Advertisement

Exercise in pregnancies complicated by obesity: achieving benefits and overcoming barriers

      An increasing number of women are entering pregnancy in an overweight or obese state. Obese women and their offspring are at increased risk of adverse perinatal outcomes, which may be improved by regular moderate-intensity antenatal exercise. Current guidelines recommend that all pregnant women without contraindications engage in ≥30 minutes of moderate-intensity exercise on a daily basis. However, obese women are usually less physically active and tend to further reduce activity levels during pregnancy. This commentary summarizes the potential short- and long-term benefits of antenatal exercise in obese pregnant women, highlights the challenges they face, and discusses means of improving their exercise levels. In addition, we make recommendations on exercise prescription for pregnancies complicated by obesity.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Robinson W.R.
        • Keyes K.M.
        • Utz R.L.
        • Martin C.L.
        • Yang Y.
        Birth cohort effects among US-born adults born in the 1980s: foreshadowing future trends in US obesity prevalence.
        Int J Obes. 2013; 37: 129-134
        • Flegal K.M.
        • Carroll M.D.
        • Kit B.K.
        • Ogden C.L.
        Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010.
        JAMA. 2012; 307: 491-497
        • Ministry of Health
        The Health of New Zealand Adults 2011/12: Key findings of the New Zealand Health Survey.
        Ministry of Health, Wellington, New Zealand2012
        • Mendez M.A.
        • Monteiro C.A.
        • Popkin B.M.
        Overweight exceeds underweight among women in most developing countries.
        Am J Clin Nutr. 2005; 81: 714-721
        • Frischknecht F.
        • Bruhwiler H.
        • Raio L.
        • Luscher K.P.
        Changes in pre-pregnancy weight and weight gain during pregnancy: retrospective comparison between 1986 and 2004.
        Swiss Med Wkly. 2009; 139: 52-55
        • Kim S.Y.
        • Dietz P.M.
        • England L.
        • Morrow B.
        • Callaghan W.M.
        Trends in pre-pregnancy obesity in nine states, 1993-2003.
        Obesity. 2007; 15: 986-993
        • Heslehurst N.
        • Ells L.J.
        • Simpson H.
        • Batterham A.
        • Wilkinson J.
        • Summerbell C.D.
        Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36,821 women over a 15-year period.
        BJOG. 2007; 114: 187-194
        • Callaway L.K.
        • Prins J.B.
        • Chang A.M.
        • McIntyre H.D.
        The prevalence and impact of overweight and obesity in an Australian obstetric population.
        Med J Aust. 2006; 184: 56-59
        • Caspersen C.J.
        • Powell K.E.
        • Christenson G.M.
        Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research.
        Public Health Rep. 1985; 100: 126-131
        • Davies G.A.
        • Wolfe L.A.
        • Mottola M.F.
        • MacKinnon C.
        Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the postpartum period.
        Can J Appl Physiol. 2003; 28: 339-341
      1. American College of Obstetricians and Gynecologists: Committee on Obstetric Practice. Exercise during pregnancy and the post partum period. ACOG Committee Opinion no. 267.
        Int J Gynaecol Obstet. 2002; 77: 79-81
        • Royal College of Obstetricians and Gynaecologists
        Exercise in pregnancy (RCOG statement no. 4).
        RCOG, London2006
        • Chu S.Y.
        • Callaghan W.M.
        • Kim S.Y.
        • et al.
        Maternal obesity and risk of gestational diabetes mellitus.
        Diabetes Care. 2007; 30: 2070-2076
        • Weiss J.L.
        • Malone F.D.
        • Emig D.
        • et al.
        Obesity, obstetric complications and cesarean delivery rate: a population-based screening study.
        Am J Obstet Gynecol. 2004; 190: 1091-1097
        • O’Brien T.E.
        • Ray J.G.
        • Chan W.S.
        Maternal body mass index and the risk of preeclampsia: a systematic overview.
        Epidemiology. 2003; 14: 368-374
        • Sebire N.J.
        • Jolly M.
        • Harris J.P.
        • et al.
        Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London.
        Int J Obes. 2001; 25: 1175-1182
        • Andreasen K.R.
        • Andersen M.L.
        • Schantz A.L.
        Obesity and pregnancy.
        Acta Obstet Gynecol Scand. 2004; 83: 1022-1029
        • Cantwell R.
        • Clutton-Brock T.
        • Cooper G.
        • et al.
        Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006-2008: the eighth report of the confidential enquiries into maternal deaths in the United Kingdom.
        BJOG. 2011; 118 (Supplement 1)
        • Heslehurst N.
        • Simpson H.
        • Ells L.J.
        • et al.
        The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis.
        Obes Rev. 2008; 9: 635-683
        • Weisman C.S.
        • Hillemeier M.M.
        • Downs D.S.
        • Chuang C.H.
        • Dyer A.M.
        Preconception predictors of weight gain during pregnancy: prospective findings from the Central Pennsylvania Women’s Health Study.
        Womens Health Issues. 2010; 20: 126-132
        • Villamor E.
        • Cnattingius S.
        Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study.
        Lancet. 2006; 368: 1164-1170
        • Soltani H.
        • Fraser R.B.
        A longitudinal study of maternal anthropometric changes in normal weight, overweight and obese women during pregnancy and postpartum.
        Br J Nutr. 2000; 84: 95-101
        • Després J.-P.
        Abdominal obesity: the most prevalent cause of the metabolic syndrome and related cardiometabolic risk.
        Eur Heart J Suppl. 2006; 8: B4-B12
        • Poirier P.
        • Lemieux I.
        • Mauriège P.
        • et al.
        Impact of waist circumference on the relationship between blood pressure and insulin: the Quebec Health Survey.
        Hypertension. 2005; 45: 363-367
        • Nohr E.A.
        • Bech B.H.
        • Davies M.J.
        • Frydenberg M.
        • Henriken T.B.
        • Olsen J.
        Prepregnancy obesity and fetal death: a study within the Danish National Birth Cohort.
        Obstet Gynecol. 2005; 106: 250-259
        • Vasudevan C.
        • Renfrew M.
        • McGuire W.
        Fetal and perinatal consequences of maternal obesity.
        Arch Dis Child Fetal Neonatal Ed. 2011; 96: F378-F382
        • Stothard K.J.
        • Tennant P.W.G.
        • Bell R.
        • Rankin J.
        Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis.
        JAMA. 2009; 301: 636-650
        • Rosenberg T.J.
        • Garbers S.
        • Chavkin W.
        • Chiasson M.A.
        Prepregnancy weight and adverse perinatal outcomes in an ethnically diverse population.
        Obstet Gynecol. 2003; 102: 1022-1027
        • Ehrenberg H.M.
        • Mercer B.M.
        • Catalano P.M.
        The influence of obesity and diabetes on the prevalence of macrosomia.
        Am J Obstet Gynecol. 2004; 191: 964-968
      2. Obesity: preventing and managing the global epidemic: report of a WHO Consultation.
        World Health Organ Tech Rep Ser. 2000; 894 (1-253): i-xii
        • Oken E.
        Maternal and child obesity: the causal link.
        Obstet Gynecol Clin North Am. 2009; 36 (ix-x): 361-377
        • Deierlein A.L.
        • Siega-Riz A.M.
        • Adair L.S.
        • Herring A.H.
        Effects of pre-pregnancy body mass index and gestational weight gain on infant anthropometric outcomes.
        J Pediatr. 2011; 158: 221-226
        • Whitaker R.C.
        Predicting preschooler obesity at birth: the role of maternal obesity in early pregnancy.
        Pediatrics. 2004; 114: e29-e36
        • Parsons T.J.
        • Power C.
        • Manor O.
        Fetal and early life growth and body mass index from birth to early adulthood in 1958 British cohort: longitudinal study.
        BMJ. 2001; 323: 1331-1335
        • Catalano P.M.
        Obesity and pregnancy: the propagation of a viscous cycle?.
        J Clin Endocrinol Metab. 2003; 88: 3505-3506
        • Dabelea D.
        • Crume T.
        Maternal environment and the transgenerational cycle of obesity and diabetes.
        Diabetes. 2011; 60: 1849-1855
        • Catalano P.M.
        Obesity, insulin resistance, and pregnancy outcome.
        Reproduction. 2010; 140: 365-371
        • Nelson S.M.
        • Matthews P.
        • Poston L.
        Maternal metabolism and obesity: modifiable determinants of pregnancy outcome.
        Hum Reprod Update. 2010; 16: 255-275
        • Surkan P.J.
        • Hsieh C.-C.
        • Johansson A.L.V.
        • Dickman P.W.
        • Cnattingius S.
        Reasons for increasing trends in large for gestational age births.
        Obstet Gynecol. 2004; 104: 720-726
        • Catalano P.M.
        • Tyzbir E.D.
        • Roman N.M.
        • Amini S.B.
        • Sims E.A.
        Longitudinal changes in insulin release and insulin resistance in nonobese pregnant women.
        Am J Obstet Gynecol. 1991; 165: 1667-1672
        • Oken E.
        • Gillman M.W.
        Fetal origins of obesity.
        Obes Res. 2003; 11: 496-506
        • Di Cianni G.
        • Miccoli R.
        • Volpe L.
        • Lencioni C.
        • Del Prato S.
        Intermediate metabolism in normal pregnancy and in gestational diabetes.
        Diabetes Metab Res Rev. 2003; 19: 259-270
        • Catalano P.M.
        • Ehrenberg H.M.
        Review article: the short- and long-term implications of maternal obesity on the mother and her offspring.
        BJOG. 2006; 113: 1126-1133
        • Bernstein I.M.
        • Goran M.I.
        • Amini S.B.
        • Catalano P.M.
        Differential growth of fetal tissues during the second half of pregnancy.
        Am J Obstet Gynecol. 1997; 176: 28-32
        • Catalano P.M.
        • Drago N.M.
        • Amini S.B.
        Maternal carbohydrate metabolism and its relationship to fetal growth and body composition.
        Am J Obstet Gynecol. 1995; 172: 1464-1470
        • Caruso A.
        • Paradisi G.
        • Ferrazzani S.
        • Lucchese A.
        • Moretti S.
        • Fulghesu A.M.
        Effect of maternal carbohydrate metabolism on fetal growth.
        Obstet Gynecol. 1998; 92: 8-12
        • Sokol R.J.
        • Kazzi G.M.
        • Kalhan S.C.
        • Pillay S.K.
        Identifying the pregnancy at risk for intrauterine growth retardation: possible usefulness of the intravenous glucose tolerance test.
        Am J Obstet Gynecol. 1982; 143: 220-223
        • Akinbi H.T.
        • Gerdes J.S.
        Macrosomic infants of nondiabetic mothers and elevated C-peptide levels in cord blood.
        J Pediatr. 1995; 127: 481-484
        • Sewell M.F.
        • Huston-Presley L.
        • Super D.M.
        • Catalano P.
        Increased neonatal fat mass, not lean body mass, is associated with maternal obesity.
        Am J Obstet Gynecol. 2006; 195: 1100-1103
        • Guihard-Costa A.M.
        • Papiernik E.
        • Kolb S.
        Maternal predictors of subcutaneous fat in the term newborn.
        Acta Paediatr. 2004; 93: 346-349
        • Yu Z.B.
        • Han S.P.
        • Zhu G.Z.
        • et al.
        Birth weight and subsequent risk of obesity: a systematic review and meta-analysis.
        Obes Rev. 2011; 12: 525-542
        • Seidman D.S.
        • Laor A.
        • Gale R.
        • Stevenson D.K.
        • Danon Y.L.
        A longitudinal study of birth weight and being overweight in late adolescence.
        Am J Dis Child. 1991; 145: 782-785
        • Curhan G.C.
        • Chertow G.M.
        • Willett W.C.
        • et al.
        Birth weight and adult hypertension and obesity in women.
        Circulation. 1996; 94: 1310-1315
        • Curhan G.C.
        • Willett W.C.
        • Rimm E.B.
        • Spiegelman D.
        • Ascherio A.L.
        • Stampfer M.J.
        Birth weight and adult hypertension, diabetes mellitus, and obesity in US men.
        Circulation. 1996; 94: 3246-3250
        • Boney C.M.
        • Verma A.
        • Tucker R.
        • Vohr B.R.
        Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus.
        Pediatrics. 2005; 115: e290-e296
      3. Impact of physical activity during pregnancy and postpartum on chronic disease risk.
        Med Sci Sports Exerc. 2006; 38: 989-1006
        • Dempsey J.C.
        • Sorensen T.K.
        • Williams M.A.
        • et al.
        Prospective study of gestational diabetes mellitus risk in relation to maternal recreational physical activity before and during pregnancy.
        Am J Epidemiol. 2004; 159: 663-670
        • Weissgerber T.L.
        • Wolfe L.A.
        • Davies G.A.L.
        • Mottola M.F.
        Exercise in the prevention and treatment of maternal-fetal disease: a review of the literature.
        Appl Physiol Nutr Metab. 2006; 31: 661-674
        • Stuebe A.M.
        • Oken E.
        • Gillman M.W.
        Associations of diet and physical activity during pregnancy with risk for excessive gestational weight gain.
        Am J Obstet Gynecol. 2009; 201: 58.e1-58.e8
        • Hall D.C.
        • Kaufmann D.A.
        Effects of aerobic and strength conditioning on pregnancy outcomes.
        Am J Obstet Gynecol. 1987; 157: 1199-1203
        • Barakat R.
        • Pelaez M.
        • Lopez C.
        • Montejo R.
        • Coteron J.
        Exercise during pregnancy reduces the rate of cesarean and instrumental deliveries: results of a randomized controlled trial.
        J Matern Fetal Neonatal Med. 2012; 25: 2372-2376
        • Voldner N.
        • Froslie K.F.
        • Haakstad L.A.H.
        • Bo K.
        • Henriksen T.
        Birth complications, overweight, and physical inactivity.
        Acta Obstet Gynecol Scand. 2009; 88: 550-555
        • Kramer M.S.
        • McDonald S.W.
        Aerobic exercise for women during pregnancy.
        Cochrane Database Syst Rev. 2006; 3: CD000180
        • Santos I.A.
        • Stein R.
        • Fuchs S.C.
        • et al.
        Aerobic exercise and submaximal functional capacity in overweight pregnant women: a randomized trial.
        Obstet Gynecol. 2005; 106: 243
        • Rooney B.L.
        • Schauberger C.W.
        Excess pregnancy weight gain and long-term obesity: one decade later.
        Obstet Gynecol. 2002; 100: 245-252
        • Barakat R.
        • Cordero Y.
        • Coteron J.
        • Luaces M.
        • Montejo R.
        Exercise during pregnancy improves maternal glucose screen at 24-28 weeks: a randomised controlled trial.
        Br J Sports Med. 2012; 46: 656-661
        • Haakstad L.A.
        • Bo K.
        Effect of regular exercise on prevention of excessive weight gain in pregnancy: a randomised controlled trial.
        Eur J Contracept Reprod Health Care. 2011; 16: 116-125
        • Polley B.A.
        • Wing R.R.
        • Sims C.J.
        Randomized controlled trial to prevent excessive weight gain in pregnant women.
        Int J Obes Relat Metab Disord. 2002; 26: 1494-1502
        • Phelan S.
        • Phipps M.G.
        • Abrams B.
        • Darroch F.
        • Schaffner A.
        • Wing R.R.
        Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study.
        Am J Clin Nutr. 2011; 93: 772-779
        • Barakat R.
        • Pelaez M.
        • Montejo R.
        • Luaces M.
        • Zakynthinaki M.
        Exercise during pregnancy improves maternal health perception: a randomized controlled trial.
        Am J Obstet Gynecol. 2011; 204: 402.e1-402.e7
        • Han S.
        • Middleton P.
        • Crowther C.A.
        Exercise for pregnant women for preventing gestational diabetes mellitus.
        Cochrane Database Syst Rev. 2012; : CD009021
        • Meher S.
        • Duley L.
        Exercise or other physical activity for preventing pre-eclampsia and its complications.
        Cochrane Database Syst Rev. 2006; : CD005942
        • Garber C.E.
        • Blissmer B.
        • Deschenes M.R.
        • et al.
        American College of Sports Medicine position stand: quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
        Med Sci Sports Exerc. 2011; 43: 1334-1359
        • Oostdam N.
        • van Poppel M.N.
        • Wouters M.G.
        • et al.
        No effect of the FitFor2 exercise programme on blood glucose, insulin sensitivity, and birthweight in pregnant women who were overweight and at risk for gestational diabetes: results of a randomised controlled trial.
        BJOG. 2012; 119: 1098-1107
        • Ong M.J.
        • Guelfi K.J.
        • Hunter T.
        • Wallman K.E.
        • Fournier P.A.
        • Newnham J.P.
        Supervised home-based exercise may attenuate the decline of glucose tolerance in obese pregnant women.
        Diabetes Metab. 2009; 35: 418-421
        • Artal R.
        • Catanzaro R.B.
        • Gavard J.A.
        • Mostello D.J.
        • Friganza J.C.
        A lifestyle intervention of weight-gain restriction: diet and exercise in obese women with gestational diabetes mellitus.
        Appl Physiol Nutr Metab. 2007; 32: 596-601
        • Mottola M.F.
        • Giroux I.
        • Gratton R.
        • et al.
        Nutrition and exercise prevent excess weight gain in overweight pregnant women.
        Med Sci Sports Exerc. 2010; 42: 265-272
        • Claesson I.M.
        • Sydsjo G.
        • Brynhildsen J.
        • et al.
        Weight gain restriction for obese pregnant women: a case-control intervention study.
        BJOG. 2008; 115: 44-50
        • Dodd J.M.
        • Crowther C.A.
        • Robinson J.S.
        Dietary and lifestyle interventions to limit weight gain during pregnancy for obese or overweight women: a systematic review.
        Acta Obstet Gynecol Scand. 2008; 87: 702-706
        • Dodd J.M.
        • Grivell R.M.
        • Crowther C.A.
        • Robinson J.S.
        Antenatal interventions for overweight or obese pregnant women: a systematic review of randomised trials.
        BJOG. 2010; 117: 1316-1326
        • Sui Z.
        • Grivell R.M.
        • Dodd J.M.
        Antenatal exercise to improve outcomes in overweight or obese women: a systematic review.
        Acta Obstet Gynecol Scand. 2012; 91: 538-545
        • Oteng-Ntim E.
        • Varma R.
        • Croker H.
        • Poston L.
        • Doyle P.
        Lifestyle interventions for overweight and obese pregnant women to improve pregnancy outcome: systematic review and meta-analysis.
        BMC Med. 2012; 10: 47
        • van Poppel M.N.M.
        • Oostdam N.
        • Eekhoff M.E.W.
        • Wouters M.G.A.J.
        • van Mechelen W.
        • Catalano P.M.
        Longitudinal relationship of physical activity with insulin sensitivity in overweight and obese pregnant women.
        J Clin Endocrinol Metab. 2013; 98: 2929-2935
        • McMurray R.G.
        • Mottola M.F.
        • Wolfe L.A.
        • Artal R.
        • Millar L.
        • Pivarnik J.M.
        Recent advances in understanding maternal and fetal responses to exercise.
        Med Sci Sports Exerc. 1993; 25: 1305-1321
        • Wolfe L.A.
        • Ohtake P.J.
        • Mottola M.F.
        • McGrath M.J.
        Physiological interactions between pregnancy and aerobic exercise.
        Exerc Sport Sci Rev. 1989; 17: 295-351
        • Sternfeld B.
        Physical activity and pregnancy outcome: review and recommendations.
        Sports Med. 1997; 23: 33-47
        • Gavard J.A.
        • Artal R.
        Effect of exercise on pregnancy outcome.
        Clin Obstet Gynecol. 2008; 51: 467-480
        • Barakat R.
        • Ruiz J.R.
        • Rodriguez-Romo G.
        • Montejo-Rodriguez R.
        • Lucia A.
        Does exercise training during pregnancy influence fetal cardiovascular responses to an exercise stimulus? Insights from a randomised, controlled trial.
        Br J Sports Med. 2010; 44: 762-764
        • Szymanski L.M.
        • Satin A.J.
        Exercise during pregnancy: fetal responses to current public health guidelines.
        Obstet Gynecol. 2012; 119: 603-610
        • Clapp J.
        Continuing regular exercise during pregnancy: effect of exercise volume on fetoplacental growth.
        Am J Obstet Gynecol. 2002; 186: 142-147
        • Hopkins S.A.
        • Cutfield W.S.
        Exercise in pregnancy: weighing up the long-term impact on the next generation.
        Exerc Sport Sci Rev. 2011; 39: 120-127
        • Bell R.J.
        • Palma S.M.
        • Lumley J.M.
        The effect of vigorous exercise during pregnancy on birth-weight.
        Aust N Z J Obstet Gynaecol. 1995; 35: 46-51
        • Leet T.
        • Flick L.
        Effect of exercise on birthweight.
        Clin Obstet Gynecol. 2003; 46: 423-431
        • Hopkins S.A.
        • Baldi J.C.
        • Cutfield W.S.
        • McCowan L.
        • Hofman P.L.
        Exercise training in pregnancy reduces offspring size without changes in maternal insulin sensitivity.
        J Clin Endocrinol Metab. 2010; 95: 2080-2088
        • Juhl M.
        • Olsen J.
        • Andersen P.K.
        • Nøhr E.A.
        • Andersen A.-M.N.
        Physical exercise during pregnancy and fetal growth measures: a study within the Danish National Birth Cohort.
        Am J Obstet Gynecol. 2010; 202: 63.e1-63.e8
        • Barakat R.
        • Lucia A.
        • Ruiz J.R.
        Resistance exercise training during pregnancy and newborn’s birth size: a randomised controlled trial.
        Int J Obes. 2009; 33: 1048-1057
        • Lindholm E.S.
        • Norman M.
        • Kilander C.P.
        • Altman D.
        Weight control program for obese pregnant women.
        Acta Obstet Gynecol Scand. 2010; 89: 840-843
        • Richards D.S.
        • Miller D.K.
        • Goodman G.N.
        Pregnancy after gastric bypass for morbid obesity.
        J Reprod Med. 1987; 32: 172-176
        • Ducarme G.
        • Revaux A.
        • Rodrigues A.
        • Aissaoui F.
        • Pharisien I.
        • Uzan M.
        Obstetric outcome following laparoscopic adjustable gastric banding.
        Int J Gynaecol Obstet. 2007; 98: 244-247
        • Kral J.G.
        • Biron S.
        • Simard S.
        • et al.
        Large maternal weight loss from obesity surgery prevents transmission of obesity to children who were followed for 2 to 18 years.
        Pediatrics. 2006; 118: e1644-e1649
        • Smith J.
        • Cianflone K.
        • Biron S.
        • et al.
        Effects of maternal surgical weight loss in mothers on intergenerational transmission of obesity.
        J Clin Endocrinol Metab. 2009; 94: 4275-4283
        • Ross R.
        Does exercise without weight loss improve insulin sensitivity?.
        Diabetes Care. 2003; 26: 944-945
        • Duncan G.E.
        • Perri M.G.
        • Theriaque D.W.
        • Hutson A.D.
        • Eckel R.H.
        • Stacpoole P.W.
        Exercise training, without weight loss, increases insulin sensitivity and postheparin plasma lipase activity in previously sedentary adults.
        Diabetes Care. 2003; 26: 557-562
        • Clapp J.F.I.
        Morphometric and neurodevelopmental outcome at age five years of the offspring of women who continued to exercise regularly throughout pregnancy.
        J Pediatr. 1996; 129: 856-863
        • Dufour D.L.
        • Reina J.C.
        • Spurr G.
        Energy intake and expenditure of free-living, pregnant Colombian women in an urban setting.
        Am J Clin Nutr. 1999; 70: 269-276
        • Evenson K.R.
        • Savitz D.A.
        • Huston S.L.
        Leisure-time physical activity among pregnant women in the US.
        Paediatr Perinat Epidemiol. 2004; 18: 400-407
        • Petersen A.M.
        • Leet T.L.
        • Brownson R.C.
        Correlates of physical activity among pregnant women in the United States.
        Med Sci Sports Exerc. 2005; 37: 1748-1753
        • Huch R.
        • Erkkola R.
        Pregnancy and exercise: exercise and pregnancy: a short review.
        BJOG. 1990; 97: 208-214
        • Melzer K.
        • Schutz Y.
        • Boulvain M.
        • Kayser B.
        Physical activity and pregnancy: cardiovascular adaptations, recommendations and pregnancy outcomes.
        Sports Med. 2010; 40: 493-507
        • Lotgering F.K.
        • Gilbert R.D.
        • Longo L.D.
        Maternal and fetal responses to exercise during pregnancy.
        Physiol Rev. 1985; 65: 1-36
        • Renault K.
        • Norgaard K.
        • Secher N.J.
        • Andreasen K.R.
        • Baldur-Felskov B.
        • Nilas L.
        Physical activity during pregnancy in normal-weight and obese women: compliance using pedometer assessment.
        J Obstet Gynaecol. 2012; 32: 430-433
        • Renault K.
        • Norgaard K.
        • Andreasen K.R.
        • Secher N.J.
        • Nilas L.
        Physical activity during pregnancy in obese and normal-weight women as assessed by pedometer.
        Acta Obstet Gynecol Scand. 2010; 89: 956-961
        • Sui Z.
        • Turnbull D.
        • Dodd J.
        Effect of body image on gestational weight gain in overweight and obese women.
        Women Birth. 2013; 26: 267-272
        • Weir Z.
        • Bush J.
        • Robson S.C.
        • McParlin C.
        • Rankin J.
        • Bell R.
        Physical activity in pregnancy: a qualitative study of the beliefs of overweight and obese pregnant women.
        BMC Pregnancy Childbirth. 2010; 10: 18
        • Stengel M.R.
        • Kraschnewski J.L.
        • Hwang S.W.
        • Kjerulff K.H.
        • Chuang C.H.
        “What my doctor didn’t tell me”: examining health care provider advice to overweight and obese pregnant women on gestational weight gain and physical activity.
        Womens Health Issues. 2012; 22: e535-e540
        • Brown A.
        • Avery A.
        Healthy weight management during pregnancy: what advice and information is being provided.
        J Hum Nutr Diet. 2012; 25: 378-387
        • Phelan S.
        Pregnancy: a “teachable moment” for weight control and obesity prevention.
        Am J Obstet Gynecol. 2010; 202: 135.e1-135.e8
        • Sallis R.
        Developing healthcare systems to support exercise: exercise as the fifth vital sign.
        Br J Sports Med. 2011; 45: 473-474
        • Bauman A.
        • Murphy N.
        • Lane A.
        The role of community programmes and mass events in promoting physical activity to patients.
        Br J Sports Med. 2009; 43: 44-46
        • Mottola M.F.
        Exercise prescription for overweight and obese women: pregnancy and postpartum.
        Obstet Gynecol Clin North Am. 2009; 36 (viii): 301-316
        • Currie S.
        • Sinclair M.
        • Murphy M.H.
        • Madden E.
        • Dunwoody L.
        • Liddle D.
        Reducing the decline in physical activity during pregnancy: a systematic review of behaviour change interventions.
        PLoS One. 2013; 8: e66385
        • Pearce E.E.
        • Evenson K.R.
        • Downs D.S.
        • Steckler A.
        Strategies to promote physical activity during pregnancy: a systematic review of intervention evidence.
        Am J Lifestyle Med. 2013; 7
        • Seneviratne S.
        • Parry G.
        • McCowan L.
        • et al.
        Antenatal exercise in overweight and obese women and its effects on offspring and maternal health: design and rationale of the IMPROVE (improving maternal and progeny obesity via exercise) randomised controlled trial.
        BMC Pregnancy Childbirth. 2014; 14: 148
        • Davenport M.H.
        • Charlesworth S.
        • Vanderspank D.
        • Sopper M.M.
        • Mottola M.F.
        Development and validation of exercise target heart rate zones for overweight and obese pregnant women.
        Appl Physiol Nutr Metab. 2008; 33: 984-989
        • Zavorsky G.S.
        • Longo L.D.
        Exercise guidelines in pregnancy: new perspectives.
        Sports Med. 2011; 41: 345-360
        • Snyder S.
        • Pendergraph B.
        Exercise during pregnancy: what do we really know?.
        Am Fam Physician. 2004; 69: 1053-1056
        • Müller-Riemenschneider F.
        • Reinhold T.
        • Willich S.N.
        Cost-effectiveness of interventions promoting physical activity.
        Br J Sports Med. 2009; 43: 70-76
        • Mummery W.K.
        • Brown W.J.
        Whole of community physical activity interventions: easier said than done.
        Br J Sports Med. 2009; 43: 39-43
      4. Royal College of Obstetricians and Gynaecologists. Recreational exercise and pregnancy: information for you: 2006. Available at: http://www.rcog.org.uk/files/rcog-corp/Recreational%20Exercise%20and%20Pregnancy.pdf. Accessed July 3, 2014.