Abstract
Background:
Health-related quality of life (HRQoL) may be altered during pregnancy due to pregnancy-related changes in all domains of women’s health.
Hypothesis:
A supervised concurrent exercise-training program from the 17th gestational week until birth positively influences HRQoL.
Study Design:
Randomized controlled trial.
Level of Evidence:
Level 1.
Methods:
Eighty-six pregnant women (age, 33.1 ± 4.6 years; prepregnancy body mass index, 23.5 kg/m2), divided into exercise (n = 41) and control (n = 45) groups, participated in this study (per-protocol basis). The exercise group followed a 60-min, 3 days/week, concurrent (aerobic + resistance) exercise training program. HRQoL was assessed with the 36-Item Short Form Health Survey (SF-36), where higher scores (0-100) indicate better HRQoL.
Results:
After adjusting for potential confounders, the exercise group decreased 16.1 points less than the control group in the SF-36 physical functioning domain [between-group differences (B): 95% confidence interval (CI), 9.02 to 23.22; P < 0.01], and 4.5 points less in the SF-36 physical component summary than the control group (between-group differences (B): 95% CI, 0.65 to 8.28; P = 0.02). Intention-to-treat basis analyses depicted similar results, where the exercise group decreased 10.03 points less than the control group the in the SF-36 social functioning domain (between-group differences (B): 95% CI, 0.39 to 19.68; P = 0.04).
Conclusion:
A supervised concurrent exercise training program ameliorates HRQoL decreases along gestation. Although HRQoL decreased throughout pregnancy in both groups, this impact was less in the exercise group, especially in the SF-36 physical functioning, the SF-36 social functioning, and the SF-36 physical component summary.
Clinical Relevance:
Healthcare providers may encourage pregnant women to exercise in this physiological stage for a better HRQoL throughout pregnancy.
ClinicalTrials.gov Identifier:
NCT02582567; Date of registration: 20/10/2015
Keywords: exercise, gestation, health-related quality of life, Short-Form Health Survey 36
Most pregnant women complain about the physical, psychological, or social components of health-related quality of life (HRQoL), especially as the pregnancy progresses. 17 In this context, a poor HRQoL during gestation is related to anxiety, depression, stress, or even pregnancy-related complications that might exert a negative influence on fetal health such as low birthweight, impaired cognitive development, or emotional problems.12,16 Thus, HRQoL is recognized as an important surveillance measure for monitoring the health of pregnant women, and therapies to obtain improvements in this regard are necessary.
Pregnancy is characterized by considerable changes in the physiological, anatomic, and biomechanical spheres of women’s health. 21 Many of these changes appear during the early second trimester of pregnancy 21 and may reduce pregnant women’s predisposition to being physically active. 33 In fact, fewer than 20% of pregnant women meet the recommendations for prenatal exercise.6,23 Nevertheless, recent literature has shown that reduced physical activity and exercise during gestation is a key factor that negatively affects pregnant women’s HRQoL. 16
Moreover, greater physical fitness, which is improved through exercise, has been associated with greater HRQoL in this population.26,28
The results of few studies which have examined the relationship between exercise and HRQoL during pregnancy are contradictory due to differences in the protocol designs, the gestational week (gw) in which the training program starts or the length of the exercise program, and the tools employed to assess HRQoL.4,20,24,27 Therefore, the optimal type of exercise, as well as the dose to enhance HRQoL in this population, is still under debate. 17
Previous literature has established that, during pregnancy, combining aerobic and resistance exercise training (hereafter, concurrent exercise) may involve further benefits than aerobic activity alone. 18 However, it is not yet well established which dose (or protocol) is most effective in promoting the greatest benefits. Therefore, this study aimed to evaluate the influence of a supervised and adapted concurrent exercise training program on HRQoL throughout pregnancy (ie, from 17th gw until birth].
Methods
Participants and Study Design
These are secondary outcomes from the GESTAtion and FITness study (ClinicalTrials.gov identifier: NCT02582567), where a novel exercise intervention was conducted.
The recruitment was performed from November 2015 to April 2018 (in 3 different waves), when attending their gynecologist at the 12th gw. Pregnant women were informed about the project in the San Cecilio and Virgen de las Nieves University Hospitals (Granada, Spain). From all the initially interested participants, 159 Caucasian women were finally recruited. All participants signed an informed consent after being individually informed about the study aims and procedures. The GESTAFIT project was approved by the Clinical Research Ethics Committee of Granada, Government of Andalusia, Spain (code: GESFIT-0448-N-15).
The GESTAFIT project was initially designed as a randomized controlled trial. Nevertheless, the randomization design was partially broken in the third wave of recruitment to avoid high withdrawal rates (due to some difficulties related to the complexity of keeping women in the control group), which represents a frequent methodological barrier among pregnant women. 15 Therefore, half of the women were not randomized but assigned to the control or the exercise group based on their personal convenience. The complete methodology, together with the inclusion-exclusion criteria (see Appendix Table A1, available in the online version of this article) and procedures of this project have been described previously.1,3
General Procedure
After recruitment, 2 evaluations (at the 16th and 34th gw), as well as the exercise intervention, were carried out at the “Sport and Health University Research Institute” (Granada, Spain).
Sociodemographics, anthropometrics, and a specific questionnaire related to HRQoL were assessed at the 16th gw (±2 weeks). Sociodemographic data included age, marital status, educational level, and working status.
At the 34th gw, the same assessments (all but sociodemographic data) were performed. The research team explained how to fill out the questionnaire properly.
Exercise Intervention
The complete exercise program has been previously published elsewhere. 3 Briefly, participants allocated into the exercise group followed a concurrent exercise program (mostly moderate with peaks of vigorous intensity) from the 17th gw until birth, 3 days/week and 60 minutes/session, and attended lectures about pregnancy health-related behavior. The exercise training program was designed by an expert multidisciplinary team following the standards by the American College of Obstetricians and Gynecologists. 25 The training sessions were supervised by an experienced exercise specialist. The attendance at the training sessions was recorded.
Control Group
Pregnant women in the control group did not take part in the exercise training program and were asked to continue with their usual activities. However, for ethical reasons and to maintain their commitment until the end of the program, they were also invited to attend the lectures.
Outcomes Measured
Gynaecologists and midwives from the hospitals and expert physiologists responsible for the assessments were blinded to the allocated treatment of the participants.
Sociodemographic and Clinical Data
Women completed a self-reported questionnaire of reproductive history and sociodemographic (age, marital, and educational) status.
Anthropometry and Body Composition
Body weight and height were assessed using a scale (InBody R20; Biospace, Seoul, Korea) and a stadiometer (Seca 22, Hamburg, Germany), respectively. Gestational weight gain [(GWG) (kg)] was calculated as the difference between 16th and 34th gw.
Health-Related Quality of Life
Participants’ HRQoL was assessed with the Short-Form Health Survey 36 (SF-36), Spanish version. 2 This HRQoL questionnaire is valid and reliable, 22 and widely used in the pregnant population. 17 The SF-36 contains 36 items grouped into 8 domains: physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The scores range from 0 to 100 in every domain, where higher scores indicate better health. These 8 domains can be summarized into 2 global concepts: the physical component summary (covered by physical functioning, physical role, bodily pain, and general health), and the mental component summary (vitality, social functioning, emotional role, and mental health). 2
Statistical Analyses
Descriptive statistics [mean and standard deviation (SD) for quantitative variables, and the number of women (%) for categorical variables] were employed to describe the baseline characteristics of the study sample. Values of the SF-36, at the 16th and 34th gw, were compared to detect differences in these outcomes between the groups; t test for repeated measures was used (see Appendix Table A2, available online).
According to the original protocol, 3 the statistical analysis was conducted on a per-protocol basis. Only women who attended ≥75% of the exercise sessions and completed both baseline and follow-up assessments were included in the per-protocol analyses to investigate the clinical efficacy of a concurrent exercise training program on HRQoL. In those participants with missing data at follow-up, specific values were estimated using a mean imputation procedure. Subsequently, the aforementioned statistical analyses were conducted on an intention-to-treat basis to evaluate more realistically the effectiveness of this concurrent exercise-training program when applied to the clinical practice.
We included the changes (34th-16th gw) in the SF-36 domains as dependent variables in separate models and the group (control = 0 and exercise = 1) as independent variables.
After considering relevant confounders suggested in previous literature, two models were tested. Model I was unadjusted. Model II was adjusted for age, educational status, and GWG (kg).
The statistical analyses were conducted with the Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, Version 20.0). The statistical significance was set at P < 0.05.
Results
A flowchart of the study participants is shown in Figure 1. From 159 participants, 73 women discontinued the study (did not attend the second evaluation at 34th gw) or did not return all the questionnaires duly completed, which meant a loss of data in some outcomes. A total of 86 pregnant women divided into control (n = 45; age, 33.3 ± 4.9 years) and exercise groups (n = 41; age, 33.0 ± 4.3 years) were included in the present analysis. The baseline characteristics of the study participants are listed in Table 1. No differences were found between exercise and control groups in baseline characteristics (all P > 0.05). Nevertheless, the HRQoL of the pregnant women, regardless of their allocation in the exercise or the control group, suffered a deterioration in most SF-36 domain scores as the pregnancy progressed (see Appendix Table A2, available online).
Figure 1.
Flowchart of the participants for these specific study aims. HRQoL, health-related quality of life.
Table 1.
Participants’ sociodemographic characteristics
| Control Group mean (SD) (n = 45) | Exercise Group mean (SD) (n = 41) | P | |
|---|---|---|---|
| Age, y | 33.3 (4.9) | 33.0 (4.3) | 0.79 |
| Percentage of attendance a | 86.1 (6.4) | ||
| Marital status | |||
| With partner | 26 (57.8) | 24 (58.5) | 0.94 |
| Single | 19 (42.2) | 17 (41.5) | |
| Educational level | |||
| Nonuniversity studies | 15 (33.3) | 16 (39.0) | 0.58 |
| University studies | 30 (66.7) | 25 (61.0) | |
| Gestational weight gains, kg b | 12.5 (5.3) | 9.6 (4.6) | <0.01 |
| SF-36 | |||
| Physical functioning (0-100) | 80.4 (14.3) | 85.0 (14.2) | 0.14 |
| Physical role (0-100) | 62.4 (23.3) | 70.0 (25.2) | 0.17 |
| Bodily pain (0-100) | 59.4 (27.6) | 67.8 (23.8) | 0.13 |
| General health (0-100) | 75.9 (15.8) | 81.7 (15.6) | 0.09 |
| Vitality (0-100) | 52.6 (17.7) | 54.6 (16.9) | 0.61 |
| Social functioning (0-100) | 78.1 (21.3) | 81.1 (21.9) | 0.52 |
| Emotional role (0-100) | 90.4 (16.9) | 93.5 (11.3) | 0.32 |
| Mental health (0-100) | 76.3 (13.8) | 77.6 (12.8) | 0.67 |
| Physical component summary | 45.3 (7.6) | 48.5 (7.9) | 0.06 |
| Mental component summary | 51.3 (7.1) | 51.6 (7.1) | 0.81 |
SD, standard deviation; SF-36, Short-Form 36 Health Survey Questionnaire; Bold values, p < 0.05
Percentage of attendance in an intention-to-treat analysis (attendance to the 75% of the exercise sessions) = 75.3% (19.6).
Gestational weight gain between 16th and 34th gestational week.
Table 2 presents the per-protocol analyses of HRQoL changes between pre- and postintervention for control and exercise groups. In the adjusted model (Model II), the exercise group decreased in the physical functioning 16.1 points less than the control group (between-group differences (B): 95% CI, 9.02 to 23.22; P < 0.01), and in the SF-36 physical component summary decreased 4.5 points less than the control group (between-group differences (B): 95% CI, 0.65 to 8.28; P = 0.02). In Model I, the results remain the same.
Table 2.
Per-protocol analyses showing the association of the changes on SF-36 with a concurrent exercise program in the intervention group (control or exercise group) in pregnant women a
| Model I | Model II | |||||
|---|---|---|---|---|---|---|
| Changes Within Control Group Post-Pre (n = 45) | Changes Within Exercise Group Post-Pre (n = 41) | Between-Group Difference (B) (95% CI) | P | Between-Group Difference (B) (95% CI) | P | |
| SF-36 | ||||||
| Physical functioning (0-100) | –23.9 (16.4) | –7.2 (14.6) | 16.694 (10.004 to 23.384) | <0.01 | 16.117 (9.018 to 23.216) | <0.01 |
| Physical role (0-100) | –13.8 (28.1) | –9.1 (29.2) | 4.604 (–7.691 to 16.898) | 0.46 | 6.580 (–6.356 to 19.517) | 0.32 |
| Bodily pain (0-100) | –11.2 (25.2) | –8.7 (24.3) | 2.497 (–8.142 to 13.136) | 0.64 | 2.931(–8.367 to 14.229) | 0.61 |
| General health (0-100) | 1.3 (14.1) | –0.3 (15.3) | –1.626 (–7.915 to 4.663) | 0.61 | –0.547 (–7.211 to 6.117) | 0.87 |
| Vitality (0-100) | –1.7 (15.2) | –1.5 (18.9) | 0.142 (–7.185 to 7.470) | 0.97 | –1.194 (–8.885 to 6.497) | 0.76 |
| Social functioning (0-100) | –5.8 (26.7) | 2.1 (21.5) | 7.967 (–2.491 to 18.426) | 0.13 | 9.946 (–1.067 to 20.959) | 0.08 |
| Emotional role (0-100) | 1.5 (15.4) | –2.6 (15.6) | –4.124 (–10.788 to 2.541) | 0.22 | –3.741 (–10.713 to 3.230) | 0.29 |
| Mental health (0-100) | –2.0 (13.2) | –1.9 (17.2) | 0.049 (–6.495 to 6.593) | 0.99 | –0.584 (–7.390 to 6.221) | 0.87 |
| Physical component summary | –7.4 (8.2) | –3.3 (8.6) | 4.094 (0.495 to 7.693) | 0.03 | 4.468 (0.655 to 8.282) | 0.02 |
| Mental component summary | 2.3 (6.8) | 0.5 (8.1) | –1.800 (–4.992 to 1.393) | 0.27 | –1.886 (5.231 to 1.459) | 0.27 |
CI, confidence interval; SF-36, Short-Form 36 Health Survey Questionnaire.
Values are shown as mean (standard deviation). Model I was unadjusted. Model II was adjusted for age, educational status, and gestational weight gain (kg). Mean results show the differences between post-pre intervention (ie, 34th-16th gestational week) for each variable with negative values indicating a reduction in the postevaluation compared with pre-evaluation; B, nonstandardized regression coefficient; bold values indicate P < 0.05 or P < 0.01. Per-protocol analyses were performed including only women who attended ≥75% of the exercise sessions. The within-group post-pre intervention changes (from the exercise training group minus the control group) are presented for Model I.
Because of the substantial percentage of missing data (average 31.4%), multiple imputations were not possible for some outcomes. Intention-to-treat analyses have been added to Table 3 to be as transparent as possible. In Model II (adjusted), the exercise group decreased in the SF-36 physical functioning 14.2 points less than the control group (between-group differences (B): 95% CI, 7.72 to 20.73; P < 0.01), the exercise group decreased in the SF-36 social functioning 10.03 points less than the control group (between-group differences (B): 95% CI, 0.39 to 19.68; P = 0.04), and decreased in the SF-36 physical component summary 3.58 points less than the control group (between-group differences (B): 95% CI, 0.31 to 6.85; P = 0.03). In Model I, the results remain the same, except for SF-36 social functioning (P > 0.05).
Table 3.
Intention-to-treat analyses showing the association of the changes on SF-36 with a concurrent exercise program in the intervention group (control or exercise group) in pregnant women a
| Model I | Model II | |||||
|---|---|---|---|---|---|---|
| Changes Within Control Group Post-Pre (n = 45) | Changes Within Exercise Group Post-Pre (n = 41) | Between-Group Difference (B) (95% CI) | P | Between-Group Difference (B) (95% CI) | P | |
| SF-36 | ||||||
| Physical functioning (0-100) | –23.7 (16.2) | –9.0 (16.3) | 14.691 (8.460 to 20.923) | <0.01 | 14.225 (7.717 to 20.733) | <0.01 |
| Physical role (0-100) | –14.1 (27.9) | –11.5 (26.4) | 2.604 (–7.785 to 12.993) | 0.62 | 4.844 (–5.905 to 15.593) | 0.37 |
| Bodily pain (0-100) | –10.2 (25.2) | –7.5 (23.9) | 2.702 (–6.678 to 12.082) | 0.57 | 2.528 (–7.312 to 12.367) | 0.61 |
| General health (0-100) | 1.5 (13.9) | 0.3 (13.9) | –1.215 (–6.562 to 4.132) | 0.65 | –0.804 (–6.414 to 4.806) | 0.78 |
| Vitality (0-100) | –1.7 (14.9) | –1.7 (19.1) | 0.015 (–6.658 to 6.688) | >0.99 | –0.343 (–7.340 to 6.653) | 0.92 |
| Social functioning (0-100) | –6.4 (26.3) | 0.8 (23.1) | 7.189 (–2.209 to 16.588) | 0.13 | 10.035 (0.392 to 19.677) | 0.04 |
| Emotional role (0-100) | 1.4 (15.1) | –2.6 (15.5) | –3.972 (–9.847 to 1.903) | 0.18 | –3.718 (–9.701 to 2.264) | 0.22 |
| Mental health (0-100) | –1.9 (12.9) | –0.6 (15.7) | 1.270 (–4.315 to 6.854) | 0.65 | 1.259 (–4.585 to 7.103) | 0.67 |
| Physical component summary | –7.3 (8.2) | –3.9 (8.1) | 3.373 (0.258 to 6.488) | 0.03 | 3.579 (0.311 to 6.846) | 0.03 |
| Mental component summary | 2.2 (6.7) | 0.9 (7.7) | –1.262 (–4.046 to 1.522) | 0.37 | –0.961 (–3.870 to 1.948) | 0.51 |
CI, confidence interval; SF-36, Short-Form 36 Health Survey Questionnaire.
Values are shown as mean (standard deviation). Model I was unadjusted. Model II was adjusted for age, educational status, and gestational weight gain (kg). Mean results show the differences between post-pre intervention (ie, 34th-16th gestational week) for each variable with negative values indicating a reduction in the postevaluation compared with pre-evaluation; B, nonstandardized regression coefficient; bold values indicate P < 0.05 or P < 0.01.
Discussion
The main findings of these secondary analyses from the GESTAFIT project suggest that this concurrent exercise program attenuated HRQoL decline across pregnancy. Specifically, the program positively influenced SF-36 physical functioning, SF-36 social functioning, and the SF-36 physical component summary.
Therefore, following a concurrent exercise program might ameliorate the SF-36 physical component summary deterioration, being of great importance during the pregnancy period, since it is known that HRQoL in general, and physical function in particular, decrease as pregnancy progresses.17,20,27 Thus, our findings are broadly consistent with other studies involving active pregnant women (ie, practicing physical activity or engaging in an exercise-training program).
In line with our results, a 3-month supervised aerobic exercise program improved the SF-36 physical functioning domain and the SF-36 physical component summary more in the exercise group than in the control group. 4 Likewise, a 4-month water exercise (aerobic + strength) program ameliorated all domains except for the SF-36 mental health domain and the SF-36 mental component summary. 27
Nevertheless, some studies have failed to show differences between groups when following an exercise program.13,19,20,24,30,34 In this regard, some protocol differences could explain this lack of results. First, regarding the length of the intervention, our exercise program involved 17 weeks, while other programs were developed during shorter periods (11-12 weeks).13,20,24 Likewise, the initiation time of the exercise programs also differs between studies, without a specific time period for starting. For instance, ranging from 14th to 24th gw, 19 18th to 22nd gw, 13 or only indicating <20th gw, 34 making more difficult the proper comparison between studies. Moreover, pregnant women suffer most anatomic and physiological changes during the early second trimester of gestation, and it may predispose them to have worse HRQoL results5,16 related to physical functioning. This fact could partially explain the lack of results of the study by O’Connor et al, 20 where pregnant women exercised from the 22nd to 34th gw. Second, some exercise programs were designed as home-based training.13,19,24,30 Although lack of time is a frequent barrier that may be supplied by exercising at home, 5 it is also noteworthy that a supervised exercise program (in a sport or research center) may contribute to higher opportunities to interact and consult with exercise professionals. Furthermore, it may increase pregnant women’s interest and motivation to participate in the exercise program, thereby increasing the impact of exercise on their HRQoL. This circumstance is especially important since low levels of motivation are a major barrier to exercise in pregnant women. 5 Third, the low adherence to the exercise program found in some studies (33-55%)13,30 might also explain the insufficiency of positive findings. Fourth, all studies were designed in isolation as uniquely resistance or aerobic (cycling or water-based) training,13,19,20,24,30,34 whereas our study included both components. In fact, it has been found that aerobic training exerts additional improvements on HRQoL during pregnancy. 17 Moreover, the latest guidelines for exercise during pregnancy recommend combining aerobic and resistance training (concurrent) in this population. 18 To summarize, the timing of assessments, the program initiation or length, its compliance, and the design of these exercise programs could contribute to the differences found between studies. In addition, there is not a specific tool to assess HRQoL in pregnant population, which also make proper comparisons between studies difficult.
According to a recent systematic review, the physical components of HRQoL might be key during pregnancy since they seem to especially decrease as pregnancy progresses. 16 Therefore, exercise programs during pregnancy may be focused on improving these physical components, which might exert improvements in the anatomic, morphological, and musculoskeletal systems of pregnant women. Thereby, exercise might imply an improvement in the functionality, motor tasks, and activities of daily living that might be compromised, 29 especially during late pregnancy, where the functional ability of the trunk during gait declines. 29 Therefore, as shown in our exercise program design, weight bearing and resistance exercises should be included to strengthen the musculoskeletal system through core-based exercises, and consequently enhance its functionality along the pregnancy course.
The exact mechanisms by which physical functioning improves are still unknown, although musculoskeletal health is an important aspect of function which improves through greater physical fitness levels. 8 Furthermore, multicomponent activities and functional exercises, such as those that combine aerobic, strength, endurance, and flexibility, translate into general improvements in daily living functioning, which has been widely shown especially in older populations.10,11 Hence, our intervention program integrates all these tasks and, therefore, could imply such an improvement.
Finally, the SF-36 social functioning domain improved in the exercise group by 10 points more than in the control group (34th-16th gw). This finding is worth mentioning since it demonstrates that, despite the isolation process that may be perceived during pregnancy caused by changes in social lifestyle compared with prepregnancy, 16 enrolling in an exercise program might encourage contact with other pregnant women, empowering their autonomy, competence, and support; facilitating positive interactions; making women feel especially valued; and so decreasing the impact of gestation, thus improving social life.5,35 Thus, the results showed in “intention-to-treat analyses” indicate that the benefits of the exercise program on social functioning might have also been mediated by another mechanism inherent to being physically active itself (more than the social contact of the participants), such as the release of β-endorphins, producing a sense of wellbeing. 9 Moreover, exercise promotes improved social factors, sociability, 7 self-esteem, self-efficacy, distraction, 32 motivation, 5 and general HRQoL. 31 Therefore, these mechanisms may partially explain why positive significant results were found even when attending less than 75% of the exercise sessions. In addition, the fact that our exercise program was conducted by an exercise specialist is a further advantage over home-based training, since it comprises encouraging participants to do their best. Furthermore, the supervised exercise program also implies peer support, addressing the lack of motivation derived from individual training. In this sense, healthcare providers and sport specialists should encourage women to participate in more social group-based exercise activities to maximize the effectiveness of exercising during pregnancy.17,35
Limitations and Strengths
Several limitations should be considered when interpreting the present results: (i) selection bias might be present since the initial, purely random component could not be finally fully kept (due to the difficulties in maintaining control participants, we had to recruit additional participants in later waves); (ii) pregnant women in our study showed a relatively good HRQoL at baseline, so there was less room for change; (iii) the missing data in the SF-36 questionnaire could partially bias our findings. The strengths of the present study include (i) the measurement tool employed to assess HRQoL (ie, the SF-36), despite not being a pregnancy-specific tool, is widely valid and reliable, 22 which guarantees the quality of these data; (ii) the exercise group followed a novel concurrent exercise-training program, which has been proved as the most useful protocol to improve other pregnancy outcomes 18 ; (iii) our exercise program attendance rate was high (ie, 86%), which may strengthen our findings through an attractive and reproducible exercise program; (iv) despite there being no specific recommendation for the ideal moment to initiate an exercise program during pregnancy,14,18 our intervention began even earlier than the most similar studies. 17
Conclusion
A supervised concurrent exercise program during pregnancy appears to ameliorate HRQoL deterioration compared with a control group, specifically with regard to SF-36 physical functioning, SF-36 social functioning, and SF-36 physical component summary.
Therefore, engaging in a well-structured group-based exercise program, preferably combining aerobic + resistance training, might be proposed as a clinical and public health tool to maintain adequate HRQoL levels during this relevant stage for maternofetal health status.
Supplemental Material
Supplemental material, sj-docx-1-sph-10.1177_19417381231189730 for Influence of a Concurrent Exercise Training Program on Health-Related Quality of Life During Advanced Pregnancy: The GESTAFIT Project by Nuria Marín-Jiménez, Laura Baena-García, Irene Coll-Risco, Marta Flor-Alemany, José Castro-Piñero and Virginia A. Aparicio in Sports Health
Acknowledgments
The authors are grateful for the cooperation and participation of all the pregnant women recruited in the GESTAFIT project. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.
Footnotes
The authors report no potential conflicts of interest in the development and publication of this article.
For financial support, the authors thank the Regional Ministry of Health of the Junta de Andalucía (PI0395–2016), the Research and Knowledge Transfer Fund (PPIT) 2016, Excellence Actions Programme: Scientific Units of Excellence (UCEES), and the Regional Ministry of Economy, Knowledge, Enterprises and University, European Regional Development Funds (SOMM17/6107/UGR) of the University of Granada. M.F.A. was additionally funded by the Spanish Ministry of Education, Culture and Sports (Grant number FPU17/03715).
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Supplementary Materials
Supplemental material, sj-docx-1-sph-10.1177_19417381231189730 for Influence of a Concurrent Exercise Training Program on Health-Related Quality of Life During Advanced Pregnancy: The GESTAFIT Project by Nuria Marín-Jiménez, Laura Baena-García, Irene Coll-Risco, Marta Flor-Alemany, José Castro-Piñero and Virginia A. Aparicio in Sports Health