–240.
Wang, C., Wei, Y., Zhang, X., Zhang, Y., Xu, Q., Sun, Y., … Yang, H. (2017). A randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in overweight and obese pregnant women. American Journal of Obstetrics and Gynecology, 216(4), 340–351.
Youngstedt S. D. (2005). Effects of exercise on sleep. Clinics in Sports Medicine, 24(2), 355–xi.
© Copyright 2018 by Australian Physiotherapy Association. All rights reserved.