Diabetes Asia (2)

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Exercise in Gestational Diabetes
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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

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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
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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

Jovanovic-Peterson et al 1989.
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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.
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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

Harris, White, 2005 Metzger, Buchanan et al 2007
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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.
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Relative contraindications for exercise in
pregnancy

• Severe anaemia
• Unevaluated cardiac arrhythmia
• Chronic bronchitis
• Poorly controlled type 1 diabetes
• Extreme morbid obesity (BMI gt 40)
• Extreme Underweight (BMIlt 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

ACOG Committee on Obstetric Practice, 2002.
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Caution

• Strenuous exercise could cause
• 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

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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

Harris, White, 2005
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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
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References

• Artal R, OToole M. Guidelines of the American
  College of Obstetricians and Gynecologists for
  exercise during pregnancy and the postpartum
  period. Br J Sports Med. 2003 February37(1)612.
  doi  10.1136/bjsm.37.1.6
• Harris, GD, White, RD. Diabetes management and
  exercise in pregnant patients with diabetes.
  Clinical Diabetes. 200523(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.....
• 
  
  

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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
  190188-93.
• 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
  200466 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.

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