Approximately 7,000 women with Type 1 diabetes become pregnant each year, according to Dr. Lois Jovanovic, an expert on pregnancy and diabetes. Having diabetes creates some risks in pregnancy but advances in care have significantly improved the outlook of these women who become pregnant. Although, poor control of blood sugars increases the incidence of spontaneous abortions and fetus abnormalities. In fact, women with poorly controlled diabetes prior to becoming pregnant have three to four times the risk of serous birth defects such as a heart defect or neural tube defect. Good blood sugar control is critical within the first 5 to 11 weeks as the baby's organs are starting to develop.
Exercise is often recommended for women to remain healthy during their pregnancy but should pregnant women with diabetes exercise? It is a well-known fact that exercise can help control diabetes by signaling the body to use insulin more efficiently. However, pregnant women with diabetes should consult their healthcare team about exercise and educate themselves about the risk-benefit of exercise during pregnancy.
The problem is that there is not a lot of information on exercising through pregnancy for anyone who becomes pregnant let alone a person with diabetes who wants to continue to exercise. Many doctors do not want their patients to start a new exercise program during pregnancy but often encourage patients to continue what they have been doing prior to becoming pregnant. Depending on whether a patient is a beginner, recreational, or competitive athlete certain precautions need to be taken and goals established. For instance, beginners often want assurance from their healthcare providers that it is safe to exercise. Recreational athletes want clarification on their exercise program where competitive athletes often need a detailed, hard-nosed approach about the risks and benefits of exercise similar to the way they approach their training.
Absolute contraindications to exercise are injury, illness, bleeding (coming from inside the womb), and pain. For healthy women some of the absolute contraindications are relative. Women carrying twins are often recommended to modify or even stop exercising due to labor starting before term and the demands for growth are much greater for two than one. If there is a history of going into labor before the last month exercise is often discouraged as well. The American College of Obstetrics and Gynecologists recommends walking, stationary bicycling, low-impact aerobics, and swimming as forms of aerobic exercise. The organization goes on to suggest that previously sedentary women keep their exercise heart rates below 140 bpm (60-70% of VO2max). This is not necessarily the case for women who have been exercising prior to becoming pregnant. For this reason, a discussion with the healthcare team will help clear up any uncertainties around exercise.
Now that we have discussed the negative side to exercising during pregnancy let us take a look at someone who has type 1 diabetes and has been able to incorporate exercise into her diabetes management during pregnancy.
Nicole Johnson Baker, Miss America 1999, an international diabetes advocate and co-host of the new weekly television show on CNBC, "dLife," became pregnant in 2005. Nicole travels extensively but still finds time to exercise during her pregnancy. Below is an interview with Nicole about three months prior to her delivery date on her experience with controlling her diabetes while maintaining an exercise program.
1. Pregnancy in patients with diabetes is associated with an increased incidence of complications. Normalizing blood glucose concentrations before and early in pregnancy can reduce risk levels. What steps have you taken in your diabetes care to reduce these risks?
Well, the key is good glucose control – both during and before pregnancy. I have worked incredibly hard on this. Currently, I am testing my BG's about 12 times a day – nearly every other hour. It is difficult, but necessary. I am also vigilant about visiting my healthcare providers. I see my OB team – High Risk Specialists – every 3 weeks (That will increase in frequency next month). I see the eye specialist every trimester and the dentist at least once during the pregnancy – I will have gone twice before it is all said and done. In terms of other complications/prevention work – my A1c is drawn monthly, my kidneys are checked every month – 2 months, there is an ultrasound scan every month and the regular BP checks at every doctor visit.
The frequent testing is so key – my insulin demands shift and increase weekly – the only way we know what to do is by having so many BG readings – this is what is keeping my A1c at 5.5%.
2. In general, how has your exercise regimen changed since becoming pregnant?
Well, it is not as intense. I am more tired now, and running or walking at a really fast clip is a little more painful. I walk about 30 minutes a day to stay fit – I also do floor exercises and light weights about twice a week. It is challenging and frustrating. I wish I could and was doing more – time is my biggest enemy right now – there are not enough hours in the day. It is especially hard when you realize you only have a few more weeks to work and then life will totally change. The pressure is incredible.
3. Is there specific exercise guidelines you follow based on your diabetes and doctor's advice?
I did have to cut back on my exercise because in the first several months of pregnancy we discovered that exercise made my BG's go a little high – I don't completely get this, but it happened. I had to reduce the time I exercised and had to stop every 15 minutes to test to detect trends. I was told that I would have to stop exercising if my BG's kept creeping with the adrenaline – that made me very unhappy, but it is most important to keep the BG's in range for the baby. So, we found a compromise. Now I try to get creative exercise in – if my BG is a little high, I will walk outside for 10-20 minutes instead of bolusing.
4. During pregnancy, it is recommended to keep very tight control of your blood sugars. Do you find it hard to maintain this tight control when exercise is part of your plan? What steps do you take around blood glucose monitoring and exercise?
I check 15 minutes before exercise, 15 minutes into cardio exercise and 5-10 minutes after cardio is complete. I then check again about 15 minutes after the exercise session is finished. It is all about detecting trends and seeing if I am dosing the right amount of insulin and carbs.
5. What advantages has wearing an insulin pump helped in your control during exercise and your pregnancy?
The insulin demands change so fast – I don't know how anyone does it without a pump. It is so valuable to be able to change my basal rates by 0.1 or 0.05. Plus, I bolus frequently - whenever I see a number out of range. If I were giving shots -- I would be giving about 10 a day!
6. What warning signs should you look for to stop or modify exercise during pregnancy?
Light-headedness; confusion; slowing down. BUT, my signs of lows have been reduced dramatically during pregnancy. It is so different - that is why I have to test so much. I don't sense lows until I am VERY low.
7. Do your endocrinologist and OB/GYN doctor communicate during your pregnancy about issues that come about throughout your term?
It is a huge challenge. Most of the doctors are so territorial. It is really frustrating. My OB practice wants to manage my diabetes, my endo wants to manage my diabetes, I want to manage my diabetes and I want to confer with professionals I trust about my diabetes -- this means there are multiple opinions and versions of advice. This is probably the most difficult medical aspect. Luckily, I am working with Dr. Lois Jovanovic and I trust her completely - I basically do whatever she tells me to do and just ride the wave with the others. My big fear is that the hospital where I am to deliver will not allow an endo to come in and work with me during delivery - they feel they can handle everything there. This is a challenge for us - so, we are training my husband to be my health advocate during that time and to be a thorn in the side of anyone who is not following the protocol we have developed. It will be very interesting to see what actually happens.
8. What advice would you give to someone who exercises a lot prior to becoming pregnant and throughout her nine months preceding delivery?
Be careful. Most important is to protect the baby. Although I would like to exercise more, I am trying very hard to listen to my body and rest when I need to rest and take things slowly - this has proven to work well for me so far. I have not gained a lot of weight and am able to do basically anything I want in terms of work, travel and other activities. Moderate exercise is good for any pregnant person - vigorous exercise could pose serious problems.
I am going to continue walking and doing leg lifts and some arm exercises, although I am freaked out about gaining a total of 30 lbs by the time this is all said and done, I know that when the baby is here and I have clearance from my doctor, I will be back to my old self - or even an improved version of my old self - in no time.
The bottom line with exercising during pregnancy is to be safe and communicate with your healthcare team. It is also a good idea to not embark on a new or more intense exercise during pregnancy. Checking blood sugars more frequently around exercise will help keep tight control without significant highs or lows, which can be problematic during exercise.
- American College of Obstetricians and Gynecologists. Gestational Diabetes. ACOG Practice Bulletin, number 30, September 2001.
- Harris, G., White, R. Diabetes Management and Exercise in Pregnant Patients With Diabetes. Clinical Diabetes 23:165-168, 2005.
Rick Philbin, MBA, M.Ed., ATC
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Last Updated: Friday September 07, 2012 11:16:40
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