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Review

Lifestyle Behaviors and Gestational Diabetes Mellitus: A Narrative Review

by
Eleftheria Taousani
1,2,*,
Konstantinos-Georgios Papaioannou
3,
Gesthimani Mintziori
2,
Maria G. Grammatikopoulou
2,4,
Angeliki Antonakou
1,
Maria Tzitiridou-Chatzopoulou
5,
Stavroula Veneti
2 and
Dimitrios G. Goulis
2
1
Department of Midwifery, School of Health Sciences, International Hellenic University, Alexander Campus, Sindos, P.O. Box 141, 57400 Thessaloniki, Greece
2
Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece
3
Independent Researcher, 54634 Thessaloniki, Greece
4
Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41110 Larissa, Greece
5
Department of Midwifery, School of Healthcare Sciences, University of Western Macedonia, 50100 Ptolemaida, Greece
*
Author to whom correspondence should be addressed.
Endocrines 2025, 6(1), 6; https://doi.org/10.3390/endocrines6010006
Submission received: 18 July 2024 / Revised: 22 January 2025 / Accepted: 26 January 2025 / Published: 10 February 2025
(This article belongs to the Special Issue Advances in Diabetes Care)

Abstract

Gestational diabetes mellitus (GDM) is a prevalent condition impacting approximately 14% of pregnancies globally, posing significant health risks to mother and child. This review explores the role of diet, physical activity (PA), and sedentary behavior (SB) in preventing and managing GDM. Consumption of fish, fruits, vegetables, and legumes, and adherence to healthy dietary patterns, like the Mediterranean diet, are linked to lower GDM risk. Higher levels of PA and structured exercise consistently show protective effects against GDM, enhancing glucose metabolism and insulin sensitivity. Conversely, SB is a risk factor for GDM; prolonged sedentary periods detrimentally affect glucose regulation. The review emphasizes the need for a combined approach integrating healthy dietary habits, regular PA, and reduced SB to mitigate GDM risk effectively. Future research should prioritize standardized assessment methods and personalized lifestyle interventions to optimize GDM prevention strategies, ultimately informing public health guidelines and clinical recommendations for healthier pregnancies and better long-term outcomes.

1. Introduction

Gestational diabetes mellitus (GDM) is the most common metabolic disorder during pregnancy, with a worldwide prevalence of 14% of all pregnancies [1]. Characterized by glucose intolerance first recognized during pregnancy, GDM is linked with adverse health and pregnancy outcomes, including an increased risk of diabetes, cardiovascular disease, perinatal morbidity, macrosomia, preterm delivery, respiratory distress syndrome, and neonatal jaundice [2]. Adapting healthy lifestyle behaviors during pregnancy holds promise in mitigating or eliminating the risk of adverse metabolic health outcomes, such as GDM [3,4]. Μajor GDM risk factors, such as obesity, progressive overweight status, family history of diabetes, low-quality diet, and sedentary lifestyle [5], can be modified or controlled by lifestyle behaviors, such as healthier dietary habits and regular physical activity or exercise. Several studies of various designs support that a healthy diet and regular physical activity (PA), either alone or in combination, can significantly reduce the risk of developing GDM [4,6,7,8,9,10,11,12,13,14]. However, there is a lack of consistency in the findings across the studies, and various factors, such as the quality, characteristics, and evaluation of diet and PA could explain a part of the heterogeneity [15].
Diet plays a crucial role in metabolism; healthy and unhealthy dietary patterns have been linked to GDM and glucose intolerance in pregnant women [7,8]. Since healthy and unhealthy foods and nutrients are included in the diet, evaluating the impact of the whole diet and overall dietary patterns is crucial. Recent review studies indicate that healthy dietary patterns can reduce the risk of GDM, while unhealthy patterns can increase it [6,16]. In addition, PA can improve glucose and insulin concentrations and benefit blood glucose control [17]. Engaging in PA before pregnancy or during the first trimester reduces GDM risk [9,13], with a dose–response association [18] that may be moderated by sedentary behavior (SB) [19]. Sedentary lifestyles have been linked to GDM and a broad range of adverse health outcomes [20,21,22]. The balance between PA and SB affects metabolic processes and increases or decreases the risk of developing GDM. As dietary patterns, PA, and SB can play a role in mechanisms involved in GDM development, such as oxidative stress and inflammation [23], the need to clarify the potential interplay (Figure 1) between these lifestyle behaviors is paramount. The present review aims to present and critically appraise the current knowledge about lifestyle behaviors affecting GDM and to suggest directions for future research.

2. Methods

For this narrative review, we conducted a comprehensive literature search to identify relevant articles examining the associations between individual lifestyle behaviors (diet, physical activity, and sedentary behavior) and the risk or prevalence of gestational diabetes mellitus (GDM). Then, we expanded the search to include studies exploring combinations of these lifestyle behaviors and their potential interactions in relation to GDM. Next, we incorporated articles discussing factors that might influence these relationships. The primary databases used were PubMed and Google Scholar, with search terms including ‘gestational diabetes mellitus’, ‘physical activity’, ‘sedentary behavior’, ‘diet’, and ‘lifestyle interventions’. Studies were selected regardless of design, aiming to summarize the current evidence on these lifestyle factors and their role in GDM prevention and management.

3. Diet and GDM

Diet plays a crucial role in the development of GDM, with various studies indicating that certain foods may influence the risk of developing this condition. For instance, higher consumption of several foods, such as fish, fruits, vegetables, and legumes, has been individually associated with a reduced risk of GDM [24,25,26,27,28]. However, not all studies agree; some have found no significant correlation between total fruit and vegetable intake and GDM risk, suggesting that the quantity and type of food consumed may be fundamental factors to consider [29]. This inconsistency highlights the challenge of linking single foods to GDM risk and emphasizes the need to consider the broader dietary context.
Given these inconsistencies, examining overall dietary patterns rather than individual foods may provide a more comprehensive understanding of diet’s impact on GDM. Research indicates that healthier dietary patterns, such as the Mediterranean and prudent diets, are generally associated with a lower risk of GDM [7,30,31]. In contrast, unhealthy diet patterns, like the Western diet, are linked to an increased GDM risk [6,14,16,31,32,33]. A recent meta-analysis supported these findings but noted that the association between dietary patterns and GDM risk can vary based on study design, dietary intake assessment, and geographic location [6]. Despite these variations, the consensus is that healthier dietary patterns lower the risk of GDM.
Beyond the specific types of foods or dietary patterns, diet quality also appears to play a role in the development of GDM through its effects on inflammation and body mass index (BMI). Chronic low-grade inflammation (LGI), marked by elevated levels of inflammatory markers, like IL-6 and TNF-alpha, has been linked to GDM and may contribute to insulin resistance and glucose intolerance in pregnant women [34,35,36]. Nevertheless, diets rich in certain foods, such as vegetables, may reduce inflammation, suggesting a potential pathway through which diet can influence GDM risk [37]. This connection between diet, inflammation, and GDM underscores the importance of focusing on diet quality as an essential factor in managing GDM risk. Also, a high-quality diet is related to lower BMI [38], highlighting the impact of a healthy diet on GDM risk. Maternal BMI is a risk factor and a significant predictor of GDM [39,40]. However, a recent study reports that BMI gain was not associated with GDM risk, suggesting that the time of BMI measurement is crucial for the relationship between BMI and GDM [40]. Notably, BMI can be modified by lifestyle interventions [41], highlighting the role of lifestyle behaviors on GDM risk and development.
Diet plays a crucial role in GDM, and while the International Diabetes Federation (IDF) recommends a diet rich in vegetables, lean proteins, whole grains, and healthy fats, these guidelines are general [42]. They aim to maintain stable blood sugar levels and reduce inflammation, but specific dietary recommendations tailored for GDM management are still needed. Future research should focus on developing and refining dietary guidelines that address GDM more precisely, considering individual metabolic responses and broader nutritional patterns.
Future research would guarantee standardized dietary assessment methods and explore how comprehensive dietary patterns affect GDM risk. Moreover, understanding the interplay between diet quality, inflammation, and GDM can help develop more targeted diet interventions. This approach would enable healthcare providers to offer personalized dietary advice, potentially enhancing the prevention and management of GDM.

4. Physical Activity and GDM

Increasing physical activity (PA) and exercise are widely recognized strategies for preventing and managing gestational diabetes mellitus (GDM) [43]. Physical activity, defined as any bodily movement produced by skeletal muscles that results in energy expenditure, encompasses a range of activities, including sports, occupational tasks, leisure-time activities, household chores, and transportation [44]. Exercise, in contrast, refers to planned, structured, and repetitive bodily movement aimed at improving or maintaining physical fitness, which relates to the ability to perform PA [44].
Higher levels of PA [10,45,46] and regular exercise [47,48] have been associated with a lower risk of developing GDM. Reviews and meta-analyses consistently support the preventive effect of increased PA on GDM risk [18,49,50,51]. Similarly, regular exercise has been linked to a reduced risk of GDM [52,53,54,55]. Also, several studies indicate that either PA or an exercise intervention can reduce GDM risk [56,57,58,59,60,61] and improve glucose levels in women with GDM [62,63].
Observational studies, including cohort and case–control studies, have demonstrated a consistent association between PA or exercise and a reduced risk of GDM before [64,65,66,67] and during pregnancy [64,68,69]. A recent meta-analysis reported a 36% lower risk of developing GDM when the authors compared pregnant women with higher PA levels with those with lower PA levels [18]. This finding aligns with previous meta-analyses, indicating a 21% to 55% lower risk for GDM with higher PA levels [10,51]. Additionally, a possible dose–response relationship suggests that increased PA during pregnancy corresponds to a greater reduction in GDM risk, with cardiorespiratory fitness (CRF) potentially mediating this association [9,70]. As individual responsiveness to PA varies [71], objectively assessing CRF levels before prescribing exercise is crucial for optimizing clinical and research outcomes.
Randomized control trials (RCTs) further support the protective role of PA and exercise against GDM. An umbrella review and meta-analysis comparing exercise interventions with standard prenatal care found that exercise interventions reduced GDM incidence by 39% [56]. The effectiveness of these interventions was enhanced when they started in the first trimester, were supervised, and included light-to-moderate- or moderate-intensity exercise. These findings underscore the importance of compliance with exercise interventions and suggest that moderate-intensity exercise can also reduce chronic low-grade inflammation (LGI) [72,73,74,75], which plays a crucial role in GDM pathogenesis [35]. Therefore, the intensity of exercise may influence its impact on GDM by modulating inflammatory pathways. In addition, exercise interventions alone can benefit another major GDM risk factor, BMI [76]. Notably, combining exercise with dietary interventions may further enhance these beneficial effects on BMI [77], highlighting the importance of addressing multiple lifestyle behaviors simultaneously.
The International Diabetes Federation (IDF) recommends that pregnant women engage in at least 30 min of moderate-intensity exercise most days of the week [42]. This guideline supports GDM prevention by improving cardiovascular fitness and metabolic health. However, to enhance GDM prevention strategies, further research is needed to determine the most effective types and intensities of exercise and tailor recommendations based on individual responses.

5. Sedentary Behavior and GDM

Sedentary behavior (SB) has been linked to several adverse metabolic outcomes, including an increased risk of gestational diabetes mellitus (GDM) in pregnant women [20,21]. It is crucial to distinguish between SB and physical inactivity, as they are two distinct concepts. SB, defined as any waking behavior with an energy expenditure of 1.5 METs or lower while sitting, reclining, or lying [78], differs from physical inactivity, which refers to insufficient physical activity (PA) to meet current recommendations [78]. Understanding these distinctions is vital for assessing their effects on health outcomes.
Variability in definitions and assessment methods for SB contributes to the heterogeneity in study findings regarding its association with GDM [79]. For instance, discrepancies in study design, sample size, GDM diagnosis methods, SB assessment, and stage of pregnancy can influence results. An overview of several indicative studies is provided in Table 1. Anjana et al. [80] report that women with GDM were significantly more sedentary compared to those without GDM. However, the use of a Physical Activity Questionnaire validated with a pedometer in this study led to partial misclassification of participants, falsely categorizing 15% as active and 30% as inactive. Additionally, a prospective cohort study associated increased SB with a higher GDM risk despite high PA levels [19], highlighting the importance of considering sedentary behavior in the context of overall lifestyle. However, this study lacks dietary information and relies on self-reported rather than objective PA measures, which limits its comprehensiveness. In contrast, a case–control study found no significant association between SB and GDM [81], while another study found no link between sitting time and GDM risk [82]. Differences in study design—such as the definition of SB, reliance on self-reported measurements, and lack of energy intake control—might explain these results. Similarly, a cross-sectional study using objectively measured SB found no association between total sedentary time and incident GDM [83]. However, assessing prolonged sedentary time in 30 min bouts may have limited this study’s ability to detect associations between SB and GDM [84], as was also observed in a study exploring the relationship between SB and inflammatory markers [85]. Overall, these methodological limitations underscore the complexity of studying lifestyle behaviors and the need for comprehensive research that incorporates all three factors—diet, physical activity, and sedentary behavior—using objective measurements to better understand their relationship with GDM risk. Furthermore, the Maastricht study [86] provides valuable context for understanding how multiple lifestyle factors interact, but it does not directly address GDM.
Recent systematic reviews have suggested a potential role of SB in GDM, but the evidence remains inconclusive [87,88], likely due to varying definitions and methodologies. Given that GDM shares pathophysiological pathways with type 2 diabetes mellitus (T2DM) [89], and both SB [90] and physical inactivity [91] are independent risk factors for T2DM, it is plausible that similar mechanisms could be involved in the relationship between SB and GDM. Studies have indicated that fundamental hormones and metabolic biomarkers, such as cortisol, leptin, and adiponectin—linked to T2DM and GDM—are also associated with SB [92,93,94].
Cortisol, which plays a crucial role in glucose homeostasis, has been associated with the pathogenesis of GDM [95,96] and, more recently, with SB [93]. Similarly, leptin, a biomarker of insulin resistance in obese T2DM patients [97], has been associated with GDM [98]. Adiponectin, another key biomarker involved in insulin resistance, obesity, and inflammation [99], shows a negative association with both T2DM [100] and GDM [101]. However, the relationship between SB and adiponectin is unclear, with some studies reporting an association [92,102], while others do not [103].
In obese women, the glucose–insulin axis is more strongly associated with SB than moderate-to-vigorous physical activity (MVPA), highlighting the relevance of SB in glucose metabolism [104]. The same study found that SB was linked to muscle insulin resistance (IR) but not liver IR, suggesting that SB may affect glucose metabolism differently across tissues. This association underscores the importance of methodological precision in detecting associations and understanding the impact of SB on insulin resistance.
Additional factors, such as fetal sex [104], gestational weight gain (GWG), BMI, and chronic low-grade inflammation (LGI) [103,105], may further influence the relationship between SB and GDM. Male offspring pregnancies, for instance, are associated with a higher risk of GDM compared to female pregnancies [106,107], and there is a notable link between fetal sex and SB [104]. Furthermore, GWG can influence GDM and its relationship with SB [19]. At the same time, pre-pregnancy BMI and GDM subtype significantly affect GWG [108], suggesting that BMI may affect the relationship between SB, GWG, and GDM. Early pregnancy BMI is a known risk factor for GDM [109], and reducing SB, along with other lifestyle behaviors, such as dietary habits [110,111] and physical activity [112], may mitigate this risk.
SB has also been associated with higher levels of several inflammatory markers in pregnant women [113,114]. LGI, which has been linked to glycemic control in T2DM [115], is more strongly correlated with SB in individuals with pre-diabetes and T2DM than in those with normal glucose metabolism [86], indicating a potential role for LGI in GDM development [34,35]. While the study by Vandercappellen et al. [86] provides valuable insights into the association between SB and LGI in pre-diabetic and T2DM adults, this review uniquely addresses the gap in the research regarding the simultaneous impact of diet, physical activity, and SB on GDM risk.
Reducing sedentary time could be an effective strategy for GDM prevention and management. Although the role of SB in GDM development is not yet fully understood, and no specific guidelines exist for SB in GDM prevention, the World Health Organization (WHO) advises limiting sedentary time and replacing it with physical activity to improve overall health [116]. This recommendation highlights the potential benefits of increasing physical activity to enhance metabolic health and reduce risk factors associated with GDM. However, more research is needed to develop specific guidelines for sedentary behavior and its impact on GDM, with future studies focusing on standardizing assessments of sedentary behavior and exploring its mechanisms concerning GDM risk.
Future research should aim to standardize definitions and assessment methods for SB, explore the mechanisms linking SB to GDM, and consider potential sex-specific pathways. Incorporating objective measures of SB, such as accelerometers, and examining the impact of breaking up prolonged sedentary periods, could yield more precise insights into the role of SB in GDM. These findings could inform public health guidelines and clinical recommendations for pregnant women, emphasizing the importance of reducing SB alongside increasing physical activity levels.
Table 1. Indicative studies examine the association between sedentary behavior (SB) and gestational diabetes mellitus (GDM) risk or incidence.
Table 1. Indicative studies examine the association between sedentary behavior (SB) and gestational diabetes mellitus (GDM) risk or incidence.
StudyStudy Design
and Participants
SB AssessmentMain Outcomes
Aburezq et al.,
2020 [117]
Cross-sectional
653 postpartum women with no history of diabetes mellitus
Pregnancy Physical Activity Questionnaire (PPAQ)No association between PA or SB and GDM
Anjana et al.,
2016 [80]
Quasi-experimental
1086 pregnant women, <28 GW
PedometerWomen with GDM were more sedentary than women without GDM (86.2 vs. 61.2%, p < 0.001)
Camargo et al.,
2021 [81]
Case–control
68 women with GDM participated in a cross-sectional study of PA and SB (20–35 GW)
Longitudinal Aging Study Amsterdam Sedentary Behavior Questionnaire (LASA-SBQ)No association of SB with adverse maternal–fetal outcomes (including GDM)
do Nascimento et al.,
2019 [22]
Cross-sectional
544 pregnant women with low income (≤1025 USD), ≤20 GW, age 18–45 years, Recife metropolitan area residency
Pregnancy Physical Activity Questionnaire (PPAQ)Sedentary PA pattern was associated with higher odds of GDM (OR 1.8, 95% CI 1.1–2.9), which did not change after adjusting for several covariates: age, race/ethnicity, sociodemographic characteristics, and reproductive and medical history (OR 1.9, 95% CI 1.2–3.1)
Leng et al.,
2016 [21]
Cross-sectional
11,450 pregnant women, 12th GW
Self-reportedSitting at home for either 2–4 h or >4 h per day was associated with increased GDM risk
Sitting time 2–4 h vs. <2 h (OR 1.59, 95% CI 1.18–2.15
Sitting time > 4 h vs. <2 h (OR 1.73, 95% CI 1.22–2.43)
Nasiri Amiri et al., 2016 [118]Case–control study
200 pregnant women: 100 with GDM as the case group, 100 as a control group
A modified version of the pregnancy physical activity questionnaire (PPAQ), a semi-quantitative questionnaire validated for pregnancyPregnant women with low intensity of sedentary behavior were at higher risk of developing GDM compared with women with higher intensity of sedentary behavior
Nguyen et al.,
2018 [82]
Cohort study
1987 pregnant women:
1. Permanent residents in study locations;
2. ≥18 years of age;
3. 24–28 GW
4. Singleton pregnancy;
5. Not having serious health conditions;
6. Able to read the information sheet and sign the consent form
Self-reportedNo association between sitting time and GDM
Oken et al.,
2006 [66]
Cohort study
1805 women attending their initial prenatal visit
Self-reportedNo association between television viewing before or during pregnancy and the risk of GDM
Padmapriya et al.,
2017 [12]
Cohort study
1083 pregnant women aged ≥18 years, major ethnic groups: Chinese, Malay, Indian, permanent residents to stay in Singapore for at least 5 years, and agreed to donate birth tissues
Self-reportedSB was not associated with FG, 2 h PG, or GDM
SB before pregnancy was not associated with the risk of GDM
SB during pregnancy was uncertain about the risk of GDM
van der Ploeg et al.,
2011 [119]
Cohort study
14,247 women in 3 age cohorts: younger (18–23 years), mid-age (45–50 years), and older (70–75 years) selected from the Medicare database
Self-reportedSB was not associated with the development of GDM in the subsequent three years
Wagnild et al.,
2019 [83]
Cross-sectional study
188 pregnant women, age ≥ 18 years, singleton pregnancy, fluent in English, no pre-existing diabetes, at least one risk factor for GDM: BMI ≥ 30 kg/m2, first-degree relative with diabetes, previous GDM, ethnic origin with a high prevalence of diabetes, or a macrosomic baby (≥4.5 kg)
AccelerometerTotal sedentary time (h/d) was not associated with incident GDM (OR 1.00, 95% CI 1.00-1.01)
Prolonged sedentary time was associated with higher fasting glucose concentrations regardless of GDM status [β 0.15, (0.01–0.30)]
Television time was associated with the development of GDM (OR 3.03, 95% CI 1.21–7.96)
The effect size for the association between television time and GDM was larger than the effect size for the association between total sedentary time and GDM
Yong et al.,
2020 [19]
Cohort study
452 women in 10–13 GW
Pregnancy Physical Activity Questionnaire
(PPAQ)
Identification of two trajectories:
-
High PA levels and SB
-
Low PA levels and SB
Women in the first trajectory with high SB were at higher risk of GDM despite high PA levels
Zhang et al.,
2006 [67]
Cohort study
21,765 women, age 24–44 years, ≥1 singleton pregnancy lasting ≥6 months
Self-reportedWatching television was associated with higher GDM risk after adjustments for age and time spent on other sedentary behaviors, total PA score, and dietary factors
Women who spent ≥20 h/wk watching television but did not perform vigorous activity had a higher GDM risk than women who spent <2 h/wk watching television and were physically active (RR 2.30, 95% CI 1.06–4.97)
2 h PG: 2-h postprandial plasma glucose, BMI: body mass index; CI: confidence interval; FG: fasting glucose; GDM: gestational diabetes mellitus; GW: gestational week; OR: odds ratio; PA: physical activity; RR: relative risks; SB: sedentary behavior; wk: week.

6. Lifestyle Behaviors and GDM

The prevention and management of GDM are multifaceted, involving various lifestyle behaviors. While diet, PA, and SB have been individually studied in relation to GDM, the integration of these three behaviors is crucial for a more comprehensive understanding of how lifestyle modifications can mitigate GDM risk. Combining healthy dietary patterns with regular PA can lead to greater reductions in GDM risk than focusing on either behavior alone. PA can enhance the body’s ability to manage glucose and improve the overall effectiveness of a healthy diet [77]. Conversely, emerging evidence suggests that prolonged sedentary behavior may attenuate some of the benefits associated with regular physical activity, particularly concerning metabolic health [120]. However, more research is needed to understand these interactions in the context of GDM. Furthermore, several studies have used combined dietary and PA interventions to examine their effects on GDM (Table 2). At the same time, a meta-analysis suggests that women who maintained either a healthy diet or high levels of PA had a significantly lower risk of GDM compared to those who did not [10]. In addition, reduced sedentary time was associated with lower GDM risk [19], highlighting the importance of an integrated approach.
The interdependence of diet and physical activity is increasingly recognized. For example, Farina et al. (2019) [121] demonstrated that diet quality is associated with physical performance, supporting the theory that dietary habits can influence activity levels. Although this study focused on Special Forces candidates, its findings highlight the broader interconnections between these behaviors, which may extend to other populations, including those at risk for GDM. Moreover, an overview by Koehler and Drenowatz (2022) emphasizes the critical need to integrate diet and physical activity to achieve sustainable health improvements [122]. The authors stress that understanding the interaction between these two behaviors is essential for developing combined interventions that minimize compensatory behaviors, a principle that is also relevant for addressing GDM risk.
Additionally, sedentary behavior and physical activity are inversely associated with sedentary time displacing light-intensity physical activity, as evidenced by a systematic review of 26 studies by Mansoubi et al., 2014 [123]. This displacement suggests that increasing physical activity, even at light intensities, may mitigate some of the negative effects of prolonged sedentary behavior. Furthermore, a recent study by Júdice et al. (2024) found that sedentary behavior, particularly leisure time and transport, is inversely associated with healthier dietary habits, such as adherence to the Mediterranean diet [124]. Specifically, individuals with higher levels of sedentary behavior reported poorer eating patterns, independent of physical activity levels. These findings suggest that sedentary behavior may independently increase GDM risk and exacerbate the effects of poor dietary habits. Therefore, considering the interplay of diet, PA, and SB is crucial for a comprehensive understanding of GDM prevention and treatment strategies.
However, the evidence from independent diet or PA interventions to treat GDM remains inconclusive [125]. Notably, a systematic review and meta-analysis found that exercise alone significantly reduced the risk of developing GDM. Still, this effect was not observed when exercise was combined with other interventions, such as dietary changes [126]. This discrepancy may be attributed to poor adherence to exercise interventions, with 67% of the studies in this meta-analysis reporting issues related to non-compliance, many of which relied on unsupervised exercise programs or general lifestyle counseling. Such factors may have limited the overall effectiveness of these interventions. Additionally, given that diet, PA, and SB are interconnected behaviors that collectively influence metabolic health, including mechanisms, such as inflammation and oxidative stress, which are linked to GDM and may play a role in its pathogenesis [23], the potential interactions between these behaviors could explain some of the inconclusive findings. This underscores the importance of supervised intervention studies to better assess the impact of exercise, whether alone or in combination with other lifestyle modifications, on GDM risk. It also highlights the need for further studies to explore the interactions between diet, PA, and SB and how they may collectively influence the pathogenesis and prevention of GDM.
The combined effects of diet, PA, and SB likely converge on shared physiological mechanisms, such as inflammation and insulin sensitivity, which collectively influence GDM risk. Regular PA enhances insulin sensitivity and glucose uptake, while a healthy diet provides essential nutrients that support metabolic health. Reducing sedentary time minimizes the periods of prolonged inactivity that are detrimental to glucose regulation. Together, these behaviors could help maintain stable blood glucose levels and reduce the inflammatory markers associated with GDM. While some studies report significant reductions in GDM prevalence (up to 30%) following combined diet and PA interventions, mainly through counseling, others observe minimal or no differences (Table 2). This variability underscores the lack of homogeneity in the literature, which may be attributed to differences in study designs that often fail to account for all three major lifestyle behaviors—diet, physical activity, and sedentary behavior. Moreover, while the interdependence between these behaviors is well-documented, no study has simultaneously examined their association with GDM risk or prevalence. Understanding this interdependence is crucial, as without it, assessing the individual effects of each behavior remains unreliable. This gap highlights the need for future research integrating these three factors to clarify their individual and combined effects.
A holistic, interdisciplinary approach that combines healthy dietary habits, regular physical activity, and reduced sedentary behavior is essential for effectively reducing the risk of GDM. Given the current paucity of integrated studies, future research should focus on lifestyle interventions that simultaneously address diet, physical activity, and sedentary behavior. Understanding the interplay between these behaviors and their synergistic effects could inform more comprehensive public health guidelines and clinical recommendations for pregnant women. Such studies should aim to identify the most effective combinations of these behaviors for preventing GDM, considering individual variability in response to lifestyle changes. Additionally, personalized interventions tailored to individual risk profiles could enhance the efficacy of GDM prevention strategies and improve patient outcomes.
Table 2. Indicative RCT studies of combined diet and physical activity (PA) interventions on gestational diabetes mellitus (GDM) risk or incidence.
Table 2. Indicative RCT studies of combined diet and physical activity (PA) interventions on gestational diabetes mellitus (GDM) risk or incidence.
StudyStudy Design
and Participants
Diet and PA
Interventions
Main Outcomes
Bruno et al.,
2016 [127]
Randomized controlled trial
191 pregnant women with BMI ≥ 25 kg/m2, age > 18 years, singleton pregnancy
Intervention group (I): healthy diet and physical activity counseling
vs.
Standard care group (SC): lifestyle advice on healthy nutrition and exercise.
GDM prevalence
18.8% (I) vs. 37.1% (SC group), p = 0.019
Ding et al.,
2021 [128]
Randomized controlled trial
215 overweight/obese pregnant women
3 face-to-face sessions about personalized dietary and exercise intervention vs. a general advice session about pregnancy nutrition and weight managementGDM prevalence
24.5% (intervention group) vs. 37.8% (control group), p < 0.05
Herring et al.,
2016 [129]
Randomized controlled trial
66 socioeconomically disadvantaged African American pregnant women with gestational age < 20 weeks, BMI: 25–45 kg/m2
Intervention group:
1. Empirically supported behavior change goals
2. Interactive self-monitoring text messages
3. Biweekly health coach calls
4. Skills training and support through Facebook.
vs.
Standard care group
GDM prevalence
4% (intervention group) vs. 4% (standard care), p = 1.00
Koivusalo et al.,
2016 [130]
Randomized controlled trial
293 pregnant women aged ≥ 18 years, <20 gestational weeks, GDM history, pre-pregnancy BMI of ≥30 kg/m2
Intervention group: individualized counseling on diet, physical activity, and weight control
vs.
Control group: standard antenatal care
GDM prevalence:
13.9% (intervention group) vs. 21.6% (control) (95% CI 0.40–0.98%, p = 0.044) after adjustment for age, pre-pregnancy BMI, previous GDM, and gestational week
Korpi-Hyovalti et al., 2011 [131]Randomized controlled trial
60 pregnant women at high risk for GDM
Counseling intervention: six one-to-one personalized diet advice sessions; six exercise encouragement sessions
vs.
Close follow-up: standard Care
GDM prevalence:
11.1% (intervention group) vs. 3.7% (close follow-up)
Lin et al.,
2020 [132]
Randomized controlled trial
Pregnant women aged ≥18 years with at least one GDM risk factor: age ≥ 35 years, pre-pregnancy BMI ≥ 25 kg/m2, family history of diabetes, history of PCOS, or GDM
Intervention group: counseling on diet, physical activity, and weight control through one face-to-face education session and continuous educational messages via the WeChat public account twice per week
vs. usual prenatal care
GDM prevalence:
14.4% (intervention group) vs. 24.6% control group (p = 0.03)
Petrella et al.,
2013 [133]
Randomized controlled trial
63 pregnant women from antenatal clinics with a pre-pregnancy BMI ≥ 25 kg/m2, aged over 18 years and single
Therapeutic lifestyle changes (TLC) group: 1700 or 1800 kcal/day for overweight and obese women, respectively, mild exercise (30 min/day, three times/week)
vs.
Control group: nutritional booklet standard care
GDM prevalence:
23.3% (TLC) vs. 57.1% (control group), p = 0.009
Phelan et al.,
2011 [134]
Randomized controlled trial
401 women, >18 years old, 10–16 gestational weeks, BMI 19.8–40 kg/m2, non-smoking, fluent in English, access to a telephone, singleton pregnancy
Intervention group:
diet and PA counseling: one face-to-face visit; weekly mailed materials promoting appropriate weight gain, healthy eating, and exercise
vs.
Standard care
GDM prevalence:
Normal weight: 8.9% (intervention) vs. 6.5% (control)
Overweight: 13.6% (intervention) vs. 8.1% (control)
Sagedal et al.,
2017 [135]
Randomized controlled trial
606 healthy, non-diabetic, nulliparous women, aged ≥ 18 years, BMI ≥ 19 kg/m2, singleton pregnancy, ≤20 gestational weeks
Norwegian Fit for Delivery (NFFD) intervention: dietary counseling twice by telephone and access to exercise groups twice/week
vs.
Control group: standard prenatal care
GDM prevalence:
12.9% (intervention) vs. 9.1% (control) (OR 1.33; 95% CI 0.77–2.32, p = 0.330)
Renault et al.,
2014 [136]
Randomized controlled trial
425 obese pregnant women, age ≥ 18 years, singleton pregnancy, normal scan in weeks 11–14, <16 gestational weeks, ability to read/speak Danish
PA group:
encouragement to increase physical activity, monitored by pedometer on 7 consecutive days every 4 weeks.
vs.
PA + diet group:
PA intervention and healthy diet instructions every 2 weeks
vs.
Control group (C):
standard care, diet counseling session
GDM prevalence:
1.6% (PA) vs. 3.8% (PA + D) vs. 5.2% (C), p = non-significant
Simmons et al.,
2017 [137]
Randomized controlled trial
436 pregnant women, aged ≥ 18 years, <20 gestational weeks, pre-pregnancy BMI ≥ 29 kg/m2
PA Group: promoting aerobic and resistance physical activity
vs.
HE Group: promoting
healthy eating
vs.
PA + HE Group:
Combination PA and HE
vs.
Control: Standard care
GDM prevalence:
21% (PA) vs. 25% (HE) vs. 20% (PA + HE)
vs. 19% (C), p = non-significant
Vesco et al.,
2014 [138]
Randomized controlled trial
114 English-speaking, obese (BMI ≥ 30 kg/m2, age ≥ 18 years, prenatal care at Kaiser Permanente, Northwest (KPNW)
Intervention group: diet and PA counseling, provision of pedometers
vs.
Control: standard care, single dietary advice session
GDM prevalence:
11% (intervention) vs. 12% (control) (OR 0.87, 95% CI 0.28-2.78), p = non-significant
BMI: body mass index; CI: confidence interval; GDM: gestational diabetes mellitus; HE: healthy eating; OR: odds ratio; PA: physical activity; PCOS: polycystic ovary syndrome; TLC: therapeutic lifestyle changes.

7. Strengths and Limitations

The present review provides a comprehensive examination of studies on modifiable lifestyle behaviors, including diet, physical activity (PA), and sedentary behavior (SB), and their influence on gestational diabetes mellitus (GDM). By integrating findings from diverse study types—such as observational studies, cohort studies, case–control studies, randomized controlled trials (RCTs), and meta-analyses—the review offers a holistic perspective on how lifestyle modifications can impact GDM risk and management. It uniquely emphasizes the physiological mechanisms linking these behaviors with GDM, such as insulin sensitivity, glucose metabolism, low-grade inflammation, and oxidative stress, thereby offering insights into how interventions can be optimized.
However, while the review addresses key physiological mechanisms, more detailed mechanisms specific to diet, physical activity, and sedentary behavior in the context of GDM could further enhance our collective understanding. Further research that integrates these mechanisms with lifestyle interventions would be valuable for informing public health guidelines.
While hormonal influences are not a primary focus of this review, they likely play a critical role in how diet, physical activity, and sedentary behavior affect GDM risk. These hormonal pathways warrant further exploration in integrated studies to better understand their role in GDM pathogenesis. Furthermore, while the review addresses some aspects of hormonal influences, a more thorough exploration of how lifestyle modifications interact with hormonal pathways could provide additional insights.
It is important to note that this review does not examine whether lifestyle changes in women with GDM could mitigate their long-term risk of metabolic disorders or affect child outcomes. Additionally, the review does not provide specific timing recommendations for lifestyle modifications to aid in GDM prevention or treatment, as studies investigating these aspects are limited. The decision to focus on the broad integration of lifestyle behaviors was made to highlight the need for further research rather than an in-depth analysis of specific methods or treatments, which would require a more extensive review.

8. Conclusions

This review highlights the intricate association between lifestyle behaviors (diet, PA, SB) and the risk of GDM. While individual studies offer valuable insights, the collective evidence underscores the importance of adopting a holistic approach to GDM prevention and management. Integrating healthy dietary patterns, regular physical activity, and reduced sedentary behavior can significantly mitigate GDM risk. However, further research is needed to understand the synergistic effects of these behaviors and how they may interact with other physiological pathways. By translating these findings into comprehensive public health guidelines and clinical recommendations, we can enhance GDM prevention efforts and improve maternal and neonatal health outcomes.

Author Contributions

Conceptualization, E.T.; writing—original draft preparation E.T. and K.-G.P.; writing—review and editing E.T., K.-G.P., G.M., M.G.G., A.A., M.T.-C., S.V. and D.G.G. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. The interplay of diet, physical activity, and sedentary behavior may influence GDM risk.
Figure 1. The interplay of diet, physical activity, and sedentary behavior may influence GDM risk.
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Taousani, E.; Papaioannou, K.-G.; Mintziori, G.; Grammatikopoulou, M.G.; Antonakou, A.; Tzitiridou-Chatzopoulou, M.; Veneti, S.; Goulis, D.G. Lifestyle Behaviors and Gestational Diabetes Mellitus: A Narrative Review. Endocrines 2025, 6, 6. https://doi.org/10.3390/endocrines6010006

AMA Style

Taousani E, Papaioannou K-G, Mintziori G, Grammatikopoulou MG, Antonakou A, Tzitiridou-Chatzopoulou M, Veneti S, Goulis DG. Lifestyle Behaviors and Gestational Diabetes Mellitus: A Narrative Review. Endocrines. 2025; 6(1):6. https://doi.org/10.3390/endocrines6010006

Chicago/Turabian Style

Taousani, Eleftheria, Konstantinos-Georgios Papaioannou, Gesthimani Mintziori, Maria G. Grammatikopoulou, Angeliki Antonakou, Maria Tzitiridou-Chatzopoulou, Stavroula Veneti, and Dimitrios G. Goulis. 2025. "Lifestyle Behaviors and Gestational Diabetes Mellitus: A Narrative Review" Endocrines 6, no. 1: 6. https://doi.org/10.3390/endocrines6010006

APA Style

Taousani, E., Papaioannou, K.-G., Mintziori, G., Grammatikopoulou, M. G., Antonakou, A., Tzitiridou-Chatzopoulou, M., Veneti, S., & Goulis, D. G. (2025). Lifestyle Behaviors and Gestational Diabetes Mellitus: A Narrative Review. Endocrines, 6(1), 6. https://doi.org/10.3390/endocrines6010006

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