Effect of dietary and lifestyle factors on the risk of gestational diabetes:

review of epidemiologic evidence14

Cuilin Zhang and Yi Ning
ABSTRACT
Gestational diabetes mellitus (GDM), defined as glucose intolerance
with onset or first recognition in pregnancy, is a common pregnancy
complication and a growing health concern. GDM has been related to
significant short-term and long-term adverse health outcomes for
both mothers and offspring. Importantly, this number is increasing
with the increasing burden of obesity among women of reproductive
age. Collectively, these data highlight the significance of understanding risk factors, in particular modifiable factors, for GDM and of preventing GDM among high-risk populations. Research in the past
decade has identified a few diet and lifestyle factors that are associated with GDM risk. This review provides an overview of emerging
diet and lifestyle factors that may contribute to the prevention of
GDM. It also discusses major methodologic concerns about the available epidemiologic studies of GDM risk factors.
Am J Clin Nutr
2011;94(suppl):1975S9S.

INTRODUCTION

Gestational diabetes mellitus (GDM), defined as glucose intolerance with onset or first recognition in pregnancy, is a common
pregnancy complication that affects 114% of all pregnancies
and is a growing health concern (1). The incidence of GDM is
increasing with the increasing burden of obesity among women of
reproductive age (2). GDM has been related to substantial shortterm and long-term adverse health outcomes for both mothers and
offspring. Women with GDM have an increased risk of perinatal
morbidity and a considerably increased risk of impaired glucose
tolerance and type 2 diabetes in the years after pregnancy (1, 3
6). Children of women with GDM are more likely to be obese and
have impaired glucose tolerance and diabetes in childhood and
early adulthood (1, 7, 8). Collectively, these data highlight the
importance of identifying risk factors, in particular modifiable
factors, for this common pregnancy complication and of preventing GDM among high-risk populations (9).
RISK FACTORS BOTH BEFORE AND DURING
PREGNANCY ARE RELEVANT

Normal pregnancy, especially the third trimester, is characterized by elevated metabolic stresses on maternal lipid and glucose
homeostasis, which includes insulin resistance and hyperinsulinemia (1012). Although the precise underlying mechanisms are
yet to be identified, insulin resistance and inadequate insulin secretion to compensate for it play a central role in the pathophysiology of GDM (9, 10). Women who develop GDM are

thought to have a compromised capacity to adapt to the increased

insulin resistance characteristic of late pregnancy, primarily during
the third trimester (10). Pregnancy-related metabolic challenges
unmask a predisposition to glucose metabolic disorders in some
women (10, 13, 14). The majority of women with GDM have b cell
dysfunction against a background of chronic insulin resistance to
which the insulin resistance of pregnancy is partially additive
(10). Factors that contribute to insulin resistance or relative insulin
deficiency both before and during pregnancy may have a deleterious effect during pregnancy and may be risk factors for GDM
(9). Limited attention has been paid to pregravid risk factors for
GDM.

OVERVIEW OF RISK FACTORS FOR GDM: EVIDENCE

FROM EPIDEMIOLOGIC STUDIES

Epidemiologic studies on risk factors for GDM are relatively

limited (15, 16). The diagnostic criteria and screening strategy for
GDM and the measurements of risk factors vary significantly
across study periods and study populations, which makes it difficult to compare findings across studies. Moreover, substantial
heterogeneity exists in the approach of analyzing the association
between risk factors and the risk of GDM. The majority of earlier
studies on risk factors for GDM failed to address bias due to
potential confounding by other risk factors. Furthermore, the actual
number of GDM cases in the majority of studies is rather low,
which hampers reaching solid conclusions. Despite these methodologic concerns, several GDM risk factors emerge consistently
(9).
Well-recognized risk factors for GDM include excessive adiposity, advanced maternal age, a family history of type 2 diabetes,
1

From the Division of Epidemiology, Statistics, and Prevention Research,

Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (CZ), and the Department of Epidemiology and Community Health, Virginia Commonwealth
University, Richmond, VA (YN).
2
Presented at the conference The Power of Programming: Developmental Origins of Health and Disease, held in Munich, Germany, 68 May
2010.
3
Supported by the Intramural Research Program of the Eunice Kennedy
Shriver National Institute of Child Health and Human Development, NIH.
4
Address correspondence to C Zhang, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of
Child Health and Human Development, National Institutes of Health, Bethesda, MD, 21205. E-mail: zhangcu@mail.nih.gov.
First published online May 25, 2011; doi: 10.3945/ajcn.110.001032.

Am J Clin Nutr 2011;94(suppl):1975S9S. Printed in USA. 2011 American Society for Nutrition

1975S

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ZHANG AND NING

and a history of GDM (1519). Among them, excessive adiposity

is the most commonly investigated modifiable risk factor with
consistent findings (2022). The risk of GDM increases significantly and progressively in overweight, obese, and morbidly obese
women. Cigarette smoking has not been consistently identified as
a risk factor for GDM (15, 17, 19, 2327). Available data suggest
that the magnitude of possible association between maternal
smoking (before and during pregnancy) and GDM may be modest.
Asian, Hispanic, and Native American women, as compared with
non-Hispanic white women, have an increased risk of GDM (15,
17, 19, 28). African American women have been reported to have
an increased risk of GDM, as compared with non-Hispanic whites,
by some (19, 29), although not all (17, 28), investigators. Other
reported risk factors include, but are not limited to, short maternal
stature (3034), polycystic ovary disease, previous stillbirth, high
blood pressure during pregnancy, and multiple pregnancies (9, 15).
DIETARY AND LIFESTYLE RISK FACTORS

Overview
In the past decades efforts to identify risk factors for GDM
have increased, in part because of the escalating prevalence of
diabetes and obesity worldwide (9). Subsequently, several potentially novel risk factors for GDM have been identified. A few
studies have provided some suggestive evidence of dietary factors
both before or during pregnancy that are related to GDM risk (35
46). Moreover, a series of studies have linked physical activity
before and/or during pregnancy with a decreased GDM risk (47
54). This effect seems to increase with increasing intensity of, and
time spent on, the physical activity (9).
Dietary factors and GDM
Substantial evidence has related diet to the development of
glucose intolerance. An extensive body of literature has reported
both protective and risk-enhancing associations between particular dietary factors and type 2 diabetes in adult men and
nonpregnant women. These studies suggest that the quality of
dietary carbohydrate and fat intake may be more relevant to type
2 diabetes risk than is the total amount of these nutrients (9).
Specific types of carbohydrates may be protective [eg, whole
grains (5558)], and specific types of fats [eg, trans fat (5963)]
may be risk enhancing (64, 65). Dietary treatment/counseling
has long been recommended for women who develop GDM.
However, studies of the association between dietary factors and
the risk of development of GDM have just emerged. A limited
number of studies have examined diet before and/or during
pregnancy in association with GDM risk (3546, 66).
Dietary factors during pregnancy and GDM risk
Earlier studies on the effect of diet during pregnancy, many of
which were cross-sectional or retrospective in design, suggested
that macronutrient components of the diet in midpregnancy may
predict incidence (37, 39, 40) or recurrence (43) of GDM (9). For
instance, findings from some studies (37, 38), although not all (37,
38, 44), suggested that polyunsaturated fat intake may be protective against glucose intolerance in pregnancy, and high intake of
saturated fat may be detrimental (39). Of note, these analyses did
not adjust for or consider the effect of other types of fat, which is

important because intake of different fat subtypes tends to be

correlated and may have opposing effects (64). A recent prospective study that considered the correlation of nutrients showed
that higher intake of fat and lower intake of carbohydrates may be
associated with increased risk of GDM and impaired glucose
tolerance (40). In addition, in a prospective study of pregnant
women, lower plasma vitamin C (35) and vitamin D concentrations
(67) in early pregnancy were significantly associated with increased GDM risk. Note that the number of GDM cases in the
majority of studies of dietary factors during pregnancy is rather
low. Inferences from the majority of available studies are further
limited by cross-sectional or retrospective design. Thus far, no
concrete conclusion can be drawn as to the role of dietary factors
during pregnancy in the development of GDM (9).
Prepregnancy diet and GDM risk
A number of pregravid dietary factors were recently associated
with the risk of glucose intolerance during pregnancy. These were
based on data primarily from a large prospective study, the
Nurses Health Study II (36, 41).
Western dietary pattern and red meat. In the Nurses Health
Study II, 2 dietary patterns, the Western pattern and the prudent
pattern, were identified by factor analyses. Strong positive associations were observed between the Western dietary pattern
score and GDM risk, whereas the prudent dietary pattern score
was significantly and inversely associated with GDM risk, even
after adjustment for major risk factors for GDM, such as family
history of diabetes, prepregnancy body mass index (BMI),
physical activity, parity, and so forth (41). The prudent dietary
pattern was characterized by a high intake of fruit, green leafy
vegetables, poultry, and fish, whereas the Western pattern was
characterized by a high intake of red meat, processed meat,
refined grain products, sweets, french fries, and pizza (9).
The association with the Western pattern was largely explained
by intake of red and processed meat products. Pregravid intake of
red and processed meats were both significantly and positively
associated with GDM risk, independent of known risk factors for
type 2 diabetes and GDM. For instance, after the adjustment for
major risk factors for GDM, which include prepregnancy BMI,
physical activity, parity, and other dietary risk factors, those who
consumed .6 servings of red meat/wk had a more than 1.7-fold
increased risk of GDM compared with those women who consumed ,1.5 servings of red meat/wk (relative risk: 1.74; 95%
CI: 1.35, 2.26).
Although the precise molecular mechanisms are unclear, the
observed associations of red and processed meat intakes with
GDM risk are biologically plausible. First, they could be related
to several possible biologically adverse effects of components in
red and processed meats, such as saturated fat and cholesterol, on
insulin sensitivity and b cell function that might be relevant to
the pathophysiology of GDM (9). In the present study, the strong
association of red meat and processed meat with GDM risk
remained significant after further adjustment for these other
dietary factors that included fatty acids and cholesterol, which
indicates that components of red meat and processed meat other
than these nutrients might also be relevant to the pathogenesis of
GDM. For example, nitrites, frequently used as a preservative
in processed meats, have been implicated in the development
of diabetes. Nitrosamines can be formed by the interaction of

DIET, LIFESTYLE, AND GESTATIONAL DIABETES

amino compounds with nitrites present either in the stomach or

within the food product (68). They have been linked to b cell
toxicity (69). In addition, low doses of the nitrosamine streptozotocin were shown to induce type 2 diabetes in animal
models (70). Another potential explanation is related to the toxic
effects of advanced glycation end products (AGEs), which can
be formed in meat and high-fat products through heating and
processing (71). Animal models and human studies suggest that
AGEs are involved in the progression of diabetes. The development of type 2 diabetes was decreased by treatment with
aminoguanidine, an AGE inhibitor, in genetically diabetic mice
(72), and improvement of various features of insulin resistance
was shown in mice fed a diet low in AGEs (73). Heme iron in
red meat might also contribute to the increased risk of GDM,
because body iron overload has been postulated to promote insulin resistance and increase the risk of type 2 diabetes (74).
More recently, iron supplements and increased iron stores in
pregnant women without iron deficiency were related to an increased risk of GDM (75). However, the association between
processed meat and GDM risk remained strong after adjustment
for heme iron. Nevertheless, it is also plausible that other unidentified components in red meat and processed meat can
contribute to the adverse effect on GDM related to them (9).
Dietary fiber and glycemic index. Pregravid consumption of
dietary fiber (ie, total, cereal, and fruit fiber) was significantly and
inversely associated with GDM risk (36). In contrast, dietary
glycemic load was positively associated with GDM risk. The
glycemic index is a relative measure of the glycemic effect of the
carbohydrates in different foods (76). Total glycemic load was
calculated by first multiplying the carbohydrate content of each
food by its glycemic index value, then multiplication of this value
by the frequency of consumption, and the summation of the values
from all food. Dietary glycemic load thus represents the quality and
quantity of carbohydrate intake and the interaction between the 2.
Each 10-g/d increment in total fiber intake was associated with
a 26% (95% CI: 9%, 49%) decrease in risk; each 5-g/d increment
in cereal or fruit fiber was associated with a 23% (936) or 26% (5
42) decrease, respectively. The combination of high glycemic load
and a low-cereal-fiber diet was associated with a 2.15-fold (95%
CI: 1.04-, 4.29-fold) increased risk of GDM compared with the
reciprocal diet (9).
Sugar-sweetened beverages. Sugar-sweetened beverages are the
leading source of added sugars in Americans diets (77). In animal
models and human studies, a high-sugar diet decreases insulin
sensitivity (78, 79) and insulin secretion (80). In the Nurses Health
Study II, after adjustment for age, parity, race, physical activity,
smoking, alcohol intake, prepregnancy BMI, and Western dietary
pattern, intake of sugar-sweetened cola was positively associated
with the risk of GDM, whereas no significant association was
shown for other sugar-sweetened beverages and diet beverages.
Compared with women who consumed ,1 serving/mo, those who
consumed 5 servings/wk of sugar-sweetened cola had a 22%
greater GDM risk (relative risk: 1.22; 95% CI: 1.01, 1.47).
In summary, epidemiologic studies on the role of dietary
factors in the development of GDM are at their early stage.
Although the observational design of this study does not prove
causality, available data did provide evidence that supports the
theory that dietary factors may play a role in the development of
GDM. Large prospective studies on dietary factors both before
and during pregnancy and the risk of GDM are warranted (9).

1977S

Physical activity and GDM

Available data from epidemiologic and clinical studies among
nonpregnant individuals support the thesis that physical activity
can influence glucose homeostasis through its direct or indirect
effects on insulin sensitivity and secretion (9). By increasing insulin sensitivity and improving glucose tolerance via several
mechanisms, physical activity has a beneficial effect on many
aspects of insulin resistance syndromes (8183). After an episode
of physical activity, insulin sensitivity was improved for up to 48 h
by increasing cellular sensitivity to circulating insulin (84). In
addition to this acute effect, longer-term, even relatively modest,
increases in habitual physical activity induce adaptations that can
profoundly affect glucose tolerance (82) and potentially decrease
GDM risk. Long-term improvement in glucose tolerance and
increased insulin sensitivity may also result from physical activity
induced decreases in fat mass and increases in lean muscle mass
(9, 85, 86).
Studies on the effect of physical activity on pregnant women are
limited. The definitions used to classify intensity, amount, and type
of physical activity vary considerably, which makes comparisons
between studies difficult. Furthermore, the actual number of GDM
cases in the majority of studies is rather low, which hampers
reaching solid conclusions (9). Despite these limitations, several
studies have linked physical activity before and/or during pregnancy to a decreased risk of GDM (4754). This effect seems to
increase as the intensity of, and time spent on, the physical activity
increases (9). For instance, in a prospective study of 21,765 women
who reported at least one singleton pregnancy in the Nurses
Health Study II, women in the highest quintile of habitual recreational physical activity before pregnancy (specifically, vigorous
activity, which is equivalent to 30 min/d of brisk walking) had
a 20% risk decrease for the development of GDM (54). Similarly, physical activity before pregnancy (particularly vigorous
activity) was associated with a decreased risk of either GDM or
any antepartum glucose intolerance (risk reductions of 44% and
24%, respectively) in another study of pregnant women (52). In
both a prospective study and a case-control study, Dempsey et al
(48, 49) showed that leisure-time physical activity (ie, nonoccupational activity) in the year before pregnancy was associated
with a significantly lower risk of GDM. A recent meta-analysis of
findings from the above studies among 34,929 women, which
included 2,813 cases of GDM, gave a pooled odds ratio of 0.45
(95% CI: 0.28, 0.75) when the highest and lowest categories were
compared (87).
Accumulative evidence has suggested that physical activity
during pregnancy may be related to GDM risk as well. One study
reported a significant protective effect (48), whereas others observed an association, but not at statistically significant levels (47,
49, 50, 52, 88). In a case-control study, participation in any
recreational activities during the first 20 wk of pregnancy was
related to a 48% decreased GDM risk (48). In 2 prospective
cohort studies (49, 52), physical activity during early pregnancy
appeared to be associated with a lower risk of developing GDM;
however, the findings were not statistically significant. Dye et al
(50) observed that women who exercised weekly for 30 min at
some time during pregnancy had a lower risk of GDM, although
this result was shown for only morbidly obese women (BMI .
33). In addition, data that were nationally representative of
women with live births indicated that those who began physical

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ZHANG AND NING

activity during pregnancy had less risk of development of GDM

than did those who were inactive during pregnancy (51). In the
same study, women with activity levels above the median had
a 67% lower risk of GDM than those who performed less
physical activity (9). In a recent meta-analysis of 4401 women,
which included 361 GDM cases, exercise in early pregnancy
was related to a 24% decreased risk of GDM (odds ratio: 0.76;
95% CI: 0.70, 0.83) (87).
CONCLUSIONS

The spreading of epidemics of obesity and diabetes worldwide,

the increase in the incidence of GDM during recent years, and the
short-term and long-term adverse health outcomes for both
women and offspring associated with GDM highlight the significance of preventing GDM among women at high risk. Accumulating evidence from observational studies suggest that
several modifiable factors, in particular pregravid body adiposity,
recreational physical activity before and during pregnancy, and
pregravid dietary patterns, may be related to GDM risk. Collectively, these data suggest an additional potential benefit of the
adoption or continuation of a healthy diet and active lifestyle for
women of reproductive age.
The authors responsibilities were as followsCZ: wrote the manuscript;
and YN: provided significant advice on the presentation slides and manuscript
and critically edited the manuscript. Both authors approved the final manuscript. The authors had no conflicts of interest to declare.

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