Gilbert et al.

BMC Pregnancy and Childbirth (2019) 19:60

https://doi.org/10.1186/s12884-019-2185-y

RESEARCH ARTICLE Open Access

How diet, physical activity and psychosocial

well-being interact in women with
gestational diabetes mellitus: an integrative
review
Leah Gilbert1* , Justine Gross1,2, Stefano Lanzi1,3, Dan Yedu Quansah1, Jardena Puder1† and Antje Horsch4,5†

Abstract
Background: Gestational Diabetes Mellitus (GDM) is associated with future cardio-metabolic risks for the mother
and her child. In addition, one-third of women with recent GDM develop postpartum depression. Given these
adverse impacts of GDM on the health of the mother and her offspring, it is important to intervene on modifiable
factors, such as diet, physical activity, and psychosocial well-being. This integrative review therefore explored
evidence on how these modifiable factors interact in women with GDM and their offspring, and how effective
combined interventions are on reducing adverse impacts of GDM.
Methods: A comprehensive search strategy included carefully selected terms that corresponded to the domains of
interest (diet, physical activity and psychosocial well-being). The databases searched for articles published between
1980 and February 2018 were: CINAHL, PsycINFO, Embase, Pubmed and Cochrane. Studies that were included in
this review were either observational or intervention studies that included at least two domains of interest. Articles
had to at least report data on maternal outcomes of women with GDM.
Results: The search strategies identified 14′419 citations after excluding duplicates. After screening titles and then
abstracts, 114 articles were selected for detailed evaluation of their full text, and 16 were included in this review:
two observational and 14 intervention studies. Results from observational studies showed that psychosocial
well-being (social support and self-efficacy) were positively associated with physical activity and dietary choice.
Intervention studies always included diet and physical activity interventions, although none integrated psychosocial
well-being in the intervention. These lifestyle interventions mostly led to increased physical activity, improved diet
and lower stress perception. Many of these lifestyle interventions also reduced BMI and postpartum diabetes status,
improved metabolic outcomes and reduced the risk of preterm deliveries and low birth weight.
Conclusion: This integrative review showed that psychosocial well-being interacted with diet as well as with
physical activity in women with GDM. We recommend that future studies consider integrating psychosocial
well-being in their intervention, as observational studies demonstrated that social support and self-efficacy helped
with adopting a healthy lifestyle following GDM diagnosis.
Keywords: Intervention, Exercise, Nutrition, Mental health, Pregnancy

* Correspondence: [email protected]
†
Jardena Puder and Antje Horsch contributed equally to this work.
1
Obstetric service, Department Woman-Mother-Child, Lausanne University
Hospital, 1011 Lausanne, Switzerland
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 2 of 16

Introduction intake [37]. Thus, physical activity has a protective effect

Gestational Diabetes Mellitus (GDM) is defined when a on the development of GDM [38, 39]. Finally, psycho-
women has a glucose intolerance with onset and first logical factors also play an important role in GDM.
recognition between 24 to 28 weeks of gestation [1, 2]. It Higher stress exposure and perceived stress are associ-
usually resolves after childbirth [2, 3], although it carries ated with increased fasting glucose levels in pregnant
pre-, peri-, and postnatal risks of adverse outcomes in women, even before they know their diagnosis [40]. Psy-
the mother and the child [1]. For example, up to 40% of chological stress and negative life events can be associated
women with GDM are known to have pre-diabetes in with higher salivary cortisol levels during pregnancy,
the early postpartum period [4]. The prevalence of GDM which might influence glucose levels [41]. Depressive
is 10.8% in Switzerland [5], 9.2% in the USA [6], 6.8% in symptoms in early pregnancy also increase the risk for
China [7], 16.3% in Qatar [8] and 7.8% among a racially/ GDM [14, 39].
ethnically diverse population [9]. Many modifiable risk factors that relate to GDM also
Mothers have a risk of up to 70% of GDM recurrence, interact with each other. In this review, the term “inter-
a seven-fold higher five to 10 year risk of type 2 diabetes, action” covers correlations or associations, found in the
and an increased risk of cardiovascular diseases [10–13]. original papers, between our domains of interest [diet
GDM is also associated with reduced psychosocial well- (including breastfeeding), physical activity and psycho-
being: women with GDM are two to four times [14] social well-being (including depression, anxiety, stress,
more likely to develop antenatal or postpartum depres- sleep, self-efficacy and social support)]. For example,
sion. Evidence shows that approximately one-third of physical activity may reduce symptoms of depression
women with recent GDM develop postpartum depres- [42], probably by reducing plasma kynurenine [43, 44].
sion [15]. Postpartum depression in turn is associated Physical activity increases energy expenditure [45], can in-
with an increase in comfort eating and a decrease in fluence total food intake [45, 46], reduces stress-induced
physical activity [16], thus putting the women at higher food intake [47] and can also regulate eating behavior via
risk of weight gain and future diabetes [15]. endocrine mediators such as insulin, leptin, and ghrelin
With regards to negative consequences for the child, [48–50]. Eating behavior, such as emotional eating or un-
GDM is associated with macrosomia at birth (> 4 kg healthy habitual eating plays an important role in explain-
birth weight), excess body fat and paediatric obesity ing the depression-BMI relationship [51–55]. Finally, the
[17–24]. Intrauterine exposure to GDM also doubles the higher risk for maternal postpartum depression is also as-
risk for type 2 diabetes in the children of GDM mothers sociated with reduced parenting skills, which may have
[25]. Apart from GDM, maternal pre-pregnancy over- negative consequences for the development of the child
weight and excessive gestational weight gain also predict [56–58]. Given the interaction of these domains, designing
higher birth weight and adiposity during infancy [26, 27]. interventions that integrate more than one domain of
Furthermore, maternal lifestyle behaviour, such as a high interest (diet, physical activity and psychosocial well-
fat diet or lack of physical activity during pregnancy, can being) may be promising. Many interventions in women
influence offspring adiposity independent of maternal with GDM focus on either diet [59–61], physical activity
obesity [27, 28]. [62–66], or combined diet and physical activity interven-
Given the deleterious impact of GDM during preg- tions [67, 68]. However, to our knowledge, there are no in-
nancy on the health of the mother and her offspring, it terventions combining diet and/or physical activity with
appears crucial to work on modifiable risk factors during psychosocial well-being. Therefore, this integrative review
the pre-, peri-and postnatal period, namely diet, physical explored how physical activity, diet, and psychosocial
activity, and psychosocial well-being [29]. Excessive ges- well-being interact in women with GDM and in their off-
tational weight gain [30] is very frequent in women with spring by analyzing and synthetizing observational and
GDM and strongly associated with lifestyle factors dur- intervention studies. In addition, we investigated how ef-
ing pregnancy [31]. High fat consumption particularly fective interventions that address more than one domain
saturated fat, trans fat and cholesterol, increases GDM of interest are in reducing risk factors associated with
risk [32–34]. A higher intake of added sugar and lower GDM. Addressing these questions may help to identify ef-
intake of vegetable and fruit fiber are independently fective ingredients of interventions to counter the negative
linked to increased fasting glucose [34]. Animal protein impact of GDM in women and their offspring.
intake is positively and vegetable protein inversely asso-
ciated with GDM risk [35]. Another important domain Methods
that can address risk factors of GDM is physical activity, Design
which decreases insulin resistance, reduces future risk of This integrative review follows the guidelines elaborated
type 2 diabetes [36], and limits gestational weight gain by Whitemore and Knafl (2005) [69]. As we were inves-
by increasing energy expenditure and altering food tigating a new topic, we needed a design that would
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 3 of 16

allow us to explore this topic in a broad manner and to least two domains of interest. Articles were published in
produce evidence-based results. We followed White- English in peer-reviewed journals and had to contain
more and Knafl’s design firstly by identifying variables of data on women with GDM (or women and their part-
interest and elaborating specific research questions. We ner), or previous GDM, with clinical outcomes reported
then used computerized databases to augment efficiency for women (or women and their baby). The decision to
as well as the scope of our review. Secondly, we defined include articles from 1980 was made in order to stay in
inclusion and exclusion criteria that guided the decision line with more up-to-date clinical practice and objectives
to exclude irrelevant articles, and we evaluated the qual- for glycemic thresholds.
ity of each original article. When analysing data, we cat-
egorized, summarized and ordered our data extracted Exclusion criteria
from primary articles and organized the results accord- We excluded study protocols, conference abstracts, rec-
ing to subgroups. Whitemore and Knafl (2005) [69] also ommendation papers, guidelines, qualitative studies, and
recommend creating data displays; thus, we summarized review articles. Articles that exclusively investigated
our findings in tables (see Additional file 1) and created women with type 1 and type 2 diabetes were excluded.
a conceptual model integrating all of our results (see Intervention studies that only tested pharmacological in-
Fig. 2). Finally, we specified the implications for clinical terventions were also excluded, as were genetic, epigen-
practice, as recommended by the authors. etic and genomic studies. Studies on diet, which focused
only on dietary supplements were also excluded. Animal
Search strategy research and papers addressing exclusively the micro-
A comprehensive search strategy included carefully biome were also excluded.
selecting terms that corresponded to the domains of
interest [diet (including breastfeeding), physical activity Data extraction and quality appraisal
and psychosocial well-being (including depression, anx- All identified citations were collated in a citation man-
iety, stress, sleep, self-efficacy and social support)] agement system (Endnote X7) and duplicates were re-
(please refer to Additional file 2 for details on the search moved. The search strategies identified 14′419 citations
strategy) by consulting a team of interdisciplinary ex- after excluding duplicates (see above and Fig. 1). After
perts and a specialised librarian. The databases searched screening titles and then abstracts, 114 articles were se-
for articles were: CINAHL, PsycINFO, Embase, for lected for detailed evaluation of their full text, and 16
which usual subject headings were used and Pubmed, were included in this review.
for which the strategy was completed with free-text Data from the 114 articles were extracted systematic-
terms to also collect the non-indexed articles, and fi- ally from all eligible papers with a modified Joanna
nally, Cochrane, for which the strategy used only free Briggs Institute (JBI) data extraction form for review and
search terms. All studies identified during the search research synthesis designed by LG. This allowed for se-
were assessed for relevance to the review based on the quential extraction of articles by LG and DYQ to make
information provided in the title and abstract. For all pa- final decisions on which papers to include and those to
pers that appeared to meet the inclusion criteria, full pa- exclude. Any disparities or disagreements were resolved
pers were retrieved. Full papers were again assessed for by consensus-based discussions with AH.
eligibility in order to determine relevance to the review Following this, JG and SL independently extracted the
objective. The period considered was from 1980 to the data and produced Additional file 1: Tables S1 and S2.
date of the first search (September, 15, 2016) and this The quality of included studies was assessed with the JBI
first search identified 16′026 articles. An update of the critical appraisal Checklist for Randomized Controlled
search was performed between the 15 of September 2016 Trials [70], Checklist for quasi-experimental studies
and the 12 of February 2018 and identified 15′744 articles. (non-randomized experimental studies) [71], Checklist
This contained articles found in the first search as well as for Analytical Cross Sectional Studies [72] and Checklist
new ones; for this reason, a large number of duplicates for Cohort studies [73]. Two reviewers (LG & DYQ)
were removed after the second search (13′760) (Fig. 1). undertook the quality assessment independently and
The second literature search yielded fewer articles than later resolved discrepancies in score ratings by consen-
the first one because we were able to exclude the time sus. The appraisal checklists assessed the aims of the
period related to our first search in Pubmed, thus avoiding study, sampling procedure, data collection methods,
the exclusion of duplicates in this database. main findings, and limitations.

Inclusion criteria Synthesis of findings

Inclusion criteria were either observational or interven- Findings from the included studies were synthesized ac-
tion studies in women with GDM that focused on at cording to the objectives of the study in a thematic
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 4 of 16

Fig. 1 Prisma Flowchart. This Prisma flowchart illustrates the process through which articles for this integrative review were included or excluded
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 5 of 16

manner, as suggested by Whittemore and Knafl (2005) For the second study, the authors used a single-group
[69]. Firstly, links between the different domains of pre-post design and measured the effect of the interven-
interest in the observational and intervention studies tion across time [77]. Finally, the last study was a single
were synthesized, forming the base for a conceptual arm pilot before and after intervention study [85]. For
framework. Secondly, the effects of interventions on these studies, these design details will always be men-
clinical outcomes were summarized. tioned in our results section.
Lifestyle interventions lasted from 6 weeks [79] to
Results 4 years [82] and either contained results at the end of
Characteristics of included studies the intervention [76, 78–86, 88, 89] or, for only two
This review included 16 studies (Fig. 1): two observational studies, after a follow-up period [77, 87]. As time effects
studies and 14 intervention studies. The observational stud- (baseline to end of the study or to follow-up) are always
ies were conducted in the USA (n = 1/2) [74] and present in initial papers for intervention groups and
Switzerland (n = 1/2) [75], employing a cross-sectional (n = given that they vary largely, they will be mentioned in
1/2) [74] or a prospective cohort design (n = 1/2) [75]. The detail in our results section.
14 intervention studies took place in eight different coun-
tries, with the highest number of them conducted in the Study participants
USA (n = 5/14) [76–80] and China (n = 3/14) [81–83]. The A total of 20,285 participants were included in the stud-
remaining studies were carried out in Australia (n = 1/14) ies, with n = 19,884 in the intervention and n = 401 in
[84], Canada (n = 1/14) [85], Finland (n = 1/14) [86], Ireland the observational studies. The lowest number of partici-
(n = 1/14) [87], Spain (n = 1/14) [88] and Thailand (n = 1/ pants in a study was 17 [85] and the largest study con-
14) [89]. Of these intervention studies, the large majority sisted of 14,168 participants [83].
were randomized controlled trials (RCTs) (n = 9/14) [76,
78, 79, 81, 82, 84, 87–89] and the remaining studies were Associations measured in the observational studies
intervention trials (n = 5/14), with two of them (n = 2/5) Both observational studies investigated the associations
containing a control group [80, 83] and the other three between diet, physical activity and psychosocial variables
(n = 3/5) using a pre/post-test design [77, 85, 86]. The (n = 2/2) [74, 75]. Specifically, the authors assessed the
majority of the included studies were published be- link between social support and diet and physical activ-
tween 2011 and 2015 (n = 10/16) [76, 77, 81, 83–89], ity, and the relationship between psychosocial well-being
whereas the remaining studies were published between (self-efficacy, social support and self-efficacy and social
2006 and 2010 (n = 3/16) [74, 78, 80] and 2016–2018 support) and diet and physical activity.
(n = 2/16) [75, 82]. One study (n = 1/16) [79] was pub-
lished in 1989. Lifestyle interventions investigated
All combined intervention studies focused solely on The lifestyle intervention adopted in all intervention
diet and physical activity and none included psychosocial studies consisted of combined diet and physical activity
well-being in their intervention. For reasons of simplicity interventions (n = 14/14). The dietary components of the
and clarity, these combined studies will be named “life- study interventions required participants to follow either
style interventions”. the American Diabetes Association (ADA) diet [76], the
In these intervention studies, the extracted data for Diabetes Prevention Program (DPP) guidelines [77, 78],
this review focused on outcomes of the intervention the Canada’s Food Guide [85], a Mediterranean diet [88]
groups which were always compared to the respective or other types of dietary guidelines [79–84, 86, 87, 89, 90].
other GDM control groups; thus we will not mention In most studies, participants were advised to either con-
this in our result section, to increase readability. Only duct moderate to vigorous physical activity for around
one intervention study (n = 1/14) [83] contained more 150 min a week [76–78, 85] or 30 min a day [81, 82], to be
than two groups. Indeed, this study had five different more active and incorporate light and moderate physical
groups (lifestyle, diet only, physical activity only, no activity as much as possible in daily life [83], to increase
intervention and a “no GDM” group). We chose to re- the number of steps (walking) a day to 10′000 [84], or to
port results for the lifestyle intervention compared to have a specific yoga routine (nine postures) [89]. In four
the “no intervention group” only, to be in line with the studies, participants were asked to exercise at moderate
other studies integrated in this review. An exception re- intensity [79, 80, 87, 88]. In one study, intervention partic-
mains for three studies (n = 3/14) that were designed dif- ipants were provided with a study pedometer to track
ferently. Indeed, one study compared the lifestyle their daily steps [84]. In another study [86], training with a
intervention group at the end of the study (1 year) to coach provided empowerment during physical activity.
the baseline of that same lifestyle intervention group All outcome variables were tested either during preg-
and thus did not contain a control group (n = 1/14) [86]. nancy [80, 83, 89] or in the postpartum period [74–88]
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 6 of 16

In intervention studies, the interventions started either was also associated with more than 4 hours spent walk-
during pregnancy [76, 79, 80, 82, 83, 89] or in the post- ing per week, but not with walking intensity and leisure
partum period [77, 78, 81, 84–88] (for details, please time activity. In the prospective observational study (n =
refer to Additional file 1: Tables S1 and S2). 1/2) [75] observing the link between social support and
physical activity, women indicated a need for personal-
Interactions between domains of interest (diet, physical ized advice (65%) and sport facilities where their chil-
activity and psychosocial well-being) dren can be looked after (69%) to facilitate their physical
Focusing on the observational studies, one prospective activity practice.
observational study (n = 1/2) [75] revealed that the main All intervention studies were combined physical activ-
normative influences for healthy behaviors (diet and ity and diet lifestyle interventions (n = 14/14). The life-
physical activity) were the husband/partner (68%) and style interventions led to a decreased fat intake in two
other family members (56%). After controlling for sig- studies, one during the intervention period (7 months)
nificant individual factors, the study showed that a lower (n = 1/2) [76] and one at 6 months follow-up after a
level of social support was related to a lower adherence three-month intervention, compared to baseline [77] (n =
to a healthy lifestyle in the postpartum period. 1/2). In one study, the lifestyle intervention lead to a higher
Regarding diet and its relationship with self-efficacy, diet adherence at the one-year follow-up after a 12-week
the authors of the cross-sectional study [74] showed that intervention (n = 1/1) [87]. Higher diet self-efficacy was
women reported low self-efficacy for not overeating. seen in two studies, once at one-year follow-up after a
They further demonstrated that self-efficacy for not three-month intervention [87] and also at the end of a
overeating was associated with better dietary quality, al- three month intervention [84]. In addition, there was a
though this association missed significance after adjust- higher proportion of women who partially or exclusively
ing for covariates. breastfed during the intervention (7 months) in one study
In terms of the relationship between diet and social (n = 1/1) [76]. Other outcomes for diet in the lifestyle inter-
support, women reported moderate social support for vention studies demonstrated that participants reported a
consuming a healthy diet [74]. Higher social support higher fibre intake at the end of the intervention (4 years)
from both friends and family for a healthy diet corre- (n = 1/1) [82] and a healthier diet pattern in the consump-
lated with better dietary quality, with a trend towards tion of unsaturated fat, saturated fat and healthy fat at the
statistical significance. The authors further demonstrated end of the intervention (3 years) (n = 1/1) [88]. In sum-
that after adjustment for covariates, stronger social sup- mary, all studies that investigated a dietary outcome
port from family and friends for dietary habits was asso- showed an improved dietary outcome.
ciated with better dietary quality. Concerning physical activity, women in the lifestyle
Regarding physical activity and its relationship with intervention group had higher physical activity, leisure
self-efficacy, Kim et al. (2008) demonstrated in the or commuting time activity and exercise at the end of
cross-sectional observational study that women reported each intervention (n = 4/4) [78, 81, 82, 88], a higher ex-
low self-efficacy for physical activity [74]. However, ercise capacity at the end of the intervention (6 months),
greater self-efficacy for physical activity was associated compared to baseline (n = 1/1) [85] and higher aerobic
with a greater number of hours spent walking and activity, flexibility and strength at 6 months follow-up
greater leisure time spent in vigorous intensity activity, after a three-month intervention, compared to baseline
but not with walking intensity. When the authors ad- (n = 1/1) [77]. In contrast, three studies (n = 3/3) re-
justed their analysis for covariates, greater self-efficacy vealed no significant differences between physical activ-
for physical activity was associated with more than ity levels between inclusion and after the interventions
4 hours per week spent walking and with spending at at 3 months [84], 7 months [76] or during the one-year
least 20 min three times a week in a vigorous activity. follow-up after a three-month intervention [87]. Thus,
Regarding associations between physical activity and six studies showed a positive impact on physical activity,
social support, the cross-sectional study (n = 1/2) [74] while three demonstrated no change.
observed that women reported moderate social support With regards to psychosocial outcomes, the lifestyle
for physical activity. Furthermore, they observed that so- interventions led to lower stress perception and higher
cial support from friends for physical activity was associ- quality of life at the end of the study (1 year) after a
ated with a greater number of hours spent walking and three-month intervention (n = 1/1) [87] and less fatalistic
greater leisure time spent in vigorous activity. Moreover, and cultural diabetes beliefs at 6 months follow-up
social support for physical activity was associated with after a three-month intervention compared to baseline
greater leisure time physical activity, but not with the (n = 1/1) [77]. Thus, two studies looked at psycho-
total number of hours spent walking. Furthermore, after social well-being as outcomes and found an improved
adjustment for covariates, social support from friends outcome.
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 7 of 16

In summary, observational studies demonstrated that in seven studies (n = 7/12) and significantly decreased in
there were interactions between lifestyle domains. The five studies (n = 5/7), always at the end of the intervention
studies hint at social support being an important factor at 3 months [84] or 6 months compared to baseline [85],
for adhering to a healthy lifestyle. Moreover, there were 1 year [81], 3 years [88] and 4 years [82]. In contrast, two
positive relationships between diet and self-efficacy and other studies reported no significant change in waist and
social support. These two factors were also positively as- hip circumference (n = 2/7), at the end of a one-year inter-
sociated with physical activity, more specifically time vention compared to baseline in one study [86] and at
and intensity were higher when women had higher 1 year follow-up after a three-month intervention in an-
self-efficacy and social support. The intervention studies other study [87]. Participants’ weight was assessed in eight
demonstrated that most lifestyle interventions improved studies (n = 8/12). Four studies (n = 4/8) revealed a signifi-
diet and physical activity, although the effect on physical cant decrease in weight after the interventions that lasted
activity was not sustained in the long term. Lifestyle in- 3 months [84], 1 year [81], 3 years [78] or 4 years [82].
terventions also augmented psychosocial well-being, but However, four other studies (n = 4/8) showed no apparent
this was only investigated in two studies. change in weight after interventions that lasted 6 months
compared to baseline [85] after a follow-up period of
Clinical outcomes 6 months after a three-month intervention, compared to
Anthropometric outcomes baseline [77], after a follow-up period of 1 year after a
Anthropometric outcomes measured in the integrated three-month intervention [87] and after a one-year inter-
studies contained BMI, weight, gestational weight gain, vention compared to baseline [86]. One study revealed a
waist and hip circumference, body composition and per- trend towards reaching the recommended 12-months
centage body fat. These outcomes were measured during postpartum weight goal at the end of a 12-month
the postpartum period, except for gestational weight intervention (n = 1/1) [76]. One study demonstrated
gain, which was measured during pregnancy. In the ob- that gestational weight gain was lower at the end of a
servational studies, only one (n = 1/2) study looked at 7.7 weeks intervention (n = 1/1) [80]. In two interven-
anthropometric outcomes, and more specifically BMI tion studies measuring body fat (n = 2/2), there was a
[74]. This study revealed no significant associations be- significant decrease in body fat at the end of the
tween self-efficacy against overeating, and social support one-year intervention (n = 1/2) [81] and at the end of
from family for diet and BMI, with the exception of a a four-year intervention (n = 1/2) [82]. Another study
weak correlation between friends’ social support for diet showed no difference in percent body fat at the end
and BMI. After adjustment for the healthy diet index of the six-month intervention, compared to baseline
score, dietary self-efficacy and social support were not as- (n = 1/1) [85]. In addition, one study showed no
sociated with BMI. The same authors also looked for asso- change in body composition at the end of the
ciations between physical activity-oriented self-efficacy three-month intervention (n = 1/1) [84].
and social support for BMI and found no significant asso- In summary, observational studies indicated that social
ciations between these types of self-efficacy and social support and self-efficacy had no significant association
support for physical activity and BMI. with BMI. Intervention studies demonstrated a de-
Regarding intervention studies, 12 interventions (n = 12/ creased waist and hip circumference and body fat, al-
14) assessed anthropometric outcomes. BMI was reported though the results of lifestyle interventions concerning
in eight different studies (n = 8/12). This outcome de- weight and BMI were inconsistent.
creased significantly in four studies (n = 4/8) at the end of
interventions: lasting 3 months [84], 1 year [81], 3 years Metabolic outcomes
[88], or 4 years [82]. However, no significant difference Metabolic outcomes included insulin, glucose, lipid pro-
was observed in three other studies (n = 3/8) at the file, cholesterol, triglycerides, HbA1c, and Apo lipopro-
follow-up measures at 1 year after a three-month inter- tein. None of the observational studies assessed metabolic
vention [87] and at 6 months after a three-month inter- outcomes. Seven of the intervention studies (n = 7/14)
vention, compared to baseline [77] and at the end of a measured metabolic outcomes. Fasting plasma glucose
six-month intervention, compared to baseline [85]. One (n = 3/7) remained unchanged at the one-year follow-
study (n = 1/8) observed that women following a diet and up of a three-month intervention (n = 1/3) [87], al-
exercise intervention during pregnancy had a higher though it was reduced significantly at the end of two
pre-pregnancy BMI compared to other groups [83]. The other interventions (n = 2/3) that lasted six [79] and 8 weeks
same study (n = 1/8) also showed that in women following [89], respectively. Concerning other glucose-related values
a lifestyle intervention, BMI increased significantly less be- (n = 3/7), all of these values were reduced in the interven-
tween pre- and late pregnancy and between mid and late tion groups (n = 3/3), demonstrating lower one-hour glu-
pregnancy. Waist and/or hip circumference was measured cose after OGTT at study end (6 weeks) (n = 1/1) [79],
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 8 of 16

lower two-hour glucose after OGTT at the 1 year follow-up reduction in the risk of diabetes progression (n = 1/2)
of a three-month intervention [87] and lower two-hour [78]. Another study (n = 1/2) [88] showed a 25% de-
postprandial blood glucose at the end of an eight-week crease in the development of glucose disorders (impaired
intervention (n = 1/1) [89]. Interestingly, insulin resistance, fasting glucose and impaired glucose tolerance) as well
which was measured in three studies (n = 3/7), decreased at as a 35% decrease in the rate of type 2 diabetes.
the end of a three-year intervention (n = 1/3) [88], but no In summary, lifestyle interventions led to a reduced
significant change was observed in two other studies (n = 2/ risk of postpartum diabetes in the two studies that eval-
3) at the end of a three-month intervention [84] or at a uated this outcome.
one-year follow-up after a three-month intervention [87]
(n = 2/3). In three studies, HbA1c (glycated haemoglobin) Delivery and other clinical outcomes
(n = 3/7) was measured. It significantly increased between None of the observational studies measured delivery or
baseline and the six-month follow-up after a three-month other clinical outcomes. Two of the lifestyle intervention
intervention compared to baseline in one study (n = 1/3) studies (n = 2/14) measured outcomes related to the de-
[77] but significantly decreased in the two remaining livery, such as macrosomia, adverse pregnancy out-
studies (n = 2/3) after a six-week intervention [79] and an comes, preterm delivery, low birth weight, and caesarean
eight-week intervention [89]. Three studies measured LDL deliveries; two other studies measured other clinical out-
(low density lipoprotein) –cholesterol (n = 3/7); this de- comes, such as blood pressure (n = 2/14).
creased after a one-year intervention compared to baseline In the studies measuring macrosomia (n = 2/2), both
in one study (n = 1/3) [86], after a three-year intervention (n = 2/2) demonstrated similar rates of macrosomia in
in another [88], and at a six-month follow-up after a both groups at the end of a 13.2-week intervention [83]
three-month intervention compared to baseline in the last and after a 7.7-week intervention [80]. This last study
study (n = 1/3) [77]. Two studies measured HDL (high also showed no differences in the rate of adverse preg-
density lipoprotein)-cholesterol. One study demonstrated a nancy outcomes [80].
rise in HDL at the end of a one-year intervention compared Preterm delivery, low birth weight, and cesarean deliv-
to the intervention baseline (n = 1/2) [86], whilst in the eries were only measured in one study (n = 1/1); a sig-
other study it remained the same as during baseline assess- nificantly decreased risk of preterm delivery and low
ments at the six-month follow-up after a three-month birth weight at the end of a 13.2-week intervention was
intervention (n = 1/2) [77]. Two studies measured triglycer- found, but there were similar rates of caesarean deliver-
ides (n = 2/7) that decreased in both studies (n = 2/2): at a ies compared to a GDM control group [83].
six-month follow-up after a three-month intervention com- In the studies measuring other clinical outcomes
pared to baseline (n = 1/2) [77] and at the end of a (n = 2/14), one study showed a reduction in diastolic
three-year intervention (n = 1/2) [88]. In two separate stud- blood pressure and no change in systolic blood pres-
ies, reductions in total cholesterol were found at a sure at the six-month follow-up after a three-month
six-month follow-up after a three-month intervention, intervention, compared to baseline (n = 1/2) [77]. The sec-
compared to baseline (n = 1/1) [77], and consistency ond study showed that systolic and diastolic blood pressure
was seen in the lipid profile at the one-year follow-up were unchanged at the end of a one-year intervention com-
after a three-month intervention in one study (n = 1/1) pared to baseline [86].
[87]. Intervention groups had lower fasting plasma insulin In summary, compared to GDM women in control
levels and Apo lipoprotein at the end of a three-year inter- groups, women in lifestyle interventions showed no dif-
vention (n = 1/1) [88] and lower plasma insulin levels at the ferences between the rates of macrosomia, adverse preg-
end of a one-year intervention (n = 1/1) [81]. nancy outcomes and caesarean section, although there
In summary, the majority of the studies that included was a decreased risk of preterm deliveries and low birth
metabolic outcomes revealed a decrease in LDL choles- weight. Concerning results for systolic blood pressure,
terol, triglycerides, and in glucose values. Results in they were similar throughout groups and time and the
HbA1c, insulin resistence and HDL cholesterol were in- results for diastolic blood pressure were inconsistent.
consistent and the other outcomes were not measured
in enough studies to draw conclusions. Quality of studies reviewed
Authors (LG & DYQ) rated the majority of included ar-
Postpartum diabetes status ticles to be of good quality [74–84, 86–89] based on the
This outcome was not reported in the observational Joanna Briggs Institute Appraisal Tools (2017) (see
studies. Only two lifestyle intervention studies (n = 2/14) Additional file 1: Tables S1 and S2). The checklist for
measured postpartum diabetes status at the end of the analytical cross-sectional studies [72] was used for the
intervention (after a three-year intervention in both cross sectional observational study [74], the checklist for
studies). One intervention study revealed a significant cohort studies [73] was used for the prospective cohort
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 9 of 16

study [75] whereas for intervention studies, the checklist domain, thus focusing on a more holistic approach of
for randomized controlled trials [70] was employed for the the individual.
randomized controlled trials [76, 78, 79, 81, 82, 84, 87–89]. Regarding anthropometric outcomes, observational
For the remaining intervention studies [77, 80, 83, 85, 86], studies demonstrated that psychosocial well-being had
we used the checklist for quasi-experimental studies no significant association with BMI. This result is not in
[71]. Studies rated as having a good quality described line with previous research showing that social support
in detail the design and methodology used, the and self-efficacy for diet are associated with greater suc-
process of recruiting participants and the study set- cess in weight control [92] and that self-efficacy over
ting, gave clear and detailed presentation of findings dietary behaviours such as emotional eating and dietary
and had study limitations that were unlikely to affect restrictions generally lead to healthier weight [93]. This
the reliability and validity of study findings. The only might be due to the fact that only one study investigated
study rated as having poor quality [85] did not ex- this relationship. Results from the intervention studies
plain the reasons for drop out in participants and did suggested that most lifestyle interventions achieved suc-
not conduct analysis to compare the drop outs to the cesses with regards to waist/hip circumference and body
participants remaining in the study. It thus had lim- fat. This is in line with previous research demonstrating
ited information on data analysis and a small sample that diet has an important role to play in weight loss,
size, both of which could lead to a high risk of bias healthier BMI and other measures of adiposity [94, 95].
and a poor generalizability of the study. Indeed, it is well known that diets setting limits on the
intake of energy, trans and saturated fat, and/or energy
Discussion from carbohydrate and increased fiber intake help GDM
This integrative review synthesized evidence on the women with weight management [2]. Physical activity
interaction between three different domains: diet (in- might also play a role in the relationship between life-
cluding breastfeeding), physical activity, and psycho- style interventions and an improvement in anthropomet-
social well-being (including depression, anxiety, sleep, ric outcomes, as studies also suggest that physical
and social support) in women with GDM and their off- activity is associated with positive changes in eating
spring. Moreover, it summarized the effectiveness of in- self-regulation and may lead to healthy eating. In par-
terventions addressing more than one lifestyle domain, ticular, it improves psychosocial well-being and could
including diet and physical activity on anthropomet- prevent emotional eating, consumption of foods high in
ric, metabolic, delivery and other clinical outcomes. calories, and binge eating [96]. Higher adherence to
To the best of our knowledge, this integrative review physical activity could therefore increase eating
is the first to synthesize evidence on the relationships self-regulation and may lead to lower anthropometric
and interaction between different lifestyle behaviors, outcomes such as weight, BMI and waist circumference
psychosocial well-being, and the efficacy of combined measures. Even though the results of lifestyle interven-
lifestyle interventions in women with GDM and their tion studies led to decreases in some anthropometric
offspring. outcomes, weight and BMI demonstrated inconsistent
Results from this review indicated that the interaction results. This might partly be due to the diversity of diet
between lifestyle domains produced desirable outcomes. and physical activity interventions, as well as the length
The two observational studies integrated in this review of the studies and adherence to the intervention.
demonstrated that psychosocial well-being such as social Regarding metabolic outcomes, the intervention stud-
support and self-efficacy were important factors associ- ies led to a decrease in LDL cholesterol, triglycerides
ated with adherence to a healthy lifestyle. Indeed, the and glucose values compared to the control groups, al-
observational studies demonstrated that social support though results for HbA1c, insulin resistence and HDL
and self-efficacy were associated to positive changes in cholesterol were inconsistent. For the decreasing out-
diet and physical activity. This is in line with another comes, the diet component of the intervention studies
intervention study showing that psychosocial well-being, might have had an impact on these findings. Indeed,
such as self-efficacy and social support was positively as- previous research has shown that the high dietary fiber
sociated with lifestyle modifications or changes [91]. intake may reduce appetite and food consumption,
Similarly, results from the intervention studies showed delay gastric emptying, slow food digestion and ab-
that lifestyle interventions improved diet and physical sorption [97]. This should have led to a decrease glu-
activity and augmented psychosocial well-being in study cose absorption and also plasma insulin levels [98].
participants, although this last outcome (psychosocial Our results are in line with these findings, as three
well-being) was only evaluated in two studies. These re- interventions measured glucose values and two stud-
sults underline the importance of apprehending health ies lead to improvements in two measured glucose
behavior changes in individuals via more than one values. The third study led to improvements in
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 10 of 16

two-hour glucose after OGTT and to similar results metabolic health during pregnancy may prevent the de-
in fasting plasma glucose. Research shows that the velopment of postpartum diabetes, as observed in this
consumption of a DASH diet leads to a decrease in review. Physical activity has also been implicated in the
lipids and fasting glucose, as it has a positive impact prevention or delay in postpartum diabetes in women
on the lipid profile in women with GDM [99], as well with GDM [111]. A prospective cohort study recently
as in other populations [100, 101]. In our review, the showed that women with GDM within the Nurses
Mediterranean diet was associated with overall im- Health Study II cohort had a 9% reduced risk for post-
proved metabolic health outcomes. In pregnancy, partum diabetes for every 100 min of moderate intensity
these diets may have protective benefits for over- physical activity. Interestingly, an increase of 150 min
weight and obese women who are at risk for both per week of moderate intensity physical activity led to a
short and long-term metabolic outcomes [102]. The 47% lower risk of diabetes after GDM [36].
physical activity component of the intervention stud- Regarding delivery and other clinical features, the re-
ies might have also played a role in the improvements sults of one study demonstrated a decrease in preterm
of some of these metabolic outcomes. Indeed, previ- delivery rates and low birth weight. Regarding preterm
ous research has shown that regular exercise increases delivery, this outcome can be caused by various
insulin action by stimulating glucose uptake in the pre-existing conditions in the mother [112] and thus
muscle through glucose transport proteins (GLUT4) might not depend on lifestyle interventions. Concerning
that mediate insulin-dependent glucose uptake [103], low birth weight, one of the studies found fewer low
and our results showed improvements in 2.5/3 of the birth weight after a 13.2-week intervention [83]. Thus,
studies analyzing glucose as an outcome. A our results are not in line with a previous systematic re-
meta-analysis of randomized controlled trials in view and meta-analysis of randomized controlled trials
women with GDM showed that exercise significantly of dietary interventions in women with GDM showing
improved postprandial glucose and lowered fasting that dietary interventions were associated with lower
blood glucose [104]. It was therefore not surprising birth weight compared with controls [113]. One explan-
that participants who had lifestyle interventions had ation could relate to the fact that women in the inte-
lower fasting plasma insulin levels and two-hour post- grated study might not have all received the same type
prandial blood glucose than those in the control of lifestyle intervention. Indeed this study mentioned
group. Results for HDL cholesterol, HbA1c and insu- that the lifestyle interventions were retrospectively
lin resistence were inconsistent in the intervention auto-reported by questionnaire [83]. Finally, we found
studies. This might be explained by the fact that the similarities in the rates of macrosomia, in the interven-
interventions were probably not intense enough to tion studies in the control as well as intervention groups
have a long term impact on these outcomes. Another [80, 83]. Thus, our results are in line with the findings of
explanation could be the low adherence to the interven- a recent review indicating that diet and/or physical activ-
tion regime. Overmore as HDL is also influenced by ity interventions lead to a similar risk of macrosomia
oestrogen status, it might be a strong confounder for this compared to a control group in overweight and obese
outcome in this population and might have impacted women [114]. Previous research has shown that macro-
these results [105]. somia, adverse pregnancy outcomes and caesarean sec-
Two intervention studies showed reductions in the tions are dependent on a number of different factors
rate of postpartum diabetes status, [78, 88]. In a system- and/or on the maternal diabetes status [1, 115, 116] and
atic review that examined the cumulative incidence of thus, lifestyle interventions might have little to no effect
type 2 diabetes in women with GDM, the progression to on these outcomes. The results for systolic blood pres-
type 2 diabetes after GDM increased steadily within the sure were similar between baseline and at 6 months
first 5 years after delivery [106]. According to Tobias follow-up after a three-month intervention [77] and
et al., diet plays a role in the reduction of postpartum similar compared to baseline in an other study [86]. Fi-
diabetes status, as higher adherence to a Mediterranean nally, for diastolic blood pressure, our results were in-
diet was associated with a 40% lower risk of diabetes consistent. These results are comparable with previous
compared to those in the lower adherence group in their research showing no difference in systolic and diastolic
cohort study [107]. In the same study, similar risk reduc- blood pressure between different control groups and
tions were observed for the DASH diet, even after mul- GDM women [117], except for one of the integrated
tiple adjustments of covariates [107]. Elevated fasting studies demonstrating a decrease in diastolic blood pres-
glucose and HbA1c levels during pregnancy may be as- sure at 6 months follow-up after a three-month inter-
sociated with a more pronounced progression to dia- vention, compared to baseline [77].
betes after GDM [108–110]. Adherence to a lifestyle Overall, evidence from this integrative review suggests
intervention designed to lower weight gain and improve that lifestyle interventions including a psychosocial
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 11 of 16

intervention during pregnancy could augment the to our knowledge, has not been done before. Nevertheless,
women’s adherence to diet and physical activity, which some limitations need to be addressed. Firstly, conducting
in turn might have complementary and interactive ef- an integrative literature review lead to integrating studies
fects on the physiological and psychological health of with large heterogeneities regarding the intervention and
women with GDM. We therefore propose that combined follow-up periods across studies, as well as in the types of
diet, physical activity, and psychosocial interventions lifestyle interventions used in each individual studies.
could positively influence physiological and psycho- Thus, our results need to be interpreted with caution. In
logical processes toward healthy outcomes (Fig. 2) and addition, psychosocial well-being was only investigated in
should be tested. Arguments that cognitive-behaviorally observational studies, even though it was assessed in inter-
supported exercises, self-efficacy and social support can vention studies as an outcome. Moreover, although we
facilitate changes in eating behavior through associated had also searched for terms, such as depression, anxiety
psychological changes have emerged, also outside of and sleep in the psychosocial well-being domain, no re-
pregnancy. This is partly because diet and physical activ- sults were found for these outcomes. This might be due to
ity domains of a lifestyle intervention may also benefit the fact that, as mentioned, psychosocial well-being was
from improved psychosocial outcomes. Thus, exercise only present in two observational studies and as an out-
during pregnancy can influence physiological processes, come in two intervention studies. Furthermore, although
such as energy metabolism and appetite, as well as psy- we had also screened for articles for parenting, we found
chological factors, including self-efficacy, body image, or no results concerning the partner except in observational
mood [118, 119]. The interactive mechanisms of these studies. Indeed, in the observational studies, the partners
factors could lead to stronger motivation and confi- appeared as “social support from family” but no other re-
dence, which could improve adherence to physical activ- sults were found. The different components of the lifestyle
ity. Long-term exercise adherence, as well as eating interventions and types of diet and physical activity as well
self-regulation and dietary compliance may also result in as the approach and the patient population may account
gestational weight gain control, improved metabolic out- for the differences in study results and conclusions. In
comes, and again higher levels of psychosocial addition, the inability of the lifestyle interventions to ac-
well-being during pregnancy and in the post-partum count for or adjust for individual attitudes and behaviors,
period. On the other hand, psychosocial vulnerability (in- particularly psychosocial factors, might have influenced
cluding depression, stress, and lack of social support), lack the results of these studies. This is because positive results
of diet self-regulation and physical inactivity may nega- on changing diet and physical activity habits are often re-
tively influence birth outcomes, including caesarean deliv- lated to self-efficacy or social support, as seen in the ob-
eries, macrosomia and other infant physiological servational studies. Finally, the issue of publication bias
disorders, such as hypoglycemia, as well as adverse out- can be a limitation to this study, as studies reporting no
comes in the mother during the post-partum period significant results are rarely published [123].
[90, 120–122]. According to our results and proposed
model (see Fig. 2), interventions targeted at mitigating Clinical implications and future directions
the risks associated with a GDM pregnancy should The findings of this integrative literature review reveal
not only include diet and physical activity domains that diet, physical activity, and psychosocial well-being
but may also integrate and/or include strategies for relate and interact in women with GDM. On the one
improving self-efficacy and self-regulation of eating, hand, diet and physical activity were associated with psy-
exercise, psychosocial well-being, and social/ family chosocial well-being. On the other hand, this review
support. After all, the success of a combined diet and showed that psychosocial well-being, such as self-efficacy
exercise intervention may also depend on the and social support may be important when adopting a
mothers’ psychosocial well-being (depression, stress, healthy diet and physical activity habits. Thus, we propose
self-efficacy and social support) during pregnancy. that any intervention focusing on behavioral change,
should evaluate and consider integrating psychosocial
Strengths and limitations well-being as part of the intervention components, as this
This integrative review has many strengths. This study might add to the lack of research in this domain. Even
followed the PRISMA guidelines as well as Whitemore though diet and physical activity interventions may reduce
and Knafl’s recommendations We used a comprehensive some of the risks associated with GDM, the findings of
search strategy and independent reviewers carried out this integrative review suggest that there may be merit in
identification of relevant studies. The majority of our in- further exploring the option of psychosocial well-being in
cluded studies were of RCT design with large sample sizes future interventions. This may increase patients’ willing-
and follow-up periods. We also included psychosocial ness to change attitudes and inform positive behavioral
well-being and focused on combined interventions, which, changes that would expand the current scope of strategies
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 12 of 16

Fig. 2 Integrative review model. Conceptual model resulting from the integrative review proposes that interventions targeted at mitigating the
risks associated with a GDM pregnancy should not only include diet and physical activity domains but may also integrate and/or include
strategies for improving self-efficacy and self-regulation of eating, exercise, psychosocial well-being, and social/ family support. In the first black
circle, diet, physical activity, and psychosocial well-being interventions for women with GDM are represented. In the second gray circle, the
outcomes which are improved for the mother following a diet, physical activity and psychosocial intervention are illustrated. Finally, the
largest gray circle represents the neonatal outcomes which may also be improved if the mother follows a diet, physical activity and
psychosocial intervention

in reducing the risk associated with GDM. Future studies be improved in this life period within a lifestyle inter-
that plan to adopt psychosocial interventions should focus vention. It is also known that prenatal maternal stress
on self-efficacy and/or social support, as both elements exposure and stress perception are associated with less
are associated with diet and physical activity habits. How- favorable obstetric outcomes, such as caesarean section
ever, this might not be easy, as it implies that women [90, 120, 121]. Thus, future interventions may focus on
already have a support system on which they can rely to the psychosocial well-being of women with GDM to
help them change their behavior and that self-efficacy can help alleviate and/or ameliorate stress symptoms [124].
Gilbert et al. BMC Pregnancy and Childbirth (2019) 19:60 Page 13 of 16

Furthermore, partners of women could also be inte- Funding

grated as social support for women with GDM that This review is a pilot study of a project grant by the Swiss National Science
Foundation (SNF 32003B_176119). This study also received funding from an
need to make lifestyle changes. Finally, it would also be unrestricted educational grant from NovoNordisk. The funding organizations
interesting to conduct a review on qualitative studies to had no role in the preparation of this manuscript for submission.
identify participant perception and lived experiences
Availability of data and materials
with lifestyle interventions in women with GDM in All relevant data are within the paper and its Supporting Information files.
order to fine-tune future interventions.
Authors’ contributions
LG participated in the conception and design of the study, coordinated the
Conclusion study and the data collection, participated in the data analysis, interpretation
This integrative review showed that diet, physical activity of data and in the writing of the manuscript. SL & JG participated in data
and psychosocial well-being interact in women with collection, conducted the data analysis, assisted with the interpretation of
the data, and commented on the manuscript. DYQ participated in the data
GDM. We found that lifestyle interventions led to a bet- collection, the interpretation of data and co-wrote the manuscript. JP participated
ter dietary quality in all studies, improvements in phys- in the conception and design of the study, assisted in the interpretation of the
ical activity in more than half of the studies measuring data and commented on the different versions of the manuscript. AH participated
in the conception and design of the study, data collection, the interpretation of
this outcome, lower stress perception, higher quality of data and co-wrote the manuscript. All authors read and approved the final
life, less fatalistic and cultural diabetes beliefs, some bet- manuscript.
ter anthropometric and metabolic health outcomes,
lower rates of diabetes progression following GDM and Ethics approval and consent to participate
Not applicable.
to less preterm deliveries and a higher birth weight. The
observational studies also demonstrated the importance Consent for publication
of social support and self-efficacy in relation to a healthy Not applicable.
lifestyle in women with GDM. Given that psychosocial
Competing interests
well-being, such as social support and self-efficacy, are The authors declare that they have no competing interests.
associated with physical activity and healthy dietary
choices, we recommend that future intervention studies Publisher’s Note
consider integrating psychosocial well-being in a com- Springer Nature remains neutral with regard to jurisdictional claims in
bined diet and physical activity intervention to investi- published maps and institutional affiliations.
gate the role of self-efficacy and social support on GDM. Author details
1
Obstetric service, Department Woman-Mother-Child, Lausanne University
Hospital, 1011 Lausanne, Switzerland. 2Service of Endocrinology, Diabetes
Additional files and Metabolism, Lausanne University Hospital, 1011 Lausanne, Switzerland.
3
Division of Angiology, Heart and Vessel Department, Lausanne University
Additional file 1: This additional file contains Table S1 and Table S2 Hospital, 1011 Lausanne, Switzerland. 4Institute of Higher Education and
which give a summary of the observational and intervention articles Research in Healthcare (IUFRS), University of Lausanne, 1010 Lausanne,
integrated in the literature review. Both tables give information about the Switzerland. 5Neonatology service, Department Woman-Mother-Child,
authors, year and country of publication, the design, sample and objective Lausanne University Hospital, 1011 Lausanne, Switzerland.
of each study, the selection criteria applied to the study participants,
information on how diet, physical activity and psychosocial well-being were Received: 5 September 2018 Accepted: 8 January 2019
assessed, and finally the quality of the study, appraised through JBI criteria.
In the tables describing the observational studies; the major findings of each
study are summarized. In the tables describing the intervention studies; the References
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