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Physical activity and maternal obesity: cardiovascular adaptations, exercise recommendations, and pregnancy outcomes
Michelle F Mottola
Although a healthy lifestyle approach is intuitive for obese pregnant women, no guidelines currently exist to manage these women throughout pregnancy. Women who are medically prescreened for contraindications can engage in a walking program three to four times per week, starting at 25 min per session and adding 2 min per week until reaching 40 min, with sessions continuing until delivery. A target heart rate of 102124 beats per minute should be promoted for women 2029 years of age and a rate of 101120 beats per minute for women 3039 years of age. A pedometer step count of 10,000 steps per day is suggested as a goal, as this level of activity provides important health benets. Combining healthy eating with a walking plan prevents excessive weight gain during pregnancy and promotes a healthy fetal environment.
2013 International Life Sciences Institute

INTRODUCTION Women of childbearing age are at a greater risk of obesity because excessive weight may be gained during pregnancy and retained after delivery. Guidelines recommend that obese (prepregnancy body mass index [BMI] 30.0 kg/m2) women gain between 11 lb and 20 lb (59 kg) during pregnancy, at a rate of weight gain of 0.40.6 lb (0.20.3 kg) per week during the second and third trimesters, assuming an initial weight gain of up to 4.4 lb (2 kg).1 Prevention of excessive weight gain during pregnancy is highly recommended to reduce the risk of obesity, gestational diabetes mellitus, type 2 diabetes, hypertension, and cardiovascular disease in women of childbearing age.2 The lifestyle that leads to obesity and excessive weight gain is often marked by an unhealthy diet and a lack of physical activity. Obesity has a direct eect on indicators of health and chronic disease risk, not only for the pregnant woman but also the developing fetus.3,4 Although the practice of a healthy lifestyle and the prevention of excessive weight gain are both important

during pregnancy, there are currently no recommendations on nutrition and physical activity to guide healthcare workers in the management of the obese pregnant woman. This article discusses cardiorespiratory adaptations during pregnancy, exercise, and obesity, and provides exercise guidelines and recommendations for a healthy lifestyle approach for obese pregnant women, including a discussion of pregnancy outcome. CARDIORESPIRATORY CHANGES DURING PREGNANCY AND RESPONSES TO EXERCISE Pregnancy may oer protection from cardiovascular disease in women at low risk of obstetric complications, as evidence suggests that the maternal cardiovascular system is remodeled in early gestation by an estrogenmediated reduction in vascular tone, which leads to a primary reduction in afterload and an increase in venous capacitance,5 reected in increased resting cardiac output of about 50% over nonpregnant values.6 An increase in ventricular cavity dimension without an increase in wall

Aliation: MF Mottola is with the R. Samuel McLaughlin Foundation Exercise & Pregnancy Laboratory, School of Kinesiology, Faculty of Health Sciences, and the Department of Anatomy, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada. Correspondence: MF Mottola, R. Samuel McLaughlin Foundation Exercise & Pregnancy Laboratory, The University of Western Ontario, London, Ontario, Canada N6A 3K7. E-mail: mmottola@uwo.ca. Phone: +1-519-661-2111, ext. 88366. Fax: +1-519-661-2008. Key words: exercise prescription, healthy lifestyle, obese pregnant women, walking
doi:10.1111/nure.12064 Nutrition Reviews Vol. 71(Suppl. 1):S31S36 S31

thickness,7 an increase in aortic capacitance,8 and a reduction in peripheral vascular resistance all occur around the same time.9 In addition, the early pregnancy-induced changes in cardiac output are thought to occur in response to an increase in resting heart rate (HR), as most of the 1520 beat increase in HR over nonpregnant values occurs in the rst trimester.10 Stroke volume also increases by approximately 10% at the end of the rst trimester11 and occurs before signicant enhancement in maternal blood volume,5 which may increase by up to 50% above nonpregnant values by late pregnancy.12 Pregnancy-induced hormones that reduce peripheral vascular resistance also activate the renin-angiotensin system, leading to increased secretion of an antidiuretic hormone (arginine vasopressin) to retain uid and maintain or slightly reduce blood pressure.5 Similarly,there are pregnancy-induced adaptations to the maternal respiratory system as remodeling and expansion of the thoracic cage occur, leading to a higher diaphragmatic midposition,13 which results in a reduction in residual volume and expiratory reserve volume. This leads to an increase in inspiratory capacity, though the eect on vital capacity is minimal.14 One of the most substantial physiological pregnancy-induced changes, which possibly serves to protect the fetus, is an increase in respiratory sensitivity to carbon dioxide. This change is observed early in pregnancy and causes an increase in tidal volume and minute ventilation, leading to a reduction in arterial carbon dioxide tension and an augmentation in arterial oxygen tension.15 These changes create a buer zone, possibly to protect the fetus from acute elevations in maternal carbon dioxide,16 and the early increase in maternal minute ventilation may prevent fetal hypercapnia and acidosis throughout pregnancy.17 Many healthy pregnant women complain of respiratory discomfort (dyspnea), especially in late pregnancy, both at rest and after exertion.18 Perceptions of respiratory eort and dyspnea appear to be reduced during submaximal steady-state exercise throughout gestation.19 It may be that the maternal anatomical and mechanical adaptations of the respiratory system reduce airway resistance, preserve breathing mechanics, and minimize the eort of ventilation, thereby reducing dyspnea with the concomitant increase in minute ventilation during exercise.20 Resting oxygen uptake (expressed as mL/kg/min) reects the increase in body mass during pregnancy and thus declines slightly during each trimester.21 Pregnancy and aerobic conditioning are biological processes that involve striking physiological adaptations that may occur in the same direction or in opposite directions, depending on the specic variable being studied.21 Although absolute oxygen uptake is well preserved in women who maintain physical activity, maximum exerS32

cise stress testing is not recommended during pregnancy. Functional cardiac reserve (maximum HR minus resting HR) is decreased during pregnancy because of elevated resting HR, and the magnitude of heart rate reserve (HRR) is also decreased compared with nonpregnant values.21 Because maternal HR increases at a slower rate in response to increases in exercise intensity, target HR zones for exercise prescription must be derived from pregnant women. The eciency of standard submaximal exercise for body-weight-supported exercise, such as cycling, does not change during pregnancy, yet for weight-bearing exercise, such as walking, the energy requirement increases in proportion to the maternal mass gain.22 OBESITY AND CARDIORESPIRATORY ALTERATIONS Obesity may inuence pregnancy by causing major health risks to both the mother and the fetus, as obese pregnant women are at increased risk of cardiovascular disease, gestational diabetes, and delivering large- or small-for-gestational-age infants. Moreover, obese women may have more complications during pregnancy and birth.3 In addition, recent evidence indicates that the fetal environment, especially as related to maternal prepregnancy BMI, and excessive gestational weight gain both increase risk factors for future chronic disease in the ospring.4 Obesity in the nonpregnant individual aects every major organ system, lowering the work rate (amount of work done at a given HR) and oxygen uptake and independently decreasing the mechanical eciency of breathing as a result of both the increased deposition of adipose tissue on the chest and abdomen and the decreased compliance of the ribcage, resulting in the characteristic rapid shallow breathing.23 Obesity also increases metabolic cost due to the increase in the energy needed to move larger limbs, the increased work of breathing, and a decreased peripheral motor eciency.20 Cardiorespiratory responses to and work eciency of graded treadmill exercise in healthy nonpregnant women (n = 14), in normal-weight (prepregnant BMI 18.9 24.9 kg/m2) pregnant women (n = 20), and in obese (prepregnant BMI 30.0 kg/m2) pregnant women (n = 20) matched for age were compared to assess the eects of obesity on pregnant women at 1620 weeks of gestation while exercising.24 Treadmill exercise was chosen instead of bike exercise to simulate normal daily living tasks. The results showed that exercise duration and peak treadmill speed were lower in pregnant normal-weight women (23.9 4.9 min; 1.6 0.2 m/s; P < 0.01) than in nonpregnant women (33.7 4.9 min; 2.0 m/s) and were further reduced in pregnant obese women (19.6 2.8 min; 1.4 0.1 m/s; P < 0.01), indicating a limitation to performing exercise, although HR and work rate were not
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signicantly dierent between groups.24 In addition, the ventilatory response both at rest and to exercise increases during pregnancy and is further augmented by obesity. However, contrary to the ventilatory response, the normal increase in HR and the concurrent diminished HRR seen in normal-weight pregnant women during exercise was not further aected by obesity at standardized submaximal exercise levels of 50 (mild intensity) and 100 (moderate intensity) watts.24 It was concluded that healthy obese pregnant women have the aerobic capacity to undertake structured walking activities at standardized submaximal levels,which lends support to the feasibility of exercise prescription for this population group.25 EXERCISE GUIDELINES FOR OBESE PREGNANT WOMEN In Canada, a medical prescreening tool called the PARmed-X for Pregnancy26 can be used by healthcare providers to screen for contraindications to exercise and to provide guidelines for exercise prescription based on the FITT (frequency, intensity, time, and type of activity) principle.26 It provides target HR ranges, based on age, that were validated in pregnant normal-weight women at an intensity of 6080% of maximum oxygen capacity27 to monitor intensity. For overweight and obese pregnant women who are medically prescreened, this intensity may be too strong and may prevent them from exercising. The American College of Sports Medicine28 suggested that previously sedentary overweight and obese pregnant women should start an aerobic exercise program at an intensity equivalent to 2039% of maximum aerobic (heart and lung) capacity, which indicates the lowest level of physical activity that would provide health benets.28 Using a graded treadmill exercise test in 106 pregnant overweight (prepregnancy BMI 25.029.9 kg/m2) and obese (prepregnancy BMI 30.0 kg/m2) women, target HR zones based on age were validated at the lower exercise intensity suggested by the American College of Sports Medicine.29 Based on the results, target HR zones of 102124 beats per minute (bpm) for women 2029 years of age and 101120 bpm for women 3039 years of age were suggested for use in exercise intensity prescription in medically prescreened, previously sedentary overweight and obese pregnant women.29 Walking appears to be the most popular activity for pregnant women.30 The frequency of other types of physical activity decreases as pregnancy progresses, but the frequency of walking has been shown to increase.30 These observations suggest that walking is an important aerobic activity that should not be ignored, as it may help maintain aerobic tness in pregnant women. Ruchat et al.31 investigated the eect of a maternal walking program of low intensity (30% HRR) or vigorous intensity (70% HRR) on cardiorespiratory responses to
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standard submaximal treadmill exercise in normal-weight (prepregnancy BMI 18.524.9 kg/m2) women before and after an 18-week intervention, starting at 1620 weeks of pregnancy. The results suggested that both exercise intensity groups experienced an improvement in submaximal aerobic capacity, with greater improvement observed in the vigorous-intensity group. However, women in both groups presented similar gestational weight gain, and all delivered healthy babies, showing that prenatal walking of low or vigorous intensity, combined with healthy eating, is an important component of a healthy pregnancy in normal-weight women.31 It would seem reasonable to suggest that walking, combined with a healthy dietary plan, would also be benecial in obese pregnant women at low obstetric risk. The American College of Obstetricians and Gynecologists32 suggests that medically prescreened pregnant women can exercise on most if not all days of the week, while the latest guidelines for Americans suggest that exercise be spread throughout the week.33 However, the frequency of structured exercise,especially in late pregnancy, was found to be a determinant of birth weight in a casecontrolled study of 526 women.The odds of giving birth to a small-for-gestational age baby was 4.6 times more likely for women who engaged in structured exercise more than ve times per week and 2.6 times more likely for women who engaged in structured exercise two or fewer times per week, regardless of exercise intensity or duration of activity.34 Small-for-gestational-age babies are at risk for obesity and cardiovascular disease later in life.4 Structured exercise performed three to four times per week,with a day of rest between each exercise day, would seem ideal and may also help reduce fatigue.26 Overweight and obese pregnant women who, after medical prescreening, wish to start a structured walking program should initially attempt 25 min per session, adding 2 min per session each week until reaching 40 min per session,35 which can be maintained until delivery, even if it is necessary to reduce the intensity or to include rest intervals.25 The best time to progress is in the second trimester, when the risks and discomforts of pregnancy are lowest.25,26 Another way to conrm the appropriate intensity is to use the talk test, which indicates that the intensity is appropriate if an obese pregnant woman can carry on a conversation while walking.26 HEALTHY LIFESTYLE APPROACH FOR OBESE PREGNANT WOMEN Although a healthy lifestyle approach is intuitive for obese pregnant women, no guidelines currently exist to help manage these women throughout their pregnancy. Gestational weight gain guidelines exist that suggest women who are classied as obese before pregnancy
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(BMI 30.0 kg/m2) should gain between 11 lb and 20 lb (59 kg) at a rate of weight gain of 0.40.6 lb (0.20.3 kg) per week during the second and third trimesters, assuming an initial weight gain of up to 4.4 lb (2 kg).1 Excessive weight gain above the recommended range for pregnant women may result in excess fat stores along with the associated health risks for mother and fetus.36 A healthy lifestyle is a balance between eating nutritious foods (not eating for two but eating twice as healthy), watching portion sizes, and being physically active.36 A recent study examined the eects of a Nutrition and Exercise Lifestyle Intervention Program (NELIP) on the prevention of excessive weight gain in overweight (prepregnancy BMI 25.029.9 kg/m2) and obese (prepregnancy BMI 30.0 kg/m2) pregnant women. The goals of the nutrition component of NELIP were to individualize the total energy intake as follows: 1) energy intake of approximately 2,000 kcal/day (8,360 kJ/ day), with a restriction not exceeding 33% of total energy intake; 2) total carbohydrate intake of 4055% of total energy intake, with carbohydrate intake distributed throughout the day; 3) three balanced meals and three to four snacks per day, emphasizing complex carbohydrates and low-glycemic-index foods; 4) total fat intake individualized to 30% of total energy intake (substituting monounsaturated fatty acids for saturated and trans-fatty acids); 5) protein intake of 2030% of energy; and 6) micronutrient and uid intakes in accordance with those recommended for pregnant women.35 The nutrition component was based on medical nutrition therapy given to women with gestational diabetes. The exercise component of NELIP was based on previous work29 and consisted of a mild walking program (30% of HRR) to facilitate compliance. All women were medically prescreened using the PARmed-X for Pregnancy,26 and all started the program between 16 weeks and 20 weeks of gestation. The exercise program began with 25 min of walking per session, three to four times per week. Each subsequent week thereafter, the exercise time increased by 2 min, until a maximum of 40 min was reached and maintained until delivery.35 Pedometers were worn to count steps, and steps were recorded in exercise logs to monitor activity.35 Comparison of preintervention (1620 weeks of gestation) with postintervention (3436 weeks of gestation) data showed that NELIP participants decreased their mean daily total energy intake from 2,228.0 474.6 kcal to 1,900.2 343 kcal, and daily carbohydrate intake dropped from 318.5 155.1 g to 259.1 93.9 g, while the percentage of daily energy from protein increased from 16.9 2.4% to 18.4 2.3% (P < 0.05). The average daily pedometer step count before the intervention program was 5,677.6 1,738.0 steps. The step counts at 25 min (length of initial exercise session) were, on average,
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2,861 287.7 steps, which increased to 4,406.9 461.0 steps at 40 min per session. When mean daily steps were added to the steps taken at the end of the program (40 min of structured walking), the women were taking more than 10,000 steps, which brought them from a preintervention rating of low active or sedentary on the activity index used to active at the end of the program.37 Maintaining a physical activity index rating of active or above is recommended to achieve a healthy lifestyle in the nonpregnant population.37 In addition, the average HR of the NELIP participants was 118 6.8 bpm, which was within the range for aerobic benets to occur.31 In terms of birth outcome, the women in the NELIP program were compared with a cohort of women matched by prepregnancy BMI, maternal age, and parity (matched 4 to 1). Infant birth weight and gestational age at delivery did not dier between the NELIP and the matched control women. However, when stratied by BMI, 3.2% of the overweight NELIP women had babies weighing between 4.0 kg and 4.5 kg, compared with 18% of the matched controls (P = 0.048). No babies born to the NELIP women weighed less than 2.5 kg, whereas 3.5% of the babies born to the matched controls had birth weights below 2.5 kg. The rate of cesarean delivery was similar in both groups: 4.6% among the NELIP women and 7% among the matched controls. In addition, 3% of NELIP women developed gestational diabetes mellitus (no insulin required), compared with 7.8% (with 55% of those needing insulin) of those in the matched control group.35 Excessive weight gain was successfully prevented in 80% of the NELIP women, many of whom had diculty with weight loss programs in the year before the current pregnancy.36 This is an important nding because many of the multiparous women (84%) had experienced excessive weight retention (10.3 kg) from previous pregnancies. In addition, before taking part in the NELIP program, many participants had already experienced excessive weight gain (4.5 kg) that was substantially more than the suggested guideline of 2 kg for women in the rst trimester.1 However, while in NELIP, subsequent weight gain was on average 6.8 4.1 kg (0.38 0.2 kg/week), with a total pregnancy weight gain of 12.0 5.7 kg and excessive weight gain occurring before NELIP began, at 16 weeks of gestation.35 Excessive weight gain during pregnancy is an important issue that needs further examination, especially with regard to pregnancy outcome. Davenport et al.38 examined whether timing of excessive weight gain, before 16 weeks (usual time for the NELIP intervention to be initiated), after 16 weeks (i.e., during the intervention), or at both time points, was important when assessing birth weight and body fatness of newborns at delivery. In a cohort of 172 women, 33.7% of whom were normal weight (prepregnancy BMI 18.524.9 kg/m2), 33.7% of whom
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were overweight (prepregnancy BMI 25.029.9 kg/m2), and 32.6% of whom were classied as obese (prepregnancy BMI 30.0 kg/m2), all women were initiated into the NELIP between 16 weeks and 20 weeks of gestation. Weight gain was assessed before the intervention (up to 1620 weeks of gestation) and from the start of the intervention to delivery (after 1620 weeks of gestation). Women were stratied, based on prepregnancy BMI category, as follows: 1) appropriate gestational weight gain that was within the Institute of Medicine recommendations1 for the rst and second halves of pregnancy (overall appropriate); 2) appropriate gestational weight gain in the rst half of pregnancy, but excessive gestational weight gain in the second half of pregnancy (late excessive); 3) excessive gestational weight gain in the rst half of pregnancy, but appropriate gestational weight gain in the second half of pregnancy (early excessive); and 4) excessive gestational weight gain throughout pregnancy (overall excessive). Infant birth weight and adiposity (according to the Catalano et al.39 equation) were compared between groups. After controlling for maternal prepregnancy BMI, maternal age, infant gestational age at delivery, and gender of the infant, it was found that those women who gained excessively prior to the intervention and then gained within the Institute of Medicine guidelines1 (early excessive) and those women who gained excessively throughout pregnancy (overall excessive) gave birth to babies with excess normative infant body fat.38 In addition, the timing of excessive maternal weight gain, specically during the rst half of pregnancy, was a stronger predictor of infant body fat at birth than total maternal weight gain,regardless of prepregnancy BMI.38 These preliminary results warrant further research on the timing of healthy lifestyle interventions and the impact of such interventions on prevention of excessive gestational weight gain and pregnancy outcomes. CONCLUSION Women of childbearing age are at a greater risk of obesity because excessive weight may be gained during pregnancy and retained after delivery. Therefore, adherence to recommendations about the amount of weight a woman should gain during pregnancy (with particular attention to BMI status) may prevent chronic disease risks for a mother and her ospring. Currently, there are no recommendations on nutrition and physical activity to guide healthcare workers in the management of obese pregnant women. Healthy obese pregnant women have the aerobic capacity to undertake structured walking activities, which lends support to the feasibility of exercise prescription for this population group. By adopting the FITT principle of exercise prescription, it is suggested that
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obese pregnant women who are medically prescreened for contraindications to exercise can engage in physical activity three to four times per week (Frequency), using a target HR range of 102124 bpm for women 2029 years of age and a range of 101120 bpm for women 3039 years of age while maintaining the ability to carry on a conversation (intensity), starting with 25 min per session and adding 2 min per week until sessions reach 40 min (time per session), and continuing until delivery. Walking (type) is the most popular activity among pregnant women and can be monitored by using pedometer step counts, which can be a great motivator.An aim of approximately 10,000 steps per day is suggested in order to obtain health benets. Combining healthy eating with a walking plan will help prevent excessive weight gain and promote a healthy fetal environment and pregnancy outcome. Further research is necessary to determine the optimal timing of initiating healthy lifestyle interventions to prevent excessive gestational weight gain in obese pregnant women and the subsequent impact on infant health and body fatness.

Acknowledgments Funding. Funding provided by the Canadian Institutes of Health Research (CIHR) and the Rx&D Health Research Foundation of Canada. Declaration of interest. The authors have no relevant interests to declare.

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