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Original Investigation |

Physical Activity and Sedentary Behaviors Associated With Risk of Progression From Gestational Diabetes Mellitus to Type 2 Diabetes Mellitus:  A Prospective Cohort Study

Wei Bao, MD, PhD1; Deirdre K. Tobias, ScD2; Katherine Bowers, PhD3; Jorge Chavarro, MD, ScD2,4; Allan Vaag, PhD, DMSc5; Louise Groth Grunnet, PhD5; Marin Strøm, PhD6; James Mills, MD1; Aiyi Liu, PhD1; Michele Kiely, DrPH1; Cuilin Zhang, MD, PhD1
[+] Author Affiliations
1Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland
2Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, Massachusetts
3Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
4Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
5Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
6Centre for Fetal Programming, Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
JAMA Intern Med. 2014;174(7):1047-1055. doi:10.1001/jamainternmed.2014.1795.
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Importance  Women with a history of gestational diabetes mellitus (GDM) are at substantially increased risk of type 2 diabetes mellitus (T2DM). The identification of important modifiable factors could help prevent T2DM in this high-risk population.

Objective  To examine the role of physical activity and television watching and other sedentary behaviors, and changes in these behaviors in the progression from GDM to T2DM.

Design, Setting, and Participants  Prospective cohort study of 4554 women from the Nurses’ Health Study II who had a history of GDM, as part of the ongoing Diabetes & Women’s Health Study. These women were followed up from 1991 to 2007.

Exposures  Physical activity and television watching and other sedentary behaviors were assessed in 1991, 1997, 2001, and 2005.

Main Outcomes and Measure  Incident T2DM identified through self-report and confirmed by supplemental questionnaires.

Results  We documented 635 incident T2DM cases during 59 287 person-years of follow-up. Each 5–metabolic equivalent hours per week (MET-h/wk) increment of total physical activity, which is equivalent to 100 minutes per week of moderate-intensity physical activity, was related to a 9% lower risk of T2DM (adjusted relative risk [RR], 0.91; 95% CI, 0.88-0.94); this inverse association remained significant after additional adjustment for body mass index (BMI). Moreover, an increase in physical activity was associated with a lower risk of developing T2DM. Compared with women who maintained their total physical activity levels, women who increased their total physical activity levels by 7.5 MET-h/wk or more (equivalent to 150 minutes per week of moderate-intensity physical activity) had a 47% lower risk of T2DM (RR, 0.53; 95% CI, 0.38-0.75); the association remained significant after additional adjustment for BMI. The multivariable adjusted RRs (95% CIs) for T2DM associated with television watching of 0 to 5, 6 to 10, 11 to 20, and 20 or more hours per week were 1 (reference), 1.28 (1.04-1.59), 1.41 (1.11-1.79), and 1.77 (1.28-2.45), respectively (P value for trend <.001); additional adjustment for BMI attenuated the association.

Conclusions and Relevance  Increasing physical activity may lower the risk of progression from GDM to T2DM. These findings suggest a hopeful message to women with a history of GDM, although they are at exceptionally high risk for T2DM, promoting an active lifestyle may lower the risk.

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Relative Risk of Type 2 Diabetes Mellitus (T2DM)

Change in total physical activity (A) and time spent watching television (TV) (B) since baseline and the risk of T2DM among women with a history of gestational diabetes mellitus. The reference group were women who maintained total physical activity (−2 to 2 metabolic equivalent hours per week [MET-h/wk], equivalent to −40 to 40 minutes per week of moderate-intensity or −20 to 20 minutes per week of vigorous-intensity physical activity) and time spent watching TV (−1 to 1 hour per week), respectively. Covariates in the multivariable model include age (months), parity (1, 2, 3, ≥4), age at first birth (12-24, 25-29, or ≥30 years), race/ethnicity (white, African-American, Hispanic, Asian, or other), family history of diabetes (yes or no), oral contraceptive use (current, former, or never), menopausal status (premenopausal or postmenopausal), change in cigarette smoking status (never to never, never to current, past to past, past to current, current to past, or current to current), and baseline and changes (all in quartiles) in alcohol intake, total energy intake, diabetes dietary score (including intakes of trans fat and cereal fiber, glycemic load, and the ratio of polyunsaturated fat intake to saturated fat intake), and baseline total physical activity. In the multivariable model for change in time spent watching TV, we additionally adjusted for change in total physical activity and baseline time spent watching TV. Error bars indicate 95% confidence interval.a7.5 MET-h/wk is equivalent to 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity physical activity, the minimum level of physical activity recommended by the US federal guideline.14

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