Abstract
Background
Exercise is known to reduce the risk of gestational diabetes mellitus (GDM). However, the effectiveness of various exercise regimens in preventing GDM remains unclear, and the optimal approach has yet to be identified. This study aims to perform a systematic review and network meta-analysis to evaluate the preventive effects of different exercise interventions on GDM and to identify the most effective exercise strategy for its prevention.
Methods
A comprehensive search of seven databases was conducted for studies published before March 2025 that examined the relationship between exercise during pregnancy and the risk of GDM. All literature underwent a rigorous screening process based on pre-defined inclusion and exclusion criteria. The quality of evidence was assessed using the Cochrane Risk of Bias (RoB) tool. Data analysis, heterogeneity testing, publication bias assessment, and sensitivity analysis were performed using the Stata 17.0 software.
Results
(1) Meta-analysis revealed that the risk of GDM was significantly lower in the exercise intervention group compared to the conventional care group (OR 0.56, 95% CI = 0.44–0.71). (2) Subgroup analysis indicated that aerobic exercise (OR 0.40, 95% CI = 0.25–0.64), yoga (OR 0.19, 95% CI = 0.05–0.69), and diet and exercise guidance (OR 0.53, 95% CI = 0.37–0.76) significantly reduced the risk of GDM compared to the control group. Exercise intervention during pregnancy effectively reduced the risk of GDM in healthy individuals (OR 0.63, 95% CI = 0.43–0.93), overweight and/or obese individuals (OR 0.53, 95% CI = 0.36–0.79), and pregnant women at risk of GDM (OR 0.53, 95% CI = 0.34–0.82). Additionally, exercise intervention initiated in early pregnancy significantly prevented the development of GDM (OR 0.51, 95% CI = 0.39–0.68). (3) Network meta-analysis results demonstrated that yoga had the lowest surface under the cumulative ranking curve (SUCRA = 6.8%), suggesting that yoga was the most effective intervention in reducing the risk of GDM.
Conclusion
Various types of exercise, including yoga, aerobic exercise, and diet and exercise guidance, are effective in preventing GDM during pregnancy. Among these, yoga appears to be particularly promising and could be considered for inclusion in preventive care strategies for pregnant women.
Trial registration
The study was registered on the International Prospective Registry of Systematic Reviews (PROSPERO) database (CRD42024552641) on 10 June 2024.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-025-24807-5.
Keywords: Exercise, Yoga, Gestational diabetes mellitus, Network meta-analysis
Introduction
Gestational diabetes mellitus (GDM) is defined as glucose intolerance first identified during pregnancy and is one of the most prevalent complications associated with pregnancy [1]. Immediate consequences of GDM for mothers include an increased risk of gestational hypertension and polyhydramnios, while for infants, it raises the likelihood of fetal macrosomia, shoulder dystocia, and neonatal hyperbilirubinemia. In the long term, GDM poses significant health risks for both mothers and children, including a heightened likelihood of developing type 2 diabetes mellitus (T2DM) and metabolic syndrome in the postnatal periods [2]. According to the International Association of Diabetes and Pregnancy Study Groups (IADPSG), the global prevalence of GDM is estimated to be 14.0% [3].
Exercise intervention is considered a key component in the management of GDM [4]. The 2020 World Health Organization (WHO) Physical Activity Guidelines [5] recommend that pregnant women without contraindications engage in at least 150 min of moderate-intensity aerobic activity per week, alongside daily physical activity. The dose–response relationship between physical activity and GDM risk was demonstrated in our prior systematic review, which indicated that a physical activity volume of approximately 50 MET h/week was associated with the greatest reduction in GDM risk [6]. Although this threshold is somewhat higher than the minimum level recommended by the WHO guidelines, it highlights the potential additional benefits of engaging in physical activity beyond the minimum recommendation. In addition, the WHO guidelines encourage a variety of exercise modalities during pregnancy, including aerobic exercise, muscle-strengthening activities, and gentle stretching. These forms of exercise have shown significant benefits for both maternal and fetal health. For pregnant women, exercise is an effective strategy for preventing various pregnancy-related complications, including GDM, excessive gestational weight gain, hypertension, urinary incontinence, lumbar and pelvic pain, anxiety, and prenatal depression [7]. Moreover, exercise during pregnancy has been associated with reduced risk of preterm birth, neonatal complications, and postpartum depression [8].
Despite the guidelines recommending exercise during pregnancy [5], several issues require further investigation. Firstly, there is a lack of consensus on the efficacy of different exercise types in preventing GDM. While some evidence indicates that yoga [9, 10], aerobic exercise [11], aerobic combined with resistance exercise [12], and diet and exercise guidance [13, 14] can effectively prevent GDM, other studies have reported inconsistent findings [15–17]. Secondly, prior research has primarily focused on managing and controlling blood glucose levels through exercise interventions, with limited attention to the potential preventive effects of early exercise on GDM. Early and proactive exercise interventions play a critical role in promoting maternal health during pregnancy, not only by preventing GDM but also by providing broader health benefits for both mothers and infants [18]. Thirdly, most studies have compared single exercise types with conventional care, with limited comprehensive comparisons among various exercise modalities. As a result, there is insufficient evidence to recommend the most suitable exercise strategies for optimal prevention. Thus, this study aims to identify the most effective exercise intervention for preventing GDM through a network meta-analysis. This approach will provide more precise exercise recommendations for pregnant women, helping to optimize prevention strategies for GDM.
Methods
All meta-analyses conducted in this study were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (see Additional file 1) [19]. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42024552641) on 10 June 2024 (available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024552641).
Literature search
A comprehensive search was conducted across multiple electronic databases, including CNKI, Wanfang, Web of Science, PubMed, Cochrane Library, Embase, and EBSCO, to identify relevant literature on the relationship between exercise during pregnancy and the development of GDM. The search utilized the following formula (see Table 1): “pregnancy” OR “pregnant women” OR “maternal” OR “gestation”, “gestational diabetes mellitus” OR “gestational diabetes” OR “GDM” OR “diabetic, pregnancy” OR “blood glucose”, and “exercise” OR “physical activity” OR “sport” OR “yoga” OR “exercise intervention”. The search covered studies from the inception of each database up to 31 March 2025. The search was restricted to articles published in Chinese or English.
Table 1.
Systematic literature search terms and strategies
| Search terms for PubMed | |
|---|---|
| #1 (pregnancy[Title/Abstract] OR pregnant women[Title/Abstract] OR maternal[Title/Abstract] OR gestation[Title/Abstract]) | |
| #2 (Gestational Diabetes Mellitus[Title/Abstract] OR gestational diabetes[Title/Abstract] OR GDM[Title/Abstract] OR diabetic, pregnancy[Title/Abstract] OR Blood glucose[Title/Abstract]) | |
| #3 (exercise[Title/Abstract] OR physical activity[Title/Abstract] OR sport[Title/Abstract] OR yoga[Title/Abstract] OR exercise intervention[Title/Abstract]) | |
| #1 AND #2 AND #3 | |
| Search terms for EBSCO | |
| #1 SU=(pregnancy OR pregnant women OR maternal OR gestation) | |
| #2 SU=(Gestational Diabetes Mellitus OR gestational diabetes OR GDM OR diabetic, pregnancy OR Blood glucose) | |
| #3 SU=(exercise OR physical activity OR sport OR yoga OR exercise intervention) | |
| #1 AND #2 AND #3 | |
| Search terms for Web of Science | |
| #1 TI=(pregnancy or gestation or pregnant women or maternal) | |
| #2 TI=(Gestational Diabetes Mellitus or gestational diabetes or GDM or diabetic, pregnancy or Blood glucose) | |
| #3 TI=(exercise or physical activity or sport or yoga or exercise intervention) | |
| #1 AND #2 AND #3 | |
| Search terms for Cochrane | |
| #1 Title Abstract Keyword (pregnancy OR gestation OR pregnant women OR maternal) | |
| #2 Title Abstract Keyword (Gestational Diabetes Mellitus OR gestational diabetes OR GDM OR diabetic, pregnancy OR Blood glucose) | |
| #3 Title Abstract Keyword (exercise OR physical activity OR sport OR yoga OR exercise intervention) | |
| #1 AND #2 AND #3 | |
| Search terms of Embase | |
| #1 TS=(pregnancy or gestation or pregnant women or maternal) | |
| #2 TS=(Gestational Diabetes Mellitus or gestational diabetes or GDM or diabetic, pregnancy or Blood glucose) | |
| #3 TS=(exercise or physical activity or sport or yoga or exercise intervention) | |
| #1 AND #2 AND #3 | |
| Search terms for CNKI (in Chinese) | |
| #1 Title Abstract Keyword = pregnancy + pregnant women + maternal + gestation | |
| #2 Title Abstract Keyword = Gestational Diabetes Mellitus + gestational diabetes + GDM + diabetic, pregnancy + Blood glucose | |
| #3 Title Abstract Keyword = exercise + physical activity + sport + yoga + exercise intervention | |
| #1 AND #2 AND #3 | |
| Search terms for Wanfang (in Chinese) | |
| #1 (Title or Keywords: ((“pregnancy”)or(“pregnant women”)or(“maternal”)or(“gestation”))) | |
| #2 (Title or Keywords: ((“Gestational Diabetes Mellitus”)or(“gestational diabetes”)or(“GDM”)or(“diabetic, pregnancy”)or(“Blood glucose”))) | |
| #3 (Title or Keywords: ((“exercise”) or (“physical activity”)or(“sport”)or(“yoga”)or(“exercise intervention”))) | |
| #1 AND #2 AND #3 |
Eligibility criteria
Inclusion criteria: (1) The study was a randomized controlled trial (RCT) investigating the prevention of GDM through exercise; (2) The study was published in Chinese or English by 30 June 2024; (3) The intervention involved exercise, while the control group received conventional care. (4) The primary outcome measure was the diagnostic results of GDM.
Exclusion criteria: (1) Conference papers, reviews, meta-analyses, animal studies, empirical reports, non-research literature, or other irrelevant publications. (2) Studies that did not include GDM as an outcome indicator or had incomplete data. (3) Chinese articles published in non-core journals. (4) Duplicate publications.
The intervention involved exercise during pregnancy. We categorized the exercise interventions into 6 types: aerobic exercise, resistance exercise, aerobic combined with resistance exercise, yoga, exercise guidance, and diet and exercise guidance. The control group received conventional care. Detailed definitions of these categories are provided in Table 2.
Table 2.
Definitions of intervention and control groups
| Intervention group | aerobic exercise | Primarily relying on aerobic metabolism to supply the energy needed for exercise. Examples include cycling, running, aerobic dancing, and other moderate-intensity activities. |
| resistance exercise | The active movement of muscles to overcome external resistance, which can be provided by another person, the individual’s healthy limbs, or equipment like dumbbells, springs, or resistance bands. | |
| aerobic combined with resistance exercise | A comprehensive exercise mode combining aerobic and resistance exercise | |
| yoga | A movement practice aimed at achieving harmony and unity of the body, mind, and spirit, It incorporates methods for adjusting body posture, regulating breathing, and practicing meditation to calm the mind. | |
| exercise guidance | Recommendations focus on total exercise volume, intensity, and duration, without prescribing a specific exercise mode. | |
| diet and exercise guidance | Diet and exercise guidance or planning is provided without centralized organizational supervision. Implementation is monitored through methods such as questionnaires, follow-up visits, WeChat communication, and record-keeping. | |
| Control group | conventional care | This refers to the standard prenatal examinations during pregnancy without additional exercise interventions. Some hospitals also provide educational and advisory services focused on maternal health during the perinatal period. |
Data extraction
The data extraction was conducted by two researchers (Y.R. and Y.G.) utilizing standardized electronic data extraction tables. In cases of disagreement, a third author (L.Z.) was consulted to resolve conflicts. In the absence of data in the original article, the research authors are contacted via email to request additional information. Extracted data items included the first author, publication year, research population, sample size, intervention details (types of interventions and their start time) for experimental and control groups, and the outcome measures (e.g., diagnosis of GDM).
Quality assessment
The risk of bias (RoB) was evaluated by two independent reviewers (Y.R. and Y.G.) using the Cochrane RoB tool, version 2. This tool evaluates five key domains: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. For each domain, the reviewers categorized the risk of bias was categorized as “low risk”, “unclear risk”, or “high risk”. Any discrepancies arising during the quality assessment were resolved by the third author (L.Z.).
Statistical analysis
Data analysis was conducted using Stata 17.0 software. The primary outcome variables were categorical, and effect sizes were quantified as odds ratio (OR), with 95% confidence intervals (CI). Heterogeneity among study results was assessed using Cochran’s Q test and the I² statistic, with I² >50% and P < 0.05 indicating significant heterogeneity. In such cases, a random-effects model was applied; otherwise, a fixed-effect model was used. Forest plots were constructed to visualize the results. Subgroup analysis was conducted to ascertain whether the effectiveness of exercise interventions varied by exercise type, and the results were presented as forest plots. Sensitivity analysis was performed using the one-by-one elimination method to evaluate the robustness of the findings. Publication bias was assessed using a funnel plot and Egger test, with a significance level of P < 0.05. Furthermore, a network meta-analysis was conducted, involving the construction of an evidence network, calculation of the surface under the cumulative ranking curve (SUCRA), and comparison of the efficacy of different interventions. Cumulative probability plots were created based on the SUCRA ranking, where smaller areas under the curve indicated a more favorable intervention effect.
Results
Search result
A total of 9,073 articles were initially identified through the preliminary search, and 210 articles were subsequently evaluated based on their title and abstract. Following a full-text review, 25 RCTs met the inclusion criteria. The detailed process of literature screening is illustrated in Fig. 1.
Fig. 1.
Literature screening flowchart for the network meta-analysis
Description of included studies
A total of 25 [9–17, 20–35] RCTs were included, involving 6,824 participants. Of these, 3,389 were assigned to the experimental group and 3,435 to the control group. The studies were published between 2010 and 2021, comprising 4 in Chinese [31–34] and 21 in English [9–17, 20–30, 35]. The studies encompassed 5 distinct intervention categories: yoga (2 studies) [9, 10], aerobic exercise (2 studies) [11, 25], aerobic combined with resistance exercise (8 studies) [12, 15, 16, 22–24, 26, 27], exercise guidance (2 studies) [20, 35], and diet and exercise guidance (11 studies) [13, 14, 17, 21, 28–34]. Detailed results are presented in Additional file 2.
Risk of bias
The results of the risk of bias assessment are summarized as percentages in Fig. 2, while detailed judgments for each risk of bias item in the included studies are shown in Fig. 3. In the randomization process, all studies adopted randomization methods. However, only 7 articles explicitly mentioned allocation concealment, which was rated as low risk. The remaining 18 articles were categorized as having an unclear risk due to insufficient information. All studies were assessed as low risk in the domains of deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Therefore, 7 studies were rated as having a low risk of overall bias, while 18 were rated as having an unclear risk.
Fig. 2.
Risk of bias assessment (expressed as percentages)
Fig. 3.
The review author’s judgments about each risk of bias item for the included studies
Meta-analysis
Meta-analysis results
A total of 25 articles, encompassing 6,824 participants, reported the occurrence of GDM. The 25 studies exhibited moderate heterogeneity (I² = 50%, P = 0.003). Using a random-effects model, the meta-analysis revealed that the risk of GDM was significantly lower in the exercise intervention group compared to the conventional care group (OR = 0.56, 95% CI = 0.44–0.71, P < 0.001), as illustrated in Fig. 4.
Fig. 4.
Forest plot of meta-analysis
Subgroup analysis results
Subgroup analysis was performed on the types of exercise intervention
Subgroup analysis was performed according to the types of exercise interventions, including yoga (I² = 0.0%, P = 0.758), aerobic exercise (I² = 0.0%, P = 0.823), aerobic combined with resistance exercise (I² = 29.0%, P = 0.197), exercise guidance (I² = 19.2%, P = 0.266), and diet and exercise guidance (I² = 64.1%, P = 0.002). The results demonstrated that, compared to the conventional care group, aerobic exercise (OR = 0.40, 95% CI = 0.25–0.64, P < 0.001), yoga (OR = 0.19, 95% CI = 0.05–0.69, P = 0.011), and diet and exercise guidance (OR = 0.53, 95% CI = 0.37–0.76, P = 0.001) significantly reduced the risk of GDM. Conversely, aerobic combined with resistance exercise (OR = 0.71, 95% CI = 0.47–1.08, P = 0.107) and exercise guidance (OR = 0.74, 95% CI = 0.32–1.73, P = 0.488) exhibited no statistically significant effect, as illustrated in Fig. 5.
Fig. 5.
Forest plot of subgroup analysis about the types of exercise interventions
Subgroup analysis by population characteristics
Subgroup analysis was conducted according to the population characteristics, classifying participants into three categories: healthy individuals (I² = 45.6%, P = 0.065), overweight and/or obese individuals (I² = 56.7%, P = 0.010), and pregnant women at risk of GDM (I² = 25.2%, P = 0.253). The results indicated that exercise intervention during pregnancy significantly reduced the risk of GDM across all subgroups: healthy individuals (OR = 0.63, 95% CI = 0.43–0.93, P = 0.019), overweight and/or obese individuals (OR = 0.53, 95% CI = 0.36–0.79, P = 0.002), and pregnant women at risk of GDM (OR = 0.53, 95% CI = 0.34–0.82, P < 0.004), as illustrated in Fig. 6.
Fig. 6.
Forest plot of subgroup analysis by population characteristics
Subgroup analysis by intervention initiation time
Subgroup analysis was performed according to the timing of intervention initiation, categorized as early pregnancy (I² = 45.3%, P = 0.020), middle pregnancy (I² = 67.7%, P = 0.079), and early and middle pregnancy (I² = 69.4%, P = 0.020). The results demonstrated that initiating exercise interventions in early pregnancy significantly reduced the risk of GDM (OR = 0.51, 95% CI = 0.39–0.68, P < 0.001). In contrast, interventions initiated during the second trimester (OR = 0.57, 95% CI = 0.13–2.48, P = 0.453) or spanning both early and middle pregnancy (OR = 0.78, 95% CI = 0.41–1.48, P = 0.446) did not yield statistically significant effects, as illustrated in Fig. 7.
Fig. 7.
Forest plot of subgroup analysis by intervention initiation time
Sensitivity analysis
Sensitivity analysis was conducted using the one-by-one elimination method, in which each study was sequentially excluded, and the remaining articles (n-1) were re-analyzed. The purpose was to assess the influence of individual studies on the overall meta-analysis results. As shown in Fig. 8, the combined results of the remaining studies remained statistically significant (95% CI < 1) after the exclusion of most studies. This indicates that the original meta-analysis results were stable and not substantially affected by changes in the number of included studies, demonstrating their robustness.
Fig. 8.
The plot of sensitivity analysis
Publication bias
The funnel plot (Fig. 9) and the Egger test results (p = 0.002) indicate the potential presence of publication bias among the included RCTs. A trim-and-fill analysis was conducted, adding six hypothetical studies to account for the bias. The adjusted funnel plot is presented in Fig. 10 (OR = 0.63, 95% CI = 0.50–0.81). The results before and after the trim-and-fill adjustment remained statistically significant, confirming the stability of the findings.
Fig. 9.
The funnel plot of meta-analysis
Fig. 10.
The funnel plot after trim-and-fill analysis
Network meta-analysis results
Network plot
The prevalence of GDM was reported in 25 studies that encompassed five distinct exercise interventions: aerobic exercise, aerobic combined with resistance exercise, yoga, exercise guidance, and diet and exercise guidance. The control group was treated with conventional care. The distribution of studies across the interventions was as follows: 2 studies on yoga, 2 on aerobic exercise, 8 on aerobic combined with resistance exercise, 2 on exercise guidance, and 11 articles on diet and exercise guidance. The network evidence graph, illustrating the relationships between these interventions, is visually represented in Fig. 11.
Fig. 11.
The plot of evidence network. Note: A = conventional care; B = aerobic exercise; C = aerobic combined with resistance exercise; D = Yoga; E = exercise guidance; F = diet and exercise guidance
Network meta-analysis
The findings indicated that compared to conventional care, aerobic exercise, yoga, and diet and exercise guidance significantly reduced the risk of GDM (P < 0.05). Conversely, other interventions showed no significant differences in reducing GDM. These findings are detailed in Table 3; Fig. 12.
Table 3.
Network meta-analysis of the preventive effects of different interventions on GDM (OR and 95% CI)
| A | 0.39 (0.19,0.82) | 0.70 (0.44,1.11) | 0.19 (0.05,0.76) | 0.76 (0.30,1.89) | 0.55 (0.39,0.78) |
|---|---|---|---|---|---|
| 2.54 (1.22,5.28) | B | 1.78 (0.75,4.21) | 0.47 (0.10,2.31) | 1.92 (0.59,6.21) | 1.40 (0.62,3.13) |
| 1.43 (0.90,2.26) | 0.56 (0.24,1.33) | C | 0.27 (0.06,1.17) | 1.08 (0.39,3.02) | 0.79 (0.45,1.37) |
| 5.35 (1.32,21.76) | 2.11 (0.43,10.25) | 3.75 (0.86,16.37) | D | 4.05 (0.76,21.63) | 2.94 (0.70,12.47) |
| 1.32 (0.53,3.30) | 0.52 (0.16,1.68) | 0.93 (0.33,2.59) | 0.25 (0.05,1.32) | E | 0.73 (0.27,1.95) |
| 1.82 (1.29,2.56) | 0.72 (0.32,1.60) | 1.27 (0.73,2.22) | 0.34 (0.08,1.44) | 1.37 (0.51,3.69) | F |
Note: A = conventional care; B = aerobic exercise; C = aerobic combined with resistance exercise; D = Yoga; E = exercise guidance; F = diet and exercise guidance
Fig. 12.
Forest plot of network meta-analysis. Note: A = conventional care; B = aerobic exercise; C = aerobic combined with resistance exercise; D = Yoga; E = exercise guidance; F = diet and exercise guidance
SUCRA ranking
The SUCRA rankings for all interventions and control measures are presented in Fig. 13. A smaller SUCRA value indicates a lower risk of GDM and greater effectiveness of the intervention. Based on SUCRA rankings, yoga emerged as the most effective intervention for preventing GDM, with the lowest SUCRA value (6.8%). It was followed by aerobic exercise (SUCRA = 25.4%), diet and exercise guidance (SUCRA = 43.5%), aerobic combined with resistance exercise (SUCRA = 63.4%), exercise guidance (SUCRA = 68.0%) and conventional care (SUCRA = 92.9%). These findings confirm that yoga is the most efficacious exercise intervention for reducing the risk of GDM.
Fig. 13.
SUCRA ranking of GDM risk for the different interventions
Discussion
GDM is a prevalent complication during pregnancy that poses serious health risks to both the mother and fetus. Physical activity during pregnancy has been identified as an effective strategy for promoting maternal health. Prior research has demonstrated that exercise not only helps regulate blood glucose levels in patients [36] but also serves as an effective method for the prevention of GDM [37]. Furthermore, compared to other intervention methods, exercise offers several benefits, including safety, efficacy, and minimal risk of adverse effects, making it particularly suitable for pregnant women. Consequently, providing appropriate exercise recommendations for pregnant women is crucial to maintaining health and preventing complications during pregnancy.
The findings of the meta-analysis indicate that exercise is an effective method for the prevention of GDM, consistent with prior research findings [37]. However, the precise mechanisms by which exercise prevents GDM remain an active area of investigation. Current evidence suggests that the etiology of GDM shares similarities with that of T2DM, with insulin resistance being a key underlying factor. Exercise has been shown to reduce insulin resistance, thereby lowering the risk of GDM [38]. The mechanisms by which exercise mitigates insulin resistance are multifaceted. Firstly, studies have demonstrated that exercise can compensate for the defects of the insulin signaling pathway, offering an alternative method to enhance glucose uptake and facilitate insulin transport [38–40]. Secondly, exercise has been shown to reduce insulin resistance by altering the distribution of specific adipokines [38, 41, 42]. Thirdly, exercise has been shown to reduce inflammation, decrease free radical levels, lower oxidative stress, and thereby protect the function of islet β cells [38, 43, 44].
Subgroup analysis revealed that compared to the conventional care group, aerobic exercise, yoga and diet and exercise guidance were significantly associated with a notably reduced risk of GDM. Aerobic exercise, which relies on aerobic metabolism to generate energy, includes activities such as brisk walking, jogging, swimming, and cycling. It has been shown to enhance glucose uptake and utilization, improve metabolic function, regulate blood sugar levels, and lower the risk of GDM [45, 46]. Yoga a holistic practice, has been shown to enhance physical, psychological, and mental well-being [47]. Research indicates that yoga can alleviate stress in pregnant women [10], and its meditation and relaxation components may contribute to GDM prevention [9]. Diet and exercise guidance also played a key role in GDM prevention by positively influencing maternal metabolism, glycemic control, weight management, and overall health [48]. Improved dietary habits and physical activity can enhance insulin sensitivity, regulate blood sugar, and lower body mass index (BMI) — a major risk factor for GDM in pregnant women [49]. However, in this study, exercise guidance and aerobics combined with resistance exercise did not show a significant effect in reducing the risk of GDM. The lack of preventive efficacy from exercise guidance may be attributed to its reliance on advice alone, without professional guidance or supervision, leading to low compliance and limited exercise effectiveness [20, 35]. Similarly, the ineffectiveness of aerobic combined with resistance exercise might be due to variations in the initiation time and duration of the interventions across studies. Additionally, the higher intensity and potential risks associated with resistance exercises may render them less suitable for pregnant individuals, thereby limiting the overall quality and impact of these interventions [12, 15, 16, 22–24, 26, 27]. Furthermore, subgroup analysis was conducted to examine both the characteristics of the intervention population and the timing of the intervention. The findings indicated that exercise interventions during pregnancy effectively prevented the occurrence of GDM in healthy individuals, overweight and obese individuals, and pregnant women at risk of GDM. Additionally, exercise intervention initiated in early pregnancy was also effective in preventing the onset of GDM. These results are consistent with previous studies [37].
The results of the network meta-analysis indicate that yoga may be the most efficacious exercise intervention for preventing GDM. Yoga incorporates millennia-old techniques that are relatively simple to learn and aim to enhance physical, psychological, emotional, and spiritual well-being. These techniques include postures to purify the body, breathing exercises to cleanse the breath, and meditative practices to calm the mind [50]. Pregnancy is a period of heightened physical and emotional stress for women, particularly due to the cardiovascular strain it places on the body [51]. Yoga has gained popularity for its ability to reduce blood pressure and alleviate stress, making it a particularly suitable exercise for pregnant women [52, 53]. Although the precise mechanism by which yoga prevents GDM remains unclear, its unique advantages set it apart from other forms of exercise. Firstly, yoga is especially well-suited for pregnant women [9] as it requires no complex equipment or specialized location. Its gentle movements and slow rhythm reduce the risk associated with high-intensity exercises, allowing women to safely practice yoga throughout pregnancy. Secondly, yoga extends beyond physical activity to include breathing and meditation, which benefit not only physical fitness but also the emotional and psychological well-being of pregnant women. Finally, yoga supports the regulation of the endocrine system, helping to balance hormone secretion [54]. This hormonal balance may contribute to stabilizing blood glucose levels, thereby reducing the risk of GDM.
Previous systematic reviews and meta-analyses have explored the preventive effects of exercise on GDM. For instance, Shan Wu et al. [55] focused on overweight and obese pregnant women, comparing the effects of diet, physical activity, and combined interventions. The results indicated that although neither dietary intervention, physical activity alone, nor their combination effectively reduced the risk of GDM in this population, there was a trend suggesting that physical activity combined with diet could be a preventive factor for GDM. Similarly, Tsironikos et al. [56] conducted a systematic review of high-risk pregnant women and found that lifestyle interventions during pregnancy may be beneficial in reducing the incidence of GDM. Another meta-analysis by Vicente Martínez-Vizcaíno et al. [37] demonstrated that exercise significantly lowers the risk of GDM in pregnant women who are not overweight or obese. Notably, the benefits were most pronounced when interventions were delivered by trained professionals, involved low to moderate intensity, and were initiated within the first trimester. While these studies provide valuable insights into the preventive role of exercise for GDM, their conclusions are primarily limited to general efficacy or specific subpopulations. In addition, our previous systematic review demonstrated a clear dose–response relationship between physical activity and GDM risk, with the lowest risk observed at approximately 50 MET-hours per week [6]. This finding provided quantitative evidence on an approximate activity volume associated with the greatest preventive benefit. Extending these findings, the present study addresses the critical question of which type of exercise is most effective. By employing a network meta-analysis that included a diverse range of participants, we comprehensively compared the preventive effects of various exercise modalities. A key finding of this study is that yoga may be the most effective intervention for preventing GDM. Taken together, these two reviews offer complementary insights, providing both quantitative targets and practical recommendations for clinical and public health practice.
Strengths and limitation
The network meta-analysis presents several strengths: (1) This network meta-analysis systematically explored the preventive effects of five exercise interventions on GDM through a comprehensive search across seven databases. (2) This study was conducted following the PRISMA guidelines, ensuring methodological rigor. The findings provide a scientific basis for the prevention and reduction of GDM. (3) Based on the analysis of the effect of exercise on GDM prevention, this study further employed the network meta-analysis to determine the most effective exercise intervention, offering evidence for precise and targeted prevention.
This review has several noteworthy limitations: (1) The limited number of included studies, particularly those focusing on yoga and aerobic exercise, may introduce potential bias into the results. (2) Comparisons between different types of exercise were indirect, as the included studies primarily compared exercise interventions to conventional care. (3) Only Chinese and English literature were included, potentially introducing publication bias. Further high-quality, large-sample studies in diverse populations are required to validate these findings.
Conclusion
Exercise during pregnancy is an effective method for preventing GDM, particularly when initiated early. Among the interventions analyzed, yoga, aerobic exercise, and diet and exercise guidance were shown to significantly reduce the risk of GDM. Yoga, in particular, appears to be the most effective and accessible option. Its simplicity, safety, and holistic benefits make yoga a potential recommended practice for pregnant women. However, there is a clear need for high-quality, large-sample RCTs to provide more robust evidence in the future.
Supplementary Information
Acknowledgements
Not applicable.
Abbreviations
- GDM
Gestational diabetes mellitus
- T2DM
Type 2 diabetes mellitus
- IADPSG
International association of diabetes and pregnancy research groups
- WHO
World health organization
- PRISMA
Reporting items for systematic reviews and meta-analyses
- PROSPERO
Prospective register of systematic reviews
- RCT
Randomized controlled trial
- RoB
Risk of bias
- OR
Odds ratio
- CI
Confidence interval
- SUCRA
Surface under the cumulative ranking curve
- BMI
Body mass index
Authors’ contributions
L.Z. and J.C. conceptualized and designed this study. Y.R., Y.G., and Y.H. conducted database searches, data extraction, and analysis. Y.R. wrote the manuscript. L.Z. revised the manuscript. All authors critically reviewed and approved the manuscript as submitted. L.Z. (2466@bsu.edu.cn) and J. C. (cjy19781031@163.com) are co-corresponding authors of this manuscript.
Funding
This work was supported by the National Natural Science Foundation of China [Grant number 81803324], the Food Science and Technology Fund of the Chinese Institute of Food Science and Technology - SCITOP BIO Young Scientists Fund [Grant number 2018-02], and the Chinese Universities Scientific Fund [Grant number 2024TZJK007].
Data availability
All data are available from the corresponding author on reasonable request: Liuwei Zhang [(2466@bsu.edu.cn)].
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yijia Ren and Liuwei Zhang contributed equally and should be considered co-first authors.
Contributor Information
Liuwei Zhang, Email: 2466@bsu.edu.cn.
Jiaoying Cheng, Email: cjy19781031@163.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data are available from the corresponding author on reasonable request: Liuwei Zhang [(2466@bsu.edu.cn)].