Running head: USING EXERCISE 1

Using Exercise for Gestational Diabetes: Implications for Practice

Jeanne Zamith

University of South Florida

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Using Exercise for Gestational Diabetes: Implications for Practice

Gestational diabetes mellitus (GDM) is a type of diabetes that occurs during pregnancy

and is considered one of the most common complications that arises from pregnancy (Buchanan,

Xiang, & Page, 2012). The effects of GDM can affect both the mother and the neonate; women

who are diagnosed with GDM and are left untreated postpartum have a 20%-60% risk of

developing type 2 diabetes mellitus 5-10 years after pregnancy (Xiang, Kjos, Takayanagi, Trigo,

& Buchanan, 2010). Infants born from mothers with GDM have an increased risk of excessive

fetal growth, clinical neonatal hypoglycemia, hyperbilirubinemia, polycythemia, and stillbirth

(Buchanan et al., 2012). At adolescence, the infants born from mothers diagnosed with

gestational diabetes were at higher risks of developing childhood obesity and having an overall

higher body mass index (BMI) than the offspring of nondiabetic mothers (Buchanan et al.,

2012). Due to the risks associated with GDM, researchers sought to discover a feasible way to

reduce the incidence of GDM, and thus far, regular exercise has shown to be successful in

reducing the risks, both short-term and long-term. Therefore, a pertinent question to address

would be: in pregnant women, how does participation in regular exercise compared to a

sedentary lifestyle affect the incidence of GDM over one year?

Synthesized Literature Search

PubMed and CINAHL were searched in order to find randomized controlled trials (RCT)

concerning exercise and its role in preventing GDM. The National Guideline Clearinghouse was

utilized to find clinical guidelines pertaining to GDM. Key search terms included gestational

diabetes mellitus, diabetes, hyperglycemia, pregnancy, exercise, and physical activity. The

searches were limited to publication dates between 2012 and 2017.

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The National Institute for Health and Care Excellence (NICE, 2015) recommends that

women with GDM engage in regular exercise in order to improve blood glucose control. Cordero

et al. (2014) found the incidence of GDM to be significantly reduced in women who participated

in exercise at least three times per week (p=.009). Garns et al. (2016) reported a reduction in

the incidence of GDM among pregnant women who engaged in vigorous cardiovascular exercise

training (p=.04). Wang et al. (2017) demonstrated a lower incidence of GDM among participants

who engaged in a cycling program thrice weekly (p<.001).

These studies concluded that participants in regular exercise during pregnancy are signifi-

cantly less likely to develop GDM. These results suggest that beginning exercise early in preg-

nancy and participating in exercise at least three times per week can reduce the incidence of

GDM.

Proposed Practice Change

Based on the synthesis of the evidence and the clinical guidelines from NICE, the clinical

recommendations include individualized education in prenatal care and the utilization of current

guidelines in practice. Individualized education should emphasize the importance of exercise

during pregnancy in preventing GDM in standard prenatal care and include evidence-based

methods, frequency, and intensity of exercise. As supported by the literature and clinical

guidelines, beginning exercise early in pregnancy and participating in exercise at least three

times per week can reduce the incidence of GDM.

Nurses are the ones seeing the direct result and effectivity of the protocols that are being

implemented; therefore, nurses have a lot of influence. Nurses constantly advocate for their

patients at the bedside, and if a career is passionate about positive patient outcomes at bedside, it

should also be passionate about how effective the implemented policies are. In this proposed
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change, nurses would be urged to educate their patients about the evidence-based methods,

frequency, and intensity of exercise during pregnancy and the risks associated with GDM.

Implications for Practice

The IOWA Model of Evidence-Based Practice to Promote Quality Care (IOWA) guides

clinicians to implement research findings into clinical practice in order to provide positive

patient outcomes (Titler et al., 2001). In the first step of IOWA, the clinical problem of the

incidence of gestational diabetes was identified. The second step of IOWA indicates the need to

review and critique relevant literature. The three RCTs and the clinical recommendation

mentioned provide sufficient evidence. Even though participants were aware of randomization

and neither providers nor participants were blind to the study groups, the participants were

randomized into either the control or the intervention group, follow-up assessments and data

collection were conducted through birth, and they each utilized valid and reliable diagnostic

guidelines. The final step of IOWA includes implementing the change and monitoring its

outcomes. Nurses would need to educate their patients to exercise at least three times per week

for at least thirty minutes each session to prevent the incidence of GDM.

The expected patient outcome is decreased incidence of GDM with the use of exercise, as

evidenced by the current research. In order to ensure this practice gets implemented, it would

need to start at the top of the hierarch. For example, the nursing operation managers must be

familiar, and passionate, about decreasing the incidence of GDM, and when they are, they must

require their nurses to stay up-to-date with the research regarding GDM and to educate their

patients about the importance of exercise to reduce the risks associated with it. Also, providers,

such as nurse practitioners and physicians can educate their patients while giving prenatal care.
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The champions will meet every six months to discuss the results and to make any needed

changes, always referring to what current research indicates.

Ethical Considerations

The desired practice utilizes the ethical principal, nonmaleficence, because the desired

outcomes do not directly harm the participants. Beneficence applies even more specifically to

because not only does it not cause harm; early exercise during pregnancy can greatly reduce the

risks of developing gestational diabetes mellitus (GDM), which promotes the health and well-

being of the participants (Munyaradzi, 2012). Autonomy, as well as veracity, is also respected in

because all patients have the choice to participate in the recommended exercise, and the nurses

educating the patients would allow complete understanding of the importance of exercise to

reduce the incidence of GDM. (University of California San Francisco, 2017a).

Conclusion

Exercising for at least thirty minutes significantly reduces the incidence of GDM. The

greatest role of that of a nurse is advocator, so it is necessary for nurses to understand the

importance of exercise and to educate their patients. The impact of research on patient outcomes

is solely reliant on its utilization in practice; therefore, the education nurses provide regarding

exercise during pregnancy should be implemented and prioritized in order to promote a

comprehensive understanding of current best practices.

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References

Buchanan, T. A., Xiang, A. H., & Page, K. A. (2012). Gestational diabetes mellitus: Risks and

management during and after pregnancy. Nat Rev Endocrinol, 8(11), 639-649.

doi:10.1038/nrendo.2012.96

Cordero Rodriguez, Y., Mottola, M. F., Vargas, J., Blanco, M., & Barakat Carballo, R. O.

(2014). Exercise is associated with a reduction in gestational diabetes mellitus. Medicine

& Science in Sports & Exercise, 47(7), 1328-1333. doi:10.1249/MSS.0000000000000547

De Lourdes Levy, M., Larcher, V., & Kurz, R. (2003). Informed consent/assent in children.

Statement of the Ethics Working Group of the Confederation of European Specialists in

Paediatrics (CESP). Eur J Pediatr, 162(9), 629-633. doi:10.1007/s00431-003-1193-z

Garns, K. K., Mrkved, S., Salvesen, ., & Moholdt, T. (2016). Exercise training and weight

gain in obese pregnant women: A randomized controlled trial (ETIP trial). PLOS Medi-

cine, 13(7), e1002079. doi:10.1371/journal.pmed.1002079

Munyaradzi, M. (2012). Critical reflections on the principle of beneficence in biomedicine Pan

Afr Med J (Vol. 11).

National Institute for Health and Care Excellence. (2015). Diabetes in pregnancy: Management

of diabetes and its complications from preconception to the postnatal period (Standard

No. 3). Retrieved from https://www.guideline.gov/summaries/summary/49120/diabetes-

in-pregnancy-management-of-diabetes-and-its-complications-from-preconception-to-the-

postnatal-period?q=exercise+during+pregnancy#420

Shirley, M., Hauch, S., Embree, J., Kinner, T., Schaar, G., Phillips, L., Ashby, S., Swenty, C., &

McCool, I. (2011). Showcasing differences between quality improvement, evidence-

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based practice and research. The Journal of Continuing Education in Nursing 42(2). 57-

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Srichumchit, S., Luewan, S., & Tongsong, T. (2015). Outcomes of pregnancy with gestational

diabetes mellitus. International Journal of Gynecology & Obstetrics, 131(3), 251-254.

doi:10.1016/j.ijgo.2015.05.033

Titler, M. G., Klieber, C., Steelman, V., Rakel, B. A., Budreau, G., Everett, L. Q., ... Goode, C. J.

(2001). The Iowa model of evidence-based practice to promote quality care. Critical

Care Nursing Clinics of North America, 13(4), 497-509.

University of California San Francisco. (2017a). Autonomy vs. Beneficence. Retrieved

from http://missinglink.ucsf.edu/lm/ethics/content pages/fast_fact_au-

ton_bene.htm (Links to an external site.)Links to an external site.

University of California San Francisco. (2017b). Beneficence vs. Nonmaleficence. Retrieved

from http://missinglink.ucsf.edu/lm/ethics/content pages/fast_fact_bene_non-

mal.htm (Links to an external site.)Links to an external site.

Valizadeh, M., Alavi, N., Mazloomzadeh, S., Piri, Z., & Amirmoghadami, H. (2015). The risk

factors and incidence of type 2 diabetes mellitus and metabolic syndrome in women with

previous gestational diabetes. International Journal of Endocrinology and Metabolism,

13(2), e21696. doi:10.5812/ijem.21696

Wang, C., Wei, Y., Zhang, X., Zhang, Y., Xu, Q., Sun, Y., ... & Shou, C. (2017). A randomized

clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and im-

prove pregnancy outcome in overweight and obese pregnant women. American Journal

of Obstetrics and Gynecology, 216(4), 340-351. doi:10.1016/j.ajog.2017.01.037

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Xiang, A. H., Kjos, S. L., Takayanagi, M., Trigo, E., & Buchanan, T. A. (2010). Detailed physio-

logical characterization of the development of type 2 diabetes in Hispanic women with

prior gestational diabetes mellitus. Diabetes, 59(10), 2625-2630. doi:10.2337/db10-0521