The Journal of Maternal-Fetal and Neonatal Medicine, November 2010; 23(11): 13101314

Physical activity and dietary habits during pregnancy: effects on glucose tolerance

ALESSANDRA BERTOLOTTO1, LAURA VOLPE1, ALESSANDRA CALIANNO2, MARIA CRISTINA PUGLIESE2, CRISTINA LENCIONI1, VERONICA RESI1, ALESSANDRA GHIO1, MARISA CORFINI1, LUCA BENZI2, STEFANO DEL PRATO1, & GRAZIANO DI CIANNI1
Section of Diabetes, and 2Section of Clinical Nutrition, Department of Endocrinology and Metabolism, Azienda Ospedaliero Universitaria Pisana and University of Pisa, Pisa, Italy (Received 28 August 2009; revised 27 November 2009; accepted 29 December 2009)
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Abstract Objectives. We designed this study to assess the potential effects of physical activity and dietary habits on glucose tolerance during pregnancy. Methods. This is an observational study involving 268 women who underwent a 50-g oral glucose challenge test (GCT) at 27 + 6.9 week of gestation. Plasma glucose level at 1-h GCT !140 mg/dl was used to dene abnormal glucose tolerance (AGT). Physical activity was evaluated using the short form of the International Physical Activity Questionnaire (IPAQ), while for dietary habits we used a food frequency questionnaire linked to a computerised program. Results. One hundred ve women had AGT (AGT) and 163 had normal glucose tolerance (AGT7). There was no difference between the two groups in demographic and clinical data, with the exception of pre-pregnancy BMI and weight gain both higher in AGT women. Also, all parameters referring to physical activity energy and diet (Kcal and diet components) were not statistically different between the two groups. After a multivariate analysis, only pre-pregnancy BMI (F-value 9.264, p 0.002) remained an independent predictor of 1-h plasma glucose. Conclusions. Our study suggests that high pre-pregnancy BMI confers a substantially high risk of AGT, independently of lifestyle during pregnancy.

Keywords: Physical activity, dietary habits, pregnancy, pre-pregnacy BMI, glucose tolerance

Introduction Pregnancy provides a physiologic test of the bodys glucoregulatory capacity involving progressive increase of maternal insulin resistance and concomitant compensatory hypersecretion and hyperplasia of pancreatic b-cell to ensure normal glucose tolerance. Nevertheless, about 8% of pregnant women develop gestational diabetes mellitus (GDM), the most common metabolic complication of pregnancy [1]. Women with GDM, as well as women with nondiagnostic abnormal glucose tolerance instead of (AGT) are at higher risk of perinatal morbidity and mortality [2,3]. More recently, the results of the Hyperglycemia and Adverse Pregnancy Outcome

(HAPO) study have shown that the relationship between glucose tolerance and adverse pregnancy events is a continuous one with no apparent threshold [4]. Besides obstetrical and neonatal complications, women with AGT and GDM are at greater risk for future development of type 2 diabetes. GDM and type 2 diabetes share the same principal pathophysiologic abnormalities (i.e. impaired insulin action and defective insulin secretion) [5] as well as the same risk factors, including positive family history of diabetes, non-white ethnicity and obesity [6]. Healthy lifestyle has a profound effect on the risk of diabetes, as regular physical activity and moderate weight loss signicantly reduces conversion from

Correspondence: Dr. Graziano Di Cianni, Department of Endocrinology and Metabolism, Azienda Ospedaliero-Universitaria Pisana, Ospedale di Cisanello, Via Paradisa, 2, I-56126 Pisa, Italy. Tel: 39-050-995649. Fax: 39-050-541521. E-mail: dicianni@immr.med.unipi.it ISSN 1476-7058 print/ISSN 1476-4954 online 2010 Informa UK, Ltd. DOI: 10.3109/14767051003678150

Lifestyle and glucose tolerance in pregnancy impaired glucose tolerance (IGT) to overt diabetes [7]. Whether such relationships between lifestyle and glucose tolerance during pregnancy also exists, is much less understood. Therefore, we designed this study to investigate the potential inuence of physical activity and dietary habits on glucose tolerance during pregnancy. Walking MET minutes=week

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3:3 walking minutes days per week Moderate MET minutes=week 4:0 moderate-intensity activity minutes days per week Vigorous MET minutes=week 8:0 vigorous-intensity activity minutes days per week The sum of all activities (walking, moderate and vigorous) represents the total weekly physical activity for each subject (MET minutes/week scores); then, data were converted in MET minutes 6 h71 6 week71. Based on these calculations, three categorical scores were arbitrarily dened: low (53 METs 6 h71 6 week71), moderate (321.9 METs 6 h71 6 week71) and high (!22 METs 6 h71 6 week71) [9]. Dietary habits To evaluate dietary habits, three trained dieticians, blinded to the GCT results, interviewed each woman by using a food frequency questionnaire linked to a computerised program (MetaDieta1, METEDA, S. ` Benedetto del Tronto, AP, Italy). The program includes a list of 1200 types of commonly consumed food categorised as small, medium and large portions, information on the frequency of food consumption as well as on cooking procedures. Once the complete information is collected, data are entered into the MetaDieta1 program allowing calculation of energy ` intake and dietary nutrient content (based on the tables of the National Institute of Nutrition and the Data Bank of Foods for the Epidemiological Studies of the European Institute of Oncology 1998). Statistical analysis Data are given as percentages or means + SD. ANOVA with post hoc Bonferroni analysis was used to assess univariate differences among continuous variables; the w2 test was used to compare observed frequency between groups for qualitative variables. Univariate and multiple logistic regression analyses were used to explore crude and adjusted effects of: energy intake, physical activity and maternal anthropometric parameters on 1-h plasma glucose during GCT. All statistical comparisons were considered signicant at p 5 0.05. Statistical analyses were performed using a statistical package (Statview SE; SAS Institute, Cary, NC) on a Macintosh computer (Apple, Cupertino, CA).

Materials and methods Study population This is an observational study involving a cohort of women who underwent a 50-g oral glucose challenge test (GCT) between 24 and 28 weeks of gestation. The study was performed according to the guidelines of the Third International Workshop Conference on GDM [8] and involved a total of 268 pregnant women consecutively referred to the Diabetes Section of the Department of Endocrinology and Metabolism of the University of Pisa, Italy. The study was approved by the Local Ethics Committee and informed consent was obtained from all women. According to the recommendations of the Regional Public Health Authority, all pregnant women were referred for a GCT between the 24th and 28th week of gestation. Plasma glucose level at 1-h GCT !140 mg/dl was used to dene abnormal glucose tolerance (AGT). Demographic, anthropometric and clinical data such as age, pre-pregnancy body weight, body weight gain during pregnancy, family history of diabetes and obstetric history were recorded for each pregnant woman. In all women, weight and height were obtained by direct measurement on the day of the screening, while pre-pregnancy weight was provided by each participant. Gestational age was estimated by the last menstrual period, conrmed or corrected by ultrasonography. Physical activity To evaluate current physical activity, all women were asked to ll in the short form of the International Physical Activity Questionnaire (IPAQ) [9]. This form addresses three types of activity: walking, moderate-intensity, and vigorous-intensity activities. The items in the questionnaire are structured to provide separate scores on the three types of physical activities (PA). Computation of the total score (expressed as METs 6 week71) requires recording of duration (in minutes) and frequency (days per week) of walking, moderate-intensity- and vigorousintensity activities. The following values were used for analysis of the IPAQ data: walking 3.3 METs, moderate PA 4.0 METs and vigorous PA 8 METs. Using these values, scores were calculated and ranked as:

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A. Bertolotto et al. with respect to pre-pregnancy BMI and weight gain (all p 5 0.05). Finally, on multivariate analysis including prepregnancy BMI, age, weight gain, METs /week, and Kcal/day, only pre-pregnancy BMI (F-value 9.264, p 0.002) resulted to be independently associated with 1-h plasma glucose (Figure 1). Discussion In spite of the fact that diet and exercise have been shown to be effective tools for prevention and treatment of all metabolic abnormalities [7], there is little information on the inuence of lifestyle on glucose tolerance during pregnancy. Epidemiological studies have examined the relationship between physical activity and the risk of gestational diabetes [1018]. Five of them [10,12,14,16,18] concluded that physical activity before pregnancy may decrease the risk of GDM but, results related to the role of physical activity during pregnancy remain suggestive although inconclusive. Equally,
Table I. Baseline clinical characteristics, metabolic parameters, according to GCT result. All (n 268) Age (years) Primiparous (%) Positive family history of diabetes (%) Pre pregnancy BMI (Kg/m2) Weight gain (kg) Smokers (%) 33.3 + 4 58 13 22.6 + 3.8 8 + 3.7 8 GCT (n 105) 33.8 + 4.2 56 13.5 23.5 + 4 8.5 + 4.3 7.4 CGT7 (n 163) 33 + 4.5 60 12.8 22 + 3.6* 7.6 + 3.3** 8.6

We studied 268 pregnant women who underwent GCT at 27 + 6.9 week of gestation; 105 of them (39%) were GCT positive (GCT) and 163 (61%) GCT negative (GCT7). No difference was present in demographic and clinical data between the two groups. Pre-pregnancy BMI and weight gain during pregnancy were both (p 5 0.05) higher in GCT women (Table I). The estimated physical activity was on average 15.4 + 15.1 METs 6 week71 with no differences between GCT and GCT7 (GCT: 16.1 + 16.2 METs 6 week71 and GCT7: 15.2 + 14.5 METs 6 week71). One-hour GCT was not different among women with low (131 + 30 mg/dl), moderate (132 + 28 mg/dl) and high (130 + 26 mg/dl) physical activities. Mean daily energy intake in the whole cohort was 1987 + 466 Kcal (CHO 44%, total fat 41%, proteins 15%, cholesterol intake 217 + 85 mg and bres 17.8 + 5.3 g). As reported in Table II, none of the parameters (Kcal and diet components) was statistically different between GCT and GCT7 groups. GCT occurred in 54% of the overweight/obese (BMI ! 25 kg/m2) women and in 36.8% of those with normal weight (BMI 5 25 kg/m2; p 5 0.002). One-hour plasma glucose progressively increased across BMI categories: 520 126 + 27.4 mg/dl, 2025 129.4 + 26.6 mg/dl, 2530 135 + 29.5 mg/dl and 430 142.5 + 28.6 mg/dl (p 5 0.01). We found no difference in 1-h GCT plasma glucose even after categorising our population in normal weight with high - (METs 6 h71 6 week71 ! 22) and low - physical activity (METs 6 h71 6 week71 5 3) and overweight/obese with high- and lowphysical activity (Table III). Univariate regression analyses failed to show any signicant association between physical activity and dietary habits, while a positive association emerged

GCT, positive glucose challenge test (abnormal glucose tolerance); GCT7, negative glucose challenge test (normal glucose tolerance); BMI, Body Mass Index. Data are expressed as mean + standard deviation (SD). *p 0.02 GCT vs. GCT7. **p 0.03 GCT vs. GCT7.

Table II. Nutritional data according to GCT result. All Daily energy intake (Kcal/day) Carbohydrates (CHO) (g/day) Complex CHO (g/day) Rened CHO (g/day) Total fats Saturated fatty acids (g/day) Monounsaturated FA (g/day) Polyunsaturated FA (g/day) Proteins (g/day) Cholesterol (mg/day) Fibres (g/day) 1987 + 466 233 + 65.5 (44%) 140.3 + 48.3 78.7 + 26 90.6 + 22 (41%) 24.7 + 7.2 52.6 + 14.7 9.7 + 2.5 75.5 + 20 (15%) 217 + 85 18.5 + 5.7 GCT 1976 + 410 228.7 + 64.3 (44%) 134 + 41.5 81.2 + 33.2 90.5 + 20.7 (41%) 24.5 + 7.5 52.8 + 13 9.7 + 2.7 75.8 + 19 (15%) 212.8 + 73.2 18.5 + 6.1 GCT7 2043 + 400 243.8 + 65 (45%) 146 + 50 83.2 + 24.3 90.7 + 22.6 (40%) 25.1 + 7 52.3 + 15 9.6 + 2.6 77 + 17.3 (15%) 226 + 81.4 18.6 + 5.6

Data are expressed as mean + standard deviation (SD). GCT, positive glucose challenge test (abnormal glucose tolerance); GCT7, negative glucose challenge test (normal glucose tolerance).

Lifestyle and glucose tolerance in pregnancy

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126 + 23 136 + 32 151 + 35

132 + 29 137 + 24 139 + 27

NS NS NS

Data are mean + SD. 1-h PG, 1-h plasma glucose after glucose challenge test; BMI, Body Mass Index. Normal weight BMI 5 25 kg/m2, Over weight BMI ! 25 5 30 kg/m2, Obese BMI !30 kg/m2. High physical activity !22 METs h71 week71. Low physical activity 53 METs h71 week71.

Figure 1. Correlation of pre-pregnancy BMI and 1-h plasma glucose during Glucose Challenge Test in 268 pregnant women. Y 19.224 0.026 6 X; R2 0.034.

while pre-pregnancy diet with low bres or high glycaemic load was associated with an increased risk of GDM [19], the role of diet during pregnancy is not well dened [20]. In our study we have analysed dietary habits and physical activity during pregnancy to determine their effects on glucose tolerance. In order to include all degrees of glucose intolerance, we have categorised our population based on 1-h GCT. This decision was based on the notion that such alteration is already associated with a maternalfetal morbidity, similar to that of GDM [4]. Our results seem to discount an inuence of dietary habits and physical activity on GCT. Women with and without altered GCT have no difference in dietary caloric intake and/or macronutrient components. Likewise, we did not observe any difference regarding physical activity in our pregnant women. Even when interaction between body weight and physical activity was considered, no difference in 1-h GCT could be found. On the contrary, our multi-

variate analysis conrms the role of pre-pregnancy BMI independently of lifestyle during pregnancy. Obviously, we cannot determine to which extent prepregnancy dietary habits and physical activity may have contributed to BMI at the time of conception. Still, our data underline the relevance of the preconception metabolic status. This impression is supported by the nding that, irrespective of diet and physical activity, a positive GCT was more common among the overweight women than among women with normal body weight. Since concomitance of obesity and alterations of glucose tolerance may exert a synergistic effect on pregnancy outcome [2123], our study suggests that the best time to address and prevent such complications must occur prior to conception. Prevention before, rather than during pregnancy, offers the best option for successful maternal and fetal outcomes. Therefore, more research in larger populations is needed to explore the effectiveness of intervention on body weight reduction by women within their reproductive age. In interpreting these results some limitations should be kept in mind. First of all, we would underline that the simple size is small to reach denitive conclusions about the role of physical activity and dietary habits on glucose homeostasis during pregnancy. Moreover, our assessment of both physical activity and diet remain, at its best, a semiquantitative one and the explored period is only a small window on a much longer period of gestation. We cannot rule out progressive accommodation in both the degree of physical activity and calorie ingestion from the rst week of gestation to the time of GCT. Also we cannot judge if lifestyle on early weeks of pregnancy may have the same impact as in third trimester. However, this can only emphasise the importance of the pre-pregnancy health status. Finally, in spite of the fact that we have not been able to show a relationship between GCT results and lifestyle parameters, this should for no reason distract from the importance of careful dietary behaviour and adequate physical activity during pregnancy. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper.

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