1. Exercise and Gestational Diabetes Moving physical activity into standard of care for diabetes and lifestyle management

2. A Perspective on Exercise 20 year perspective and journey Work in the late 1980s

3. A Perspective on Exercise My work at Sansum vs. my own two kids / pregnancies Who is at risk? Training throughout pregnancy ◦ Just “who” can really exercise? Monitoring in all three trimesters Modifying workloads – applying real exercise standards to the pregnancy population

4. GDM in the News

5. More than 250,000 women who give birth have diabetes Harms developing baby – but increases risk of diabetes later in life Costs are 55% higher for delivery in diabetic women

6. GDM in the News High BG numbers for fasting, post prandial, or OGTT now pose greater risks Gaining weight in first trimester are at higher risk of GDM

7. Theme for this presentation What’s changed in exercise programming for pregnancy in general over the past 20 plus years? How can we apply these types of programs to GDM prevention and therapy?

8. Goals for Exercise Exercise through entire pregnancy Manage glucose and stress hormone levels Develop a safe weight training program with modifications Stay with low impact aerobic training Pilates and Yoga are gaining popularity Post partum exercise – weight loss, depression, improved fitness, life style habits

9. Goals of Exercise #1 – Regulate blood sugars – both acute (post exercise), and chronic (lower A1c) #2 – Regulate body weight gain – good weight vs. excess fat #3 – Maintain good blood flow – reduce edema, blood pressure increases, etc. #4 – Maintain or improve lifestyle. Exercise sets the stage for health status of mother and baby

10. Exercise in the Equation So how do we integrate exercise into a pregnancy for women at risk for GDM that is safe, effective, and may cause a shift in lifestyle habits that would last after the baby is born?

11. Recent info on Exercise and Pregnancy Amazon shows a lot of books on the subject – so the information is out there.

12. Exercise and GDM Tieu, J. Dietary advice in pregnancy for preventing GDM. Chochrane Database Syst. Rev. 2008. ◦ Low GI diets improved baby birthweights ◦ One trial used combination of standard exercise (?) with diet ◦ However – results in general were inconclusive deBarros, MC, et al. Resistance exercise and glycemic control in women with GDM. AJOG – 2010 ◦ 21% of exercise vs. 56% required insulin, 80% of EX maintained BG levels throughout trial Tobias, DK – PA before and during pregnancy and risk of GDM. Diabetes Care. 2010. ◦ Pre pregnancy PA in 34,900 participants – OR =.45 of highest / lowest categories. EX in early pregnancy in 4,400 women was protective OR =.76. PA assoc. with sig. reduction in GDM. Clapp, JF. Effects of diet and exercise on insulin resistance in pregnancy. Met. Synd. Relat. Dis. 2006 ◦ Decrease in maternal and fetal weight ◦ Lowers insulin resistance, lowers blood glucose

13. Current Info on Exercise and Diabetes Exercise must be important – as many web sites are including it as part of the “prevention” formula

14. Sam’s Club and Prevention What you get: For $99, buyers of the program get an annual subscription to a web-based program that includes an at-home blood screening test that tracks an individual's cholesterol, blood sugar and hemoglobin levels. Buyers also get access to a 24/7 nurse line, two health coaching sessions, recommended prevention screenings, schedule and alerts based on age, gender and risks and a physician summary that can be shown to a doctor.

15. Exercise and GDM Prevention 1992 case study on the use of exercise and the prevention of GDM ◦ Diagnosed in first pregnancy – exercise to reduce symptoms ◦ Exercise in first trimester of second pregnancy – less weight gain, higher fitness, and no GDM diagnosis at 24 weeks. ◦ Compare first to second pregnancies – clear that exercise had effect on outcome ◦ Eric P. Durak, MSc, Lois Jovanovic, MD, Charles M. Peterson, MD. The Use of Exercise to Prevent Gestational Diabetes Mellitus: A Case Report. Sports Medicine, Training, & Rehab Journal. 3:230, 1992

16. Exercise and GDM for Today What do we know about exercise and GDM today? Can we prevent diabetes through exercise? Can we prevent GDM through exercise http://www.gestationaldiabetes.org/Treatment/exercise.html http://www.livestrong.com/article/112764-exercise-gestational-diabetes/

17. Exercise in the Equation What’s missing? ◦ Comprehensive method of using exercise as part of prevention ◦ Numbers are great – but using exercise systematically can reduce numbers even more ◦ How can we construct the “perfect” exercise program that can improve on the prevention concept? ◦ Who’s qualified to conduct exercise programs for “at risk” diabetic or pre-diabetic pregnant women?

18. Exercise in the Equation Current thoughts on exercise for pregnancy ◦ Upper body ergometry is still a standard ◦ Many types to chose in health club setting

19. Other forms of Exercise In the Home ◦ Walking program ◦ Swimming ◦ Strength training and stretching At work ◦ Walking / machine work With friends ◦ Small group fitness program through pregnancy

20. An Exercise Prescription Exercising based on HR and PRE Exercising multiple times per day Training for BG control Time of day to best exercise Biomechanics and balance issues Type of aerobic machine Weight lifting for pregnancy ◦ Functional performance training for two

21. An Exercise Prescription Times per week = 3-5 ◦ Work up from 1-2 times at start ◦ May walk 2X per day for BG control ◦ Monitor BG levels post exercise Training Type ◦ Breathing and imagery training (BG response) ◦ Linear movement patterns (front/ back, side to side) ◦ Light to moderate stretching  Yoga programs  Standing Pilates

22. Strength through Pregnancy Weight lifting for pregnancy ◦ Functional performance training for two ◦ Small muscle group exercise ◦ Sets and reps ◦ Rest period ◦ Hydration / rehydration ◦ Tubing, medicine ball, balance ◦ http://www.youtube.com/watch?v=mPzSniJZv4Y&feature=r elated - Exercise http://www.youtube.com/watch?v=mPzSniJZv4Y&feature=r elated ◦ with Dr. Kathy

23. Strength in Pregnancy Modifying range of motion in exercise (squat), and even picking up weights.

24. Strength in Pregnancy Use of rubber tubing training Use of body weight exercises ◦ Wall push ups ◦ Body weight fitness ball squats

25. Yoga for Pregnancy One of the best types of exercises for increased oxygen, range of motion, pain reduction, and relaxation

26. Yoga and Pregnancy Working on range of motion while keeping a wide stance for balance

27. Pilates and Pregnancy Pregnancy exercises for upper body strengthening that do not affect the abdominal area

28. Pilates and Pregnancy Post partum core training exercises Pilates instructor KarenaLineb ack

29. Contraindications ContraindicationSolution Toxemia / high blood pressureBreathing exercises, stretches, ITP type exercise program Ketones / excess proteinsMD recommendations Edema / pain in feetWater exercise / foot (general) massage Low back pain / lordosisPosture exercises, stretches, Pilates training, massage Joint laxityWater training, slow rhythmic exercises, walking program, aerobic machines

30. Cost of exercise program 3 pairs of neopreme dumb bells ◦ 5 lb, 8 lb, 10 lb. $50-55.00 Yoga Mat$25.00 3 rubber tubing cords$18.00 45-55 CM fitness ball$25.00 1-2 exercise videos$20.00 Good pair of shoes$55.00 ◦ TOTAL$150-200.00

31. Is exercise part of the “standard of prenatal care”? Referrals / information from doctors Oncologists need a listing of qualified instructors from health clubs, Pilates studios, and private practice trainers Work with physical therapist and pre natal nurses in terms of medical issues

32. Diet and GDM What about diet – what is critical in terms of changing metabolism? Movement to Ornish / vegetarian ADA general recommendations for diet to manage diabetes Hidden sugars – substitutes and HFCS

33. Facebook – diet and pregnancy

34. Holistic medicine and GDM Holistic medicine – is there a place for GDM prevention? ◦ Stress reduction techniques ◦ Use of pre-natal supplements ◦ Organic foods

35. Self care – self management How about self care – what can women do to improve their odds of prevention? ◦ Daily food logs ◦ Visits to RD in first trimester ◦ Develop a life-long exercise program ◦ Learning to avoid diabetes-related risks

36. Working with the Exercise Community What about the diabetes community – how can they incorporate exercise? Work with local health clubs and YMCAs to provide programs Computer based outcomes for glucose / body weight / A1c / lipids, etc. Follow ups after pregnancy

37. Fitness for the long haul Long term health consequences of regular exercise ◦ Develop all exercise plans in first trimester ◦ Have initial instruction and supervision as needed ◦ Write down fitness and diabetes outcomes! ◦ Monitoring of BG pre and post exercise – see trends over weeks (see graph next slide)

38. BG monitoring over time

39. Future GDM and Wellness Issues Future thoughts and action plan for exercise and GDM ◦ Health club referrals ◦ Bi-lingual education programs for exercise ◦ Information packet / referral pad in OB-GYN offices

40. Questions ? ? ? ? ? ? ? ? ? ? ? ? ?