Gestational diabetes mellitus (GDM) is the most common metabolic disorder during pregnancy [1, 2]. GDM is defined as glucose intolerance of varying severity with onset during pregnancy [3, 4]. The global prevalence of GDM ranges from 6.6% to 45.3% [5, 6]. According to a systematic review and meta-analysis, GDM affects 14.8% of pregnancies among Chinese women [7]. Relevant risk factors for developing GDM include being overweight, having a family history of type 2 diabetes mellitus (T2DM), advanced maternal age, and physical inactivity [8].

Women with GDM may experience both short- and long-term complications [4, 9]. Short-term complications of GDM may include an increased risk of high blood pressure or preeclampsia, preterm delivery, induced labor, perineal trauma, and cesarean section delivery [9, 10]. GDM also increases the risk of the fetus being born large for gestational age and experiencing birth injury [9]. Regarding long-term complications, nearly half of women with GDM are at an increased risk of developing T2DM. Additionally, their children are more likely to develop metabolic syndrome during childhood and continue to experience it into early adulthood [10, 11].

First-line therapies for GDM include physical activity and dietary modifications [12]. Physical activity can reduce insulin resistance and thereby decrease the risk of adverse outcomes for women with GDM [13]. Previous research has reported that aerobic exercise (AE) and resistance training (RT) are commonly used interventions for managing GDM [14, 15, 16]. Regular AE and RT can increase muscle glucose uptake and improve the oxidative capacity of glucose in tissues. This improvement enhances insulin sensitivity and vascular function, lowers blood sugar levels, and reduces systemic inflammation [13, 17].

Although several reviews and recent trials have reported the benefits of AE or RT for GDM [14, 15, 16, 18, 19], no studies have explored the effects of combining of AE with RT (AE+RT) for women with GDM. Therefore, this study aimed to examine the effects of three different exercise interventions on glycemic control, pregnancy outcomes (including reduced incidence of preterm birth, gestational hypertension, and postpartum hemorrhage), and neonatal outcomes (such as lower birth weight and reduced incidence of neonatal complications like macrosomia and respiratory distress syndrome). Additionally, the study sought to identify the most effective exercise patterns for women with GDM.

This study hypothesized that exercise interventions — AE, RT, and a combination of both (AE+RT) — would significantly improve glycemic control, reduce the incidence of preterm birth, gestational hypertension, and postpartum hemorrhage, and improve neonatal outcomes in women with GDM compared to those who do not participate in structured exercise programs.

A total of 280 participants were screened, of which 184 were included in the study. Each group comprised 46 participants (Fig. 1). The sociodemographic and clinical characteristics of the participants at baseline are presented in Table 1. No significant differences were observed among the four groups in terms of age, gestational weeks, BMI, proportion of primiparous individuals, occupation, or education level.

Fig. 1.

Study design diagram. AE, aerobic exercise; RT, resistance training.

This study aimed to examine the effects of various exercise interventions on pregnancy and neonatal outcomes. AE alone, RT alone, and combined AE+RT had significant effects in reducing FBG, 2h-PBG, and HbA1c levels compared to the control group, which did not receive any exercise intervention. Among these three exercise interventions, combined AE+RT had a more significant effect on glycemic control compared to AE or RT alone. This finding is consistent with previous research in pregnant populations [23].

The potential mechanism by which exercise interventions reduce blood glucose levels may involve increased insulin sensitivity [24, 25]. The pathways through which exercise increases insulin sensitivity include elevated concentrations of glucose transporter proteins in skeletal muscle, changes in muscle fiber types, and increased glycogen synthase activity. Studies have found that long-term AE can increase capillary density, improving the efficiency of glucose delivery to muscles and enhancing insulin activity to boost muscle glucose uptake [23, 24, 25]. RT can enhance muscle capillary networks, increase muscle volume, reduce body fat, actively stimulate signaling pathways, lower inflammation levels, improve antioxidant capacity, and increase adiponectin levels. These effects contribute to enhancement of the adiponectin pathway, which helps to effectively improve blood glucose levels [23, 24]. Combined AE+RT leverages different physiological mechanisms by activating both metabolic pathways, potentially offering greater physiological benefits than using either approach alone [23, 25].

Existing studies comparing different exercise methods for patients with T2DM have similarly shown that the combined AE+RT results in better glycemic control compared to other exercise approaches [26, 27]. One study conducted a 26-week exercise study on adult patients with T2DM and found that combined AE+RT led to the greatest improvement in blood glucose control compared to the groups receiving AE or RT alone [26]. Xu et al. [27] also reported that among elderly patients with T2DM undergoing 24 weeks of combined AE+RT, blood glucose levels were better controlled compared to those undergoing only AE or RT alone. Given that the combination of AE and RT shows superior glycemic control in both pregnant women with GDM and adult patients with T2DM, this combined intervention should be recommended for pregnant women with GDM.

Postpartum hemorrhage is a common complication following childbirth and is a leading cause of maternal mortality. This study found that women with GDM in the three exercise intervention groups experienced lower postpartum bleeding volumes compared to the control group. In particular, the combined AE+RT group had the lowest postpartum bleeding volume, which is consistent with previous research by Zhong et al. [23]. Regarding neonatal outcomes, this study found no statistically significant differences among the three exercise intervention groups compared with the control group. However, a higher occurrence of macrosomia was observed in the control group. Recent research suggests that glycemic variability may significantly influence the relationship between GDM and excessive neonatal birth weight, indicating that improved glycemic control can effectively reduce the risk of macrosomia [28].

Overall, this study’s strengths include the implementation of multiple exercise interventions and the demonstration of positive effects on both maternal and neonatal outcomes. (1) The study examined the effects of comprehensive interventions of AE, RT, and their combined effect on glycemic control, pregnancy, and neonatal outcomes, providing insights into the most effective exercise regimen for managing GDM. (2) The study demonstrated that the combined exercise intervention not only improved glycemic control but also significantly reduced postpartum hemorrhage volume, highlighting that the combined AE+RT intervention could be considered as the most effective management strategy for GDM.

This study has several limitations. (1) It focused exclusively on the effects of exercise in pregnant women with GDM and did not include pregnant women with type 1 or 2 diabetes. (2) The study did not include postpartum follow-up assessments to evaluate the risk of diabetes in participants or the risk of diabetes and other diseases in their offspring. Future research should focus on long-term follow-up to assess the sustained effects of exercise interventions on both maternal and infant health. (3) The study monitored the effects of exercise interventions on glycemic control using traditional methods administered by healthcare providers. With advancements in digital technologies, future research should utilize fitness trackers and smartwatches to monitor the blood glucose control in women with GDM [15]. (4) This study did not collect detailed information on medication use for all participants.

The combined AE+RT intervention was more effective than the control group in reducing FBG, 2h-PBG, HbA1c levels, and postpartum bleeding. Additionally, of the combined AE+RT intervention demonstrated greater effect on 2h-PBG and HbA1c levels than single exercise groups. Therefore, combined AE+RT interventions may be a more effective for managing GDM in pregnant women.

Data is available upon request. Please contact Dr. Yingchun Zeng by chloezengyc@qq.com.

YZ, XW, XD, QH designed this study. YZ drafted the main manuscript. YZ, XM, MW, and YQ collected data and ran the statistical analyses. All authors provided edits and feedback on the manuscript. QH secured funding and were responsible for study design. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

This study was approved by The Second Affiliated Hospital of Guangxi Medical University, approved number 2020-KY-E-117. All participants were consented for this research study and provided written consent form. All research was carried out in accordance with the Declaration of Helsinki.

This research was supported by the following research projects: Joint Project on Regional High-Incidence Diseases Research of Guangxi Natural Science Foundation (#2023GXNSFAA026241); Guangxi Medical and Health Appropriate Technology Development and Application Project (#S2022095); Guangxi Medical and Health Appropriate Technology Development and Application Project (#S2019101).

The authors declare no conflict of interest.

During the preparation of this work the authors used ChatGpt-3.5 in order to check spell and grammar. After using this tool, the authors reviewed and edited the content as needed and takes full responsibility for the content of the publication.